A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy

Thrombotic complications following bariatric surgery: how medical tourism poses challenges to comprehensive care in obesity medicine

The global prevalence of obesity has more than tripled since 1975. Unfortunately, bariatric surgery waiting lists can last many years therefore many patients seek alternative options such as "medical tourism" by venturing abroad for surgery. We describe two cases of porto-mesenteric venous thrombosis in patients who travelled abroad for bariatric surgery. Upon returning both cases required interventional radiological management, and in the first case, the patient underwent a small bowel resection for bowel ischaemia. Porto-mesenteric complications are significant and have profound lifelong consequences. Therefore, it is imperative that patient education is significantly improved, and more stringent regulations by health authorities are put in place to avoid the growing complications of negative health tourism.

Defecation-Induced Splenic Rupture in a Patient With Portal Vein Thrombosis After Sleeve Gastrectomy: Case Report and Literature Review

Sleeve gastrectomy is the most commonly performed bariatric surgery, with a relatively high safety profile. Splenic rupture following portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy is a rare life-threatening complication. A morbidly obese 38-year-old female patient presented with acute onset abdominal pain 13 days after a laparoscopic sleeve gastrectomy. Radiological studies revealed portal vein thrombosis (PVT) and splenic hematoma. On the second day of hospitalization, while under observation with stable vital signs, the patient developed sudden hypotension and tachycardia after defecation. Emergency diagnostic tests revealed a splenic rupture, and an emergency laparotomy and splenectomy were performed. The patient received low-molecular-weight heparin (LMWH) and was discharged uneventfully 10 days after surgery. Patients who develop PVT after bariatric surgery should be closely monitored due to the risk of splenic rupture, especially in situations that cause intra-abdominal pressure changes such as defecation.

Rare Complications Following Laparoscopic Sleeve Gastrectomy

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

Portomesenteric Venous Thrombosis after Bariatric Surgery: A Case Series and Systematic Review Comparing LSG and LRYGB

(1) Background: Portomesenteric Venous Thrombosis (PMVT) is a rare but serious complication of Metabolic Bariatric Surgery (MBS). Although more frequently reported after laparoscopic sleeve gastrectomy (LSG), the risk factors for PMVT remain unclear. This study aims to compare the incidence and determinants of PMVT between LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB). (2) Methods: A retrospective analysis of 5235 MBSs conducted at our institution between 2015 and 2023 identified five cases of PMVT. Additionally, a systematic review in March 2023, covering PubMed, Web of Science and Scopus, was performed. Several data were analyzed regarding risk factors. (3) Results: In our case series, the incidence of PMVT was 0.1%. The five cases described involved four females with a BMI between 39.7 and 56.0 kg/m2. Their comorbidities were associated with metabolic syndrome, all women used oral contraceptive and two patients were diagnosed with thrombophilia or pulmonary embolism. Per protocol, thromboprophylaxis was administered to all patients. Diagnosis was made at a median of 16 days post-surgery, with abdominal pain being the main presenting symptom. Acute cases were managed with enoxaparin, unfractionated heparin and fibrinolysis. One patient required surgery. Ten studies were included in the systematic review and 205 patients with PMVT were identified: 193 (94.1%) post-LSG and 12 post-LRYGB. The most common comorbidities were dyslipidemia, hypertension, diabetes, sleep apnea and liver disorders; (4) Conclusions: PMVT is a potentially life-threatening complication after MBS, requiring preventive measures, timely diagnosis and several treatments. Our findings suggest a higher occurrence in women with an elevated BMI and post-LSG. Tailored thromboprophylaxis for MBS patients at risk of PMVT may be warranted.

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates

BACKGROUND

Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days.

OBJECTIVES

Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis.

SETTING

University Hospital.

METHODS

Between 2012-2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018-2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed.

RESULTS

A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively.

CONCLUSIONS

Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

Portosystemic shunt surgery for severe portal hypertension due to portal thrombosis after bariatric surgery

Portal vein thrombosis is a rare complication after laparoscopic sleeve gastrectomy, a widely performed bariatric surgery procedure. Occasionally, the development of portal vein thrombosis can progress to more severe conditions, including portal hypertension and cavernomatosis, thereby presenting a complex and challenging clinical scenario. The management of such complications often requires careful consideration; however, surgical intervention in the form of a splenorenal shunt is an exceptional indication. We present the case of a 33-year-old female patient who had previously undergone laparoscopic sleeve gastrectomy in 2014 and subsequently developed portal thrombosis, followed by cavernomatosis and associated complications of portal hypertension. A proximal splenorenal shunt procedure and splenectomy were successfully performed to manage portal hypertension. The presentation of this clinical case aims to contribute to the available evidence and knowledge surrounding this rare and challenging pathology.

