Anne-Marie Carpenter, BS, Alexander L Ayzengart, MD, MPH. University of Florida
INTRODUCTION: Bariatric surgery is the most effective treatment for morbid obesity. Of all available procedures, laparoscopic sleeve gastrectomy (LSG) is now the most popular worldwide. Common complications of LSG include gastroesophageal reflux, stricture, and staple-line leak. Although rare, portomesenteric venous thrombosis (PMVT) and liver retractor-induced injuries are increasingly reported. We present a case of isolated left portal vein thrombus after routine LSG that was likely caused by prolonged compression of left liver lobe by the Nathanson retractor.
CASE PRESENTATION: A 55-year-old female with a BMI of 39 and biliary colic due to cholelithiasis underwent LSG with hiatal hernia repair and cholecystectomy. She tolerated the procedure without complication and was discharged home on the following day. On postoperative day 9, she presented to the emergency department with fever and epigastric pain. Contrast CT revealed an isolated filling defect within the proximal left portal vein; abdominal Doppler demonstrated an acute thrombus occluding the left portal vein with normal flow in the main and right portal veins. The patient was treated with a 3-month course of therapeutic anticoagulation with lovenox. A complete hematologic workup did not uncover any hypercoagulable conditions. The patient recovered well and remained asymptomatic at her follow-up visit 12 weeks after operation.
DISCUSSION: PMVT is a rare surgical complication with multifactorial etiology. In bariatric surgery, evidence suggests LSG elicits more frequent PMVT compared with Roux-en-Y gastric bypass. A 2017 systematic review cited the incidence rate of PMVT as 0.3-1% after LSG. The mechanisms are thought to be due to pneumoperitoneum, procoagulant obese state, manipulation of portomesenteric venous system during division of the gastrocolic ligament, and postoperative dehydration. Liver retraction is paramount during laparoscopic bariatric surgery to provide adequate visualization of the upper stomach and diaphragmatic hiatus. Most methods of liver retraction produce significant pressure on the liver parenchyma by compressing it against the diaphragm. Three types of liver injury have been documented in literature: minor congestion, traumatic parenchymal rupture, and delayed liver necrosis. Uniquely, we propose an additional type of injury – left portal vein thrombosis due to compression of left liver lobe with the Nathanson retractor.
CONCLUSION: The case described herein represents the first documented report of isolated left portal vein thrombosis after LSG. This is a unique presentation of retraction-related liver injury causing PMVT by mechanical compression of liver parenchyma. As surgical procedures increase in duration, intermittent release of liver retraction should be performed at regular intervals.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85096
Program Number: P579
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster