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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18 Case Report and Literature Review Bariatric Times • June 2017 INTRODUCTION Obesity is epidemic in the United States and worldwide. The adverse effects of obesity on health and longevity were formally recognized and established by the National Institutes of Health in 1985. 1 Metabolic and bariatric surgery have been shown to be safe, and remain the most effective and durable treatments for clinically severe obesity with a documented reduction in all-cause mortality and long-term survival benefit. 2 Laparoscopic Roux-en-Y gastric bypass (RYGB) was the most common bariatric procedure performed in the United States from 2004 to 2012, after which sleeve gastrectomy (SG) became the most common procedure. 3 Laparoscopic sleeve gastrectomy was originally designed as the first step procedure in a duodenal switch or a Roux-en-Y gastric bypass procedure, but has gained popularity as a stand-alone procedure given its similar results in weight loss and resolution in comorbid conditions. 4 As worldwide obesity rates and, in turn bariatric procedures increase, complications of these surgeries are being reported in the literature. Venous thromboembolism (VTE) is one of the most common postoperative complications following bariatric surgery, with deep venous thrombosis (DVT) being the most common etiology, followed by pulmonary embolism. 5 In 2013 the American Society of Metabolic and Bariatric Surgeons (ASMBS) issued an update on prophylactic measures to reduce the risk of VTE in bariatric patients. CASE REPORT A 36-year-old Caucasian woman with a history of a recent laparoscopic sleeve gastrectomy (weight: 162.478kg, body mass index [BMI]: 58.96kg/m 2 ) and hiatal hernia repair with anterior cruroplasty in late 2015 presented to the emergency department three weeks following surgery with increasing abdominal pain. She also complained of mustard brown diarrhea, dark urine, weakness, and fatigue; her remaining review of systems was negative. Her past medical history was significant for asthma, obstructive sleep apnea (treated with continuous positive airway pressure by BRYCE M. BLUDEVICH, MS-IV; SEAN M. WRENN, MD; and WASEF ABU-JAISH, MD, FACS, FASMBS Bariatric Times. 2017;14(6):18–22. Massive Portal Vein Thrombosis Three Weeks Following Laparoscopic Sleeve Gastrectomy ABSTRACT The authors present a case of portal vein thrombosis three weeks postoperatively following a laparoscopic sleeve gastrectomy, which was also complicated by a concurrent episode of diverticulitis. They discuss the case and provide a review of the l iterature pertaining to postoperative portal vein thrombosis, a rare and potentially fatal complication that can follow bariatric surgery. They retrospectively review the case as compared to others reported in the literature and conclude that alarmingly vague presenting symptoms of abdominal pain, diarrhea, or constipation, nausea, and vomiting are similar throughout. The authors conclude that both physicians and patients should be made aware of the possible complication of portal venous thrombosis, and the potential symptoms. They conclude that further study is needed to determine if the standard of care anticoagulation given to bariatric patients is sufficient to prevent possible venous thromboembolisms or if the surgical technique used to complete a sleeve gastrectomy needs to be standardized. Additionally, further study should focus on increasing the length of anticoagulation therapy post-operation, along with identifying the most effective anticoagulant agent. KEYWORDS Laparoscopic sleeve gastrectomy, portal vein thrombosis, diverticulitis, morbid obesity View the accompanying video at http://casereports.metabolicsurgery.tv/ Exclusive Digital Content FIGURE 1. Coronal computed tomography image with intravenous and oral contrast of patient demonstrating extensive acute portal vein thrombosis (red arrow). No extraluminal extravasation of enteric contrast was appreciated within the gastric sleeve. Inflammatory changes in the pelvis secondary to sigmoid diverticulitis were also noted (yellow arrow) with secondary pelvic abscess (not pictured). FIGURE 2. Postoperative day one upper gastrointestinal fluoroscopic swallow study demonstrating passage of contrast through the gastric sleeve conduit without contrast extravasation.