Surgical Management of Bariatric Complications and Weight Regain

The history and evolution of bariatric/metabolic surgical procedures allows for only a brief introduction to complications and surgical approaches for improved weight loss. Our specialty lacks standardization of our operations such as gastric pouch size, intestinal bypass lengths, and consensus on which procedure is best for each individual patient. Anatomic construct as well as adherence to lifestyle modifications can affect short- and long-term outcomes.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48 kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

Portomesenteric Vein Thrombosis in Patients Undergoing Sleeve Gastrectomy: an Updated Systematic Review and Meta-Analysis of 101,914 Patients

INTRODUCTION

Portomesenteric vein thrombosis (PMVT) is a rare but potentially fatal complication of sleeve gastrectomy (SG). The rising prevalence of SG has led to a surge in the occurrence of PMVT, while the associated risk factors have not been fully elucidated. This study aims to determine the incidence and risk factors of PMVT in patients undergoing SG.

METHODS

A comprehensive literature search was performed in PubMed and EMBASE databases. Proportion and regression meta-analyses were conducted.

RESULTS

In a total of 76 studies including 101,914 patients undergoing SG, we identified 357 patients with PMVT. Mean follow-up was 14.4 (SD: 16.3) months. The incidence of PMVT was found to be 0.50% (95%CI: 0.40-0.61%). The majority of the population presented with abdominal pain (91.8%) at an average of 22.4 days postoperatively and PMVT was mainly diagnosed with computed tomography (CT) (96.0%). Hematologic abnormalities predisposing to thrombophilia were identified in 34.9% of the population. Advanced age (p=0.02) and low center volume (p <0.0001) were significantly associated with PMVT, while gender, BMI, hematologic abnormality, prior history of deep vein thrombosis or pulmonary embolism, type of prophylactic anticoagulation, and duration of prophylactic anticoagulation were not associated with the incidence of PMVT in meta-regression analyses. Treatment included therapeutic anticoagulation in 93.4% and the mortality rate was 4/357 (1.1%).

CONCLUSION

PMVT is a rare complication of sleeve gastrectomy with an incidence rate <1% that is associated with low center volume and advanced age but is not affected by the duration or type of thromboprophylaxis administered postoperatively.

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis

OBJECTIVE

Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis.

METHODS

All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease).

RESULTS

Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival.

CONCLUSIONS

Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

30-Day Post-Discharge Prophylaxis with Rivaroxaban Prevents Porto-mesenteric Venous Thrombosis Following Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Porto-mesenteric venous thrombosis (PMVT) is a significant complication that occurs more frequently after laparoscopic sleeve gastrectomy (SG) than other bariatric procedures and presents later than other venous thromboembolic (VTE) events often 2 weeks after the operation. The common current practice in bariatric surgery of perioperative chemoprophylaxis until discharge may not adequately prevent PMVT. Therefore, a 30-day post-discharge chemoprophylaxis (PDC) might reduce the incidence of PMVT. The objective of this study is to determine whether 30-day PDC with rivaroxaban 10 mg daily following SG can reduce the incidence of PMVT.

METHODS

In a retrospective cohort study, 292 consecutive patients undergoing SG by a single surgeon were either prescribed rivaroxaban 10 mg daily for 30 days upon discharge (group A) or did not receive any PDC (group B). Primary outcome was PMVT and secondary outcome was bleeding. Patients on chronic anticoagulation therapy were excluded from the study.

RESULTS

PMVT events differences were significant between the groups while bleeding events were not. Group A had zero PMVT events, while group B had four (p = .045). There were 4 bleeding events in group A and 7 bleeding events on group B (p = .341).

CONCLUSION

A 30-day PDC regimen of rivaroxaban 10 mg daily is both safe and effective. This study demonstrated zero PMVT events without an increased risk of bleeding using this regimen.

