Porto-Mesenteric Venous Thrombosis (PMVT) Following Laparoscopic Bariatric Surgery: Incidence, Clinical Presentation, Analysis of the etiology and Management in 1434 Cases

Abstract

Background: Porto-mesenteric venous thrombosis (PMVT) is a rare but severe surgical complication developing in patients who underwent laparoscopic bariatric surgery; with difficult diagnosis and potentially severe consequences due to higher risk of bowel infarction. Its clinical presentation, management, and sequelae remain poorly understood. We aimed to describe the incidence, clinical features, management and outcome, in patients with PMVT after laparoscopic bariatric surgery. Patients and methods: This was a retrospective analysis of patients who underwent laparoscopic bariatric surgery for morbid obesity between October 2014 and September 2016 who developed PMVT. Age, sex, body mass index(BMI), personal risk factors for thrombosis, family history of thrombosis, surgical technique, thrombo-embolic prophylaxis, primary surgery outcomes, clinical features and long term postoperative follow up findings were analyzed in this study. The diagnosis was established with an abdominal computed tomography (CT) scan as well as duplex ultrasound of the portal venous system. All patients received long- term anticoagulation. Results: Of 1434 patients who underwent laparoscopic bariatric surgery; 947 patients underwent laparoscope sleeve gastrectomy (LSG) while 487 underwent laparoscopic mini-gastric bypass (LMGBP). 4 patients of those who underwent LSG (0.42%) developed PMVT. On the other hand no patients experienced PMVT following LMGBP. Three patients were males, the mean age was 34 years, and the mean body mass index was 43 kg/m2. The time of onset of symptoms was within one to two weeks post operatively in 3 cases while one case (the female patient) presented late after 86 days and the presentation was atypical and rapidly progressive and the patient died within two weeks. New-onset epigastric pain was present in all patients, while other signs and symptoms were variable. Ultrasonography and computed tomography scan were performed and were diagnostic in all cases. The decision regarding the type of drug and the duration of anticoagulation therapy was based on hematology consultant assessment as regards patients’ clinical course, result of thrombophilic evaluation, presence of other thrombotic risk factors and follow-up Doppler studies. One patient underwent surgical intervention: laparotomy with splenectomy and necrotic small-bowl resection. One patient died. Conclusion: PMVT is a rare but serious complication after LSG. Familiarity with this dangerous entity is important. It requires early diagnosis and management as these cases carry significant morbidity and mortality. Prompt diagnosis and anti- coagulation therapy led to favorable outcomes in most cases. Significantly lower rates of thrombosis were found in patients who received an extended course of anticoagulation.