This case involves a woman in her mid-30s with a who underwent a gastric sleeve procedure. She had previously undergone a Nissen fundoplication procedure which had failed. EGD studies revealed the wrap coming undone and evidence of a stomach hernia with reflux. The patient sought the opinion of a different bariatric surgeon than the one she had seen for her surgery. This surgeon suggested the patient undergo a vertical sleeve gastrectomy as a revision of the previous surgery. During the procedure, it was suspected that the gastroesophageal junction was perforated. The surgeon conducted an intraoperative air test to confirm the staple line was stable and there was no bleeding. The week after the operation, the patient went into multi-system organ failure. It was alleged that due to the patient’s history, she should have received a Roux en Y gastric bypass as a revision rather than a sleeve procedure. An expert in bariatric surgery with experience in revision surgery was sought to review the case and opine on the standard of care.
Question(s) For Expert Witness
- 1. Please describe your background in bariatric surgery.
- 2. How often do you treat patients similar to the one described in the case?
- 3. Given the case summary, was the patient an ideal candidate for the gastric sleeve procedure?
- 4. Could the patient have received a more optimal procedure? Please explain.
Expert Witness Response E-001161
I am a fellowship-trained bariatric surgeon and an assistant professor of surgery at a major northeast university medical institution. I routinely take care of similar patients and I have not had a patient develop these types of complications. Patients who have failed a prior Nissen fundoplication usually have severe reflux as a result of the original pathology, and of the operation itself. Therefore, in revising a failed Nissen to a bariatric procedure, technical, anatomical, and patient-related issues need to be considered. I have revised Nissens, and I have performed revision bariatric surgery. However, I never revise a Nissen to a sleeve, due to the issues stated above. The patient should have undergone a Roux en Y gastric bypass, which may have been a simpler operation due to less scarring from the prior Nissen.