The Role of Thromboprophylaxis in Patients with Portal Vein Thrombosis: A Life-Threatening Complication after Laparoscopic Sleeve Gastrectomy Following 8 Years of Experience in a Bariatric Center of Excellence

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Independent predictors and timing of portomesenteric vein thrombosis after bariatric surgery

BACKGROUND

Portomesenteric vein thrombosis (PVT) is a rare complication following bariatric surgery but can result in severe morbidity as well as death.

OBJECTIVE

Identification of risk factors for PVT to facilitate targeted management strategies to reduce incidence.

SETTING

Prospective, statewide bariatric-specific clinical registry.

METHODS

We identified all patients who underwent primary bariatric surgery between June 2006 and November 2021 (n = 102,869). Patient characteristics, procedure type, operative details, and 30-day postoperative complications were analyzed with multivariable logistic regression to evaluate for independent predictors of PVT.

RESULTS

A total of 117 patients (.11%) developed a postoperative PVT, with 6 (5.1%) associated deaths. The majority of PVTs occurred in patients who underwent sleeve gastrectomy (109 patients; 93.2%), and the PVT occurred most commonly during the second (37%), third (31%), and fourth weeks (23%) after surgery. Independent risk factors for PVT included a prior history of venous thromboembolism (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.64-5.98; P = .0005), liver disorder (OR = 2.3; 95% CI: 1.36-4.00; P = .0021), undergoing sleeve gastrectomy (OR = 12.4; 95% CI: 4.98-30.69; P < .0001), and postoperative complications including obstruction (OR = 12.5; 95% CI: 4.65-33.77; P < .0001), leak (OR = 7.9; 95% CI: 2.76-22.64; P = .0001), and hemorrhage (OR = 7.6; 95% CI: 3.57-16.06; P < .0001).

CONCLUSIONS

Independent predictors of PVT include a prior history of venous thromboembolism, liver disease, undergoing sleeve gastrectomy, and experiencing a serious postoperative complication. Given that the incidence of PVT is most common within the first month after surgery, extending postdischarge chemoprophylaxis during this time frame is advised for patients with increased risk.

Efficacy and Safety of Pharmacoprophylaxis for Venous Thromboembolism in Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis

This study aims to assess the efficacy and safety of pharmacoprophylaxis regimens for venous thromboembolism (VTE) in patients undergoing bariatric surgery. A total of 15 studies were included. Low molecular-weight heparins (LMWH) and fondaparinux may be equally effective in reducing VTE risk (OR 1.02, 95% confidence interval [CI] 0.14-7.39). Pooled estimate suggested uncertain effects of augmented LMWH dosing on VTE prophylaxis compared with standard dosing (OR 0.57, 95% CI 0.07-4.39), but may increase major bleeding (OR 3.03, 95% CI 0.38-23.96). Very low-quality evidence showed an inconclusive effect of extended prophylaxis on VTE (OR 0.54, 95% CI 0.15-1.90) and major bleeding (OR 1.24, 95% CI 0.92-1.68) compared with restricted prophylaxis. Standard LMWH dosing may be effective and safe. Current evidences are insufficient to support extended prophylaxis.

Portomesenteric vein thrombosis following sleeve gastrectomy: Case report focusing on the role of pathogenetic factors

INTRODUCTION

Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication.

CASE REPORT

A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms.

DISCUSSION

Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein.

CONCLUSION

Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors?

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Portal venous system thrombosis after bariatric surgery: A systematic review and meta-analysis

BACKGROUND

Portal venous system thrombosis can develop after bariatric surgery. A systematic review and meta-analysis was conducted to evaluate the incidence of portal venous system thrombosis after bariatric surgery and clarify the role of anticoagulation for the prevention of portal venous system thrombosis after bariatric surgery.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of portal venous system thrombosis after bariatric surgery was pooled by a random-effect model. Subgroup analyses were performed to explore the incidence of portal venous system thrombosis according to the average duration of prophylactic anticoagulation (extended versus short-term). Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity.

