Journal of Obesity and Metabolic Research

CASE REPORT
Year
: 2015  |  Volume : 2  |  Issue : 1  |  Page : 35--36

Porto mesenteric thrombosis: An uncommon complication after laparoscopic sleeve gastrectomy


Tarun Mittal, Mohan V Pulle, Ashish Dey, Vinod K Malik 
 Department of Gen and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Tarun Mittal
Department of Gen and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi
India

Abstract

Although rare, Porto mesenteric thrombosis is a well described complication after abdominal surgeries. In recent years the incidence of this condition has been on an increasing trend with the advent of laparoscopic surgery, particularly bariatric surgery. The pathogenesis of this condition can be explained by propensity of obese people for thrombotic events, intraoperative insult to portal tributaries and post operative dehydration. The clinical spectrum can vary from mild abdominal pain to severe bowel gangrene. Here in we are reporting a case of porto mesenteric thrombosis that occurred in an obese patient after laparoscopic sleeve gastrectomy.



How to cite this article:
Mittal T, Pulle MV, Dey A, Malik VK. Porto mesenteric thrombosis: An uncommon complication after laparoscopic sleeve gastrectomy.J Obes Metab Res 2015;2:35-36


How to cite this URL:
Mittal T, Pulle MV, Dey A, Malik VK. Porto mesenteric thrombosis: An uncommon complication after laparoscopic sleeve gastrectomy. J Obes Metab Res [serial online] 2015 [cited 2019 Jun 18 ];2:35-36
Available from: http://www.jomrjournal.org/text.asp?2015/2/1/35/148613


Full Text

 Introduction



Portomesenteric venous thrombosis is rare, but potentially lethal condition reported after laparoscopic surgery and particularly in obese patients. Although the exact cause is not known, possible etiologic factors include venous stasis due to increased intra-abdominal pressure, intraoperative manipulation causing damage to the splanchnic vasculature and systemic hypercoagulable states. [1] Although this condition has also been seen after other surgeries including Nissen fundoplication, colectomy, cholecystectomy and appendectomy, [2] it has also increasingly been seen after laparoscopic bariatric surgery. Because obese patients are more prone to thrombus formation during surgery, these mechanisms may be accentuated in this group of the high-risk population. This condition is particularly dangerous for these patients who have poor reserve and are obviously high-risk candidates for surgery. This condition may have potentially severe consequences due to a high risk of bowel infarction with few demonstrable signs. [3],[4] Although deep venous thrombosis (DVT) is a known complication in this group of patients only a handful of cases of portal-mesenteric thrombosis after bariatric surgery has been described in the literature. [5],[6],[7] We hereby present our experience in management of an acute portomesenteric thrombosis after laparoscopic sleeve gastrectomy.

 Case Report



A 54-year-old male patient underwent laparoscopic sleeve gastrectomy for morbid obesity. Associated comorbidities were snoring and joint pains. There was no history of smoking or symptoms of hypercoagulability or DVT in the past. Both intraoperative and postoperative course has been uneventful, and he had an excellent recovery and discharged on the 3 rd postoperative day. On postoperative day 21, patient presented with complaints of diffuse abdominal pain, nausea, vomiting and general feeling of being unwell. Although the abdomen was distended it was soft and nontender. Hematological investigations showed the leukocytosis and high creatinine count. Computed tomography with intravenous contrast revealed splenoportal vein and mesenteric vein thrombosis along with mesenteric stranding with diffuse wall thickening of the proximal jejunal loops and reduced wall enhancement suggestive of ischemia. Work up for hypercoagulable states was noncontributory. The patient was treated with adequate hydration, nil per orally, antibiotics and anticoagulation therapy (Inj. Dalteparin 5000 IU subcutaneously once daily was started and continued for 14 days). He needed no surgical interventions and was gradually started on diet after 3 days. He was discharged on the 5 th day after admission, on Inj. Dalteparin in the same dosage. At following of 1 month, the patient was doing well with no new complaints.

 Discussion



Portomesenteric venous thrombosis following laparoscopic surgery usually manifests as nonspecific abdominal pain. [8] Due to the rarity of this condition it should be regarded with a high index of suspicion. This is because this condition can present with symptoms ranging from nonspecific abdominal pain to severe bowel ischemia or gangrene leading to perforation peritonitis and sepsis.

