Portomesenteric Vein Thrombosis Research Articles

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates

BackgroundVenous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days. ObjectivesEvaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis. SettingUniversity Hospital. MethodsBetween 2012–2018, SG patients were discharged on extended chemoprophylaxis for patients deemed “high-risk” for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018–2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed. ResultsA total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively. ConclusionsRoutine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

Portomesenteric Vein Thrombosis in Patients Undergoing Sleeve Gastrectomy: an Updated Systematic Review and Meta-Analysis of 101,914 Patients.

Portomesenteric vein thrombosis (PMVT) is a rare but potentially fatal complication of sleeve gastrectomy (SG). The rising prevalence of SG has led to a surge in the occurrence of PMVT, while the associated risk factors have not been fully elucidated. This study aims to determine the incidence and risk factors of PMVT in patients undergoing SG. A comprehensive literature search was performed in PubMed and EMBASE databases. Proportion and regression meta-analyses were conducted. In a total of 76 studies including 101,914 patients undergoing SG, we identified 357 patients with PMVT. Mean follow-up was 14.4 (SD: 16.3) months. The incidence of PMVT was found to be 0.50% (95%CI: 0.40-0.61%). The majority of the population presented with abdominal pain (91.8%) at an average of 22.4 days postoperatively and PMVT was mainly diagnosed with computed tomography (CT) (96.0%). Hematologic abnormalities predisposing to thrombophilia were identified in 34.9% of the population. Advanced age (p=0.02) and low center volume (p <0.0001) were significantly associated with PMVT, while gender, BMI, hematologic abnormality, prior history of deep vein thrombosis or pulmonary embolism, type of prophylactic anticoagulation, and duration of prophylactic anticoagulation were not associated with the incidence of PMVT in meta-regression analyses. Treatment included therapeutic anticoagulation in 93.4% and the mortality rate was 4/357 (1.1%). PMVT is a rare complication of sleeve gastrectomy with an incidence rate <1% that is associated with low center volume and advanced age but is not affected by the duration or type of thromboprophylaxis administered postoperatively.

A113 Routine Extended (30 days) Chemoprophylaxis for Patients Undergoing Laparoscopic Sleeve Gastrectomy May Reduce Portomesenteric Vein Thrombosis Rates

A113 Routine Extended (30 days) Chemoprophylaxis for Patients Undergoing Laparoscopic Sleeve Gastrectomy May Reduce Portomesenteric Vein Thrombosis Rates

A116 Long-Term Follow Up of a Series of Patients who developed Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy; Defining the Optimal Treatment Strategy

A116 Long-Term Follow Up of a Series of Patients who developed Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy; Defining the Optimal Treatment Strategy

A157 Porto-Mesenteric vein thrombosis after bariatric surgery: a six-year review at our institution

A157 Porto-Mesenteric vein thrombosis after bariatric surgery: a six-year review at our institution

Interventional Approach to Portal Vein Thrombosis and Liver Transplantation: State of the Art.

Porto-mesenteric vein thrombosis (PVT) is a well-recognized but uncommon disease entity in patients with and without cirrhosis. Given the complexity of these patients, there are many differing treatment algorithms depending on the individual circumstances of a given patient. The focus of this review is primarily patients with cirrhosis, with an emphasis on liver transplantation considerations. The presence of cirrhosis substantially affects work-up, prognosis, and management of these patients and will substantially affect the patient treatment and have additional implications for prognosis and long-term outcomes. Here, we review the incidence of portal vein thrombosis in known cirrhotic patients, medical and interventional treatment options that are currently used, and, in particular, how to approach cirrhotic patients with PVT who are awaiting liver transplantation.

The Role of Thromboprophylaxis in Patients with Portal Vein Thrombosis: A Life-Threatening Complication after Laparoscopic Sleeve Gastrectomy Following 8 Years of Experience in a Bariatric Center of Excellence

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Independent predictors and timing of portomesenteric vein thrombosis after bariatric surgery.

