Portal-Mesenteric Thrombosis Following Laparoscopic Sleeve Gastrectomy A Rare but Potentially Serious Complication

Marcos Berry, MD, Patricio Lamoza, MD, Lionel Urrutia, MD, Alvaro Bustos, MD, Marco Schulz, MD, Eduardo Luna, MD, Macarena Haddad, MD. Clinica Las Condes.

Laparoscopic Sleeve Gastrectomy (LSG) has shown to be an effective surgical technique for obesity control and its associated co-morbidities, with comparable results to gastric bypass.
It has risks with associated morbidity and mortality from 0% to 1% according to different series.
Obese patients have a relative risk to develop venous thromboembolism (VTE) of 2.5 compared with non obese patients.
VTE represents the main cause of mortality in bariatric surgery. Porto-Mesenteric Thrombosis (PMT) in bariatric surgery has an incidence of 0.5 – 3% and a global mortality of 0.21%. Incidence of PMT in relation to LSG reaches up to 1%.
The objective of this study is to evaluate the incidence of PMT in a LSG series of patients and analyze their characteristics, risk factors, thrombosis extension and sequels.

Methods and Procedures:
Descriptive & retrospective study based on the analysis of a data base of consecutively LSG operated patients, by the same surgical team between April 2006 and August 2013.

Out of 1370 LSG, 4 patients developed PMT, Incidence 0.29%. Female / Male: 2 / 2, Mean Age 32 years old (22-38), Initial Weight 100.8 kg (87-126), Initial BMI 36 (32-42). Preop known risk factors: Contraceptive users 2, Smoke 3, DVT Family History 1, OR Time: 91 min (80 – 95), Conversions 0, DVT Prophylaxis all with enoxaparin 40 mg sc/day, Mean Hospital stay 3 days.
Abdominal pain 4, nausea/vomits 1. Post op presentation day: 15 (10-59), Images: Abdominal-pelvic CT Scan / Angio CT. Re-admission mean hospital stay 7.5 days (6-30). CT findings: Portal vein (PV) exclusive 1, PV extended to Splenic Vein(SpV) 1, PV extended to SpV + SMV 1, other findings: Intestinal segmental ischemia 1.Treatment:
NPO, Anticoagulant (heparin and/or enoxaparin): Successful 3, Failed in 1 (PVT extended to SMV patient and intestinal ischemia & Intestinal necrosis), Surgery: small bowel resection.
Follow Up: 12 months (3-24), all asymptomatic, AngioCT complete permeabilization in 4. Thrombophilia Study: Positive 2, Factor V Deficit in 1, Factor VIII Excess in 1, Negative 2.

Although PMT is a rare complication, it must be considered in the differential diagnosis of abdominal pain in the days or months following LSG. Prompt diagnosis is crucial to properly treat these patients and minimize morbidity. Thrombophilia is frequently identified as an underlying cause in our experience. LSG results are not affected in terms of weight loss in the midterm followup.

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