Is Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy Related to Short-Course Prophylaxis of Thromboembolism? A Monocentric Retrospective Analysis About an Infrequent but Not Rare Complication and Review of the Literature

Abstract

Background:

Portomesenteric vein thrombosis (PMVT) is considered a rare and potentially fatal complication of bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures in the world. PMVT in LSG was first reported in 2009 by Berthet et al. in a thrombophilic patient. No data exist regarding the real prevalence of this complication specifically after LSG.

Methods:

We examined retrospectively all the clinical records of patients who underwent LSG for morbid obesity from January 2011 to December 2016. Moreover, we performed a literature search of PubMed, Medscape, and EMBASE databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

2854 patients underwent LSG for morbid obesity from January 2011 to December 2016. The retrospective analysis of our records revealed only 1 case of PMVT. The 18 studies selected include 62 cases of PMVT after LSG with a prevalence of 0.52% (ranging from 0.2% to 1.81%) and a mortality rate of 1.61%.

Conclusions:

PMVT is an infrequent but not rare complication in patients who undergo LSG. Short-course antithrombotic prophylaxis (<10 days) could increase the risk of this complication. The authors recommend a postoperative prophylaxis with sodium enoxaparin 40 mg sc once a day for 4 weeks. PMVT mortality in patients who undergo LSG is lower than other causes of portal vein thrombosis (hepatic cirrhosis, tumors, myeloproliferative disorders, etc.) If risk factors for PMVT are present preoperatively, the authors recommend a prophylaxis with sodium enoxaparin 40 mg sc twice daily for 4 weeks.

Introduction

Portomesenteric vein thrombosis (PMVT) is considered a rare and potentially fatal complication of both bariatric and general abdominal surgery. In 2009, a review by James et al. described 18 cases of PMVT after laparoscopic surgery with a mortality rate of 11.11% (2/18).¹ Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures in the world, and since 2015 it has been the most common in Italy.^2,3 It consists of a 70%–80% reduction of gastric volume through a longitudinal resection. Recent studies assessed the feasibility, safety, and reproducibility of LSG with optimal results in terms of weight loss and improvement/resolution of obesity-related comorbidities.² PMVT in LSG was first reported in 2009 by Berthet et al. in a thrombophilic patient.⁴ Since then, numerous case reports and case studies about PMVT after LSG have been published.^4–21 However, no data exist regarding the real prevalence of this complication specifically after LSG. The aim of this work was to determine the prevalence, mortality, and, eventually, risk factors for PMVT after LSG.

Materials and Methods

At our bariatric center of excellence Policlinico San Marco in Osio Sotto (Zingonia–Bergamo), we examined retrospectively all the clinical records of patients who underwent LSG for morbid obesity from January 2011 to December 2016. We included in the analysis all the patients who underwent primary or re-do LSG (resleeve gastrectomy or sleeve gastrectomy after gastric banding).

Surgical technique

The procedure is performed under general anesthesia following the French laparoscopic approach, with the surgeon standing between patient's legs. Palmer's point Veress entry is used to create the pneumoperitoneum. Four trocars are then introduced as follows: a 10-mm trocar is placed in the left hypocondrium, below the costal margin and lateral to the mid-clavicle line; a 5-mm trocar is positioned in the epigastric region; another 5-mm trocar is placed in the right flank/hypocondrium (according to surgeon's preference); finally, a 15-mm trocar is positioned in the supraumbilical area. The 10-mm trocar is used for the insertion of a 30° angled optic that guarantees a complete exploration of the peritoneal cavity at the beginning of the operation, helping the correct placement of the other three trocars as well.

The first surgical step is the dissection of the gastrocolic ligament, and to free the greater gastric curvature, we use a 5-mm radiofrequency dissector (Ligasure Maryland; Medtronic), starting at 5 cm from the pylorus and dissecting the ligament until gastric fundus is completely mobilized through phreno-fundic ligament section. A 38-Fr orogastric tube is used to guide the resection: sleeve gastrectomy is performed using a stapler, in a caudal–cranial direction, starting at 4–5 cm from the pylorus and involving as much fundus as possible, to achieve the therapeutic success of the procedure. Stapling is usually performed with two black and four purple 60 mm cartridges (Endo GIA with Tri-Staple technology; Medtronic). Once gastrectomy is completed, the 38Fr tube is removed and a drainage is placed along the resection line.