Portomesenteric vein thrombosis (PVT) is a rare complication following bariatric surgery but can result in severe morbidity as well as death. Identification of risk factors for PVT to facilitate targeted management strategies to reduce incidence. Prospective, statewide bariatric-specific clinical registry. We identified all patients who underwent primary bariatric surgery between June 2006 and November 2021 (n = 102,869). Patient characteristics, procedure type, operative details, and 30-day postoperative complications were analyzed with multivariable logistic regression to evaluate for independent predictors of PVT. A total of 117 patients (.11%) developed a postoperative PVT, with 6 (5.1%) associated deaths. The majority of PVTs occurred in patients who underwent sleeve gastrectomy (109 patients; 93.2%), and the PVT occurred most commonly during the second (37%), third (31%), and fourth weeks (23%) after surgery. Independent risk factors for PVT included a prior history of venous thromboembolism (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.64-5.98; P = .0005), liver disorder (OR = 2.3; 95% CI: 1.36-4.00; P = .0021), undergoing sleeve gastrectomy (OR = 12.4; 95% CI: 4.98-30.69; P < .0001), and postoperative complications including obstruction (OR = 12.5; 95% CI: 4.65-33.77; P < .0001), leak (OR = 7.9; 95% CI: 2.76-22.64; P = .0001), and hemorrhage (OR = 7.6; 95% CI: 3.57-16.06; P < .0001). Independent predictors of PVT include a prior history of venous thromboembolism, liver disease, undergoing sleeve gastrectomy, and experiencing a serious postoperative complication. Given that the incidence of PVT is most common within the first month after surgery, extending postdischarge chemoprophylaxis during this time frame is advised for patients with increased risk.

Venous Thromboembolism Prophylaxis in Inflammatory Bowel Disease Inpatients: Systematic Review and Meta-Analysis

Background: Inflammatory bowel disease (IBD) patients are three times more likely to develop venous thromboembolism (VTE) compared to the general population, especially during disease flares and while hospitalized. Current guidelines recommend prophylaxis during all hospitalizations, though data are sparse. In this systematic review and meta-analysis, we sought to pool all existing data on the efficacy and safety of VTE prophylaxis in hospitalized IBD patients. Methods: We performed a systematic review and meta-analysis. We searched MEDLINE and other databases up to 2/2022, for studies reporting on hospitalized IBD patients (both adult and pediatric, in medical or surgical wards), who were treated with non-therapeutic dose anti-coagulation during hospitalization, compared to no prophylaxis. Our primary efficacy outcome was any VTE (deep vein thrombosis, portomesenteric vein thrombosis, catheter-related thrombosis, and pulmonary emboli), and the primary safety outcome used was major bleeding. Results were pooled using a random-effects model meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Risk of bias was assessed with the ROBINS-I tool and the Cochrane Collaboration's tool for randomization method. Results: We were able to extract data from 18 observational studies, and 2 subgroups from randomized trials, published between 2003 and 2021. The studies were highly variable regarding the study populations, interventions, and outcome definitions, as well as methodological quality. Meta-analysis of all studies did not show a significant effect of prophylaxis on VTE events (OR 0.97 [95% CI 0.49-1.95]). A sensitivity analysis of 8 studies with moderate or lower risk of bias showed a statistically significant reduction in VTE events (OR 0.27 [95% CI 0.13-0.55), with a number needed to treat (NNT) of 35 (95% CI 26.8-49.8). Among studies with lower risk of bias, a significant protective effect of VTE prophylaxis persisted in subgroup analyses of long-term follow up VTEs (OR 0.24 [95% CI 0.08-0.69]), of adult patients only (OR 0.27 [95% CI 0.12-0.61]), and of a mixed population of surgical and medical patients (OR 0.37 [95% CI 0.19-0.74]). Major bleeding was reported in three studies classified with moderate or lower risk of bias, and meta-analysis showed a significantly increased risk in the prophylaxis group (OR 2.02 [95% CI 1.11-3.67], number needed to harm (NNH) of 114 (95% CI 40.7-very large number). Discussion: The main analysis did not show a reduction in VTE events in hospitalized IBD patients treated with prophylaxis. However, in studies with lower risk of bias, a protective benefit of prophylaxis consistent across several subgroups was shown (NNT=35), which should be carefully considered against an increased risk of major bleeding (NNH=114). Currently available data is limited, and mostly retrospective, and randomized controlled trials dedicated to hospitalized IBD patients are needed before universal VTE prophylaxis can be recommended. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Catheter-Directed Thrombolysis in the treatment of acute Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy

BackgroundPortomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient’s clinical details, radiological findings, safety, and efficacy are reported.Cases presentationTwo patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery.ConclusionPMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

A007 Independent Predictors and Timing of Portomesenteric Vein Thrombosis after Bariatric Surgery

A007 Independent Predictors and Timing of Portomesenteric Vein Thrombosis after Bariatric Surgery

CURRENT VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS PRACTICES AFTER SURGERY FOR IBD: SAVES-IBD TRIAL INITIAL REPORT

Abstract BACKGROUND Despite standard of care chemoprophylaxis, postoperative VTEs occur in ∼4% of IBD patients, and little data on current practices in IBD has been reported. We cultivated a baseline cohort to inform power calculations for a forthcoming prospective, multicenter trial of VTE prophylaxis comparing the efficacy &amp; safety of standard of care vs. aspirin (SAVES-IBD Trial). In this initial report we describe the current standard of care VTE prophylaxis practice patterns in our collaborative. METHODS The National Surgical Quality Improvement Program (NSQIP) IBD Collaborative designed and implemented 6 VTE specific-variables including 1) Inpatient VTE chemoprophylaxis, 2) extended (post-discharge) prophylaxis, 3) length of time on primary prophylaxis, 4) VTE location, and 30-days bleeding requiring 5) transfusion or 6) reoperation. Data was collected prospectively from Sept 2020 – Mar 2021. Patients age &amp;gt;18 undergoing elective or emergent colectomy or proctectomy with a post-op IBD diagnosis were included. Patients with VTE present at admission (n=10, 2.3%) were excluded. RESULTS Over 6-months, 434 patients from 13 centers were accrued; median 22 cases, IQR 18.5 – 28. Demographics: median age 41.5 years, 50% female, median BMI 24.7 kg/m2. Diagnoses: 263 (60.9%) Crohn’s vs. 169 (39%) UC/IBDu, while 359 (82.7%) and 75 (17.3%) patients underwent colectomy and proctectomy, respectively including 69 (15.9%) IPAAs and 256 (59.0%) ileostomies, and 21 (4.8%) emergency cases. IBD Medications: 237 (54.6%) biologics, 233 (53.7%) steroids, 51 (11.8%) immunomodulators. A total of 395 (91.4%) received inpatient chemoprophylaxis including LMWH in 236 (59.7%), UFH in 158 (40.0%), DOAC in 1 (0.3%), and aspirin (none), and no chemoprophylaxis in 37 (8.5%). Extended chemoprophylaxis was utilized in 209 (48.7%) and included LMWH in 179 (85.6%), DOAC in 18 (8.6%), aspirin in 7 (3.3%), and UFH in 5 (2.4%). Overall, bleeding complications occurred in 38 (8.8%) patients with 34 (8.4%) requiring transfusion and 9 (2.1%) needing reoperation. Postoperatively, VTEs were diagnosed in 19 (4.4%) patients. VTE locations: portomesenteric vein thrombosis 8 (42%), upper extremity 3 (15.8%) or lower extremity 3 (15.8%) DVT, pulmonary embolism 2 (10.5%), and other 3 (15.8%). Univariate analysis of risk factors is shown in Table 1. Patients with 0-2 risk factors had a VTE rate of 2.9%, while in those with &amp;gt;2 risk factors, 31.8% developed VTE (p&amp;lt;0.0001). CONCLUSION In this cohort of surgical IBD patients from IBD specialty centers, we observed a 2.3% rate of pre-operative, and a 4.4% rate of post-operative, VTE. These rates have informed the SAVES-IBD power calculations. We also observed that almost half of IBD surgery patients in these centers were prescribed extended chemoprophylaxis, most commonly with enoxaparin, rarely with aspirin. Validation of the prophylaxis variables is in-progress.