RESULTS

Among 2,714 papers initially screened, 68 studies were included. Among 100,964 patients undergoing bariatric surgery, 300 developed portal venous system thrombosis. The pooled overall incidence of portal venous system thrombosis after bariatric surgery was 0.419% (95% confidence interval: 0.341%-0.505%). The pooled incidence of portal venous system thrombosis after bariatric surgery was numerically lower in patients who received extended prophylactic anticoagulation protocol after bariatric surgery than those who received short-term prophylactic anticoagulation protocol (0.184% vs 0.459%). Meta-regression analyses demonstrated that sample size (P = .006), type of surgery (P < .001), and average duration of prophylactic anticoagulation (P = .024) might be sources of heterogeneity, but not region, publication year, history of bariatric surgery, follow-up duration, or use of prophylactic anticoagulation. Sensitivity analyses could not identify any source of heterogeneity. The estimated mortality of portal venous system thrombosis after bariatric surgery was 1.33%.

CONCLUSION

Portal venous system thrombosis after bariatric surgery is rare, but potentially lethal. Extended prophylactic anticoagulation protocol may be considered in patients at a high risk of developing portal venous system thrombosis after bariatric surgery.

Thromboelastography-Based Profiling of Coagulation Status in Patients Undergoing Bariatric Surgery: Analysis of 422 Patients

INTRODUCTION/PURPOSE

Some clinical indicators suggest hypercoagulability/hyperaggregability in patients with morbid obesity. Thromboelastography (TEG®) has been used to profile coagulation status in surgical patients. We aimed to assess coagulation profiles in patients with morbid obesity undergoing bariatric surgery by correlating demographic and patient characteristics to pre-operative TEG® values.

MATERIALS AND METHODS

Pre-operative TEG® values from 422 patients undergoing bariatric surgery were evaluated. TEG® results were analyzed by gender, use of medications known to alter the coagulation profile, and body mass index (BMI).

RESULTS

Patients have a mean of 45.03 ± 11.8 years, female (76.3%), and with a mean BMI of 42 kg/m ¹. The overall coagulation profile of female patients was significantly different from males, even in the sub-cohort without use of medications known to alter coagulation. The majority of patients (94%) with a G value > 15 dynes/cm ¹ (clot strength) were female. In females, there was no association between BMI and TEG® values; however, in men, there was a statistically significant difference in TEG® values for those with BMI < 40 kg/m ¹ compared to those with BMI > 50 kg/m².

CONCLUSIONS

TEG®-based analysis of coagulation profiles offers unique insights. Compared to laboratory normal values (R time, angle, maximal amplitude, and G values), patients with morbid obesity may have a tendency for hypercoagulability/hyperaggregability, with mean values at the higher limit. A significant hypercoagulable difference in TEG® values was identified in female as compared to male patients. Male patients with a BMI greater than 50 kg/m² were also found to be increasingly hypercoagulable.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

Venous mesenteric ischemia carries high procedural burden and elevated mortality in patients with severe presentation

OBJECTIVE

Venous mesenteric ischemia (VMI) presents with variable severity resulting in a spectrum of outcomes. This study sought to characterize the natural history of VMI and identify drivers of intervention and adverse outcomes.

METHODS

All patients who presented to our institution with acute and subacute VMI between 1993 and 2016 were identified. Images were reviewed to determine thrombosis location and charts were reviewed to identify clinical factors and outcomes. Univariate analysis was performed for demographics, comorbidities, and presenting characteristics, with primary outcomes of intervention, readmission, and 30-day mortality. A survival analysis was performed with log-rank difference testing for demographics, comorbidities, and presenting characteristics.

RESULTS

We identified 103 patients with acute and subacute VMI. The locations of the thrombosis included the superior mesenteric vein (SMV) (31.1%); SMV and portal vein (35.9%); SMV, portal, and splenic veins (15.5%); and other combinations of portomesenteric veins (17.4%), without correlation between the location and outcomes. Most patients were male (60.6%), 22.3% were actively smoking, and the median Charlson comorbidity score was 4 (interquartile range, 2-7). The mean patient age was 61.3 years. More than one-half had a known hypercoagulability (52.4%), 22.3% had prior bowel resection, and 8.7% had prior mesenteric venous intervention, including transjugular intrahepatic portosystemic shunt procedures. Thirty-five patients underwent 83 procedures during their hospitalization, and 23 patients underwent surgical intervention specifically. Prior mesenteric venous procedure, abdominal tenderness, and lactatemia of more than 1.5 mmol/L were associated with an increased need for surgical intervention (P < .05). Patients with leukocytosis of greater than 10K/μL had increased surgical intervention (P = .10), although without statistical significance. However, symptoms for less than 2 weeks (P < .05) were associated with decreased surgical intervention. The 30-day mortality was low in this cohort (6.8%), but was increased in patients requiring intervention (11.4%). For those undergoing procedures, a shorter time to intervention was associated with an improved 30-day mortality (8.7% for procedures on hospital days 0-1 vs 16.7% for hospital day 2 or later; P = .01). Abdominal tenderness and lactatemia were associated with increased 30-day mortality (6.8% vs 3.6% [P < .01] and 16.0% vs 3.8% [P = .03], respectively). A Kaplan-Meier survival analysis revealed a median survival of 7.1 years, with a 1-year survival rate of 74.9%, a 3-year survival rate of 67.1%, and a 5-year survival rate of 57.9%. Negative predictors of survival included a higher Charlson comorbidity index (hazard ratio, 3.7; P < .01) and malignancy (hazard ratio, 3.1; P < .01).

