MSS 2020 FALL ePOSTER
PORTAL VEIN THROMBOSIS FOLLOWING LAPAROSCOPIC SLEEVE GASTRECTOMY
Dhami, Jaya BS; Abdelwahab, Hisham; Harmon, James MD PHD; Leslie, Daniel MD; Wise, Eric MD MA.
University of Minnesota
Poster Presenter: Jaya Dhami, BS
University of Minnesota
Introduction/Objective: Portal vein thrombosis is a rare documented and life threatening complication of laparoscopic sleeve gastrectomy.
Case Presentation: We present a 34 year-old female with history of obesity (BMI 36), pre-diabetes, hyperlipidemia (HLD), and polycystic ovary syndrome (PCOS) on oral contraceptive pills (OCPs) post laparoscopic sleeve gastrectomy (LSG). On post-operative day (POD) ten, she developed severe postprandial lower abdominal pain with associated nausea, vomiting and diarrhea. Her labs in the emergency department the following day showed a white blood cell count of 12,000 per microliter, and mildly elevated liver function tests. A computed tomography (CT) scan showed a portal vein thrombosis (PVT). OCPs were discontinued and anticoagulation with enoxaparin and then transitioned to IV heparin. She developed RUQ pain on admission day 2. Repeat CT scan demonstrated hemoperitoneum and multiple heterogeneously hyper-dense subcapsular lesions most suspicious for hematomas in the liver. Her serum hemoglobin dropped. Heparin was held until CT angiogram confirmation of lack of extravasation, as well as stabilization of her hemoglobin. She was discharged on POD 19 on a three-month course of therapeutic enoxaparin, with interval resolution of the portal vein thrombosis on follow-up CT scan at two months.
Discussion: PVT is a potentially lethal complication with anatomic local (e.g. trauma surgical and non-surgical) and systemic risk factors (e.g. inflammatory state, sepsis) (Quarrie et al). In a retrospective analysis by Salinas et al 17 out of 1,713 LSG patients developed PVT, about 1%. Our patient’s risk factors included a high BMI of 36, HLD, OCPs, LSG surgery itself and decreased mobilization. One review study showed that OCPs were present in 20% of PVT cases post LSG (Shaheen et al). Moon et al. reported that Type 2 DM was also associated with increased risk of PVT. As seen with this patient, the most common presenting symptom is abdominal pain, primarily epigastric; however, in others pain was diffuse according to Shaheen et al. These authors also report nausea as the second most common symptom, with or without vomiting. Median time to presentation varied in literature. A systematic review of 104 patients by Karaman et al, reported mean presentation at 2 weeks post-op. Of note, our patient was not provided with anticoagulation after her LSG nor were her OCPs stopped. One case report and systematic review stated “anticoagulation prophylaxis with low-molecular weight heparin (LMWH) should be considered at least one month postoperatively” (Karaman et al). Thrombophilia workup was not performed on our patient as her PVT was considered provoked; however,
some studies have shown evidence of thrombophilia in similar cases and could be a consideration for the future.
Conclusion: PVT is a rare but recognized complication of LSG, and should be on the differential for any patient with postoperative abdominal pain. There are multiple recognized risk factors, and presentations can be vague. Further research is needed for clear guidance to identify patients at increased risk for this complication and possible anticoagulation therapy postoperatively. This patient had a Caprini score of 5 with recommendations for anticoagulation prophylaxis for 7-10 days and 1.8% VTE risk. Failure to treat PVT can lead to ischemia or infarction of the bowel. This can lead to intestinal perforation, peritonitis, shock, multiorgan failure, and death (Kumar et al).
- Author(s) Dhami, Jaya BS; Abdelwahab, Hisham; Harmon, James MD PHD; Leslie, Daniel MD; Wise, Eric MD MA.
- Program University of Minnesota
- Category Bariatric Surgery | Education Science
- Presentation Type ePoster