CURRENT VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS PRACTICES AFTER SURGERY FOR IBD: SAVES-IBD TRIAL INITIAL REPORT

Despite standard of care chemoprophylaxis, postoperative VTEs occur in ∼4% of IBD patients, and little data on current practices in IBD has been reported. We cultivated a baseline cohort to inform power calculations for a forthcoming prospective, multicenter trial of VTE prophylaxis comparing the efficacy & safety of standard of care vs. aspirin (SAVES-IBD Trial). In this initial report we describe the current standard of care VTE prophylaxis practice patterns in our collaborative. The National Surgical Quality Improvement Program (NSQIP) IBD Collaborative designed and implemented 6 VTE specific-variables including 1) Inpatient VTE chemoprophylaxis, 2) extended (post-discharge) prophylaxis, 3) length of time on primary prophylaxis, 4) VTE location, and 30-days bleeding requiring 5) transfusion or 6) reoperation. Data was collected prospectively from Sept 2020 – Mar 2021. Patients age >18 undergoing elective or emergent colectomy or proctectomy with a post-op IBD diagnosis were included. Patients with VTE present at admission (n=10, 2.3%) were excluded. Over 6-months, 434 patients from 13 centers were accrued; median 22 cases, IQR 18.5 – 28. Demographics: median age 41.5 years, 50% female, median BMI 24.7 kg/m2. Diagnoses: 263 (60.9%) Crohn’s vs. 169 (39%) UC/IBDu, while 359 (82.7%) and 75 (17.3%) patients underwent colectomy and proctectomy, respectively including 69 (15.9%) IPAAs and 256 (59.0%) ileostomies, and 21 (4.8%) emergency cases. IBD Medications: 237 (54.6%) biologics, 233 (53.7%) steroids, 51 (11.8%) immunomodulators. A total of 395 (91.4%) received inpatient chemoprophylaxis including LMWH in 236 (59.7%), UFH in 158 (40.0%), DOAC in 1 (0.3%), and aspirin (none), and no chemoprophylaxis in 37 (8.5%). Extended chemoprophylaxis was utilized in 209 (48.7%) and included LMWH in 179 (85.6%), DOAC in 18 (8.6%), aspirin in 7 (3.3%), and UFH in 5 (2.4%). Overall, bleeding complications occurred in 38 (8.8%) patients with 34 (8.4%) requiring transfusion and 9 (2.1%) needing reoperation. Postoperatively, VTEs were diagnosed in 19 (4.4%) patients. VTE locations: portomesenteric vein thrombosis 8 (42%), upper extremity 3 (15.8%) or lower extremity 3 (15.8%) DVT, pulmonary embolism 2 (10.5%), and other 3 (15.8%). Univariate analysis of risk factors is shown in Table 1. Patients with 0-2 risk factors had a VTE rate of 2.9%, while in those with >2 risk factors, 31.8% developed VTE (p<0.0001). In this cohort of surgical IBD patients from IBD specialty centers, we observed a 2.3% rate of pre-operative, and a 4.4% rate of post-operative, VTE. These rates have informed the SAVES-IBD power calculations. We also observed that almost half of IBD surgery patients in these centers were prescribed extended chemoprophylaxis, most commonly with enoxaparin, rarely with aspirin. Validation of the prophylaxis variables is in-progress.

Portomesenteric Venous Thrombosis in Patients after Laparoscopic Bariatric Surgery

Objective: Obesity has become a worldwide epidemic that is directly related to chronic tissue inflammation and impaired fibrinolysis, both of which lead to an increased risk of thrombosis. The management of complications after bariatric surgery is still a challenge. The study aims to report the incidence of portomesenteric venous thrombosis (PMVT) in patients undergoing bariatric surgery. Introduction: Bariatric surgery is the procedure of choice for the treatment of obesity type III. Despite the safe technique, the surgeon must be aware of the risks linked to laparoscopy such as the PMVT. Computed tomography (CT) with intravenous contrast was the imaging method of choice for diagnosis. Materials and Methods: We performed a retrospective analysis of 4790 patients from August 1999 to June 2020 was observed the incidence of PMVT in this group. Of all patients, 72.8% were female and 27.2% male. The mean age was 46.3 years (34 - 72) and the mean BMI before bariatric surgery was 41.4 kg/m2. Results: The study showed an incidence of PMVT of 0.12% (N = 6), portal vein thrombosis was of 0.10% (n = 5) and 0.03% of MVT (n = 1). Of these, 72.5% (n = 3473 patients) underwent laparoscopic gastric bypass, 23.6% (n = 1131 patients) were submitted to the laparoscopic sleeve gastrectomy and 3.8% (n = 186 patients) to other procedures. The mean postoperative hospital stay for bariatric surgery was 3.3 days. The average time of hospital stay of patients complicated with PMVT range from 5 to 14 days. No patient died of complications related to PMVT. Conclusion: Portomesenteric vein thrombosis is a rare presentation after laparoscopic bariatric surgery. However, it is a serious complication that has a high index of suspicion for making its diagnosis. Conservative treatment using anticoagulants and thrombolytics is effective, it should always be considered the main treatment option. However, these patients must be followed up in the long term, as late complications can occur in high numbers of patients.

