CMPA Warns Canadian Surgeons About Risks of Bariatric Surgery

Regular readers will note that I fully support the use of bariatric surgery as a treatment for patients presenting with severe obesity, especially when these patients present with obesity related complications (EOSS Stage 2 and higher).

However, as regular readers will also note, I am the first to remind clinicians (and my patients) that surgery is surgery and that even in the best hands, serious life-threatening complications can occur.

In a recent issue of its journal, the Canadian Medical Protective Association (CMPA), which provides mandatory medical liability protection to the majority of Canadian physicians, warns that surgeons and physicians involved in caring for bariatric surgical patients should be fully aware of the medico-legal issues regarding bariatric care.

As the authors of the article note:

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.”

The article lists in detail the problems that were identified by the experts reviewing these cases:

Pre-Surgical Issues:

– 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.

Intra-Surgical Issues:

– 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.

Post-Operative Issues:

– 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 postoperative 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.

While 27 cases may not sound a lot given the thousands of bariatric operations performed during this time period, they should serve as a reminder to both clinicians and patients that surgery is surgery and that complications happen.

Indeed, these may happen even when no ‘mistakes’ are made. Thus, in a case study presented in the article, 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. For the patient this of course means no compensation from the surgeon or from anyone else.

Because of these inherent risks, even rare as they may seem, any attempts to trivialize the risks of even the simplest forms of bariatric surgery (e.g. adjustable gastric banding) and any practices that seek to push surgery onto patients who have no immediate or urgent medical need for such surgery can only be deemed questionable practice.

Edmonton, Alberta

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