Our postoperative protocol includes a long course (4 weeks) of thromboembolic prophylaxis with low-molecular-weight heparin (LMWH), specifically with enoxaparin sodium 40 mg once daily. High-risk patients are treated with enoxaparin sodium 40 mg twice daily. After hospital discharge, patients' follow-up in the dedicated outpatient clinic is scheduled at 1-3-6-12-24-36-48-60 months.

In this study, all the patients operated between January 2011 and December 2016 have been evaluated for postsurgical development of portal, mesenteric, or splenic vein thrombosis or for the association of two or more of these conditions.

Moreover, we performed a literature search of PubMed, Medscape, and EMBASE databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including articles in English, Italian, and French. The following search terms were used: “thrombosis, portomesenteric thrombosis, portal thrombosis, mesenteric thrombosis, and sleeve gastrectomy.”

We collected data regarding the number of procedures performed, age, sex, body mass index (BMI), comorbidities of patients, length of postoperative thromboembolic prophylaxis, days between surgery and clinical onset of PMVT, site of venous thrombosis, type of treatment of PMVT, length of hospital stay to treat the complication and its evolution, and presence of any specific risk factors for the development of venous thrombosis (e.g., the presence of genetic mutations linked to thrombophilia).

The main objectives of the study were to assess the following:

– The prevalence of PMVT after LSG;

– the mortality rate related to PMVT after LSG;

– possible risk factors linked to the development of PMVT after LSG.

Results

At the bariatric center of excellence Policlinico San Marco in Osio Sotto (Zingonia–Bergamo), 2854 patients underwent LSG for morbid obesity from January 2011 to December 2016. Among these, 2634 patients underwent LSG as primary surgery, 84 underwent laparoscopic resleeve gastrectomy, and 136 patients underwent LSG after laparoscopic adjustable gastric banding (LAGB).

The retrospective analysis of our records revealed only 1 case of PMVT among the 2854 patients treated.

Case Report

A 48-year-old woman with clinical history of morbid obesity (actual BMI: 41 Kg/m²) presented at our emergency department with fever (38.5°C) and generalized abdominal pain, both started 24 hours earlier. She was in the 20th postoperative day after LSG, performed 6 months after the removal of an adjustable gastric band (both procedures were performed by our institution, while the LAGB had been performed 7 years before by a different center). The postoperative course had been unremarkable, and patient had been discharged in 5th postoperative day. No personal history of thromboembolism was reported, neither a documented thrombophilic condition. Patient admitted to have suspended the postoperative thromboprophylaxis with enoxaparin sodium earlier than recommended, at postoperative day 7. Oral alimentation and bowel habits were normal. Blood tests showed no leukocytosis (WBC 9.9 × 10⁹/L), while P-reactive protein and total bilirubin were slightly high (21.66 mg/dL and 1.3 mg/dL, respectively, with unconjugated bilirubin 0.9 mg/dL). Subsequently, the patient underwent abdominal computed tomography scan with both intravenous and oral medium contrast: the examination excluded the presence of a gastric fistula but demonstrated an extended thrombosis of portal, superior mesenteric, and splenic veins, without evidence of bowel ischemia. The patient was then admitted to the ICU and treated with continuous intravenous (IV) unfractionated heparin (UH). The following hospital stay was uneventful and the patient was discharged after 7 days on oral anticoagulant therapy (e.g., warfarin). She received also the indication to perform further tests to exclude the presence of thrombophilic disorders once stopped the pharmacological anticoagulation.

Review of the Literature

After searching the literature (flowchart Fig. 1), 18 studies were identified and included in the quali–quantitative analysis: five retrospective analysis, five case series, and eight case reports. Five other retrospective studies were excluded from the quali–quantitative analysis (because it was not possible to extract data regarding single patients), but included in the analysis of PMVT prevalence in patients who underwent LSG.

