Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: 3 Case Reports and a Literature Review

Post laparoscopic sleeve gastrectomy portal vein thrombosis with venous mesenteric ischemia: a case report with literature review

Saudi Arabia's obesity prevalence is 19.2% among men and 21.4% among women. Treatment includes lifestyle modifications, medication, and bariatric surgery. Procedures reach up to 1200 annually in our center. Porto-mesenteric venous thrombosis associated with venous mesenteric ischemia and bowel necrosis is a rare complication that necessitates an early workup and management. A 29-year-old Saudi male underwent laparoscopic sleeve gastrectomy. Post-surgery, he experienced abdominal pain, nausea, and vomiting, exacerbated by eating and smoking. Abdomen computed tomography scans revealed engorged portal veins, congested mesenteric veins, and small bowel thickening. He underwent exploratory laparoscopy shifted to laparotomy with resection of an infarcted omentum and 1 m of jejunal small bowel loop, and was discharged postoperatively after 7 days. Porto-mesenteric venous thrombosis is a rare complication after laparoscopic sleeve gastrectomy, requiring early diagnosis and appropriate treatment. Patients present with non-specific symptoms, necessitating high suspicion for computed tomography recommendations.

Prevalence and Risk Factors for Portal Cavernoma in Adult Patients with Portal Vein Thrombosis

Portal vein thrombosis (PVT) represents a restriction or occlusion of the portal vein by a blood clot, which can appear in liver cirrhosis, inherited or acquired thrombophilia, malignancies, abdominal infection, abdominal inflammation, and injury to the portal vein; it can evolve to local venous extension, recanalization, or portal cavernoma (PC). This research represents an observational study of patients admitted with a diagnosis of PVT between January 2018 and December 2022. We assessed the rate of and risk factors for PC. In total, 189 patients with PVT were included; the rate of PC was 14.8%. In univariate and multivariate analysis, the main risk factors for the presence of PC were etiology (thrombophilia, myeloproliferative disorders, local inflammatory diseases, and idiopathic causes), prior PVT, and complete versus incomplete or single-branch portal obstruction. In patients with superior mesenteric vein (SMV) thrombosis, distal obstruction was more prone to PC than proximal obstruction. The main predictive factors were etiology, prior PVT, complete PVT obstruction, and no prior non-selective beta-blocker (NSBB) use; in patients with SMV thrombosis, the distal extension was more significantly associated with the risk of PC. We propose a composite score for the prediction of PC which includes etiology, prior diagnosis of PVT, prior NSBB use, complete versus incomplete PVT, and distal versus proximal SMV thrombosis, with good accuracy (AUC 0.822) and an estimated sensitivity of 76.92% and specificity of 82.39% at a cut-off value of 4.

A rare complication with superior mesenteric vein thrombosis after laparoscopic sleeve gastrectomy: A case report

Laparoscopic sleeve gastrectomy (LSG) has become a frequent procedure to reduce weight and morbid obesity. The procedure involves laparoscopic resection of more than 75% of the greater curvature of the stomach, resulting in early satiety and neuro-hormonal changes that collectively promote effective weight loss. We present a rare case of complication of superior mesenteric vein thrombosis (SMVT) and splenic vein after LSG, with consequent bowel ischemia that was treated with open laparotomy and appropriate anticoagulation therapy. A 56-year-old obese woman (BMI of 42.5 kg/m²), smoker for 30 years, presented to the emergency department with symptoms such as abdominal pain, fever, nausea and vomiting, 2 weeks after LSG intervention. Her white blood cell count was 15.5 (normal values: 3.8-10.4 × 10³ /µL), while C- reactive protein level was 193 (normal values: 0.0-6.0 mg/L) and her D-Dimer level 4.69 (normal values: 0-0.50 mg/L). Abdominal CT with contrast showed a filling defect in the superior mesenteric and splenic vein, free perihepatic and Douglas pouch fluid, as well as small bowel thickening. An open laparotomy was performed and the necrotic segment of bowel of 80 cm was removed. The postoperative period went relatively well, despite the diarrhea that continued for the next 4 months after the intervention. The most common causes leading the development of this complication include: hypercoagulable state, dehydration, increased intra-abdominal pressure during the procedure and other secondary factors. The main symptom is abdominal pain, followed by nausea, vomiting, diarrhea and bleeding from the gastrointestinal tract. SMVT and SVT should be considered as a possible complication in patients with abdominal pain and increased inflammatory parameters after LSG. Early diagnosis through CT imaging and rapid anticoagulation therapy is considered to reduce further complications such as intestinal infarction and portal hypertension.

