54 y.o. man dies of hemorrhagic shock after laparoscopic Roux-en-Y gastric bypass

A patient who presented with hypotension and tachycardia needed urgent intervention with either the endoscopy or surgery, but the details matter in terms of how the patient responded to initial resuscitation and whether they continued to show signs of bleeding or sepsis. A review of the records can look at these nuances and make a better guess if the delay was outside the standards of care. Marginal ulcer perforations and bleeding are not common but are serious known complications of RYGB.

If there is delay in intervention, this could have contributed to the eventual poor outcome and death.

He should have had immediate investigation rather than plan for studies in wks as prescribed. He had a major operation and one must assume that the bleeding and subsequent death were related to the surgery

Same as above Had he been studied or perhaps explored, he likely would not have bled as he did

The CT report with patient’s clinical findings warranted surgery. A suspected ulcer with perforation and a dropping hemoglobin needs surgical intervention. The continued drop in hemoglobin demonstrates persist bleeding that was not amenable to an EGD or angiogram.

The patient died from hemorrhagic shock that was diagnosed in 4/11. The CT was very detailed in the findings. The surgeon should have aggressively obtained the outside images OR repeat the study. The CT findings are very worsening. At minimum a diagnostic laparoscopy should have been completed with a high likelihood of an open procedure for revision of the anastomosis. Ulcer formation with or without bleeding and/or perforation are well documented. The management of the case did not meet the standard of care and was negligent with a tragic outcome that could have been prevented.

The medical error I see here is in the first hospitalization. If a patient had a massive GI bleed, they had an indication for an EGD - this should not have been to follow up as an outpatient. The patient should have had a scope in the first admission, or if not, a bleeding scan or some other sort of test to see what was going on. If those things were not possible, surgery would be an option and should have been performed before the patient's hospitalization ended. He, very predictably, bled again, because the original issue was not managed properly in the first hospitalization. The second hospitalization seems like a reasonable course of action given the information that you had about the patient. There is not enough information to know if there is an error in the second hospitalization when the patient became obtunded and was put in hospice. However, all the work done in the second hospitalization should have been done at the first major GI bleed.

I don't think a medical error caused the problems. The patient's marginal ulcer is a known complication of the gastric bypass procedure. It's unknown if the patient was prescribed ulcer medication, if it was indicated, and if they were compliant with that medication, but it doesnt seem like there was a medical error with the gastric bypass. The medical error was one of omission - not scoping or fully adjudicating the reason for GI bleeding during the first April hospitalization.

Patients should have had the EGD sooner, since the gastric bypass surgery was over 3 months. Unclear based on the available history what happened when he was in the step down unit

Patient neurological deterioration " minimally responsive" was not followed up on

The records provided are somewhat incomplete but it is very concerning that the marginal ulcer with perforation vs ischemia was not more aggressively treated on 4/11. This should have been worked up further with testing/imaging or even laparoscopy to address those findings. It is noted that the images weren't viewable but this doesn't invalidate the radiology read. GI should have performed an EGD. If they weren't comfortable they should have transferred the patient to a facility with that expertise. Failing that the surgeon could have considered doing the EGD themselves or laparoscopy. We know there is a significant problem. The patient is bleeding, hypotensive and tachycardic. To ignore this is clear error--perhaps the records provided were incomplete and more workup was done I would have to review the entire record. Then 4/17 the patient returns with further bleeding, what workup was done? If none then again this is an error. The EGD on 4/18 is borderline too late as it is, to not go to the operating room until the next day is inexplicable (unless the EGD was done very late in the evening and the operation in the early post-midnight hours). Something serious further occurred 4/25 that is not present in the records provided, likely an additional error occurred here as well.

As stated above, there was delay in obtaining an appropriate diagnosis to justify the radiology reads from 4/11. Outpatient follow-up is not appropriate for those findings. Then there is delay on the readmission. There is this third nebulous period from 4/25 onward that likely contains another mal-event.

Because on 4/11/23 when the pt came in to the ED, He was hypotensive and tachycardic in the setting of a gastric bypass 4 months earlier. There is a definite inherent concern for a marginal ulcer here and yet surgery passed on the case deferring to GI who felt waiting was appropriate. Unclear why bariatric surgery did not do anything in this case either especially considering a CTA concerning for marginal ulceration with blood. An EGD by someone should have been done during that hospitalization.

The lack of earlier further evaluation in the OR or endoscopy suite did not cause the ulcer or bleeding from the ulcer. However, not investigating at an earlier time led to a delay in eventual needed treatment.

There is high concern for both the initial management of this patient upon admission and for failure to rescue after the return to the operating room on 04./19. The patient underwent a Roux En Y gastric bypass nearly 4 months prior to presentation and was in class 4 hemorrhagic shock on admission with a likely component of septic shock due to breakdown/compromise of the Roux en Y anastomosis. It is unclear to me why the patient did not go to the OR or undergo EGD until 1-2 days after admission; this is an emergent situation that requires expeditious care. The initial plan of care should have been to admit the patient to a surgical ICU setting, focus on resuscitation with blood products and come up with a definitive plan of care to address the bleeding/ischemic portion of the anastomosis once stabilized to limit further bleeding (usually an EGD is done first with bariatric surgery on standby for operative exploration or ideally, perform this in conjunction in the OR). This is usually done within hours of admission if the patient is in shock, not 1-2 days after admission. Additionally, the patient had sequelae of shock and multi system organ dysfunction following the take back to the OR. I would need to review the medical records closely, but I would need to know what the status of the patient was prior to moving out of the ICU to the step down unit and what the plan of care was for this patient. Additionally, on 04/25, the patient had an acute change in mental status following a surgical procedure. This is bleeding versus intra-abdominal sepsis until proven otherwise, and there are a multitude of otehr diagnoses that need to be ruled out following recent surgical intervention/in a post-operative patient.

From the perspective of the patient developing a marginal ulcer following Roux En Y, this is a very common complication associated with the procedure and patients often present to the ER several weeks to months after the surgery with a hemorrhage or bleeding between the layers of the bowel wall leading to ischemia and perforation. The multidisciplinary teams involved could have approached the patient's initial care plan better based on what I can see in the records provided above, but this complication was not due to surgical/technical error. However, it is possible that during the patient's takeback to the OR for reinforcement of the Roux En Y, there was a technical error that manifested post-operatively after the patient was downgraded from the ICU and this may have led to the patient's decompensation and demise. The most concerning thing for this case is the time during which the patient was downgraded from the ICU. I would need to review the chart in detail to ascertain what happened post-operatively in the ICU and what happened one the patient left the ICU as I have high concern for failure to rescue based on the acute decompensation and would need to review what the thought process was and what steps were taken following his development of AMS on 04/25.

The patient developed a marginal ulcer with bleeding and eventual perforation at the gastrojejunostomy four months after his initial roux-y gastric bypass. At his presentation on 4/11, neither GI nor surgery intervened and apparently the bleeding stopped spontaneously. It is unclear from the summary when the CT occurred, but it demonstrated findings consistent with ulcer with perforation. There was no intervention. However, the patient returned with bleeding 1 week later, at which time EGD demonstrated disruption of the anastomosis, and he proceeded to surgery. The error here was the delay in diagnosis of the bleeding and perforation. By the time the patient made it to laparotomy, a week or longer had progressed. This may have consumed his physiologic reserve as demonstrated by his ICU stay and prolonged time on the ventilator. I definitely need more information, however, particularly regarding the findings at operation, and the change in neurologic status.

Please see above -- delay in diagnosis, delay in getting patient to surgery, prolongation of hemorrhagic shock leading to depleted physiologic reserve.