FIG. 1.

Flowchart. Article selection criteria.

The 18 studies selected include 62 cases of PMVT after LSG (Tables 1 and 2). The median age was 34.44 years (range 14–56), with female prevalence (M:F = 1:2.6). Median BMI was 40.26 Kg/m² (range 30.5–59.1). Common comorbidities such as arterial hypertension (38.7%), glycemic impairment (38.7%), and dyslipidemia (37.09%) often associated. In the majority of cases, the most affected site was the portomesenteric confluence (59.66%) alone or in association with other vessels, while isolated splenic vein thrombosis was infrequent (6.45%). In 15 cases, no data about postoperative thromboprophylaxis were reported, while in almost all the remaining cases of PMVT, the duration of prophylaxis was inferior to 10 days (97.87%). The major preexisting risk factors were as follows: the use of oral contraceptive therapy (31.81%), the presence of genetic mutations causing thrombophilia (27.41%), and cigarette smoking (25.8%). The most used therapy of PMVT was anticoagulation with continuous iv UH (56.45%) or LMWH (27.41%). Intestinal resection was necessary in four cases (6.45%). Only 1 patient was treated with thrombolysis with tissue plasminogen activator. In five cases, no specific therapy was adopted. Among the 62 cases considered in the analysis, 1 patient died from complications of PMVT (1.61%).

Table 1.

