Bariatric Times

JUN 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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20 Case Report and Literature Review Bariatric Times • June 2017 DISCUSSION Portal vein thrombosis (PVT) can be a potentially devastating complication of laparoscopic surgeries, especially bariatric l aparoscopic surgeries. Portomesenteric thrombosis can lead to mesenteric ischemia or infarction which can be life threatening. 6 Common risk factors t hat may lead to acute PVT are myeloproliferative disease, Janus kinase 2 (JAK 2) positive gene mutation, antiphospholipid syndrome (an autoimmune disease w hich can cause frequent clotting in arteries and veins), hormonal contraception or replacement therapy use, along with a personal history or family history of DVT. 7 L ocal factors, like acute pancreatitis, cholecystitis, or cholangitis, liver abscesses, or gastritis have also been found to be more common risk factors of PVT. 7 P VT have been identified as possible complications of laparoscopic adjustable gastric banding and laparoscopic Roux-en- Y gastric bypass surgeries. 6,8–13 There h ave been an increasing number of case reports about PVT following laparoscopic sleeve gastrectomies (LSG), which may be due to the increasing popularity of LSG. 6,14,15 R ecently , Salinas et al completed a retrospective analysis of 1,713 LSGs and reported a one-percent incidence of portomesenteric vein thrombosis (PMVT). 16 LSG p rocedures have been found to be associated with a lower 30-day risk adjusted serious morbidity compared to laparoscopic gastric bypass and an equivalent 30-day m ortality; which may in part explain its increasing popularity. 15 More commonly, possible complications of LSG include: staple line leaks, pulmonary embolism, DVTs, r espiratory insufficiency, hemorrhage, stricture, and splenic injury. 6,15 The vast majority of cases of PMVT that have been reported occur following LSG, and not l aparoscopic gastric bypass surgery, potentially indicating that this particular complication may be procedurally related. 17 Case reports of PVT in the b ariatric population continue to note the importance of clinical suspicion when faced with a potential PVT in a recent operative patient given their non-specific p resentations. 1 4,18 M ost patients tend to present with vague abdominal pain, diarrhea, or constipation, nausea, and vomiting, which are similar to the symptoms that g enerally follow major bariatric surgery. 4,6,18 Some surgeons have begun listing PVT as a formal complication of bariatric surgery and have begun to include it in the differential diagnosis for abdominal pain following bariatric surgery. 14 The etiology of PVT can be divided into local and systemic causes, some of which can be controlled. 6,19 Surgical manipulation of the portomesenteric vessels has been known to predispose patients to PVT, and can be avoided with good surgical technique. 6 Portal venous flow during the procedure is affected inversely by increased intraabdominal pressure with carbon dioxide pneumoperitoneum. 4 It is suspected that this inverse relationship may contribute to the prothrombotic state in the portomesenteric circulation, but it is unclear what intra-abdominal pressure level needs to be reached before this change in flow becomes clinically significant. 4,6 Other factors that may contribute to increased prothrombotic state during LSG are the pro-inflammatory state associated with baseline obesity, visceral vasoconstriction secondary to intraoperative release of vasopressin, steep reverse Trendelenburg position, and retained CO2 causing increased portal pressure. 4,6 In particular, this patient's continued use of oral contraceptive pills after her surgery may have also contributed to her pro-coagulable state. 4 OUR SURGICAL TECHNIQUE For VTE (venous thromboembolic complications) prophylaxis, 5,000 units of unfractionated heparin is injected subcutaneously on the morning of the surgery. Following surgery, LMWH is continued during the patient's hospitalization. Sequential compression devices are also used

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