This case involves a severely obese male weighing over 400 pounds with a past medical history of HTN, CAD, and Diabetes who was admitted to hospital for elective sleeve gastrectomy. After being discharged to his home the patient immediately complained of nausea and diarrhea. He proceeded to call the surgeon who advised him to take antibiotics. The intra-operative notes do not indicate that a running of the bowel was performed. The intra-operative notes further indicate a laceration of the liver from the retractor. Radiographic testing revealed dilation of the small bowel with evidence of a small bowel obstruction and possible small bowel ischemia. The patient went into renal failure and was diagnosed with a severe C-difficile infection. The surgeon performed an exploratory laporotomy for resection of the bowel. The surgeon identified bowel necrosis, fibrinous exudate on much of the bowel and identified a perforation. The patient died due to complications of C-Diff and malnutrition due to resection of a significant amount of bowel.
Question(s) For Expert Witness
1. Is the failure to run the bowel a departure from good and accepted medical practice following elective sleeve gastrectomy?
2. Was this patient a viable candidate for elective sleeve gastrectomy?
Expert Witness Response E-004817
If the surgical note indicates that there was a laceration during the procedure and some bleeding was noticed to be coming from an unidentified source, then it would indeed be a failure not to run the bowel to identify and stop the bleed. Contraindications to bariatric surgery include illnesses that greatly reduce life expectancy and are unlikely to be improved with weight reduction, including advanced cancer and end-stage renal, hepatic, and cardiopulmonary disease. This patient was severely obese and seemed to have multiple comorbidities but I do believe that the benefits of proceeding with this surgery far outweighed the risks.
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