Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis

Management of Acute Mesenteric Venous Thrombosis: A Systematic Review of Contemporary Studies

Background and Aims:

Acute mesenteric venous thrombosis accounts for up to 20% of all patients with acute mesenteric ischemia in high-income countries. Acute mesenteric venous thrombosis is nowadays relatively more often diagnosed with intravenous contrast-enhanced computed tomography in the portal phase than at explorative laparotomy No high-quality comparative studies between anticoagulation alone, endovascular therapy, or surgery exists. The aim of the present systematic review was to offer a contemporary overview on management.

Materials and Methods:

Eleven relevant published original studies with series of at least ten patients were retrieved from a Pub Med search between 2015 and 2020 using the Medical Subject Heading term “mesenteric venous thrombosis.”

Results:

When MVT is diagnosed early, immediate anticoagulation with either unfractionated heparin or subcutaneous low-molecular-weight heparin should commence. Surgeons need to be aware of the importance to scrutinize the computed tomography images themselves for assessment of secondary intestinal abnormalities to mesenteric venous thrombosis and the risk of bowel resection and worse prognosis. Progression toward peritonitis is an indication for explorative laparotomy and assessment of bowel viability. Frank transmural small bowel necrosis should be resected and bowel anastomosis may be delayed for several days until second look. Meanwhile, intravenous full-dose unfractionated heparin should be given at the end of the first operation. Postoperative major intra-abdominal or gastrointestinal bleeding occurs rarely, but the heparin effect can instantaneously be reversed by protamine sulfate. Patients who do not improve during conservative therapy with anticoagulation alone but without developing peritonitis may be subjected to endovascular therapy in expert centers. When the patient’s intestinal function has recovered, with or without bowel resection, switch from parenteral unfractionated heparin or low-molecular-weight heparin therapy to oral anticoagulation can be performed. There is a trend that direct oral anticoagulants are increasingly used instead of vitamin K antagonists. Up to now, direct oral anticoagulants have been shown to be equally effective with the same rate of bleeding complications. Patients with no strong permanent trigger factor for mesenteric venous thrombosis such as intra-abdominal cancer should undergo blood screening for inherited and acquired thrombophilia.

Conclusion:

Early diagnosis with emergency computed tomography with intravenous contrast-enhancement and imaging in the portal phase and anticoagulation therapy is necessary to be able to have a succesful non-operative succesful course.

Mesenteric venous thrombosis

OBJECTIVE

This review explores the current literature on the natural history, diagnosis, and management of mesenteric venous thrombosis (MVT) in the modern era.

METHODS

A review of the contemporary literature from 1997 to 2016 on MVT and its pathogenesis, diagnosis, and treatment was performed.

RESULTS

MVT is an insidious and lethal disease associated with acute mesenteric ischemia. The prevalence of MVT has increased sharply during the past two decades commensurate with an increase in radiographic imaging for abdominal complaints. The optimal treatment of and approach to MVT is controversial, given the poorly understood natural history of this rare disease. Both endovascular and open surgical strategies in addition to systemic anticoagulation have been used as adjuncts to treat MVT with limited success. Despite advances in treatment, mortality associated with MVT is still high. Furthermore, recent studies have shown that failure to recanalize the portomesenteric venous system leads to an increased risk for development of sequelae of portal hypertension.

CONCLUSIONS

MVT is a challenging disease to treat, given the difficulty in establishing a prompt initial diagnosis and the inability to reliably monitor patients for evidence of impending bowel infarction. Careful selection of patients for endovascular, open, or hybrid approaches is key to achieving improved outcomes. However, the paucity of prospective data and our evolving understanding of the natural history of MVT make consensus treatment strategies difficult to ascertain.

Mesenteric vein thrombosis can be safely treated with anticoagulation but is associated with significant sequelae of portal hypertension

BACKGROUND

Mesenteric venous thrombosis (MVT) is a relatively uncommon but potentially lethal condition associated with bowel ischemia and infarction. The natural history and long-term outcomes are poorly understood and under-reported.

METHODS

A single-institution retrospective review of noncirrhotic patients diagnosed with MVT from 1999 to 2015 was performed using International Classification of Diseases, Ninth Revision and radiology codes. Patients were excluded if no radiographic imaging was available for review. Eighty patients were identified for analysis. Demographic, clinical, and radiographic data on presentation and at long-term follow-up were collected. Long-term sequelae of portal venous hypertension were defined as esophageal varices, portal vein cavernous transformation, splenomegaly, or hepatic atrophy, as seen on follow-up imaging.