Review of Our Experience Using Modified Staple Line Suturing Technique in Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgical method in recent years. Although LSG provides good outcomes, serious complications such as leakage, bleeding, and stenosis may develop postoperatively. Numerous staple line reinforcement methods have been used to reduce complications. Whether each one of these practices is effective remains controversial. Our study aims to assess outcomes and safety of modified (purse-string+oversewing) staple line suturing technique for patients who underwent LSG. A total of 505 patients who underwent LSG with modified staple line suturing technique between March 2018 and February 2021 were included in this retrospective study. Age, sex, body mass index, operation time, perioperative and postoperative 30-day complications were recorded in all patients. Of 505 patients (59.6% female) with a mean age of 37.6 years (minimum to maximum: 12 to 68 y) and median body mass index of 40.2 kg/m2 (minimum to maximum: 32 to 75 kg/m2) underwent LSG. LSG was performed as revision surgery in 17 (3.4%) patients. Five (1%) patients also underwent concomitant cholecystectomy. The mean operation time was 92 minutes (75 to 110 min) in our primary LSG cases. Operative complications included minor hepatic injury in 8 (1.6%) and anesthesia awareness in 3 (0.6%) patients. Postoperative complications included bleeding which occurred in 2 (0.4%) patients, portomesenteric vein thrombosis in 1 (0.2%), and minor wound infection in 3 (0.6%) patients. There was no leak, no stenosis, and no mortality. Sleeve gastrectomy with modified staple line suturing technique is an effective method and could be safely applied with low morbidity.

Portomesenteric venous thrombosis in a prophylactically anticoagulated obese patient after laparoscopic sleeve gastrectomy: a case report

BackgroundObesity is associated with an increased risk of morbidity and mortality, so weight reduction is important. Bariatric surgery is a well-tolerated approach for reducing body weight, with laparoscopic sleeve gastrectomy commonly performed. An uncommon and potentially fatal sequela of laparoscopic sleeve gastrectomy is portomesenteric vein thrombosis, which may result in severe bowel ischemia.Case reportA 32-year-old Middle Eastern obese man (body mass index 33) presented to the emergency department with severe, generalized abdominal pain 2 weeks after laparoscopic sleeve gastrectomy. Computed tomography of the abdomen and pelvis revealed extensive acute on chronic portosplenic and superior mesenteric vein thrombosis with associated small bowel ischemia. Laparoscopic exploration was converted to midline laparotomy and an extensive ischemic small bowel resection.ConclusionLaparoscopic sleeve gastrectomy carries a risk of both morbidity and mortality. Venous thromboembolism is a well-known risk of bariatric surgery, but portomesenteric vein thrombosis is also a rare but sometimes serious complication. A high index of suspicion for portomesenteric vein thrombosis to prompt early detection is essential in patients who have undergone laparoscopic sleeve gastrectomy to minimize complications and optimize outcomes. Uncertainty still remains around the optimal dose and duration of anticoagulation after laparoscopic sleeve gastrectomy.

Portomesenteric Vein Thrombosis after Bariatric Surgery: An Online Survey.

Portomesenteric vein thrombosis (PMVT) is a rare post-operative complication of bariatric procedures, occurring in between 0.3% and 1% of cases. A structured questionnaire consisting of 27 items was available online to members of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to investigate the occurrence of PMVT. A total of 89 bariatric surgeons from 61 countries participated. Twenty-six (29.21%) reported at least one case of PMVT (46.15% males; 53.84% females). The surgery most associated with PMVT occurrence was sleeve gastrectomy (84.6%), followed by Roux-en-Y gastric bypass (RYGB) (7.69%), and laparoscopic adjustable gastric banding (LAGB) (7.69%). The time gap between surgery and PMVT was 19.28 ± 8.72 days. The predominant symptom was abdominal pain in 96.15% of patients, followed by fever in 26.9%. Complete occlusion of the portal vein was reported in 34.6% of cases, with involvement of the portal system in 69%, extension to the superior mesenteric district in 23%, and extension to the splenic vein in two patients (7.7%). Our survey, which is the largest regarding PMVT to date, revealed a diffuse lack of standardization in the choice, duration, and dosing of prophylaxis regimens as well as treatment modalities, reflecting the literature gap on the topic.

