Raman Krimpuri, MD, Christopher McHenry, MD, ViceChairman of Surgery, Christopher Brandt, MD, Chairman of Surgery, Jeffrey Claridge, MD, Sergio Bardaro, MD, Director Metabolic Bariatric Surg. MetroHealth Medical Center – Case Western Reserve University
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a fast growing option for morbidly obese patients. LSG has proven to be an effective procedure with a low rate of complications. However, an increasing number of cases of portomesenteric venous thrombosis (PMVT) are being reported in the literature.
The aim of this presentation is to emphasize the presence of subtle clinical presentation and the importance of early recognition and treatment of PMVT.
CASE REPORT: We present a 44yo female (BMI 40.8) with history of hypertension, OSA and a long history of oral contraceptive use. She underwent an uneventful LSG. Received peri-operative pharmacological thromboprophylaxis, intra and post-operative SCDs and early ambulation. On POD 11, she presented to the ER with throbbing mid epigastric and back pain for 3 days. Pain worsened over the last 24 hours. One episode of non-bilious emesis, nausea and poor PO intake was reported. She was conservatively managed with symptom improvement and discharged.
48 hours later, she returned with recurrent symptoms. Abdominopelvic CT scan showed superior mesenteric vein thrombosis and a partially occlusive thrombus of the main portal vein with no signs of bowel ischemia. Physical exam was without peritoneal signs. The patient was adequately resuscitated including anticoagulant therapy. Her symptoms completely resolved within 72 hours and she remained asymptomatic with diet. On HD 6, she was discharged on anticoagulation therapy for 6 months. Hematological prothrombotic work-up performed was negative.
DISCUSSION: PMVT is a rare complication but literature has shown when it comes to bariatric surgery, it is more commonly reported with LSG. Clinical presentation is usually subtle and suspicion should rise early. It is crucial to have a high index of suspicion to perform early diagnosis and treatment. Identification of risk factors with clinical history should lead to a low threshold for clinical suspicion. In the absence of any prothrombotic disease and despite receiving appropriate peri-operative thromboprophylaxis, our patient developed PMVT. Inferring that further discussion is needed to establish improved peri-operative prophylaxis guidelines in order to prevent potential life threatening sequelae.
CONCLUSION: Subtle signs and symptoms and the infrequency with which PMVT is encountered makes it a diagnostic challenge. Familiarity with PMVT is critical for prompt diagnosis and treatment. Demonstrating the importance of examining the likelihood of PMVT and its dangerous manifestations when developing differential diagnosis. Thus, having a high index of suspicion may result in early recognition and action, potentially preventing unforeseen consequences.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80174
Program Number: P538
Presentation Session: Poster (Non CME)
Presentation Type: Poster