Details of PMVT Cases After LSG

Author (year of publication)	Total number of LSG performed	Cases of PMVT after LSG age—sex	BMI (Kg/m²)	Comorbidities	Site of thrombosis	Diagnosis of thrombosis (pod)	Postoperative LMWH prophylaxis (duration in term of days)	Risk factors	Thrombophilia	Therapeutic approach	Hospital stay (no. of days)	Clinical course
Berthet et al.⁴	NR	1
		42 yo—F	NR	No	PVT, SVT, MVT	14	10	Estrogen–progestin OC, cigarette smoking, previous LAGB	Factor II mutation (Heterozygosis)	Unfractionated Heparin iv	NR	Uneventful
Bellanger et al.⁵	800	3
		46 yo—F	53	Type 2 diabetes, OSAS, hypercolesterolemy, discal hernias	MVT	25	NR	NR	No	Unfractionated Heparin iv	5	Uneventful
		45 yo—F	36	No	PVT, SVT	14	NR	NR	No	Unfractionated Heparin iv	14	Uneventful
		40 yo—F	38	Arterial hypertension, polycystic ovary syndrome, dyslipidemia, GERD, depression	PVT, SVT, MVT	13	NR	NR	No	Unfractionated Heparin iv	5	Uneventful
Franco et al.⁶	NR	2
		42 yo—F	35.5	Nephrotic syndrome	PVT	14	8	NR	NR	Supportive therapy	NR	Portal cavernoma, portal hypertension, ascites, splenomegaly
		35 yo—F	39	Dyslipidemia	PVT	14	8	NR	NR	Unfractionated Heparin iv	NR	Uneventful
Rosenberg et al. (2010)⁷	55	1
		41 yo—M	42	Arterial hypertension, OSAS, dyslipidemia	PVT	10	4	NR	No	Unfractionated Heparin iv	NR	Uneventful
Lopez and Flint⁸	NR	1
		40 yo—F	46	GERD, major depression, trigeminal neuralgia, arthralgias	PVT	42	NR	Estrogen–progestin OC	No	Unfractionated Heparin iv	NR	Uneventful
Pineda et al.⁹	NR	1
		NR	NR	NR	MVT	42	NR	NR	No	LMWH	NR	Uneventful
Hughes et al.¹⁰	NR	1
		58 yo—F	49	Arterial hypertension, type 2 diabetes, dyslipidemia, GERD, ulcerative colitis, NASH cirrhosis	PVT, MVT	17	NR	Hepatic cirrhosis, portal hypertension	NR	Unfractionated Heparin iv, bowel resection	NR	Uneventful
Salinas et al.¹¹	1713	17
		36 yo—F	35.2	Insulin resistance, arterial hypertension	PVT, SVT	15	Until discharge (2–5 days)	Thrombophilia	Protein C deficiency	Unfractionated Heparin iv	6	Portal cavernoma
		45 yo—F	35	Insulin resistance, arterial hypertension, dyslipidemia	PVT, SVT	9	Until discharge (2–5 days)	Estrogen–progestin OC, cigarette smoking, Thrombophilia	Protein C deficiency + Prothrombin G20210A mutation	Unfractionated Heparin iv	6	Portal cavernoma
		42 yo—F	35	Arterial hypertension	PVT, SVT	21	Until discharge (2–5 days)	Estrogen–progestin OC, cigarette smoking	No	Unfractionated Heparin iv	6	Portal cavernoma
		30 yo—F	34.8	No	PVT, SVT	1	Until discharge (2–5 days)	Estrogen–progestin OC, cigarette smoking	No	Unfractionated Heparin iv	6	Portal cavernoma
		34 yo—F	36.6	Insulin resistance, arterial hypertension	PVT, SVT	10	Until discharge (2–5 days)	No	No	Unfractionated Heparin iv	6	Portal cavernoma
		45 yo—F	35.1	Arterial hypertension	PVT, SVT	11	Until discharge (2–5 days)	Cigarette smoking	No	Unfractionated Heparin iv	6	Portal cavernoma
		26 yo—F	32.5	Insulin resistance, dyslipidemia	PVT, SVT	6	Until discharge (2–5 days)	Estrogen–progestin OC, thrombophilia	Proteins C and S deficiency	Unfractionated Heparin iv	6	Portal cavernoma, portal hypertension
		44 yo—F	36	No	PVT, SVT, MVT	415	Until discharge (2–5 days)	No	No	Unfractionated Heparin iv	6	Portal cavernoma, portal hypertension
