Duties and responsibilities
Know the issues and risks of bariatric surgery
Originally published June 2012
About one-quarter of Canadian adults are obese1, putting them at risk for many serious health problems such as Type 2 diabetes, hypertension, and cardiovascular disease. Some morbidly obese Canadians, when unable to lose weight with dietary therapy and physical activity, turn to bariatric surgery — an operation that can provide significant benefits2.
Understanding the medico-legal risks of caring for patients having bariatric surgery in Canada allows surgeons, and other physicians involved in caring for these patients, to better manage those risks.
Between 2006 and 2011, the CMPA had 27 medico-legal cases relating to bariatric surgery, 21 of which were closed. A review of the closed cases showed the main allegations from patients were that consent discussions were lacking and histories were inadequate. Experts did not express concerns with the appropriateness of the surgery. The only CMPA members involved were general surgeons. The procedure performed most often was gastric banding, (i.e. vertical banding or adjustable gastric banding), followed by open or laparoscopic Roux-en-Y gastric bypass, and open biliopancreatic bypass (i.e. biliopancreatic diversion or duodenal switch). The patients' body mass indexes (BMI) ranged from 35 to 74, and many had co-morbid conditions such as Type 2 diabetes mellitus, hypertension, and sleep apnea.
It is not the role of the CMPA to recommend one type of bariatric surgery over another, nor to comment on the criteria used to select patients for the operation. All surgical approaches carry risk. In the CMPA cases that were reviewed, all three surgical approaches commonly used in Canada had significant complications. For the gastric banding procedures, complications included surgical site infection, gastric band leakage, and slippage or erosion with secondary peritonitis. Complications of Roux-en-Y gastric bypass included ventral incisional hernia, anastomotic leak, and death from septic shock. Complications following biliopancreatic bypass included gastrojejunal anastomotic stricture, and persistent diarrhea and nutritional deficiencies.
What are the issues with bariatric care?
In these CMPA cases, the practising surgeons who acted as peer experts for the defence identified issues with the clinical care during the pre-operative, intra-operative, and post-operative periods. In some cases, there was more than one issue.
- failure to evaluate the patient, discuss the risks including the alternatives to surgery, and document the consent discussion
- failure to rule out pregnancy
- failure to order prophylactic antibiotics
- not requesting the assistance of a second surgeon to help with a laparotomy for a complex patient with peritonitis
- internal injuries (e.g. to stomach and small bowel) sustained during a laparoscopic approach from manipulations of the organs; often these were diagnosed post-operatively when patients became symptomatic with nausea, vomiting, fever, or abdominal pain
- inadequate attempts to locate and repair the source of a gastric leak
- retention of a large malleable retractor, discovered 2 years after the operation; instrument counts were not done as per hospital policy
- failure to convert from a laparoscopic to an open procedure when experiencing significant difficulty identifying anatomical structures
- misconstruction of the small bowel limbs during Roux-en-Y gastric bypass
- delayed recognition of respiratory distress and the need for treatment
- premature hospital discharge of a patient with fever and erythema at the surgical incision site with delayed recognition of the underlying wound infection and dehiscence; the nursing care was also criticized for inadequate post-operative monitoring of vital signs and wound assessment
- lack of documentation of a patient's condition on discharge and inadequate discharge instructions given to the patient and family
- failure to investigate a patient's complaint of abdominal pain, nausea, and vomiting when readmitted a few days after surgery
- delay in diagnosing suture line dehiscence of a duodenal closure
- inadequate follow-up care, including inadequate assessment of the patient's nutritional status and need for nutritional supplements
Case example: Lack of attention to communication, documentation
This case illustrates why it is important to have an appropriate informed consent discussion, comprehensively document all care, and be attentive to communication issues with patients and families.
