A 57-year-old woman, who had undergone Roux-en-Y gastric bypass surgery 9 years earlier, was admitted to the intensive care unit because of pneumonia. Despite antibiotic therapy, she died 40 days later, apparently because of sepsis and organ failure related to the pneumonia. However, the patient's family requested an autopsy, which revealed that her death was due to perforation of the Roux limb of her gastric bypass, which had resulted in severe peritonitis. The perforation was caused by a nasogastric tube inserted for enteral nutrition. We discuss ways nasogastric tubes might be inserted more safely after gastric bypass, the response of Baylor University Medical Center at Dallas to this complication, and the role of autopsy in improving the quality of hospital care.
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