Thrombus Trifecta: A Laparoscopic Sleeve Gastrectomy Complication


We describe a case of generalized, extreme, colicky abdominal pain after laparoscopic sleeve gastrectomy in which the patient developed thrombosis in the portal vein, superior mesenteric vein, and splenic vein visualized with computed tomography (CT) imaging. The case was treated with the standard of care, which is anticoagulation and/or surgery, both of which were used in this case.

introduction

In laparoscopic sleeve gastrectomy (LSG), the great curve and fundus of the stomach are removed; The partial gastrectomy is oriented vertically, parallel to the lesser curvature of the stomach. The procedure causes restrictive weight loss [1]. The portal vein is formed by the confluence of the splenic and superior mesenteric veins, which drain the spleen and small intestine, respectively. Occlusion of the portal vein by a thrombus typically occurs in patients with acquired diseases (such as cirrhosis, hepatocellular carcinoma, myeloproliferative diseases, antiphospholipid syndrome, paroxysmal nocturnal hemoglobinuria, and recent pregnancy) and/or prothrombotic diseases (such as Factor V Leiden, prothrombin) for gene mutations, protein C or S deficiency and antithrombin deficiency).

case presentation

A 40-year-old man presented to the emergency department with pain and vomiting from an uncomplicated LSG two weeks previously. The patient confirmed severe mild epigastric abdominal pain that worsened over two days, inability to eat without immediate vomiting, and multiple bouts of nonbloody diarrhea. Vital signs were within normal limits and pain was rated 10/10. The patient appeared alert and oriented, visibly anxious and in mild distress. His abdomen was diffusely tender, with severe epigastric tenderness and mild ascites.

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In this case, abdominal and pelvic computed tomography (CT) with IV and oral contrast agent (according to local bariatric protocol due to recent LSG) showed complete portal vein thrombosis (PVT), partial splenic vein thrombosis, and superior mesenteric vein thrombosis (Figure 1). The patient was anticoagulated with low molecular weight heparin (LMWH) and admitted to the medical center. Two days later, due to blood clots and deteriorating liver function tests, he was transferred to the surgical department of a regional medical center for vascular surgery. A transjugular intrahepatic portosystemic shunt (TIPS) was performed (Fig 2) and a large amount of the clot was removed (Fig 3). Follow-up tests for hereditary coagulation disorders were negative.

Transjugular-intrahepatic-portosysetmic-shunt-procedure-performed-with-fluoroscopy

coagulation load removed

discussion

Although rare after bariatric surgery, PVT is most common after LSG. In a study of over 5700 patients undergoing laparoscopic bariatric surgery, 17 had thrombosis, 16 of whom underwent gastric sleeve surgery [2].

In a study of nearly 24,000 autopsies in Sweden performed from 1970 to 1982, the prevalence of PVT was 1% without LSG [3]. PVT decreases hepatic venous outflow while preserving arterial inflow, which can lead to complications such as intestinal ischemia, portal hypertension, and portal cholangiopathy [4]. As in this patient, liver tests are typically normal as hepatic arterial blood flow compensates for decreased portal influence [5].

The primary treatment for acute PVT is anticoagulation and, when possible, treatment of predisposing diseases. Anticoagulation is recommended for LMWH. Several case reports have documented the successful lysis of acute PVT with streptokinase or tissue plasminogen. Other successful modalities include thrombectomy via the TIPS procedure [6]. TIPS placement reduces elevated portal pressure by creating a low-resistance channel between the hepatic vein and an intrahepatic branch of the portal vein. The typical indication is portal hypertension with complications such as variceal bleeding and ascites. TIPS is typically performed by interventional radiology.

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Conclusions

Abdominal pain is one of the most common complaints in the emergency room. The threshold for CT in these patients is often low. However, in the case of recent abdominal surgery, the threshold for a CT scan should be even lower. Although rare, PVT, as well as splenic and superior mesenteric vein involvement, can occur in patients without the above risk factors. It is advisable to take a thorough medical history and physical exam in all patients in order to provide the best possible medical care.





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