Placement of a transjugular intrahepatic portosystemic shunt in addition to recanalization of acute and chronic portomesenteric vein occlusions - a retrospective evaluation.

BackgroundPortomesenteric vein thrombosis may be life-threatening due to bowel ischemia caused by venous stasis, or variceal bleeding caused by portal hypertension.PurposeTo evaluate the effectiveness and safety of recanalization combined with transjugular intrahepatic portosystemic shunt in acute and chronic portomesenteric vein thrombosis in patients with and without liver cirrhosis.Material and Methods21 consecutive patients (5 women, 16 men; mean 48 years) with portomesenteric vein thrombosis (8 acute, 13 chronic) treated at the Interventional Radiology department between March 2014 and September 2018 were retrospectively reviewed. The main portal vein was completely obliterated and the portomesenteric vein thrombosis extended into the superior mesenteric vein in all patients. The portomesenteric vein thromboses were recanalized transhepatically, a transjugular intrahepatic portosystemic shunt was inserted, thrombectomy was performed in acute portomesenteric vein thrombosis, and angioplasty with or without additional stenting was performed in chronic portomesenteric vein thrombosis.ResultsRecanalization was successful in 8/8 patients (100%) with acute portomesenteric vein thrombosis, and in 11/13 patients (85%) with chronic portomesenteric vein thrombosis. In 12 patients, blood flow was restored in one session. Several sessions were more frequently needed in patients with acute portomesenteric vein thrombosis compared to those with chronic portomesenteric vein thrombosis (p = 0.003). Re-occlusion occurred and was recanalized in 10/19 patients and was more frequent in patients with chronic (n = 8/11) than on those with acute (n = 2/8) portomesenteric vein thrombosis (p = 0.04). Adverse events occurred in five patients. There was no 30-day mortality.ConclusionRecanalization and insertion of a transjugular intrahepatic portosystemic shunt is safe and effective in patients with acute and chronic portomesenteric vein thrombosis with or without cirrhosis. Recanalization was more likely to stay patent in acute compared with chronic portomesenteric vein thrombosis.

Thrombophilia prevalence in patients seeking laparoscopic sleeve gastrectomy: extended chemoprophylaxis may decrease portal vein thrombosis rate

Portomesenteric vein thrombosis (PMVT) may occur after laparoscopic sleeve gastrectomy (LSG). Previous studies have shown that PMVT patients may have undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel in every LSG patient preoperatively. To estimate the thrombophilia prevalence in patients seeking LSG, and determine if extended chemoprophylaxis post LSG reduces PMVT. University hospital. Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at 2 high-volume accredited bariatric surgery centers. A positive panel included factor VIII >150%; protein C <70%; protein S <55%; antithrombin III <83%; and activated protein C resistance <2.13. Patients with a positive panel were discharged on extended chemoprophylaxis. PMVT rates and bleeding occurrences were recorded for LSG patients from August 2018 to March 2019 and were compared with a historic cohort of LSG performed from January 2014 to July2018. One thousand seventy-five patients seeking LSG had thrombophilia panel checked preoperatively. The cohort was 83% female; mean age and body mass index were 39.2 years and 43 kg/m2, respectively. Of the cohort, 52.4% (563/1075) had positive thrombophilia panel, including factor VIII elevation (91.5%), antithrombin III deficiency (6.0%), protein S deficiency (1.1%), protein C deficiency (.9%), and activated protein C resistance (.5%). Between January 2014 and July 2018, 13 PMVT were diagnosed among 4228 LSG (.3%) and there were 17 bleeding occurrences (.4%). After August 2018, one PMVT was diagnosed among 745 LSG (.1%) and there were 5 bleeding occurrences (.6%). The estimated thrombophilia prevalence in patients seeking LSG is 52.4%. The majority (91.5%) of these patients have factor VIII elevation. Extended prophylaxis may decrease PMVT postLSG.