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.

Water Tolerance After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is taking the lead as the most popular bariatric procedure in most regions of the world. Unlike other liquids, water is particularly affected by LSG. Because of its importance for safe hospital discharge, weight loss, and patients' lifestyle, we evaluated water tolerance after LSG.

METHODS

The study included 106 consecutive patients who underwent LSG. All patients had upper gastrointestinal series (UGI) 48 h (early) and 3 months postoperatively (late), during which flow patterns (esophageal and gastric transit time) for water and juice were measured and correlated with subjective tolerance for water and juice at the same time of the contrast studies. Intraoperative measurements of the sleeve were also correlated with subjective tolerance.

RESULTS

One-hundred and two (94 females, 92%) completed the 3-month follow-up. The mean age was 30.75 years; mean pre-operative BMI 46.76 kg/m². The mean %EWL after 3 months was 32.17% ± 9.5%. Fifty patients (49%) expressed early difficulty drinking water (EDDW), and 30 (29.41%) showed late difficulty drinking water (LDDW), compared with 8 patients (7.8%) with early difficulty drinking juice (EDDJ) and 6 (5.9%) with late difficulty drinking juice (LDDJ).

CONCLUSION

LSG reduces water tolerance significantly more than other liquids (juice) in the early postoperative period. Good water tolerance is a critical parameter for early hospital discharge after LSG. Larger studies with longer follow-up are warranted to determine the long-term fate of fluid tolerance following LSG and its effect on weight loss and quality of life.

Incidence of Splanchnic Vein Thrombosis After Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Abdominal surgery may increase the risk of splanchnic vein thrombosis (SVT). We determined the incidence of SVT after abdominal surgery and identified groups at highest risk.

MATERIALS AND METHODS

MEDLINE and Embase were searched for clinical studies evaluating the incidence of postoperative SVT after abdominopelvic surgery. Study selection, data abstraction, and risk of bias assessment were carried out independently by two reviewers. Clinical heterogeneity was explored by subgroup analyses (i.e., type of intra-abdominal procedure and organ group).

RESULTS

Of 5549 abstracts screened, 48 were analyzed. Pooled incidence of SVT (n = 50,267) was 2.68% [95% confidence interval (CI), 2.24 to 3.11] (1347 events), I² = 96%. Pooled incidence of SVT in high-risk procedures were splenectomy with devascularization (24%), hepatectomy in patients with cirrhosis (9%), and pancreatectomy with venous resection (5%). Pooled incidence of symptomatic and asymptomatic SVT was 1.02% (95% CI: 0.97% to 1.07%) and 0.98% (95% CI 0.88% to 1.07%), respectively. Most common causes of SVT-related mortality were irreversible thrombosis, bowel ischemia, liver failure, and gastrointestinal bleed. Most studies included were at a high risk of bias due to lack of prospective data collection and lack of SVT screening for all participants.

CONCLUSIONS

Incidence of SVT after abdominal surgery is low but remains a relevant complication. Patients undergoing procedures involving surgical manipulation of the venous system and splenectomy are at the highest risk. Given the life-threatening risks associated with SVT, there is a need for larger prospective studies on the incidence and impact of SVT after abdominal surgery.

Case series: Portomesenteric venous thrombosis complicating laparoscopic bariatric procedures

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Portomesenteric vein thrombosis is a rare but potentially fatal complication of bariatric surgery.

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Portomesenteric venous thrombosis complicated 3 of 1030 cases (0.29%).

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Management is primarily with anticoagulants, but surgery is required if the patient shows signs of sepsis.

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A high index of suspicion, early diagnosis and subsequent adequate management is required.

Introduction

Portomesenteric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide.

Methods

A retrospective analysis was performed on all bariatric procedures performed in our center between July 2012 & December 2017 to identify cases complicated by portomesenteric venous thrombosis. The cases were compared in terms of operative details, patient presentation, diagnosis, patient risk factors for developing thrombosis, demographics and thrombophilia analysis & subsequent treatment and prognosis.

Results

A total of 1030 bariatric procedures were performed between July 2012 & December 2017. Portomesenteric venous thrombosis complicated 3 of these cases (0.29%). Two of these cases had underwent a laparoscopic sleeve gastrectomy while the third had underwent a gastric band removal and a conversion to a single anastomosis gastric bypass. Amongst these patients, 2 were female while 1 was male with an average BMI 38.9 kg/m². Only one of these patients was a smoker while none of them tested positive for thrombophilias. The diagnosis of portomesenteric venous thrombosis was confirmed with a contrast CT of the abdomen as all patients were re-admitted between 4–20 days post operatively after being discharged on postoperative day 2. All three cases were managed with systemic anticoagulants and none underwent invasive procedures or were re-explored surgically. All were subsequently discharged in good condition.