RESULTS

There were 80 patients (57.5% male; mean age, 57.9 ± 15.6 years) identified; 83.3% were symptomatic, and 80% presented with abdominal pain. Median follow-up was 480 days (range, 1-6183 days). Follow-up radiographic and clinical data were available for 50 patients (62.5%). The underlying causes of MVT included cancer (41.5%), an inflammatory process (25.9%), the postoperative state (20.7%), and idiopathic cases (18.8%). Pancreatic cancer was the most common associated malignant neoplasm (53%), followed by colon cancer (15%). Twenty patients (26%) had prior or concurrent lower extremity deep venous thromboses. Most patients (68.4%) were treated with anticoagulation; the rest were treated expectantly. Ten (12.5%) had bleeding complications related to anticoagulation, including one death from intracranial hemorrhage. Four patients underwent intervention (three pharmacomechanical thrombolysis and one thrombectomy). One patient died of intestinal ischemia. Two patients had recurrent MVT, both on discontinuing anticoagulation. Long-term imaging sequelae of portal hypertension were noted in 25 of 50 patients (50%) who had follow-up imaging available. Patients with long-term sequelae had lower recanalization rates (36.8% vs 65%; P = .079) and significantly higher rates of complete as opposed to partial thrombosis at the initial event (73% vs 43.3%; P < .005). Long-term sequelae were unrelated to the initial cause or treatment with anticoagulation (P = NS).

CONCLUSIONS

Most cases of MVT are associated with malignant disease or an inflammatory process, such as pancreatitis. A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases. Operative or endovascular intervention is rarely needed but important to consider in patients with signs of severe ischemia or impending bowel infarction. There is a significant incidence of radiographically noted long-term sequelae from MVT related to portal venous hypertension, especially in cases of initial complete thrombosis of the mesenteric vein.

Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a rare disease that most commonly affects the elderly. The vague symptoms often lead to delayed diagnosis and consequent high mortality. Physical exam and laboratory findings lack the sensitivity and specificity to exclude AMI, but computed tomography angiography can rapidly and accurately confirm the diagnosis. Survival improves with prompt restoration of perfusion and resection of nonviable bowel. Advances in imaging, operative techniques, and critical care have led to a steady decline in overall mortality; however, long-term survival is limited because of the comorbidities in this patient group.

Incidence, risk factors, and management options for portal vein thrombosis after hepatectomy: a 14-year, single-center experience

BACKGROUND

Portal vein thrombosis (PVT) after hepatectomy is rare; however, it increases mortality and morbidity. Few studies have been conducted that focused on PVT following major hepatectomy.

METHODS

Patients who underwent hepatectomy at a single institution were retrospectively reviewed, and risk factors and management options were evaluated.

RESULTS

Of the 1,193 patients undergoing hepatectomy, 25 patients developed PVT. Right-sided hepatectomy, caudate lobectomy, splenectomy, and postoperative bile leakage were independent risk factors for PVT following hepatectomy. PVT occurred more frequently after major hepatectomy compared with minor hepatectomy. Increased instability and reduced portal venous flow caused by kinking was the reason for increasing the risk of PVT after right-sided hepatectomy with caudate lobectomy. The new operative procedure, suturing the posterior wall of the portal vein with the anterior wall of the inferior vena cava, was effective for reducing the risk of PVT following right-sided hepatectomy. Operative thrombectomy showed significant benefits for PVT detected within 5 days after hepatectomy.

CONCLUSIONS

PVT frequently occurs following major hepatectomy. Urgent operative thrombectomy is strongly recommended for PVT with early detection.

Follow-up results of acute portal and splenic vein thrombosis with or without anticoagulation therapy after hepatobiliary and pancreatic surgery

Purpose

Acute portal and splenic vein thrombosis (APSVT) after hepatobiliary and pancreatic (HBP) surgery is a rare but serious complication and a treatment strategy has not been well established. To assess the safety and efficacy of anticoagulation therapy for treating APSVT after HBP surgery.

Methods

We performed a retrospective case-control study of 82 patients who were diagnosed with APSVT within 4 weeks after HBP surgery from October 2002 to November 2012 at a single institute. We assigned patients to the anticoagulation group (n = 32) or nonanticoagulation group (n = 50) and compared patient characteristics, complications, and the recanalization rate of APSVT between these two groups.