CONCLUSIONS

The 30-day mortality of VMT is low, but more than one-third of patients required an intervention beyond anticoagulation. Comorbidity, a prior mesenteric vessel or intestinal operation, and presentation with tenderness or relevant laboratory abnormalities portend worse outcomes. Early intervention is associated with improved outcomes.

Splenic Abscess Complicating Bariatric Surgery : A Systematic Review

INTRODUCTION

Bariatric surgery has become one of the most rapidly growing subspecialty performed globally, and it has been well reported to be associated with low morbidity and mortality rates. Splenic abscess is a rare but serious complication of bariatric surgery that has not been previously systematically reviewed in the literature.

METHODS

The authors have performed a systematic review of the evidence that has looked into the pathophysiology, clinical presentation, and the management options of splenic abscess complicating bariatric surgery.

RESULTS

This systematic review has been unsurprisingly based on level-IV evidence due to the rarity of the explored condition. The final analysis included 27 relevant reported cases. The mean age was 38 years and the mean of the time interval between the initial operation and developing splenic abscess was 72 days, with the male to female ratio being 1:1.6. Laparoscopic sleeve gastrectomy was the initial operation in 85.2% of the patients. Nearly half of the patients did not have an objective evidence of local or systemic sepsis that could explain the abscess formation. Nonsurgical management was attempted in 14 patients, with 34% success rate only. Splenectomy was needed in 41.7% of the patients. No mortality was reported.

CONCLUSIONS

Splenic abscess is a rare and rather late but serious complication of bariatric surgery that could result in splenectomy in a relatively young group of patients. It is more commonly reported following laparoscopic sleeve gastrectomy. Early diagnosis with intervention in a timely manner is crucial to avoid life threatening complications.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

BACKGROUND

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

METHODS

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

RESULTS

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

CONCLUSION

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Prophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy could reduce the frequency of portomesenteric venous thrombosis

INTRODUCTION

Portal and mesenteric venous thrombosis is a rare but potentially serious complication after laparoscopic sleeve gastrectomy. There are no consistent studies that prove the safety and effectiveness of oral anticoagulant thromboprophylaxis with rivaroxaban after laparoscopic sleeve gastrectomy. The objective was to evaluate the effect of rivaroxaban on the frequency of portal and mesenteric venous thrombosis and its safety profile after laparoscopic sleeve gastrectomy.

MATERIALS AND METHODS

This retrospective analysis of prospectively collected data includes all laparoscopic sleeve gastrectomies performed by a single surgeon at Pontificia Universidad Católica de Chile Hospital between January 2009 and June 2019. All patients received low molecular weight heparin thromboprophylaxis during the whole hospital stay. Between July 2012 and June 2019, patients received additional post-discharge thromboprophylaxis with rivaroxaban. Patient demographics, impaired renal, post-surgical portal and mesenteric venous thrombosis, and bleeding episodes were registered.

RESULTS

A total of 516 patients were identified; 95 patients were excluded. Results for 421 patients were analysed: 198 received only intrahospital thromboprophylaxis (group 1) and 223 received additional post-discharge thromboprophylaxis with rivaroxaban (group 2). There was no statistically significant difference between the two groups concerning age, sex and body mass index. In group 1, four cases of portal and mesenteric venous thrombosis were registered and no cases were reported in group 2 (p < 0.05). All cases occurred before 30 days after surgery. No bleeding episodes and no adverse reactions were detected in group 2.

