Portomesenteric thrombosis after bariatric surgery in the Pan-Arab region

Abstract

Background: Bariatric surgery has been shown to be the most effective method to treat morbid obesity and obesity-related comorbidities compared to intensive medical therapy. However, bariatric surgery is not without complications. Some rare complications after bariatric surgery are underestimated. One of these rare complications is portomesenteric thrombosis (PMT). We herein examine the prevalence of PMT after bariatric surgery in the Pan-Arab region. Methods: We sent a questionnaire to the members of the Pan-Arab Bariatric Society for Metabolic and Bariatric Surgery in 2014. This is a group that started on social media in 2012, that represents surgeons practicing in the following countries: United Arab Emirates (UAE), Kingdom of Saudi Arabia (KSA), Qatar, Bahrain, Oman, Kuwait, Egypt, Iraq, Palestine, Jordan, and Lebanon. The questionnaires were sent by email and placed on a link on the Facebook page of the group, and reminders were sent through social media to the members of the group and in our monthly Tele-video conference meeting. All data of procedures carried out in the Pan-Arab region were included. Any procedures performed outside the region were excluded. Results: We sent 77 and received back 18 completed questionnaires (23.4%). The data represent 21 surgeons from 13 hospitals in 9 countries (Iraq, Palestine, UAE, Qatar, Lebanon, Jordan, KSA, Egypt, Kuwait). Data for patients operated in Austria and in the United States were excluded. We received no responses from Bahrain, Iraq, or Oman. The total number of cases performed was 13,274, 9% laparoscopic adjustable gastric banding, 68% laparoscopic sleeve gastrectomy (LSG), 17% laparoscopic Roux-en-Y gastric bypass, 3% one anastomosis gastric bypass/mini gastric bypass, 1% laparoscopic greater curvature plication, 1% biliopancreatic diversion, and 2% others. Our surgeons encountered 30 PMT cases (0.23%). PMT was in both the portal and mesenteric veins in 57% of patients. The rest was observed in either the portal or mesenteric veins. History of travel was found to be associated with PMT in 7/30 [23%]. PMT cases were observed after all procedures, however, mostly after LSG 25/30 (83%). Our practice of deep vein thrombosis prophylaxis is quite variable before and after surgery in different countries. However, most patients with PMT received anticoagulation for less than a week (1–6 days and most of them were on unfractionated heparin 2–3 times/day, or low molecular weight heparin 40 mg once daily during their hospital stay). All patients with PMT complained of abdominal pain in the first 1 to 4 weeks after surgery. Computed tomography scan detected PMT in all except one patient, who was diagnosed by abdominal ultrasound. Two patients required surgical resection of the small bowel and all others were treated medically with anticoagulation. There were no mortalities. Conclusion: PMT is an uncommon complication after bariatric surgery. However, a high index of suspicion is needed to detect this complication. It is most commonly observed after LSG outcome with appropriate intervention is favorable. Majority of patients can be treated without surgical intervention.