Results

APSVT was diagnosed a mean of 8.6 ± 4.8 days after HBP surgery. Patients' characteristics were not significantly different between the two groups. There were no bleeding complications related to anticoagulation therapy. The 1-year cumulative recanalization rate of anticoagulation group and nonanticoagulation group were 71.4% and 34.1%, respectively, which is statistically significant (log-rank test, P = 0.0001). In Cox regression model for multivariate analysis, independent factors associated with the recanalization rate of APSVT after HBP surgery were anticoagulation therapy (P = 0.003; hazard ration [HR], 2.364; 95% confidence interval [CI], 1.341-4.168), the absence of a vein reconstruction procedure (P = 0.027; HR, 2.557; 95% CI, 1.111-5.885), and operation type (liver resection rather than pancreatic resection; P = 0.005, HR, 2.350; 95% CI, 1.286-4.296).

Conclusion

Anticoagulation therapy appears to be a safe and effective treatment for patients with APSVT after HBP surgery. Further prospective studies of larger patient populations are necessary to confirm our findings.

Portal vein thrombosis after hepatectomy

BACKGROUND

Although various complications after hepatectomy have been reported, there have been no large studies on postoperative portal vein thrombosis (PVT) as a complication. This study evaluated the incidence, risk factors, and clinical outcomes of PVT after hepatectomy.

METHODS

The preoperative and postoperative clinical characteristics of patients who underwent hepatectomy were retrospectively analyzed.

RESULTS

A total of 208 patients were reviewed. The incidence of PVT after hepatectomy was 9.1 % (n = 19), including main portal vein (MPV) thrombosis (n = 7) and peripheral portal vein (PPV) thrombosis (n = 12). Patients with MPV thrombosis had a significantly higher incidence of right hepatectomy (p < 0.001), larger resection volume (p = 0.003), and longer operation time (p = 0.021) than patients without PVT (n = 189). Multivariate analysis identified right hepatectomy as a significant independent risk factor for MPV thrombosis (odds ratio 108.9; p < 0.001). Patients with PPV thrombosis had a significantly longer duration of Pringle maneuver than patients without PVT (p = 0.002). Among patients who underwent right hepatectomy, those with PVT (n = 6) had a significantly lower early liver regeneration rate than those without PVT (n = 13; p = 0.040), and those with PVT had deterioration of liver function on postoperative day 7. In all patients with MPV thrombosis who received anticoagulation therapy, PVT subsequently resolved.

CONCLUSIONS

Postoperative PVT after hepatectomy is not rare. It is closely related to delayed recovery of liver function and delayed liver regeneration.

Acute Mesenteric Ischaemia

Acute mesenteric ischaemia (AMI) is a surgical emergency, and has a high mortality. The term AMI covers arterial embolism, arterial thrombosis, non-occlusive mesenteric ischaemia and venous thrombosis which all lead to ischaemia/reperfusion syndrome of the bowel. Multi-detector row helical CT (MDCT) technology has dramatically improved the performance of CT by allowing rapid volumetric data acquisition to provide increased resolution, leading to better identification of the site, level and cause of ischaemia. CT angiography for diagnosing mesenteric ischaemia is now highly sensitive and specific, and should be used as first line when AMI is suspected. The aim of management is to restore intestinal blood flow in a timely manner. Therapeutic decisions are based on the presence of peritonitis, the presence of irreversible ischaemia or infarcted segments of the bowel, the general condition of the patient and the pathophysiological process underlying the ischaemia. AMI remains a challenging condition with high mortality. There is a need for good general surgical cover on the intensive care unit, with continuing care and clinical review by experienced senior surgeons with an interest in this condition.

Portal venous system thrombosis after pancreatic resection

BACKGROUND

Portal venous system thrombosis (PVST) is a rare, potentially fatal complication after pancreatic resection. The aim of this study was to assess the incidence, presenting symptoms, management, and treatment of PVST in a large cohort of patients.

METHODS

Prospectively collected data on patients undergoing pancreatic resection between 1997 and 2009 were reviewed retrospectively. Preoperative and postoperative imaging were analyzed for the presence or absence of venous thrombi. All patients received standard thromboprophylaxis with low-molecular-weight heparin (LMWH).

RESULTS

Of 516 pancreatic resections performed, 18 (3.5 %) were complicated by PVST. The most common clinical presentations were abdominal pain (n = 9) and ascites (n = 5) but never any alarm symptoms. Other symptoms were vague and nonspecific (e.g., weight loss, fatigue, fever). Total pancreatectomy was a risk factor compared to hemipancreatectomy (p < 0.01), whereas the underlying disease per se did not make any difference. The median interval between surgery and diagnosis of PVST was 105 days (range 1-1,440 days). PVST was at least a contributing factor in the postoperative deaths of two patients. LMWH therapy did not significantly affect survival.

