title: Delayed diagnosis of Wernicke encephalopathy with irreversible neural damage after subtotal gastrectomy for gastric cancer: A case of medical liability?
abstract: BACKGROUND
  Wernicke's encephalopathy (WE) is a neurological syndrome caused by thiamine deficiency, and clinically characterized by ophthalmoplegia, ataxia and acute confusion. In developed countries, most cases of WE have been seen in alcohol misusers. Other reported causes are gastrointestinal tract surgery, hyperemesis gravidarum, chronic malnutrition, prolonged total parenteral nutrition without thiamine supplementation, and increased nutrient requirements as in trauma or septic shock. WE is a well-known postoperative complication of gastric restrictive surgery for morbid obesity, after which patients often experience protracted nausea and vomiting, leading to malnutrition and massive weight loss.
  
  
  METHODS
  This case report concerns WE occurring in a patient who underwent Roux-en-Y subtotal gastrectomy for gastric cancer, and subsequently experienced neurological symptoms that proved irreversible probably due to the lengthy time elapsing between their clinical presentation and the diagnosis of WE.
  
  
  CONCLUSIONS
  There have been some reports of WE occurring after total or subtotal gastrectomy for gastric cancer in non-obese patients with no history of alcoholism, but monitoring for WE has yet to be recommended in the clinical guidelines in this setting (as it has for bariatric surgery). Because of its rarity and variable clinical presentation, WE is often under-diagnosed and under-treated, and confused with other neurological problems.
  
  
  CONCLUSIONS
  There is an urgent need for the specific guidelines to take into account not only the neoplastic follow-up of such patients, but also the possible side effects of necessary surgery, since this could help to ensure the timely diagnosis and management of WE in this setting, and to avoid, when possible, claims for medical malpractice that may cause enormous costs both in economical and professional terms.
authors.affiliation: Department of Molecular Medicine, University of Padova, via Falloppio 50, 35121 Padova, Italy.
authors.forename: Pamela
authors.initials: P
authors.lastname: Tozzo
authors.affiliation: Department of Molecular Medicine, University of Padova, via Falloppio 50, 35121 Padova, Italy.
authors.forename: Luciana
authors.initials: L
authors.lastname: Caenazzo
authors.affiliation: Department of Molecular Medicine, University of Padova, via Falloppio 50, 35121 Padova, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Rodriguez
authors.affiliation: Legal Medicine, University of Padova, via Falloppio 50, 35121 Padova, Italy. Electronic address: matteobolcato@gmail.com.
authors.forename: Matteo
authors.initials: M
authors.lastname: Bolcato
keywords: Case report; Diagnostic delay; Medical liability; Oncological gastric surgery; Wernicke’s encephalopathy