The proper post-operative procedure for a gastric lap band surgery involves performing a leak test. A leak test is a standard, inexpensive, readily available diagnostic step performed specifically to confirm that no perforation or leak is present before a patient leaves the facility after upper gastrointestinal surgery.
The perforation of the stomach or intestines is a surgical emergency that requires immediate intervention. A leak test is an imperative step in the post-operative care of a patient because if digestive fluids and bacteria leak into the abdominal cavity and are left there, severe complications including sepsis, abscesses, and internal bleeding can occur.
Surgeons have an obligation to their patients to perform all standard tests to ensure safety and prevent life-threatening complications. In this case, our client’s surgeon did not follow the standard of care necessary for her post-op recovery, which ultimately led to life-changing injuries.
The Townsley Law Firm fought for her and secured over $3,000,000 in a settlement.
What Happened: A Perforation That Was Never Checked For, Never Found, and Never Treated Until It Was Almost Too Late
The Lap Band Removal and the Surgical Injury
Our client underwent the surgical removal of a gastric lap band, a device that had been placed around the upper portion of the stomach as part of a bariatric weight loss procedure. Lap band removal is a surgical procedure that involves dissecting and freeing the band from the tissue that has grown around it over time, then removing it without damaging the underlying stomach or adjacent structures.
During this procedure, our client’s surgeon caused a perforation to her stomach and her intestines. A perforation is a hole or tear in the wall of a hollow organ, in this case the gastrointestinal tract, through which the contents of that organ can leak into the surrounding body cavity.
Perforations of the stomach and intestines during upper gastrointestinal surgery are a recognized potential complication of these procedures. The failure to identify a perforation before it causes serious harm and the failure to use the diagnostic tools that exist specifically to identify perforations before a patient is discharged is considered medical negligence.
In this case, our client’s surgeon should have performed a leak test. Instead, this tool was not utilized, and our client was sent home with digestive fluids and bacteria flowing freely in her abdominal cavity.
The Leak Test That Was Never Performed
A leak test is a standard diagnostic procedure performed after upper gastrointestinal surgery to confirm that no perforation or anastomotic leak is present in the stomach or intestinal structures. The test involves introducing a contrast agent or air into the gastrointestinal tract under controlled conditions and observing whether it remains contained within the tract or escapes through a defect.
In bariatric and upper gastrointestinal surgery, leak testing before discharge is not optional. It is the safety checkpoint that exists because surgeons and surgical teams know that perforations and leaks can occur during these procedures, that they may not be apparent during the operation itself, and that sending a patient home with an undetected perforation exposes that patient to life-threatening risks.
Sent Home With a Perforated Stomach and Told the Pain Was Normal
After being discharged, our client’s condition deteriorated. The perforation in her stomach and intestines allowed gastrointestinal contents, including digestive fluids, bacteria, and partially digested material, to leak into her abdominal cavity. Peritonitis, a systemic infection that follows untreated gastrointestinal perforation, was developing.
She sought guidance from her care team. She was prescribed anti-inflammatory medication. She was told that the pain she was experiencing was normal.
This pain was not normal. Our client was experiencing the pain of an abdominal cavity contaminated by the contents of a perforated gastrointestinal tract. Anti-inflammatory medication does not treat peritonitis, seal a perforation, or stop the spread of bacteria through the abdominal cavity. Prescribing it and sending this patient home with reassurance was not the standard of care.
The Emergency Room, the Collapsed Blood Pressure, and the Fight to Survive
Our client’s husband brought her to the emergency room. By that point, her body’s response to the spreading infection had pushed her into cardiovascular collapse. Her blood pressure had plummeted to a level incompatible with adequate organ perfusion. She required vasopressors, medications that constrict blood vessels and force blood pressure upward, to maintain circulation to her vital organs.
She became septic, and the emergency and intensive care teams that received her fought to keep her alive. Despite their success, the physiological cascade that had been set in motion by an untreated gastrointestinal perforation over the preceding days had already inflicted damage throughout her body that could not be reversed.
The Complications: What Septic Shock Did to Her Body
Septic Shock
Septic shock is the most severe form of sepsis, the systemic inflammatory response to infection. In septic shock, the infection triggers a dysregulated immune response so extreme that it damages the body’s own organs and vascular system. Blood pressure drops, blood flow to vital organs becomes inadequate, and without aggressive intervention, multi-organ failure and death follow rapidly.
The source of our client’s septic shock was the bacterial contamination of her abdominal cavity from the untreated gastrointestinal perforation. Every day that passed between her discharge and her emergency room admission was a day during which bacteria spread further, the infection deepened, and the physiological damage accumulated.
Disseminated Intravascular Coagulation
Disseminated intravascular coagulation, known as DIC, is one of the most severe complications of septic shock. It is a condition in which the body’s clotting system is activated throughout the entire circulatory system simultaneously, consuming clotting factors faster than they can be replaced. Blood clots form in small vessels throughout the body, blocking circulation to tissues and organs, while at the same time the consumption of clotting factors leaves the patient unable to form the normal clots needed to stop bleeding.
