A Melbourne widow who died after her stomach was perforated by a gastric balloon should never have been fitted with the device, particularly because of her age and obesity, a coroner has found.
Retired accountant Thelma Holt, 79, had a long history of morbid obesity and weight-related struggles until she died in March 2009 after emergency surgery at the Epworth Hospital.
Mrs Holt had tried extreme low-calorie diets, exercise programs, weight-loss medication and had been referred to a respiratory doctor and gastroenterologists, the Coroners Court was told this week.
In 2004, Mrs Holt was referred to a new gastroenterologist, Michael Merrett. While using a modified diet and medicine, she lost 10 kilograms in three years, but remained obese.
In 2007, Dr Merrett placed a gastric balloon in Mrs Holt's stomach. At the time, he was the only gastroenterologist who was using the balloons for obesity treatment.
Once inserted into the stomach, a gastric balloon is inflated with saline to reduce the stomach's capacity.
Within five months, Mrs Holt lost 22kg but by August, she needed surgery to have a hernia removed. Her gastric balloon was removed but Mrs Holt's recovery was slow. In March 2008, a surgeon noted that she had a recurrent hernia and that he could not operate again until she lost between 10 and 20 kilograms.
The surgeon recommended Mrs Holt use an abdominal binder to alleviate her discomfort. She said she would "rather be dead than wear an abdominal binder forever" and was determined to have a second gastric balloon to lose weight because of how much weight she had lost the first time.
In September, Dr Merrett gave Mrs Holt a second gastric balloon.
On January 30, 2009, Mrs Holt was taken to the Epworth's emergency department with a "significant small bowel obstruction", and doctors planned to keep her at the Epworth for the weekend and have the balloon deflated on the Monday at the Frankston Private Hospital.
But, coroner Jane Hendtlass said in her finding, Mrs Holt's condition worsened and she was diagnosed with a stomach perforation. Her condition continued to deteriorate after a bowel reconstruction on February 10 and on February 25, she had a stroke. She died on March 14 of pneumonia caused by her perforated stomach.
Although in the months after the balloon was inserted Dr Merrett said Mrs Holt felt "much improved", a second gastroenterologist who Mrs Holt consulted said she had become unwell, including slight anaemia and a urinary tract infection. A third doctor noted Mrs Holt's ongoing belching and halitosis. Mrs Holt also had problems with constipation and vomiting.
Between the second balloon being inserted and her return to hospital in January 2009, Mrs Holt was nauseous and constipated and had chest and urinary infections, low blood pressure and severe abdominal pain.
When she arrived at hospital, an X-ray revealed Mrs Holt's gastric balloon was blocking her pylorus – a region of the stomach which connects to the small intestine.
Peter Prichard, the experienced gastroenterologist at the Epworth who cared for Mrs Holt, had never seen a gastric balloon before and the hospital did not have the equipment to remove it without surgery. He spoke with Dr Merrett, who was doubtful that the balloon would cause "significant obstruction", Dr Hendtlass said.
The coroner explained that one of the most important features of the gastric balloon was how its volume places pressure on the stomach walls to make the patient feel as though they have eaten sufficiently. The pressure also changes levels of the hormone ghrelin, which reduces the drive and desire to eat.
The state government's guidelines for bariatric surgery prioritise patients aged between 18 and 65. The federal government in 2008 refused to provide Medicare cover for the cost of gastric balloon treatment because of its additional risks and the lack of clinical benefits when compared to other treatments for morbid obesity.
Mrs Holt was in a group of people for whom gastric balloons were not recommended, Dr Hendtlass said, because of her age, her obesity, her hernia and a 1995 operation to treat reflux, which reduced her stomach capacity.
The coroner ruled that the 2004 advice to Mrs Holt to continue with an alternative diet and medication was appropriate.
She said Dr Merrett had not properly explained to Mrs Holt the risks of gastric perforation because of the balloon. She also said it appeared he was acting in isolation from his peers in using the procedure.
Among Dr Hendtlass' recommendations were that patients who want a gastric balloon procedure be carefully screened and rejected if they do not meet the profession's guidelines for suitable patients.
She also recommended that gastroenterologists who do fit patients with gastric balloons monitor patients for abdominal hernia while the balloon is in place.