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December 2020: Physicians Quarterly Newsletter

Signs and Symptoms: The Importance of Pre- and Post-Op Discussions

Stan Strasner, CWCP
Senior Claims Consultant

This month’s newsletter discusses the importance of both preoperative discussions and postoperative monitoring in conjunction with weight loss surgery.

The claim involves a female patient who underwent a gastric bypass procedure. She had a BMI of 31 and passed the preoperative screening conducted by the operating physician. The procedure itself was performed without any complications.

The patient began to vomit shortly after the procedure and had a decreased fluid intake. Over the next year, the patient continued to complain to the doctor about the inability to eat or drink much, the feeling of having food come up the esophagus after meals, severe acid reflux and extreme fatigue. Her surgeon continued to advise her that such symptoms were normal side effects from this particular type of surgery.

As time went on, the patient suffered from bladder infections and dehydration. She saw her PCP, who referred her to a gastroenterologist. The gastroenterologist diagnosed the patient with a twisted stomach and corrective surgery was done.

The medical record shows that no diagnostic testing was done by the physician that performed the original surgery. In addition, no referrals were made to evaluate the patient’s complaints.

The resulting PCF complaint focused on the failure to monitor the patient post-op, failure to properly manage the patient’s care post-op and failure to make proper referrals in response to the patient’s complaints. The complaint also stated the twisting of the stomach occurred while the patient was under the care of the physician that performed the surgery.

An unfavorable panel opinion was rendered and a sizable settlement was subsequently paid. The panel ruled:

“Persistent complaints of reflux and dysphasia warrant investigation. Failure to perform an esophagram or endoscopy to investigate the patient’s persistent symptoms of reflux and dysphasia is a deviation from the standard of care.”

The panel did not comment on additional allegations that the surgeon fell below the appropriate standard of care preoperatively by not referring the patient –or at least advising of the option– to seek psychological or mental counseling before surgery. Therefore, the complaint alleged that the surgeon had not obtained proper “informed consent” for this specialized weight loss surgery. Many surgeons who perform this type of procedure mandate such counseling before they will agree to move forward with the surgery.

Caroline Stegeman, RN, BSN, MJ, ONC, CPHRM, CPSO
Director of Patient Safety

Weight loss or bariatric surgery has become more commonplace today. As with all medical procedures, postoperative complications can sometimes occur.

Signs of postoperative complications can present in both the early and late postoperative phase, so it is imperative to continuously assess patients for potential complications. Acute care surgeons, hospital patient care staff and physician office staff need to be very familiar with the signs and symptoms of potential complications due to bariatric procedures. All facilities are encouraged to have a process in place that allows staff to communicate these signs and symptoms so that postoperative issues can be addressed promptly.

A patient’s normal anatomy is permanently altered during a bariatric procedure. This can lead to complications at any time in the patient’s life post-surgery. Early-onset complications from bariatric procedures include leaks, stenosis, twists or kinks, bleeding, venous thromboembolism and balloon complications.

Healthcare providers caring for postoperative bariatric patients should have designated training on the signs and symptoms of potential complications. Staff members should also understand the necessary urgency to contact the physician promptly when the signs of complications arise.

Most patients who undergo bariatric surgery will not be familiar with the anatomical changes that occurred during the procedure. It is important to educate bariatric patients about:

  • Potential complications that can occur with the planned/performed procedure.
  • Signs and symptoms of these complications.
  • When to contact the physician if symptoms do occur.

Patient education should take place during both the preoperative and postoperative phases and can be accomplished through active teaching and learning techniques such as:

  • In-depth conversation between the patient and the surgeon
  • Educational handouts and DVDs that the patient can take home to review and share with family/friends
  • Online resources
  • Support groups

Undergoing bariatric surgery is a permanent lifestyle change that can create complications long after the surgery is performed. Bariatric patients must receive and understand specific instructions about who to contact and when if they experience any symptoms indicating a possible complication. Physicians and staff members should continue to make sure patients are aware of what to look for in the event of a complication during the postoperative period and follow-up appointments.

If you have any questions related to this newsletter, please contact:

Mike Walsh, AIC, CPCU
Liability Claims Manager
Stacie Jenkins, RN, MSN, CPSO
Vice President, Patient Safety and Risk
Kathy Terry
Vice President, Business Development