Portal-mesenteric-splenic vein thrombosis following laparoscopic gastric sleeve operation

A 42-year-old female patient who underwent gastric sleeve operation 2 weeks prior, was admitted to the ER due to diffuse abdominal pain, worsening over the last 24 hours. Patient experienced no other GI symptoms except slight nausea.

Contrast-enhanced CT of the abdomen and thorax was performed showing severe thrombosis in the portal-splenic-mesenteric axis. The extent of the occlusion is best viewed on the coronal images where the superior mesenteric veins, splenic vein, portal vein as well as right and left portal hepatic veins were completely thrombosed. Furthermore, substantial spleen infarction was found with only sparse contrast enhancement in the peripheral spleen parenchyma.

Laparoscopic sleeve gastrectomy (LSG) has become a popular surgical procedure for the treatment of morbid obesity, partly due to the simplicity of the procedure as well as the low complication rate [1]. Some of the most common acute and subacute complications include post-operative bleeding, staple line leak and intraabdominal abscess [2]. Portal-mesenteric vein thrombosis (PMVT) is considered a rare event following bariatric surgery with reported incidences around 0,4% [3], however with the increasing popularity of LSG there has been an increasing number of reported PMVT cases following LSG [4].

Most PMVT events following bariatric surgery present sub-acutely between days 3-30. Clinically it may present acutely in which symptoms occur suddenly (minutes/hours) and is associated with higher risk of complications such as intestinal ischaemia. In the subacute form of presentation, abdominal pain is present for days/weeks and intestinal ischaemia is less frequent [5]. Finally, there is a chronic form of PMVT of which up to 50% of patients are asymptomatic due to development of collateral veins. PMVT symptoms are generally quite vague and non-specific with the overarching symptom being abdominal pain, however other symptoms such as nausea, vomiting and constipation may also occur [6, 7].

Contrast-enhanced CT is considered the golden standard in patients with acute PMVT with sensitivity rates above 90% [7], as it not only allows for the evaluation of the vascular structures, but also pathology secondary to PMVT. In this case, the main secondary finding to the PMVT was an infarction of the spleen.  Intestinal and/or mesenteric ischaemia may also be present secondary to PMVT [8], however no signs of ischaemia were found in this, nor in subsequent CT scans.

Initial medical treatment includes anticoagulants more specifically unfractionated heparin or LMWH. Depending on the extent of thrombosis as well as the patient symptoms; more invasive procedures such as interventional thrombectomy and/or systemic/local thrombolysis may be relevant. Signs of bowel ischaemia or perforation usually warrants acute explorative laparotomy including intraoperative thrombectomy and local lysis treatment [9]. General prognosis for PMVT is better than arterial thrombosis and mortality rates range from 20-50%, but have been decreasing over the years most likely due to faster diagnostics and more aggressive treatment plans [10].

This particular patient underwent thrombectomy through a transjugular intrahepatic portosystemic shunt (TIPS) resulting in more or less complete reperfusion of the portal, mesenteric and splenic veins with no major complications secondary to the PMVT. Furthermore, the patient started on daily anticoagulants and regular follow-ups, including further investigations for other underlying causes such as thrombophilia.

In conclusion, this case presents a rare complication to LSG showing substantial thrombosis and occlusion of the portal-splenic-mesenteric veins.

Written informed patient consent for publication has been obtained.