CONCLUSIONS

PVST remains a relatively infrequent complication after pancreatic resection. Because accurate diagnosis and timely intervention may reduce morbidity and mortality, the possibility of PVST should be considered in patients presenting with vague symptoms. Whether anticoagulant treatment is needed is still not clear; there were no obvious differences in outcome between treated and untreated patients.

Management of acute post-operative portal venous thrombosis

BACKGROUND

Portal vein thrombosis can be a devastating, but often overlooked, complication of hepatobiliary procedures. Symptoms of acute portal vein thrombosis range from nondescript abdominal pain to septic shock secondary to mesenteric ischemia.

DISCUSSION

The surgeon must be cognizant of these symptoms and the potential for portal vein thrombosis after any hepatobiliary procedures as an expedient diagnosis and treatment is necessary in order to prevent thrombus propagation, bowel ischemia, and death. This report outlines the symptoms, diagnosis, and a review of the literature on the treatment of acute portal vein thrombosis after hepatobiliary surgery with a special note made regarding a case of portal vein thrombosis after pancreatectomy and autologous islet cell transplantation.

Portal and mesenteric vein thromboses in a patient with prothrombin G20210 mutation, elevated lipoprotein (a), and high factor VIII

A 65-year-old man was examined for abdominal pain. Portal and mesenteric vein thromboses were described by ultrasound and computed tomography. No local cause was found. The patient had a positive history of venous thromboembolism. Thrombophilia workup revealed prothrombin G20210A mutation (heterozygous), C677T mutation of methylenetetrahydrofolate reductase gene (homozygous), elevated level of lipoprotein (a), and high level of coagulation factor VIII. Anticoagulation was started and planned for a long-term duration. The etiology of portal vein thrombosis is often multifactorial, with various combinations of systemic factors (inherited or acquired prothrombotic conditions) and local precipitating factors (inflammation, injury to the portal venous system, cancer of the abdominal organs, cirrhosis). The reported prevalence of hypercoagulable states in patients with portal vein thrombosis has been very heterogeneous so far. Some authors support a role of the prothrombin G20210A mutation. In the reported patient, this mutation was revealed in a combination with other hypercoagulable states.

Thrombosis of the portal venous system

Portal vein thrombosis (PVT) is a rare cause of portal hypertension. Its diagnosis has been facilitated by improvements in imaging techniques, in particular Doppler sonography. The prevalence is about 1% in the general population, but much higher rates are observed in patients with hepatic cirrhosis (7%, range 0.6-17%), particularly those who also have hepatocellular carcinoma (HCC) (35%). The most common causes of PVT are myeloproliferative disorders, deficiencies of anticoagulant proteins, prothrombotic gene mutations, cirrhosis with portal hypertension, and HCC. Its development often requires the presence of two or more risk factors (local and/or systemic), e.g., a genetically determined thrombophilic state plus an infectious episode or abdominal surgery. It is clinically useful to distinguish between cirrhotic and noncirrhotic forms. Portal vein thrombosis is also traditionally classified as acute or chronic, but this distinction is often difficult. Color Doppler ultrasound is the first-line imaging study for diagnosis of PVT; magnetic resonance angiography and CT angiography are valid alternatives. The main complications are ischemic intestinal necrosis (in acute PVT) and esophageal varices (in chronic cases); the natural history of the latter differs depending on whether or not the thrombosis is associated with cirrhosis. The treatment of choice for PVT has never been adequately investigated. It is currently based on the use of anticoagulants associated, in some cases, with thrombolytics, but experience with the latter agents is too limited to draw any definite conclusions. In chronic thrombosis (even forms associated with cirrhosis), anticoagulant therapy is recommended and possibly, beta-blockers as well. Naturally, treatment of the underlying pathology is essential.

Thrombolysis via an Operatively Placed Mesenteric Catheter for Portal and Superior Mesenteric Vein Thrombosis: Report of a Case

Mesenteric venous thrombosis (MVT) is a catastrophic form of mesenteric vascular occlusion. In the absence of peritoneal signs, anticoagulation therapy should be started immediately. For selected patients, thrombolysis through the superior mesenteric artery (SMA), jugular vein, or portal vein via a transhepatic route might be successful; however, exploratory laparotomy is mandatory when peritoneal signs develop. We report a case of acute MVT associated with protein C and S deficiency, treated successfully by limited bowel resection and simultaneous thrombolytic infusion, given via an operatively placed mesenteric vein catheter.

