This case takes place in Louisiana and involves a middle aged patient with a past medical history of morbid obesity. The patient had undergone a vertical banded gastroplasty before, but failed to lose weight following the procedure. He was also suffering from severe acid reflux and was taking Nexium regularly. As a result, he sought revision surgery several years after the initial procedure. The patient underwent laparoscopic revision of open vertical banded gastroplasty, laparoscopic Roux-en-Y gastric bypass and partial gastrectomy and hiatal hernia repair. The surgery was complicated by subcutaneous emphysema (SE). The patient was intubated for airway protection and sedated. The patient subsequently developed extensive bilateral pulmonary emboli and was started on anticoagulant therapy with a combination of anticoagulants.
Following the initial procedure, she was extremely short of breath and her functional status was limited. The patient recovered and was discharged on Coumadin and Lovenox. The patient returned to the hospital shortly after discharge with severe shortness of breath. Investigations revealed the patient had suffered a large GI bleed due to a large gastric intramural hematoma and was suffering from acute blood anemia as a result of the bleed. The patient’s anticoagulants were discontinued and she received blood products to reverse the anemia. She made a good recovery and was discharged again. The patient presented to the ER one week following discharge with hypotension, weakness, nausea and vomiting. She underwent thrombectomy but developed respiratory failure during the procedure. Post-operatively, the patient became acidotic, hypotensive and suffered a cardiac arrest, She was also found to be in acute renal failure. The patient’s condition continued to decline and she became comatose. The decision was made to stop life support and the patient was not resuscitated when she coded again.
Question(s) For Expert Witness
- 1. Do you treat bariatric patients? If so, how often?
- 2. Could you review the medical records for this patient and opine as to whether the treatment he received was within the standard of care?
Expert Witness Response E-001161
I am a fellowship trained bariatric surgeon, and I currently work at one of the top medical institutions in the country. Over half of my practice is bariatric surgery. In reviewing the brief description, there may have been a few points of care where the standard of care was not fully met. The timing and dose of anticoagulation is important to prevent DVT/PE. Once diagnosed, the appropriate treatment of DVT requires a balance of anticoagulation, and preventative therapies such as an IVC filter to be placed before a PE occurs.