As in all thrombotic conditions, Virchow's triad, that is, venous stasis, endothelial injury and hypercoagulability are essential prerequisites. Obese patients however appear to be more at risk because they have a more sedentary lifestyle, have peripheral venous stasis and has metabolic syndrome. This condition is associated with elevated levels of prothrombogenic factors.

Laparoscopic surgery in these patients causes CO 2 to cause splanchnic vasoconstriction. This alongwith use of liver retractor, higher pneumoperitoneal pressures, reverse Trendelenburg position, and long operating time predisposes to this condition. [8]

This condition may present in acute, subacute and chronic form. In the acute form, the portal thrombus formation is rapid and complete. Patients present with severe abdominal pain progressing rapidly over few hours, vomiting and abdominal distention. The symptoms, of course, are out of proportion to the signs. In the subacute form, the occlusion of the portal venous system causes mesenteric ischemia although there may be enough time to lead to the establishment of collaterals. In the chronic form, the patient has persisting occasional dull aching pain with associated symptoms of portal hypertension. Bowel infarction is unlikely because of the well-established collateral blood supply.

Computed Tomography, particularly 3-phase computed tomography scan can readily provide the diagnosis and demonstrate the extent of the disease. [9] Treatment should be individualized based on the extent of thrombosis and the presence of bowel ischemia. [10] Initial treatment includes supportive measures, including adequate hydration, rest to the bowel, analgesics and anticoagulants to maintain the international normalized ratio to between 2.5 and 3. This treatment is to be titrated against the risk of bleeding in high-risk patients but has to be continued for several weeks. However in a patient with obvious bowel infarction and peritonitis, surgical exploration without delay should be undertaken with resection of the involved bowel segment.

 Conclusion



Portomesenteric venous thrombosis is a condition where its presentation, treatment and outcomes still remain poorly understood. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation of splanchnic vasculature, and systemic thrombophilic states together results in this potentially lethal condition. This condition is more likely to be present in morbidly obese patients undergoing laparoscopic bariatric surgery. Prompt diagnosis and a high index of suspicion, is crucial for saving the patient's life. Because prothrombotic state is a well-known issue in morbidly obese patients, the importance of prompt initiation of adequate hydration and adequate preoperative thromboprophylaxis cannot be overemphasized.

References

1Salinas J, Barros D, Salgado N, Viscido G, Funke R, Pérez G, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy. Surg Endosc 2014;28:1083-9.
2James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. Portomesenteric venous thrombosis after laparoscopic surgery: A systematic literature review. Arch Surg 2009;144:520-6.
3Ogren M, Bergqvist D, Björck M, Acosta S, Eriksson H, Sternby NH. Portal vein thrombosis: Prevalence, patient characteristics and lifetime risk: A population study based on 23,796 consecutive autopsies. World J Gastroenterol 2006;12:2115-9.
4Webster GJ, Burroughs AK, Riordan SM. Review article: Portal vein thrombosis - New insights into aetiology and management. Aliment Pharmacol Ther 2005;21:1-9.
5Huerta S, Li Z, Livingston EH. Outcome of portal injuries following bariatric operations. Obes Surg 2006;16:105-9.
6Denne JL, Kowalski C. Portal vein thrombosis after laparoscopic gastric bypass. Obes Surg 2005;15:886-9.
7Johnson CM, de la Torre RA, Scott JS, Johansen T. Mesenteric venous thrombosis after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1:580-2.
8Goitein D, Matter I, Raziel A, Keidar A, Hazzan D, Rimon U, et al. Portomesenteric thrombosis following laparoscopic bariatric surgery: Incidence, patterns of clinical presentation, and etiology in a bariatric patient population. JAMA Surg 2013;148:340-6.
9Haddad MC, Clark DC, Sharif HS, al Shahed M, Aideyan O, Sammak BM. MR, CT, and ultrasonography of splanchnic venous thrombosis. Gastrointest Radiol 1992;17:34-40.
10Rosenberg JM, Tedesco M, Yao DC, Eisenberg D. Portal vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity. JSLS 2012;16:639-43.