Conclusion

Portomesenteric venous thrombosis is an uncommon yet potentially fatal complication of bariatric surgery. A high index of suspicion, early diagnosis and subsequent adequate management is required. Based on this case series and the potential risk of portomesenteric venous thrombosis, we altered our clinical practice to include a 1 week course of low molecular weight heparin to be administered to all patients after discharge.

Portomesenteric Venous Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Do Energy Systems Pose as Instigating Factor to This Infrequent Complication?

Background

Portomesenteric venous thrombosis (PMVT), a rare complication after laparoscopic sleeve gastrectomy (LSG). Severe consequences are owed to a high risk of bowel ischemia. Our aim is to present a series of patients who developed PMVT after LSG, highlighting the potential role of the vessel sealer and divider as a risk factor.

Methods

Medical records of seven patients who underwent LSG and developed PMVT from April 2010 to January 2019, at King Abdullah University Hospital and Jordan University Hospital, Jordan were reviewed. Our findings were studied, audited, and compared with published data.

Results

A sum of 4900 patients underwent LSG, 7 (0.14%) developed PMVT. The mean age and body mass index (BMI) were 36.8 years and 45 kg/m², respectively. Four were women. Epigastric pain radiating to the back was the presenting symptom at a median time of 9 days after surgery. Computed tomography (CT) of the abdomen confirmed the diagnosis. Five patients presented with a total portal vein thrombosis (PVT), one with splenic vein thrombosis and one with dual portal and mesenteric vein thrombosis.

Conclusion

Portomesenteric venous thrombosis is a relatively uncommon complication following LSG. Early recognition is required to avoid catastrophic outcomes. The role of energy systems in the development of PMVT remains unknown and requires further elaboration.

Portomesenteric vein thrombosis following laparoscopic greater curve plication for morbid obesity

Portomesenteric venous thrombosis (PMVT) is an uncommon condition associated with intra-abdominal visceral ischemia that is often difficult to manage. While postoperative PMVT has been rarely reported following laparoscopic abdominal surgery, its occurrence in morbidly obese patients is gaining increasing concern due to its relatively higher incidence after laparoscopic bariatric surgery. Diagnosis of PMVT can be readily accomplished by computed tomography scan. Although prompt treatment with recanalisation of portovenous system and reversal of mesenteric venous ischemia can be potentially life-saving, the overall mortality of postoperative PMVT can only be controlled by understanding the underlying etiologies and preventing its occurrence. Here, we report a case of PMVT in a morbidly obese lady who presented at 10days after an uneventful laparoscopic greater curve plication. The potential etiology and management of this rare complication are elucidated in details.

Portomesenteric Vein Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Case Series and Literature Review

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is today one of the leading procedures in bariatric surgery, and portomesenteric vein thrombosis (PMVT) has been reported as one of its rare complications. The purpose of this study is to determine the prevalence, clinical presentation, and outcomes of PMVT in patients undergoing LSG.

METHODS

A retrospective study of a database of all post-LSG patients was conducted on the patients who developed PMVT post-LSG from July 2011 to March 2016, at Amiri Hospital, Kuwait.

RESULTS

A total of 2280 patients underwent LSG during the study period. Nine (0.39%) patients were diagnosed with PMVT post-LSG. Diagnosis was confirmed by CT scan for eight patients, and one had urgent laparotomy. The median age was 34 years (20-50), and there were 7 women and 2 men. Median preoperative body mass index (BMI) was 42 kg/m² (37.5-74.6), and median operative time was 80 min (60-150). The median post-operative anticoagulation duration was 4 days (2-22). The median onset of diagnosis after the surgery was 28 days (18-453), and two patients had a positive thrombophilia study. All patients were treated medically except one patient who underwent urgent laparotomy for small bowel necrosis and eventually had small bowel transplant.

CONCLUSIONS

PMVT post-LSG is a rare but possibly dangerous complication. It should be suspected with patients presenting with unresolving abdominal pain. Treatment is mainly conservative and surgical intervention might be needed for small bowel necrosis. Extended anticoagulation prophylaxis is a hypothesis for patients after LSG, and may play a role in preventing PMVT.