		35 yo—M	35.6	Insulin resistance, dyslipidemia	PVT, SVT, MVT	17	Until discharge (2–5 days)	Cigarette smoking	No	Unfractionated Heparin iv	6	Portal cavernoma, portal hypertension
		29 yo—F	36.1	Insulin resistance, arterial hypertension	PVT, MVT	12	Until discharge (2–5 days)	Cigarette smoking, Estrogen–progestin OC	No	Unfractionated Heparin iv	6	Uneventful
		19 yo—F	36	Insulin resistance	PVT, MVT	4	Until discharge (2–5 days)	Estrogen–progestin OC, Thrombophilia	Protein S deficiency	Unfractionated Heparin iv	6	Uneventful
		56 yo—F	33.2	Insulin resistance, dyslipidemia, NAFLD	MVT	2	Until discharge (2–5 days)	No	No	Unfractionated Heparin iv	6	Uneventful
		46 yo—F	36.8	Insulin resistance, dyslipidemia, arterial hypertension	MVT	14	Until discharge (2–5 days)	No	No	Unfractionated Heparin iv	6	Uneventful
		44 yo—F	31.8	Insulin resistance, arterial hypertension, dyslipidemia, NAFLD	MVT	4	Until discharge (2–5 days)	No	No	Unfractionated Heparin iv	6	Uneventful
		28 yo—F	33.2	Type 2 diabetes	MVT	18	Until discharge (2–5 days)	Cigarette smoking, Estrogen–progestin OC	No	Unfractionated Heparin iv	6	Uneventful
		37 yo—F	33.7	No	MVT	1	Until discharge (2–5 days)	Thrombophilia	Protein C deficiency + Prothrombin G20210A mutation	Unfractionated Heparin iv	6	Uneventful
		51 yo—F	30.5	Insulin resistance, dyslipidemia, NAFLD	MVT	11	Until discharge (2–5 days)	Thrombophilia Cigarette smoking	Prothrombin G20210A mutation	Unfractionated Heparin iv	6	Uneventful
Kassir et al.¹²	NR	2										Uneventful
		40 yo—M	41	OSAS, depression	MVT	40	NR	Cigarette smoking	NR	Unfractionated Heparin iv	NR	Uneventful
		47 yo—F	43	No	PVT	17	NR	Estrogen–progestin OC	NR	LMWH	NR	Uneventful
Keung et al.¹³	NR	1
		14 yo—F	53.7	OSAS	SVT, MVT	12	NR	NR	NR	Unfractionated Heparin iv, bowel resection	NR	Death
Darcy et al.¹⁴	NR	1
		55 yo—F	41.1	Type 2 diabetes, arterial hypertension, coronaropathy, dyslipidemia	MVT, SVT	14	NR	No	No	Unfractionated Heparin iv, bowel resection	NR	Uneventful
Baba et al.¹⁵	NR	2
		43 yo—F	NR	Type 2 diabetes, GERD, psoriasis	PVT, MVT	14	NR	Thrombophilia	Prothrombin G20210A mutation	Unfractionated Heparin iv	NR	Uneventful
		23 yo—M	NR		PVT, MVT	14	NR	Thrombophilia	Prothrombin G20210A mutation	Unfractionated Heparin iv	NR	Uneventful
Muneer et al. (2016)¹⁶	NR	3										Uneventful
		27 yo—M	41	No	PVT	7	Until discharge (<7 days)	NR	NR	Unfractionated Heparin iv	NR	Uneventful
		46 yo—F	38	No	PVT, MVT	14	Until discharge (<7 days)	NR	NR	Retrograde thrombolysis with tPA + Unfractionated Heparin iv	NR	Uneventful
		46 yo—M	44	Arterial hypertension, Type 2 diabetes, dyslipidemia	PVT, SVT, MVT	14	Until discharge (<7 days)		NR	Unfractionated Heparin iv + bowel resection		Uneventful
Bhatia et al.¹⁷	NR	1										Uneventful
		50 yo—M	52	Arterial hypertension, OSAS	MVT	15	5	No	NR	LMWH	NR	Uneventful
Villagrán et al.¹⁸	1236	5
		43 yo—F	37.4	Insulin resistance, arterial hypertension, NAFLD	PVT, MVT	15	7	Estrogen–progestin OC	Protein C deficiency	Unfractionated Heparin iv	7	Uneventful
		37 yo—F	36.1	Impaired glucose tolerance, insulin resistance, NAFLD, dyslipidemia	PVT, MVT	50	7	Cigarette smoking, Estrogen–progestin subcutaneous implant	NR	Unfractionated Heparin iv	8	Uneventful