CONCLUSIONS

Thromboprophylaxis during the whole hospital stay (two to three days), followed by rivaroxaban 10mg once daily for 10 days after discharge (completing in total 13-14 days of prophylaxis), could reduce cases of post-surgical portal and mesenteric venous thrombosis without an increase in bleeding complications.

Portomesenteric vein thrombosis after bariatric surgery: a case series

OBJECTIVE

Portomesenteric vein thrombosis (PMVT) is a potentially severe complication that can occur after bariatric surgery. PMVT has gained importance because of the increasing number of bariatric surgeries being performed. to report a rare and severe complication after bariatric surgery, which is difficult to manage. To try to identify common characteristics among the cases and discuss potential causes comparing our data to the available literature.

METHODS

We describe six cases of PMVT in young women with different presentations.

RESULTS

All six cases occurred in young women 29-41 years old with obesity - body mass index - BMI: 36-39) and weighing 105-121 kg. The patients had few comorbidities (all of which were related to metabolic syndrome) and moderate hepatic steatosis with no sign of cirrhosis. Five patients used oral contraceptives until a few days before the operation. One patient tested positive for thrombophilia. Five patients underwent a laparoscopic sleeve gastrectomy and one underwent a gastric bypass with no complications during the operation (median operating time: 61.3 min, range 52-91 min). The mean duration of follow-up after hospitalization was 12.3 months (range: 7-18 months) and to-date only one patient has had no recanalization.

CONCLUSION

The frequency of PMVT appears to be increased in woman and after sleeve gastrectomy. Our findings indicate that patients with abdominal pain weeks after bariatric surgery must be investigated.

Weight-adjusted tinzaparin for the prevention of venous thromboembolism after bariatric surgery

Essentials The optimal dose and duration of thromboprophylaxis after bariatric surgery are unclear. We evaluated the safety of weight-adjusted tinzaparin prophylaxis in 1212 patients. In-hospital rates of venous thromboembolism and major bleeding were 0.2% and 1.8% respectively. In a sub-set of patients, trough anti-Xa levels did not show excessive anticoagulant activity.

SUMMARY

Background Patients undergoing bariatric surgery are at moderate to high risk of venous thromboembolism (VTE). The optimal dose and duration of anticoagulant prophylaxis is uncertain. Objective To evaluate the safety of extended-duration weight-adjusted tinzaparin after bariatric surgery. Patients/methods We conducted a single-center retrospective cohort study of consecutive patients undergoing bariatric surgery who received weight-adjusted tinzaparin 4500-14 000 IU daily (75 IU kg-1 rounded to the nearest prefilled syringe) for 10 days after surgery (7-9 days post-hospital discharge). Primary safety outcomes were the frequency of VTE and major bleeding within 30 days of surgery in patients receiving at least one dose of tinzaparin. Results A total of 1279 patients undergoing bariatric surgery between July 2009 and December 2012 were reviewed, of whom 1212 received weight-adjusted tinzaparin. Safety outcomes were collected for 819 patients at 30 days, and for 1212 patients in-hospital only. The median age was 45.0 years, median weight was 130.0 kg and 98.8% of patients underwent gastric bypass or sleeve gastrectomy. In patients completing 30 days of follow-up, VTE occurred in 4/819 (0.5%) and major bleeding occurred in 13/819 patients (1.6%). In-hospital rates of VTE and major bleeding during surgical admission were 3/1212 (0.2%) and 22/1212 (1.8%), respectively. Conclusions Extended thromboprophylaxis with weight-adjusted tinzaparin appears to be a safe strategy after bariatric surgery, with low rates of postoperative VTE and major bleeding.

Nutritional issues in patients with obesity and cirrhosis

Obesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes from simple accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced by each of the two conditions alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. Diet, physical activity and protein intake should be carefully monitored in these fragile patients according to recent recommendations. Bariatric surgery is sporadically used in patients with morbid obesity and cirrhosis also in the setting of liver transplantation. The risk of sarcopenia, micronutrient status, and the recommended supplementation in patients with obesity and cirrhosis are discussed in this review. Furthermore, the indications and contraindications of bariatric surgery-induced weight loss in the cirrhotic patient with obesity are discussed.

Factor VIII elevation may contribute to portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: a multicenter review of 40 patients

BACKGROUND

Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis.

OBJECTIVES

To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG.

SETTING

University hospitals.

METHODS

A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers.

RESULTS

Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m² (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities.

CONCLUSIONS

A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.