A 60-year-old man was referred to a general surgeon for morbid obesity (BMI 40) and co-morbidities of Type 2 diabetes, hypercholesterolemia, hypertension, and asthma. During the consent discussion, the surgeon gave a detailed description of two procedures, the laparoscopic Roux-en-Y gastric bypass and the laparoscopic gastric banding, as well as the risks and benefits of each. Based on the patient's choice, a laparoscopic adjustable gastric banding was performed and the patient was discharged from hospital the same day.
The following evening the patient arrived in an emergency department with abdominal pain and nausea. He was afebrile and tachycardic, and had a distended abdomen and a slightly elevated white blood cell count. A plain abdominal X-ray revealed mild gastric dilatation and the gastric band appeared to be in an appropriate location.
The patient's pain persisted overnight. Even though an abdominal CT scan was unremarkable, the consulting surgeon was concerned about peritonitis and took the patient back into the operating room. Peritonitis was confirmed and a small perforation of the small bowel was identified. The surgeon performed a bowel resection and removed the gastric band. The patient was admitted to the ICU and his post-operative recovery was complicated by a surgical site wound infection. The family perceived the surgeon's communications to be dismissive and unsympathetic to the patient's condition. The patient was discharged home several weeks later.
At the follow-up appointment, the patient asked the surgeon for monetary reimbursement of the cost of the gastric band. The surgeon told the patient he could not give a refund, but offered to arrange for another gastric bypass. The offer was declined. The patient and family complained to the regulatory authority (College) alleging the surgeon failed to obtain informed consent for the bariatric surgery, and was negligent in performing the procedure which led to the perforation of the small bowel. They also complained the surgeon was unprofessional in manner.
Based on the medical record, the College was satisfied pre-operative consent discussions took place. The College concluded the surgery was done in a standard and acceptable manner and that bowel perforation is a recognized complication of this type of surgery. Finally, the College stated that some of the surgeon's comments could be perceived as insensitive. In response, the surgeon said his comments were not meant to be unsympathetic or sarcastic, and he apologized. The College counselled the surgeon to be more sensitive in his communication with patients and families at all times.
Managing the risks of bariatric surgery
The following suggestions for managing the risks of bariatric surgery are based on the opinions of the surgical experts who examined the clinical care in the CMPA cases.
- The informed consent discussion should inform patients about the proposed surgical procedure, the anticipated outcome, significant risks and complications, and available alternatives. A note in the medical record made at the time of the consent discussion can later serve as important confirmation that a full discussion took place.
- Appropriate measures include identifying possible pregnancy in female patients, and considering the provision of prophylactic antibiotics and DVT prophylaxis.
- The necessary steps should be taken to correctly identify anatomical structures and lessen the possibility of injury. Physicians should consider converting from a laparoscopic to an open approach when uncertain of the anatomy or when experiencing difficulty.
- The patients should be provided with discharge instructions including signs and symptoms of potential complications and the importance of seeking additional care, with whom and when.
- Physicians should inform patients of arrangements for follow-up, including who will be providing the care. The discharge advice, general and customized, should be documented in the medical record with a reference to or copy of any associated handout material provided to the patient.
- Patients experiencing complications after surgery may seek help from their family physician or an emergency department, and investigations and referrals may be indicated. All physicians should be aware that it is often challenging to assess patients with complications from bariatric surgery as the symptoms can be non-specific and develop anywhere from a few hours to years after the surgery.
- Shields, M., Tremblay, M., Laviolette, M., Craig, C., Jansse, I., Connor, Gorber, S., "Fitness of Canadian adults: Results from the 2007-2009 Canadian Health Measures Survey," Health Reports [Internet] (March 2010) Vol. 21, no.1 p.1-15. Retrieved on March 2, 2012 from: http://www.statcan.gc.ca/pub/82-003-x/2010001/article/11064-eng.htm.
- Christou, N., Sampalis, J., Liberman, M., Look, D., Auger, S., McLean, A., MacLean, L., "Surgery decreases long-term mortality, morbidity, and health care use in morbid obese patients," Annals of Surgery [Internet] (September 2003) Vol. 240, no.3 p.416-424. Retrieved on March 2, 2012 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356432/