Assessing risk factors, presentation, and management of portomesenteric vein thrombosis after sleeve gastrectomy: a multicenter case-control study

BACKGROUND

Portomesenteric vein thrombosis (PMVT) is a rare complication of laparoscopic sleeve gastrectomy.

OBJECTIVES

To identify incidence, patient factors, diagnosis, and treatment of PMVT after laparoscopic sleeve gastrectomy in a large administrative data registry.

SETTING

Academic Hospitals and Private Practices, United States.

METHODS

A retrospective chart review of 5538 sleeve gastrectomy patients between January 1, 2008 and September 30, 2016 was performed at 5 bariatric centers in the United States. A total of 11 patients were identified as developing PMVT, and 3 controls for each patient were selected by matching age, sex, preoperative body mass index, and center.

RESULTS

After adjusting for confounding variables, 2 patient factors significantly impacted the risk of PMVT after sleeve gastrectomy including personal history of malignancy (odds ratio 62, 95% confidence interval (CI) 1.4-99.9), and type 2 diabetes (odds ratio 12.7, 95% CI 1.2-137.3) compared with controls. Mean period from laparoscopic sleeve gastrectomy to presentation of PMVT was 19.3 ± 15.11 days (range, 8-62). All patients except 1 complained of abdominal pain as the main presenting symptom. Other complaints included nausea and vomiting, no bowel movement, decreased appetite, diarrhea, and dehydration, and leukocytosis was present in 45.5% of the patients. All diagnoses were made by using computed tomography. All initial treatments were anticoagulation, heparin drip being the most common method (90.9%). Of patients, 9 (81.8%) required a secondary anticoagulation therapy, and 1 (9.1%) patient required a reoperation.

CONCLUSION

Incidence of PMVT is low after sleeve gastrectomy. A personal history of malignancy and type 2 diabetes increase the risk of PMVT. Increasing abdominal pain in a context of dehydration is common presenting symptoms with diagnosis confirmed by computed tomography. Anticoagulation is the standard treatment. There was no mortality associated with the occurrence of PMVT in this cohort.

Is Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy Related to Short-Course Prophylaxis of Thromboembolism? A Monocentric Retrospective Analysis About an Infrequent but Not Rare Complication and Review of the Literature

BACKGROUND

Portomesenteric vein thrombosis (PMVT) is considered a rare and potentially fatal complication of bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures in the world. PMVT in LSG was first reported in 2009 by Berthet et al. in a thrombophilic patient. No data exist regarding the real prevalence of this complication specifically after LSG.

METHODS

We examined retrospectively all the clinical records of patients who underwent LSG for morbid obesity from January 2011 to December 2016. Moreover, we performed a literature search of PubMed, Medscape, and EMBASE databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

2854 patients underwent LSG for morbid obesity from January 2011 to December 2016. The retrospective analysis of our records revealed only 1 case of PMVT. The 18 studies selected include 62 cases of PMVT after LSG with a prevalence of 0.52% (ranging from 0.2% to 1.81%) and a mortality rate of 1.61%.

CONCLUSIONS

PMVT is an infrequent but not rare complication in patients who undergo LSG. Short-course antithrombotic prophylaxis (<10 days) could increase the risk of this complication. The authors recommend a postoperative prophylaxis with sodium enoxaparin 40 mg sc once a day for 4 weeks. PMVT mortality in patients who undergo LSG is lower than other causes of portal vein thrombosis (hepatic cirrhosis, tumors, myeloproliferative disorders, etc.) If risk factors for PMVT are present preoperatively, the authors recommend a prophylaxis with sodium enoxaparin 40 mg sc twice daily for 4 weeks.

Portomesenteric venous thrombosis complicated by a haemorrhagic shock: a rare complication of laparoscopic gastrectomy

Portomesenteric venous thrombosis is a rare complication reported in only a few cases involving laparoscopic bariatric surgery. We report a case of a 44-year-old woman who presented 14 days after recent laparoscopic sleeve gastrectomy with the chief complaint of abdominal pain and associated nausea. Abdominal CT demonstrated thrombi in her superior mesenteric, portal and splenic veins. She was initiated on therapeutic heparin but developed haemorrhagic shock shortly afterwards. Subsequent CT angiogram failed to localise the source of her haemorrhage. Her haemodynamic instability improved following a 6-day intensive care unit stay requiring vasopressive agents and blood transfusions. Further hypercoagulable workup revealed that she was a heterozygous carrier of the prothrombin gene mutation, and thus started on lifelong oral anticoagulation.