		27 yo—F	39	Impaired glucose tolerance, insulin resistance, NAFLD, dyslipidemia	PVT, MVT, SVT	11	7	Cigarette smoking	NR	Unfractionated Heparin iv	10	Uneventful
		29 yo—M	39.1	Hyperuricemia, insulin resistance, dyslipidemia	PVT, MVT, SVT	12	7	Cigarette smoking	Protein C deficiency	Unfractionated Heparin iv	6	Uneventful
		36 yo—M	40.9	Impaired glucose tolerance, insulin resistance, NAFLD, dyslipidemia, OSAS	PVT, MVT, SVT	16	14	Cigarette smoking	No	Unfractionated Heparin iv	7	Uneventful
Carli and Pintar¹⁹	NR	1
		37 yo—F	50.2	Arterial hypertension, OSAS, dilatative cardiomyopathy	SVT, MVT	21	3	NR	NR	LMWH	NR	Sepsis, hepatic abcess, portal hypertension
Bridges et al.²⁰	NR	3
		44 yo—F	43.5	No	PVT	18	NR	Previous LAGB		LMWH	29	Uneventful
		43 yo—F	40.6	Arterial hypertension	PVT	19	NR	NR	NR	Unfractionated Heparin iv	26	Uneventful
		47 yo—M	59.1	Arterial hypertension, asthma, Myasthenia, OSAS	MVT	16	NR	NR	NR	Unfractionated Heparin iv	31	Uneventful
Rottenstreich et al.²¹	2886	16
		36 yo—F	46	No	PVT, MVT, SVT	18	Until discharge (2–4 days)	Estrogen–progestin OC	No	LMWH	NR	Uneventful
		23 yo—M	39	No	PVT, MVT	14	Until discharge (2–4 days)	No	Factor V Leyden	LMWH	NR	Uneventful
		51 yo—M	40	Dyslipidemia	PVT, MVT	60	Until discharge (2–4 days)	No	No	LMWH	NR	Uneventful
		46 yo—F	38	Arterial hypertension	PVT	14	Until discharge (2–4 days)	Positive family history	JAK2 mutation + elevated factor VIII levels	LMWH	NR	Uneventful
		50 yo—M	56	Arterial hypertension, dyslipidemia	MVT	38	Until discharge (2–4 days)	No	No	LMWH	NR	Uneventful
		33 yo—F	38	No	PVT, MVT	11	Until discharge (2–4 days)	No	Elevated factor VIII levels	LMWH	NR	Uneventful
		41 yo—M	40	Dyslipidemia	PVT, MVT	41	Until discharge (2–4 days)	No	No	LMWH	NR	Uneventful
		29 yo—M	44	Arterial hypertension	PVT, MVT, SVT	13	Until discharge (2–4 days)	Positive family history	NR	LMWH	NR	Uneventful
		27 yo—F	39	No	PVT, MVT	15	Until discharge (2–4 days)	No	No	LMWH	NR	Uneventful
		27 yo—F	41	No	PVT	321	Until discharge (2–4 days)	No	Prothrombin G20210A mutation + elevated factor VIII levels	LMWH	NR	Uneventful
		41 yo—F	43	Arterial hypertension, Type 2 diabetes, dyslipidemia	SVT (causing splenic infarction)	39	Until discharge (2–4 days)	No	NO	Supportive therapy + antibiotics	NR	Uneventful
		50 yo—M	41	Arterial hypertension, Type 2 diabetes, NAFLD	SVT (causing splenic infarction)	2569	Until discharge (2–4 days)	No	NO	Supportive therapy + antibiotics	NR	Uneventful
		28 yo—M	43	No	SVT (causing splenic infarction)	53	Until discharge (2–4 days)	Cigarette smoking	NO	Supportive therapy	NR	Uneventful
		47 yo—F	40	Arterial hypertension, dyslipidemia, NAFLD	SVT (causing splenic infarction)	9	Until discharge (2–4 days)	Personal history of PTE	Factor V Leyden (heterozygosis)	LMWH	NR	Uneventful
		25 yo—F	38	No	PVT (causing hepatic infarction)	76	Until discharge (2–4 days)	Cigarette smoking, Estrogen–progestin OC	Elevated factor VIII levels	LMWH	NR	Uneventful
		21 yo—F	44	No	PVT (causing hepatic infarction)	951	Until discharge (2–4 days)	Estrogen–progestin OC	No	Supportive therapy	NR	Uneventful
												Uneventful
Our casistic	2854	1										Uneventful
		48 yo—F	41	No	PVT, MVT, SVT	20	7	No	NR	Unfractionated Heparin iv	7	Uneventful

