Physician action

On December 12, General Surgeon A, with assistance from General Surgeon B, performed a Roux-en-Y gastric bypass and an umbilical hernia repair on a 65-year-old man.

The patient had a history of heart disease, gastroesophageal reflux disease, gout, hypertension, hyperthyroidism, obstructive sleep apnea, and class III obesity. The patient’s history also included myocardial infarction followed by a coronary artery bypass graft at the age of 38.

After three days of post-surgical observation in the hospital, General Surgeon B discharged the patient with pressure dressings for wound leakage and instructions for home care. Because the patient had difficulty passing gas and having bowel movements, simethicone, a sodium phosphate enema, and magnesium hydroxide were recommended.

After discharge, the patient continued to experience abdominal pain and remained unable to pass gas or stool. He also reported difficulty urinating.

On December 18, the patient returned to the hospital with reports of severe and constant abdominal pain (rated 10 out of 10), inability to urinate or defecate, swollen ankles, and a tender, distended abdomen. He was readmitted under the care of General Surgeon B.

Laboratory results were abnormal, including sodium of 131 mmol/L, potassium of 3.4 mmol/L, blood urea nitrogen (BUN) of 27 mg/dL, creatinine of 1.13 mg/dL, serum lipase of 1,155 U/L, and a white blood cell (WBC) count of 3.8 without bands or a left shift.

A CT scan showed a mechanical small bowel obstruction at the level of the supraumbilical hernia distal to the jejunojejunal anastomosis, associated with dilation of the alimentary limb and the excluded stomach/biliary pancreatic limb of the GI tract.

After consulting with General Surgeon A, General Surgeon B manually reduced the hernia at the bedside. The patient was kept overnight for observation. The following day, a hospitalist group admitted the patient for management of the enlarging hernia and bowel obstruction.

On December 20, a CT scan showed dilation of the bowel limbs and remnant stomach, with contrast passing through the herniated area. Hospitalist A documented an ileus and prescribed laxatives because the patient had not yet achieved a full return of bowel function. Labs were noted as normal.

The next day, Hospitalist A noted that the patient was improving, but required an additional 24 hours for the ileus to resolve. However, the nurses documented that the patient reported severe pain.

On December 22, the patient developed tachycardia. He reported pounding pain rated 8 out of 10 and had a WBC count of 13 with 24 bands; his BUN was 28 mg/dL. The nurses’ notes reported no suspected infection and that the patient was not passing gas.

Over the next three days, General Surgeon B documented slight daily improvement. The nurse practitioner, however, recorded that the patient was uncomfortable, unable to tolerate enemas beyond a certain point, and had absent bowel sounds in all four quadrants. The medical record also indicated systemic inflammatory response syndrome (SIRS) with possible infection. Although the notes stated that the patient was receiving antibiotics, none had been ordered or administered.

On December 25, General Surgeon B noted that the patient had improved from the day before but his abdomen remained distended and he was passing gas. Later, his laboratory results worsened, he became hypoxic, was struggling to breathe, and his abdominal distention increased. No CT scan was performed due to holiday-related staffing shortages. The nurses’ notes indicated the patient was positive for SIRS and infection was suspected.

On December 26, a CT scan showed complete breakdown of the jejunojejunal anastomosis of the Roux-en-Y. The patient was started on antibiotics. General Surgeon C, assisted by General Surgeon B, performed an exploratory laparotomy.

A procedure to resect some stomach and small bowel was aborted after the patient developed ST-segment changes on ECG. The patient was transferred to the ICU.

The next day, General Surgeon C, assisted by General Surgeon A and General Surgeon B, reopened the incision and completed an intra-abdominal washout, reconstruction of the gastrojejunostomy, and esophagogastrojejunostomy. The patient then returned to the ICU.

While in the ICU, the patient developed asystole overnight and required resuscitation. He was stabilized, but he coded again the following night. The family then withdrew supportive care, and the patient died.

Allegations

The patient’s family filed a lawsuit against General Surgeon A, General Surgeon B, and the hospital, alleging failure to timely assess and treat the ileus and subsequent anastomotic leak, resulting in the patient’s death.

Legal implications

Defense consultants generally supported the initial surgery and early postoperative care, noting that ileus is a rare complication after gastric bypass surgery. However, they criticized the delays in diagnosis and treatment after the patient’s readmission. Consultants stated that the CT findings and clinical signs—including free air eight days after surgery—warranted earlier surgical exploration.

One consultant criticized General Surgeon B for releasing the patient with a leaking abdominal wound without attempting to locate the source of the leakage. He also felt that an earlier diagnosis of the ileus may have saved the patient’s life.

Plaintiff’s experts also criticized the postoperative care, citing delayed intervention, especially when the patient was leaking fluid through the incision soon after surgery. They stated the physicians should have investigated whether the leak pointed to possible dehiscence of the previously repaired abdominal wall hernia.

They further identified inconsistencies in the medical record during Hospitalist A’s management, which they viewed as evidence that the nursing staff failed to report and document the patient’s symptoms.

Disposition

The case was settled on behalf of General Surgeon A, General Surgeon B, and the hospital.

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