DIC is both a clotting disorder and a bleeding disorder occurring at the same time. It is a life-threatening emergency that requires intensive management and that causes direct, irreversible damage to the tissues and organs whose blood supply is disrupted by the microthrombi that form throughout the vasculature.
In our client’s case, DIC contributed directly to the ischemic damage that led to her amputations and permanent disabilities.
Ischemia and the Amputation of All Ten Toes
Ischemia is the deprivation of blood flow to tissue. When tissue is deprived of oxygenated blood for long enough, it dies. In the setting of septic shock and DIC, ischemia can develop in the extremities as circulation is redirected to vital organs and as microvascular clots block blood flow to the fingers and toes.
Our client developed ischemia in her extremities severe enough to cause irreversible tissue death in all ten of her toes, requiring amputation. The tissue damage in her fingers was severe enough to cause permanent contracture, meaning her fingers are permanently curled and cannot be straightened, a lasting physical reminder of the systemic damage that spread through her body during the days her perforation went untreated.
The Pacemaker and the Tracheotomy
The cardiovascular strain of septic shock and the physiological insult of the critical illness that followed created cardiac consequences that required permanent intervention. Our client required the implantation of a pacemaker, a device that regulates the heart’s electrical activity, to manage the cardiac arrhythmia or conduction abnormality that developed as a result of her illness.
She also required a tracheotomy, a surgical procedure in which an opening is created in the throat to allow placement of a breathing tube. Tracheotomies are performed in critically ill patients who require prolonged mechanical ventilation or who have airway compromise. The need for a tracheotomy reflects the severity of her respiratory compromise during the acute phase of her illness and the length of time for which mechanical ventilatory support was required.
These interventions are lasting, life-altering consequences of an untreated perforation that a leak test could have identified before she ever left the surgical facility.
What Is the Standard of Care for Leak Testing After Upper Gastrointestinal Surgery?
The standard of care for surgeons performing upper gastrointestinal procedures, including gastric band removal, gastric sleeve surgery, gastric bypass, and other bariatric and esophagogastric procedures, includes assessment for perforation or anastomotic leak before the patient is discharged from the facility.
This standard exists because perforations and leaks in the upper gastrointestinal tract are a recognized and serious complication of these procedures that may not be clinically apparent during the operation itself. A perforation that is not visually obvious at the time of surgery may nevertheless allow gastrointestinal contents to leak into the abdominal cavity after closure. A leak test identifies this before it becomes a life-threatening crisis.
The test itself is simple and adds minimal time to the post-operative process. The consequences of not performing it, as this case demonstrates, can include septic shock, multi-organ involvement, permanent disability, and devastating injury that reshapes a patient’s entire life.
Failing to perform a leak test following a procedure in which the stomach and intestines were manipulated, particularly when a perforation occurred during that procedure, is a departure from the standard of care. It is the type of omission that, when it results in the patient’s harm, forms a central element of a surgical malpractice claim.
Dismissing Post-Operative Pain as Normal When It Is Not
One of the most damaging failures in this case occurred after the patient was discharged. When our client reported worsening pain to her care team, she was told the pain was normal and given anti-inflammatory medication.
In post-operative surgical care, worsening pain is never assumed to be normal without an adequate clinical assessment to support that conclusion. Pain that is increasing rather than decreasing in the days following surgery, particularly upper abdominal or gastrointestinal surgery, is a recognized warning sign of a developing surgical complication. The differential diagnosis for worsening post-operative abdominal pain includes anastomotic leak, bowel perforation, peritonitis, abscess formation, and other serious conditions requiring urgent evaluation.
The standard of care requires that a patient who contacts her care team with worsening pain following upper gastrointestinal surgery be evaluated for these possibilities, not reassured and prescribed medication that has no therapeutic relevance to the actual cause of her symptoms.
Telling a patient that worsening post-surgical pain is normal, when that patient has an undetected gastrointestinal perforation, is clinically incorrect. It is a departure from the standard of care that delayed the recognition of a life-threatening emergency.
What Is a Gastric Lap Band and What Does Its Removal Involve?
A gastric lap band is an adjustable silicone band placed around the upper portion of the stomach during bariatric surgery to restrict the amount of food the stomach can hold, thereby limiting intake and promoting weight loss. It is placed laparoscopically and can be adjusted over time by adding or removing saline from a port located under the skin.
Lap band removal is performed when the band needs to be taken out due to complications including band slippage, erosion, infection, or a patient’s decision to pursue a different treatment approach. The removal procedure requires the surgeon to dissect the scar tissue and fibrosis that forms around the band over time and carefully separate it from the stomach and surrounding structures. The stomach and the gastroesophageal junction in this area can be vulnerable to injury during dissection, particularly if the band has been in place for many years or if significant tissue adhesion has occurred.
Because of this risk, the standard of care following lap band removal and other upper gastrointestinal procedures includes intraoperative assessment for injury and, before discharge, a leak test to confirm that the gastrointestinal tract is intact.