BMI, body mass index; GERD, gastroesophageal reflux disease; LAGB, laparoscopic adjustable gastric banding; LSG, laparoscopic sleeve gastrectomy; LMWH, low molecular weight heparin; MVT, mesenteric vein thrombosis; NAFLD, nonalcoholic fatty liver disease; NR, not reported; OC, oral contraceptive; OSAS, obstructive sleep apnea syndrome; PMVT, portomesenteric vein thrombosis; PVT, portal vein thrombosis; SVT, splenic vein thrombosis; tPA, tissue plasminogen activator.

Discussion

PMVT is considered a rare complication after abdominal surgery.¹ Mortality rate ranges from 20% to 50%, depending on the time of onset and diagnosis (acute or chronic), the etiology (thrombophilic disorders, hematological disorders, inflammatory conditions, established hepatic cirrhosis with portal hypertension), the grade of thrombosis (massive versus limited), and on the development of septic or ischemic complications.²² The gold standard in the treatment of acute postoperative uncomplicated PMVT is represented by continuous intravenous infusion of UH. Systemic heparin therapy is initiated with a bolus injection of 5000 U, followed by a continuous infusion, adjusting the dose to maintain the activated partial thromboplastin time of the patient at least twice the normal value. Anticoagulation may be started even in the presence of gastrointestinal bleeding, if the risk of bleeding is outweighed by the benefit of preventing bowel infarction. Supportive measures include nasogastric tube, fluid resuscitation, and bowel rest. Oral anticoagulation with warfarin should be started once ongoing bowel ischemia is ruled out. Although gastroesophageal varices at risk of bleeding may eventually develop, the benefits of long-term anticoagulation outweigh the hemorrhagic risk. In the absence of an ongoing thromboembolic disorder, the duration of anticoagulation may be limited from 6 months to 1 year.²² In case of sepsis, antimicrobial therapy is recommended. If visceral ischemia is suspected, an explorative laparotomy for eventual intestinal resection is mandatory.

Postoperative thromboembolic prophylaxis

Sixty-two cases of PVMT taken from 18 different articles were analyzed.^4–21 In 15 cases, no information was provided about postoperative thromboembolic prophylaxis, while in almost all the other cases the prophylaxis was inferior to 10 days (97.87%). Our protocol consists of long-course (4 weeks) postoperative thromboembolic prophylaxis. In our records, just 1 case of PMVT was observed among 2854 patients who underwent LSG: in this case the patient self-stopped the prophylaxis after 7 days from surgery. A recent multicenter retrospective analysis conducted by Rottenstreich et al.²¹ underlined how the thrombosis rate was significantly lower in patients who received long-course anticoagulation therapy.

In 2013, the American Society of Metabolic and Bariatric Surgeons position paper²³ concluded that extended postdischarge prophylaxis should be considered for all patients, although the specific dose and duration remained unclarified.

The authors of the present article agree that a thromboembolic prophylaxis of 4 weeks after LSG with sodium enoxaparin 40 mg as subcutaneous (sc) injection minimizes the risk of PMVT.

Prevalence of the complication

PMVT is currently regarded as a rare complication of LSG, even if in the last years, an increasing number of reports have been published (Table 1). The analysis of literature^{5,7,11,18,24–27} highlights a prevalence of 0.52% (ranging from 0.2% to 1.81%) (Table 3). In our records (1 case on 2854 LSG), prevalence of PMVT is 0.03%. In western countries, a condition is considered rare if its prevalence is lower than 0.05%.²⁸ For this reason, PMVT cannot be considered a rare complication among patients who undergo LSG and postoperative short-course thromboembolic prophylaxis (< of 10 days).

Table 3.

PMVT Rate After LSG

Authors (year of publication)	No. of LSG	No. of PMVT	PMVT rate after LSG (%)
Bellanger et al.⁵	800	3	0.37
Rosenberg et al. (2010)⁷	55	1	1.81
Goitein et al.²⁴	4355	16	0.36
Salinas et al.¹¹	1713	17	0.99
Alsina et al.²⁵	100	1	1.00
Gibson et al.²⁶	500	1	0.20
Villagrán et al.¹⁸	1236	5	0.40
Belnap et al.²⁷	646	4	0.61
Rottenstreich et al.²¹	2886	16	0.55
Total	12291	64	0.52
Our casistic	2854	1	0.03

LSG, laparoscopic sleeve gastrectomy; PMVT, portomesenteric vein thrombosis.

From our descriptive analysis, the substantial difference between our group and the others reported in Tables 1 and 2 is represented by the duration of postoperative thromboembolic prophylaxis.

Table 2.

