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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21 Case Report and Literature Review Bariatric Times • June 2017 t hroughout surgery and following surgery. A second generation cephalosporin is also given prophylactically before surgery, and continued for 24 hours following s urgery. After the patient is prepped, draped, and trocars are placed; the patient is placed in slight reverse Trendelenburg position. Creation of p neumoperitoneum of 15mmHg then occurs and the liver is retracted with a liver retractor. The gastroesophageal (GE) junction is inspected for possible hiatal hernia, and the pylorus is identified. Dissection of the stomach from the greater omentum up to the GE junction then occurs. The left crus of the diaphragm at the GE junction is identified to ensure complete mobilization of the gastric fundus. In this case the peritoneum covering over the left crus, as well as the right crus was taken down and the hernia sac was dissected. The esophagus was freed from nearby connective tissue and mobilized with confirmation of about 3cm intraabdominally. The hernia sac was excised together with a Murphy's esophageal fat pad. The 40-French ViSiGi 3D ™ (Boehringer Laboratories Inc., Phoenixville, Pennsylvania) bougie was then advanced under direct vision until the proximal pyloric channel, secured against the lesser curvature of the stomach and placed to suction. Hiatal hernia repair was completed by approximating the 2 crus anteriorly, anterior cruroplasty, using interrupted #1 figure-of-eight Ethibond (Ethicon, Inc., Cincinnati) one sutures while the bougie in place. The integrity of the repair was tested and confirmed to be tight enough, but without compressing the esophagus. Insertion of the transoral bougie occurs, followed by vertical transaction of the stomach to create the gastric sleeve. Imbrication of the stable line is followed by the removal of the bougie. After testing the staple, a drain is placed and closure of the skin follows. The definitive diagnosis of PVT can be made with non-invasive imaging, such as PO contrast enhanced CT abdomen imaging a nd/or color Doppler ultrasonography. Our patient received both of these imaging modalities, along with magnetic resonance angiogram (MRA) to m onitor the stability of her clot. Currently, no randomized control trials have been completed in the bariatric surgery population to determine the ideal c hemoprophylaxis anticoagulation protocol for this patient population. 4 The routine chemoprophylaxis protocol used by many institutions continues to follow the protocol created by Carmody et al, 20 which was instituted in 1998 and includes a preoperative injections of 5,000 units of subcutaneous heparin and a daily injection of 40 units of LMWH following completion of the procedure. 4 Following the diagnosis of an acute PVT, previously recommended treatment algorithms have included systemic therapeutic anticoagulation in stable, non- cirrhotic patients along with treatment of any possible predisposing conditions. The suggested duration of anticoagulation was 6 to 12 months depending on the extent of the thrombus. 6 However, these treatment algorithms remain in debate regarding optimum medical management of postoperative patients with acute PVT. While treatment of PVT is essential, modifying risk factors prior to bariatric surgery may also be helpful. Factors associated with a high risk of VTE include: older age, elevated BMI, prior history of VTE, male gender, long procedure time (>3 hours), and procedure type (Duodenal switch > open gastric bypass > laparoscopic sleeve gastrectomy). 6,4 Prolonging post- procedure anticoagulation in patients with many risk factors may be beneficial. CONCLUSION PVT is a rare and potentially fatal complication that can follow bariatric surgery. Recently, more reports of PVT following sleeve gastrectomy have been published, all with alarmingly vague presenting symptoms of abdominal pain, diarrhea, or constipation, nausea, and vomiting. 14,18 Given this case presentation was complicated by a concurrent episode of diverticulitis, it is hard to know which issue occurred first—the portal venous thrombosis or the diverticular abscess. Physicians and patients should be made aware of the possible complication of PVT and the potential symptoms. 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. REFERENCES 1. Health implications of obesity. National Institutes of Health Consensus Development Conference Statement. Ann Intern Med. 1985;103(1):147–151. 2. Kim J, Eisenberg D, Azagury D, et al. American Society for Metabolic and Bariatric Surgery Position Statement on Long-term Survival Benefit after Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2014;10(6):1208–1219. 3. Nguyen NT, Nguyen B, Gebhart A, et al. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252–257. 4. Berthet B, Bollon E, Valero R, et al. Portal Vein thrombosis due to Factor 2 Leiden in the post- FIGURE 3. A. Demonstration of pelvic abscess (white arrow) with air-fluid level adjacent to sigmoid colon. B. Diverticulitis appearance of sigmoid colon. C. Successful image- guided percutaneous drainage of the pelvic abscess. D. Follow up fluoroscopic images demonstrate minimal residual abscess cavity, but continued fistulization of abscess to adjacent sigmoid colon (black arrow). FIGURE 4. Coronal view of follow up magnetic resonance imaging of liver demonstrating cavernous transformation of portal vein without ongoing thrombosis. While treatment of PVT is essential, modifying risk factors p rior to bariatric surgery may also be helpful. Factors a ssociated with a high risk of VTE include: older age, e levated BMI, prior history of VTE, male gender, long procedure time (>3 hours), and procedure type (Duodenal switch > open gastric bypass > laparoscopic sleeve gastrectomy). 6,4

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