Portomesenteric venous thrombosis

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PMVT following laparoscopic surgery. Our first case is a 71‑year‑old morbidly obese woman admitted for elective laparoscopic giant hiatus hernia (LGHH) repair ...
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Unusual Case

Portomesenteric venous thrombosis: A rare but probably under‑reported complication of laparoscopic surgery: A case series Yan Mei Goh, Ajay Tokala1, Tarek Hany2, Kishore G. Pursnani, Ravindra S. Date Departments of Upper Gastrointestinal Surgery, 1Radiology and 2Colorectal Surgery, Lancashire Teaching Hospitals NHS Trust, Preston, UK Address for Correspondence: Dr. Ravindra S. Date,  The University of Manchester, Manchester Academic Health Science Centre, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, UK. E‑mail: [email protected]

Abstract

INTRODUCTION

Portomesenteric venous thrombosis (PMVT) is a rare but well‑reported complication following laparoscopic surgery. We present three cases of PMVT following laparoscopic surgery. Our first case is a 71‑year‑old morbidly obese woman admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. Post‑operatively, she developed multi‑organ dysfunction and computed tomography scan revealed portal venous gas and extensive small bowel infarct. The second patient is a 51‑year‑old man with known previous deep venous thrombosis who also had elective LGHH repair. He presented 8 weeks post‑operatively with severe abdominal pain and required major bowel resection. Our third case is an 86‑year‑old woman who developed worsening abdominal tenderness 3 days after laparoscopic right hemicolectomy for adenocarcinoma and was diagnosed with an incidental finding of thrombus in the portal vein. She did not require further surgical intervention. The current guidelines for thromboprophylaxis follow‑up in this patient group may not be adequate for the patients at risk. Hence, we propose prolonged period of thromboprophylaxis in the patients undergoing major laparoscopic surgery.

Portomesenteric venous thrombosis (PMVT) is a rare but well‑documented complication following laparoscopic surgery. PMVT, generally, presents 2 weeks post‑operatively.[1] The presentation of PMVT is non‑specific, and as a result, the diagnosis is often delayed or incidental.

K e y w o r d s : C o m p l i c a t i o n , l a p a ro s c o p i c s u r g e r y, portomesenteric venous thrombosis

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DOI: 10.4103/0972-9941.195582

CASE REPORTS Case 1 A 71‑year‑old woman was admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. She was morbidly obese with asymptomatic varicose veins. Intra‑operatively, she had large hiatus hernia with two‑third of the stomach in the mediastinum. Her surgery was difficult and operating time was approximately 3½ h. Intra‑abdominal pressure was maintained at 12 mmHg throughout the surgery. Intermittent pneumatic compression was commenced intra‑operatively. In the post‑operative period, she was admitted to high dependency unit and thromboprophylaxis was commenced. She had a stormy post‑operative course and developed acute kidney injury, sepsis and severe lactic acidosis This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Goh YM, Tokala A, Hany T, Pursnani KG, Date RS. Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series. J Min Access Surg 2017;13:143-5. Date of submission: 20/06/2016, Date of acceptance: 15/08/2016

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requiring haemodialysis and supportive therapy. Computed tomography (CT) of the abdomen and pelvis revealed an extensive small bowel infarct involving the greater curvature of the stomach wall and portal venous gas within the left lobe of the liver [Figure 1]. She developed multi‑organ dysfunction and the decision was made for supportive care and palliation. This patient died a week after surgery.

day 3, she was pyrexia and complained of worsening abdominal tenderness. A CT of the chest, abdomen and pelvis performed revealed a thrombus in the portal vein [Figure 2]. She was commenced on treatment doses of enoxaparin (1.5 mg/kg) for a total of 3 months. She did not require any further surgical intervention. Follow‑up at 6 weeks was unremarkable.

Case 2 A 51‑year‑old man was referred to this tertiary centre with severe reflux, intolerance to solids, vomiting and weight loss. He was on long‑term warfarin for a deep vein thrombosis. pH manometry showed a DeMeester score of 18.4%. He underwent LGHH, Nissen fundoplication, gastropexy and on table gastroscopy. Pneumoperitoneum, intra‑operatively, was maintained at 15 mmHg. Post‑operatively, the patient was continued on therapeutic enoxaparin (1.5 mg/kg) and intermittent pneumatic compression overnight. He made an uneventful recovery and was discharged 3 days post‑operatively with a plan to continue on therapeutic doses of enoxaparin until his international normalised ratio had returned to target range.

DISCUSSION

Eight weeks post‑operatively, he presented as an emergency to his local hospital with peritonitis. Intra‑operative findings at emergency subtotal colectomy and formation of ileostomy showed faecal peritonitis secondary to perforated gangrenous bowel. The patient was managed in the Intensive Care Unit post‑operatively. He is awaiting reversal of his stoma. Case 3 An 86‑year‑old woman with significant comorbidities underwent uneventful laparoscopic right hemicolectomy for Duke’s B adenocarcinoma. She was commenced on thromboprophylaxis post‑operatively. On post‑operative

Figure 1: Extensive small bowel infarct involving the greater curvature of the stomach and portal venous gas

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In this case series of three patients, we report mortality of one patient as a result of PMVT causing bowel infarction and morbidity in another, who required major bowel resection. The aetiology of venous thrombosis is often multifactorial. Proposed risk factors for PMVT following laparoscopic surgery include high intra‑abdominal pressures, operation type, underlying disease process and length of surgery. Increased intra‑abdominal pressure by carbon dioxide (CO2) insufflation causes a fall in mesenteric and portal venous flow due to the rise in intra‑abdominal pressure.[2,3] Some animal studies have shown that CO2 insufflation at lower intra‑abdominal pressures of