Mesenteric and portal vein thrombosis: treated with early initiation of anticoagulation

OBJECTIVE

Superior mesenteric vein thrombosis (SMVT) is generally difficult to diagnose and can be fatal. Mesenteric and portal vein thrombosis is rare and can be presented as more serious conditions than that of SMVT. We report patients with combined SMVT and portal vein thrombosis (PVT) who were treated successfully with early initiation of anticoagulation.

METHODS

The medical records of six patients (five male, one female) who presented with combined SMVT and PVT in our institute between January 1994 and September 2003 were reviewed retrospectively. All of the patients were treated with early initiation of anticoagulation using unfractionated heparin or low molecular weight heparin.

RESULTS

The mean hospital stay was 31 days and the mean follow-up period was 32 months. Three patients had an antithrombin III deficiency. The most common symptom was diffuse abdominal pain and signs included abdominal distension and tenderness. During the follow-up period, there were two patients who developed stricture of the small bowel necessitating resection and anastomosis of the small bowel. There was no case of peritonitis due to bowel necrosis or mortality.

CONCLUSION

The early initiation of anticoagulation in patients of SMVT combined with PVT could minimise the serious complication such as peritonitis due to bowel necrosis required immediate exploratory laparotomy.

Long-term follow-up of partial thrombosis of the superior mesenteric vein in a cirrhotic patient with hepatocellular carcinoma: a case report

Superior mesenteric venous thrombosis (SMVT) is an uncommon but potentially life-threatening disorder. We describe a cirrhotic patient with hepatocellular carcinoma who had partial SMVT for at least 28 months. Our experience may help in the management of such patients. The partial SMVT was not treated at the time of discovery because there was no evidence of bowel infarction. Moreover, the patient had a tendency to bleed severely and was in a poor condition. SMVT was followed using regular ultrasonography and the pattern of SMVT did not change significantly during the follow-up period. A symptom that may have been related to SMVT was abdominal colic pain after meals, which was sometimes followed by diarrhea and / or nausea and vomiting. There was no evidence of bowel ischemia or infarction during follow-up. Abdominal discomfort can be successfully treated using anticholinergic drugs with or without analgesia.

Superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases

OBJECTIVE

Our purpose was to examine the clinical presentation, imaging appearance, etiology, and clinical outcome in patients who had acute thrombosis of the superior mesenteric vein with radiologically occult cause.

CONCLUSION

The most common predisposing factors in superior mesenteric vein thrombosis with radiologically occult cause are recent abdominal surgery, infection, and hypercoagulable states. Although no correlation was noted between risk factor and outcome, the presence of bowel wall thickening and mesenteric congestion on CT or MR imaging was associated with the development of bowel ischemia. Prognosis is good in this group of patients, with a mortality of only 7%, although bowel ischemia was noted in 21%.

Acute mesenteric venous thrombosis: case for nonoperative management

OBJECTIVE

Initial treatment in the management of acute mesenteric vein thrombosis (MVT) is controversial. Some authors have proposed a surgical approach, whereas others have advocated medical therapy (anticoagulation). In this study, we analyzed and compared the results obtained with surgical and medical treatment to determine the best initial management for this disease.

METHODS

We retrospectively reviewed the records of patients treated for MVT in a secondary care surgical department from January 1987 to December 1999. Before January 1995, our departmental policy was to perform surgery in patients with suspected MVT. Since January 1995, we have preferred a medical approach when achievable. Each patient in this study was assessed for diagnosis, initial management (laparotomy or anticoagulation), morbidity, mortality, duration of hospitalization, the need for secondary operation, portal hypertension, and survival rates.

RESULTS

Twenty-six patients were treated, 14 before January 1995 (group 1) and 12 since January 1995 (group 2). Morbidity, mortality, secondary operation, portal hypertension, and 2-year survival rates were 34.6%, 19.2%, 15.3%, 19.2%, and 76.9%, respectively. No statistical difference was observed between the two groups. The mean duration of hospitalization was 51.6 days in group 1 and 23.2 days in group 2 (P < .05). Among the 12 patients treated by means of laparotomy with bowel resection, 10 patients (83%) had mucosal necrosis without transmural necrosis at pathologic study.

CONCLUSION

Nonoperative management for acute MVT is feasible when the initial diagnosis with a computed tomography scan is certain and when the bowel infarction has not led to transmural necrosis and bowel perforation. The morbidity, mortality, and survival rates are similar in cases of surgical and nonoperative management. The length of hospital stay is shorter when patients are treated with a nonoperative approach. A nonoperative approach, when indicated, avoids the resection of macroscopically infarcted small bowel (without transmural necrosis) in cases that are potentially reversible with anticoagulation alone.

Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy

Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.