Laparoscopy-Associated Portal Vein Thrombosis: Description of an Evolving Clinical Syndrome

CO2 artificial pneumothorax on coagulation and fibrinolysis during thoracoscopic esophagectomy

BACKGROUND

CO2 artificial pneumothorax creates a sufficient operative field for thoracoscopic esophagectomy. However, it has potential complications and continuous CO2 insufflation may impede coagulation and fibrinolysis. We sought to compare the effects of CO2 artificial pneumothorax on perioperative coagulation and fibrinolysis during thoracoscopic esophagectomy.

METHODS

We investigated patients who underwent thoracoscopic esophagectomy with (group P, n = 24) or without CO2 artificial pneumothorax (group N, n = 24). The following parameters of coagulation-fibrinolysis function: intraoperative bleeding volume; serum levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), thromboelastogram (TEG), D-Dimer; and arterial blood gas levels were compared with two groups.

RESULTS

Group P showed higher levels of PaCO2, reaction time (R) value and kinetics (K) value, but significantly lower pH value, alpha (α) angle and Maximum Amplitude (MA) value at 60 minutes after the initiation of CO2 artificial pneumothorax than group N ((P < .05, all). The t-PA level after CO2 insufflation for 60 minutes was significantly higher in group P than in group N (P < .05), but preoperative levels were gradually restored on cessation of CO2 insufflation for 30 min (P > .05). There was no significant difference in D-dimer.

CONCLUSION

CO2 artificial pneumothorax during thoracoscopic esophagectomy had a substantial impact on coagulation and fibrinolysis, inducing significant derangements in pH and PaCO2.

TRIAL REGISTRATION

The study was registered at the Chinese clinical trial registry (ChiCTR1800019004).

Portal vein thrombosis in laparoscopic vertical gastrectomy - laparoscopic sleeve gastrectomy: a case series

Grade III obesity is defined as excessive accumulation of fat in the body in a person with a BMI>40kg/m² and is related to a series of comorbidities. It is therefore of fundamental importance that appropriate treatment is adopted to reduce its harmful effects on health. Laparoscopic vertical gastrectomy is well-established for treatment of grade III obesity. Although rare, portal vein thrombosis is one of the most serious of possible postoperative complications. In our study, eight cases are analyzed of laparoscopic vertical gastrectomy patients who developed portal vein thrombosis as a postoperative complication. In our series, we observed an increase in the incidence of portomesenteric venous thrombosis, especially among patients who did not follow the recommendations for oral hydration in the postoperative period. Most patients with this complication respond positively to anticoagulation, with complete or partial recanalization of the portal vein. Treatment with anticoagulants is effective and should be considered the first option. Vigorous hydration has also been shown to be an essential conduct in the postoperative period of these patients, and should always be encouraged.

Splanchnic Vein Thrombosis - an Uncommon Complication after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is an innovative and relatively safe surgical approach for weight reduction in morbidly obese people. Splanchnic vein thrombosis (SVT) is an extremely rare complication of LSG and, if not recognized, carries a high mortality rate. This paper highlights a potentially lethal condition of SVT after LSG.

CASE REPORT

A 37-year-old morbidly obese woman was referred to our institution for LSG. Three weeks after the intervention, she was readmitted with abdominal pain, vomiting, nausea, diarrhea, and fever with positive family anamnesis to viral disease. Abdominal X-ray as well as utrasonography were both normal, and no X-ray contrast medium leakage was observed. One week later, she was readmitted with septic condition. An abdominal computed tomography scan diagnosed lienal vein thrombosis along its whole length and partial thrombosis of the superior mesenteric vein.

CONCLUSION

SVT presents very heterogeneously, which makes it extremely challenging to diagnose and to make an appropriate treatment decision. With regard to the high prevalence of obesity and the increasing frequency of LSG, prompt diagnosis and management are crucial.

Article Commentary: Laparoscopy Associated Mesenteric Vascular Complications

Since the first reported case in 1994, a small but significant number of patients have developed major mesenteric arterial and venous thromboses after laparoscopy, usually with catastrophic outcomes. The basic science data in both animal and human models suggest that these events were due in part to specific predisposing patient factors, combined with the physiologic changes in splanchnic hemodynamics that occur during induction and maintenance of pneumoperitoneum. The following manuscript examines the science of this phenomenon in detail and the features of the reported cases to date, with the goal being to increase awareness of this serious and likely underreported phenomenon.

Portal vein thrombosis

Portal vein thrombosis is a condition not infrequently encountered by clinicians. It results from a combination of local and systemic prothrombotic risk factors. The presentation of acute thrombosis varies widely from an asymptomatic state to presence of life-threatening intestinal ischemia and infarction. In the chronic stage, patients typically present with variceal bleeding or other complications of portal hypertension. Abdominal ultrasound color Doppler imaging has a 98% negative predictive value, and is considered the imaging modality of choice in diagnosing portal vein thrombosis. Controlled clinical trials to assist with clinical decision-making are lacking in both acute and chronic portal vein thrombosis. Oral anticoagulant therapy is initiated if the risks of bleeding are low, but long-term anticoagulation is generally not recommended in patients with concomitant hepatic cirrhosis. The roles of invasive therapeutic approaches such as thrombolysis and transjugular intrahepatic portosystemic shunt continue to evolve. This review conflates dissenting views into a rational approach of managing patients with portal vein thrombosis for the general internist.

Portal vein thrombosis following laparoscopic total mesorectal excision: case report

Data continue to grow regarding the safety and technical feasibility of laparoscopically assisted total mesorectal excision (TME). As this minimally invasive alternative to open colonic resection becomes more popular, it is inevitable that information on the benefits and complications associated with it will continue to expand. Portal vein thrombosis (PVT) has been reported after a variety of laparoscopic procedures. We report a case of superior mesenteric, splenic and portal vein thrombosis following laparoscopically assisted TME. To our knowledge, this complication of laparoscopic TME has not been previously reported in the literature. PVT should be ruled out in patients who present with vague abdominal symptoms. The course of this complication, while potentially devastating, is usually benign and responds well to lysis and/or anticoagulation.