Demographic Data

Data	Results
Number of cases	62
Age, years (range)	34.44 (14–56)
Male/female (ratio)	17/44 (1/2.6)
BMI (range)	40.26 (30.5–59.1)
Comorbidity, n (%)
None	18 (29.03)
Arterial hypertension	24 (38.70)
Glycemic alterations	24 (38.70)
OSAS	7 (11.29)
Dyslipidemia	23 (37.09)
Nonalcoholic fatty liver disease	10 (16.12)
Gastroesophageal reflux disease	4 (6.45)
Hyperuricemia	1 (1.61)
Depression	3 (4.83)
Nephrotic syndrome	1 (1.61)
Arthralgias	2 (3.22)
Cardiopathy	2 (3.22)
Site of thrombosis, n (%)
PVT	12 (19.35)
MVT	12 (19.35)
SVT	4 (6.45)
PVT + MVT	13 (20.96)
PVT + SVT	8 (12.90)
MVT + SVT	3 (4.83)
PVT + MVT + SVT	10 (16.12)
Diagnosis of PMVT after LSG, median postoperative days (range)	86.7 (1–2569)
Postoperative thromboprophylaxis with LMWH, n (%)
Not reported	15 (24.19)
< = 10 days	46 (74.19)
>10 days	1 (1.61)
Risk factors, n (%)
Cigarette smoking	16 (25.80)
Alcohol	6 (9.67)
Estrogen–progestin oral contraceptive	14 (31.81)^*
Trombophilia	17 (27.41)
Previous bariatric surgery	2 (3.22)
Hepatic cirrhosis	1 (1.61)
Management, n (%)
Supportive therapy	5 (8.06)
UH iv	35 (56.45)
LMWH sc	17 (27.41)
Thrombolysis + UH	1 (1.61)
UH + bowel resection	4 (6.45)
Mortality, n (%)	1 (1.61)

Only female population.

BMI, body mass index; LSG, laparoscopic sleeve gastrectomy; LMWH, low molecular weight heparin; MVT, mesenteric vein thrombosis; OSAS, obstructive sleep apnea syndrome; PMVT, portomesenteric vein thrombosis; PVT, portal vein thrombosis; SVT, splenic vein thrombosis; UH, unfractionated heparin.

Mortality

Considering all possible causes, PMVT has a mortality of 20%–50%.²² Thrombosis after LSG must be considered as acute, noncirrhotic, and nonneoplastic. A recent article published in 2015²⁹ underlines how early diagnosis, increased clinical awareness, advanced diagnostic techniques, and the use of early anticoagulation have improved the 5-year survival rate up to 85%. Among the 62 cases considered in this review, there was only one case of fatal PMVT (1.61%) in a 14-year-old girl without apparent risk factors or thrombophilic status.¹³ Early diagnosis is crucial to immediately start anticoagulant therapy, avoiding the instauration of bowel ischemia and sepsis.

Risk factors

From our review of the literature, no elements of relevance have emerged, except for short-term thromboembolic prophylaxis (<10 days). Contraceptive therapies (31.81%), congenital thrombophilic status (27.41%), and tobacco smoking (25.8%) are already known risk factors for deep and mesenteric vein thrombosis²² and seem to correlate with the development of PMVT in LSG. In the presence of preoperative known risk factors, in our center, we prescribe a long-course of thromboembolic prophylaxis with sodium enoxaparin 40 mg sc twice daily for 4 weeks.

Conclusions

It is not possible to extrapolate definitive conclusions from this descriptive, monocentric, and retrospective review. However, it seems mandatory to underline some aspects:

– PMVT is an infrequent but not rare complication in patients who undergo LSG.

– Short-course antithrombotic prophylaxis (<10 days) could increase the risk of this complication. The authors recommend a postoperative prophylaxis with sodium enoxaparin 40 mg sc once a day for 4 weeks.

– PMVT mortality in patients who undergo LSG is lower than other causes of portal vein thrombosis (hepatic cirrhosis, tumors, myeloproliferative disorders, etc.)

– If risk factors for PMVT are present preoperatively, the authors recommend a prophylaxis with sodium enoxaparin 40 mg sc twice daily for 4 weeks.

Further randomized prospective studies are needed to confirm these findings.

Footnotes

Acknowledgment

The authors thank Benedetta Furgiuele for his precious support.

Compliance with Ethical Requirements

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study. Additional informed consent was obtained from all patients for whom identifying information is included in this article. All institutional and national guidelines for the care and use of laboratory animals were followed.

Disclosure Statement

No competing financial interests exist.

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