Monitoring of Hypercoagulability by Thromboelastography in Bariatric Surgery

Background

Obesity is known as a major risk factor for postoperative vein thrombosis. Thromboelastography (TEG) is used to monitor viscoelastic features of blood clots. The aim of this study was to determine hypercoagulable states in patients undergoing bariatric surgery and to assess dynamics of coagulation parameters in the perioperative setting using TEG.

Material/Methods

We included 60 consecutive patients undergoing bariatric surgery. TEG alterations were assessed at 4 time points: at baseline, after the surgery, and on postoperative day 1 (POD1) and 2 (POD2). Hypercoagulable state was defined when patients showed clot strength (G) of ≥11 dynes/cm² or maximum amplitude (MA) ≥68 mm.

Results

Fourteen patients (23.3%) out of 60 showed hypercoagulability prior to surgery on TEG. Fibrinogen levels were significantly higher in the G ≥11 group compared to the G <11 group, at 4.2 and 3.8 g/l, respectively (p=0.02). Seventeen patients (28.3%) had MA ≥68 mm at baseline. Fibrinogen levels increased significantly from 3.90 at baseline to 4.16 g/l in POD2 (p<0.001). There was an increase in mean reaction time from baseline (6.74 s) to POD2 (7.43 s, p=0.022). We found a correlation between baseline fibrinogen levels and MA (R=0.431, p=0.001) or G (R=0.387, p=0.003). ROC curve analysis showed that fibrinogen levels can predict clot strength (G) ≥11 dynes/cm² with AUC=0.680 (p=0.044).

Conclusions

A considerable proportion of patients referred to bariatric surgery show a trend towards hypercoagulability on TEG. This study shows the potential of hypercoagulation monitoring by TEG in the perioperative setting of bariatric surgery.

A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy

BACKGROUND

Portomesenteric vein thrombosis (PMVT) is considered an uncommon complication in general surgery; nevertheless, with the growing popularity of sleeve gastrectomy (SG) as a bariatric procedure we have seen an increase in the occurrence of this complication.

OBJECTIVES

To elucidate the question if it is a procedure-related complication and explore the modalities of prevention and treatment of this complication, a systematic review of available literature regarding PMVT events after SG was conducted.

METHODS

Our systematic review yielded 28 studies enclosing 89 patients. Perioperative data was collected from each study and analyzed.

RESULTS

The incidence of PMVT after SG ranged from .37% to 1%, 65% of the patients were female, and the mean body mass index was 41.63 kg/m². Perioperative co-morbidities including hypertension, diabetes, and dyslipidemia were recorded in 39.7%, 41.63%, and 38.23% of cases respectively. Tachycardia and fever were reported only in 23.9% and 20.89%, respectively, and hereditary thrombophilia studies were positive in 30.43% of cases. The rate of acute major complications after PMVT was 14.6% (13 cases), and mortality was reported in 3 cases (average 3.37%).

CONCLUSION

PMVT seems to be an uncommon multifactorial disease, with unpredictable symptoms and varieties of the treatments options, but additional studies are required to further define optimal management and prevention algorithms.

Laparoscopic Gastrectomy with Enhanced Recovery After Surgery Protocol: Single-Center Experience

Background

Surgery remains the mainstay of gastric cancer treatment. It is, however, associated with a relatively high risk of perioperative complications. The use of laparoscopy and the Enhanced Recovery After Surgery (ERAS) protocol allows clinicians to limit surgically induced trauma, thus improving recovery and reducing the number of complications. The aim of the study is to present clinical outcomes of patients with gastric cancer undergoing laparoscopic gastrectomy combined with the ERAS protocol.

Material/Methods

Fifty-three (21 female/32 male) patients who underwent elective laparoscopic total gastrectomy due to cancer were prospectively analyzed. Demographic and surgical parameters were assessed, as well as the compliance with ERAS protocol elements, length of hospital stay, number of complications, and readmissions.

Results

Mean operative time was 296.4±98.9 min, and mean blood loss was 293.3±213.8 mL. In 3 (5.7%) cases, conversion was required. Median length of hospital stay was 5 days. Compliance with ERAS protocol was 79.6±14.5%. Thirty (56.6%) patients tolerated an early oral diet well within 24 h postoperatively; in 48 (90.6%) patients, mobilization in the first 24 hours was successful. In 17 (32.1%) patients, postoperative complications occurred, with 7 of them (13.2%) being serious (Clavien-Dindo 3-5). The 30-day readmission rate was 9.4%.

Conclusions

The combination of laparoscopy and the ERAS protocol in patients with gastric cancer is feasible and allows achieving good clinical outcomes.