Malpractice defense: Midgut Volvulus Following Gastric Bypass and Ventral Hernia Repairs

In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies (APS), a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety.To learn more contact: Timothy Croke, Director of Demonstrative Evidence Group. tcroke@aps-web.com or 617-357-0553 ext. 6664.Here’s the Advanced Practice Strategies case of the month.Judgment for the DefenseMidgut Volvulus Following Gastric Bypassand Ventral Hernia RepairsThe plaintiff underwent an uncomplicated gastric bypass procedure in 1999, followed by a successful ventral hernia repair in early 2001. Subsequently, in December 2001, she had an elective procedure by a general surgeon, in collaboration with a plastic surgeon, solely to repair abdominal wall laxity, with no bowel herniation present. The plaintiff tolerated the procedure well and was admitted post-operatively to the Plastic Surgery service. In the recovery room a few hours later, however, she complained of significant pain and nausea, which was brought under control with medication.The next day, the plaintiff’s pain returned, and an initial upright x-ray film revealed apparent enlargement of the colon. A complete series of abdominal x-rays confirmed the initial finding of colonic enlargement and raised the possibility of Ogilvie Syndrome (acute pseudo-obstruction and dilation of the colon in the absence of any mechanical obstruction).A barium enema demonstrated no distal obstruction of the colon but indicated distention in the ascending and transverse colon. At that point, the plaintiff was transferred to the General Surgery service for further evaluation of her abdominal distention, low blood pressure, and urine output. GI and renal consults were obtained, and a CT scan showed an enlarged colon with no obstruction, consistent with the Ogilvie Syndrome diagnosis.An x-ray taken three days following the plaintiff’s surgery showed colonic distention with increased enlargement to the small bowel, which was interpreted as progression of the Ogilvie Syndrome. The plaintiff was transferred to the Surgical Intensive Care Unit, where a colonoscopy showed dilation of the ascending and transverse colon but a normal distal colon to the cecum. The surgical team placed a rectal tube to facilitate bowel decompression but a follow-up abdominal x-ray several hours later revealed marked dilation of the transverse colon that terminated near the splenic flexure. At that time, surgery was recommended to identify the reason for continued enlargement of the colon. During the procedure a large midgut volvulus with three rotations of the small bowel and colon was discovered. Following extensive surgery to remove the nonviable intestine, the plaintiff experienced further complications; her condition eventually deteriorated to the point that the family decided to remove life support, and the patient died.PLAINTIFF'S CLAIM:Attorneys for the plaintiff claimed that the midgut volvulus should have been discovered during the procedure to repair her abdominal wall laxity. Furthermore, they argued, the actual cause of the plaintiff’s colonic distention following the initial surgery should have been recognized and addressed sooner in the post-operative course, before irreversible damage to the small bowel and colon had occurred. Finally, given the plaintiff’s prior gastric bypass surgery, the plaintiff’s attorneys contended that the clinicians should have suspected something more serious was behind the colon dilation and been more aggressive in her care.DEFENSE'S ARGUMENT:The defense raised the counterargument that the procedure to repair the plaintiff’s abdominal wall laxity did not require the surgeons to enter the peritoneal cavity, where the intestines would have been exposed, allowing a diagnosis of any problems with the colon or small bowel. Moreover, the operation did not involve the intestines, making it highly unlikely it would itself cause a volvulus; the diagnosis of this rare condition was thus even more challenging. The defense contended that the plaintiff was followed closely during her postoperative course, with constant monitoring of her vital signs and laboratory studies for signs of serious infection. In additional, the plaintiff’s care was consistent and vigilant: more than nine physicians from multiple disciplines were involved in the effort to diagnose and treat her colonic dilation.___________________________________________________________________VISUAL STRATEGY:Collaborating with experts and with the defense attorneys, APS created visual aids to help illustrate the defendants’ positions.The first board explained the normal digestive system.A second board explained the changes in the plaintiff’s anatomy resulting from the gastric bypass procedure done prior to the abdominal wall repair surgery.The defense attorneys for the surgeons who repaired the plaintiff’s abdominal wall laxity wanted the jury to be clear about the difference between the anterior abdominal wall and the peritoneal cavity (the location of the small bowel and the colon). We created a board illustrating the sagittal and anterior view of the abdomen to show clearly these two distinct areas of the body.The next series of diagrams showed the procedure performed to repair the plaintiff’s abdominal wall laxity.* Step one: exposure of the abdominal wall muscles.* Step two: midline division of the abdominal muscles and the exposure of the peritoneum.* Step three: release of the external oblique muscles and the midline suture repair of the fascia.* Step four: placement of the SIS patch over the abdominal muscles to help reinforce the anterior abdominal wall.Finally, we created a diagram showing the extent of the plaintiff’s midgut volvulus.This series of illustrations helped the defense to convey successfully to the jury the following key points:* The surgeons who performed the procedure to repair the plaintiff’s anterior wall laxity did not enter the peritoneal cavity and so never viewed or came in contact with her intestines.* A midgut volvulus is an extremely rare condition, and its diagnosis is especially unlikely following a procedure that did not directly involve the colon or small bowel.RESULT:The jury found in favor of the defense for all of the defendants named in the case."Thank you for your help—we got defense verdicts for everyone yesterday afternoon.”—Attorney, Alan Rindler, Rindler & Morgan, Boston, MA“In almost every case we try, communicating with jurors and allowing our physician clients to fully educate jurors is greatly enhanced by our partnering with APS. The illustrations are always clear and helpful, but more importantly, accurate and whenever practicable, specific to the case. APS works closely not only with the attorneys, but also the experts and physician clients to make sure that everyone is in agreement regarding the accuracy and relevance of the illustrations.”—Attorney, George Wakeman, Adler, Cohen, Harvey, Wakeman and Guekguezian LLP, Boston, MA