Presentation of portomesenteric thrombosis after one-anastomosis gastric bypass: Case report

Abstract

Introduction

Obesity is a serious situation that leads to non-communicable diseases like diabetes, hypertension, and others. The prevalence of obesity is growing very fast worldwide, so follow the results bariatric surgery, the most effective treatment of obesity, is increasing. Portomesentric vein thrombosis (PMVT) is one of the rare, fatal post-bariatric complications seen most commonly in sleeve gastrectomy and Roux-en-Y gastric bypass.

Presentation of case

A 50-year-old menopausal female with a body mass index (BMI) of 38 was admitted with acute abdominal pain 10 days after one-anastomosis gastric bypass (OAGB). Her lab tests were normal, but in her abdominal CT scan with IV contrast, subacute complete intraluminal thrombosis with luminal expansion at the left branch of the portal vein and its segmental branches was seen. Her diagnostic laparoscopy was normal, and she was discharged with no symptoms and a prescription for rivaroxaban.

Discussion

PMVT is one of the complications after bariatric surgery that is very uncommon and fetal. It has been seen more in laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass, and early diagnosis of PMVT is essential due to its high mortality rate and cause of gastrointestinal ischemia.

Conclusion

In this case report, we saw that PMVT could happen after OAGB, and it is important to consider PMVT as one of the complications after OAGB to not miss the cases.

Highlights

• •Portomesentric vein thrombosis (PMVT) is one of the rare fetal complications after bariatric surgery.
• •It happens mostly after laparoscopic sleeve gastrectomy.
• •It is possible to see PMVT after one-anastomosis gastric bypass regardless of past medical and drug history.

Abbreviations

PMVT

Portomesentric vein thrombosis

BMI

body mass index

OAGB

one-anastomosis gastric bypass

LSG

Laparoscopic sleeve gastrectomy

SMV

superior mesenteric vein

RYGB

Roux-en-Y gastric bypass

LFT

liver function test

1. Introduction

Obesity is a serious condition that cause a slew of comorbidities and NCDs (noncommunicable diseases) such as diabetes, hypertension, and others [1,2]. According to WHO report until the year 2022 more than one billion people around the world are facing obesity and by the year 2025, 167 million people will be suffering from the consequences of obesity [1].

Bariatric Surgery is the most effective and long-term treatment for obesity [3]. The prevalence of laparoscopic surgery has been increasing due to the increased prevalence of obesity worldwide and its long-term and significant effects on obesity [4]. Laparoscopic sleeve gastrectomy (LSG) is the most prevalent surgical method [5]. One-anastomosis gastric bypass (OAGB), is one of the surgical techniques that has advanced in recent years [6].

Portomesentric vein thrombosis (PMVT) is a rare and lethal condition in which the portal venous system in the intra- or extra-hepatic venous tract becomes partially or completely blocked with potentially effect on the splenic or superior mesenteric veins [7]. PMVT has been reported after different bariatric surgeries especially LSG and the incidence of PMVT after LSG is estimated at 0.3 % to 1 % [8]. But based on our research there was no report of PMVT after OAGB. Here we are presenting a case of PMVT after OAGB.

This work has been reported in line with SCARE criteria [20].

2. Presentation of case

A 50-year-old menopausal female with a body mass index (BMI) of 38 was admitted to the hospital with the chief complaint of one-day severe, sudden, acute, and positional abdominal pain, especially on the left upper and lower quadrant and left flank (pain score: 10/10) with nausea and vomiting. She had undergone OAGB for the first time 10 days before the current admission and she was hospitalized for two days after surgery without needing to ICU. She was prescribed pantoprazole 40 mg BD and heparin BD which she has used regularly.

She had no past medical history, no history of smoking, using OCPs, and any significant familial history. On examination, she looked ill and in pain. Her initial vital signs were: blood pressure 120/75, pulse rate 79, respiratory rate 14, and frontal temperature 37.2. On physical examination, she had left side of the abdomen tenderness without distention. The laparoscopic wounds had relatively improved. Initial laboratory findings were normal except for lipase which was slightly high (lipase: 62, Normal range < 60). Her initial abdominal and pelvic spiral CT scan with IV contrast showed acute complete intraluminal thrombosis with luminal expansion at the left branch of the portal vein and its segmental branches with no bowel thickening and no extra luminal extravasation. Also, it was reported that the right portal vein, main portal vein, superior mesenteric vein (SMV), and splenic vein were patent without thrombosis, and some prominent hepatic artery branches around the left branch of the portal vein and in portahepatis were seen (Fig. 1).

Fig. 1.

Acute thrombosis at the left branch of the portal vein and its segmental branches.

After admission, intravenous heparin (5000 units stat then 1000 units per hour) was started. Relative response to heparin was seen after two days and the patient's pain improved significantly but, in the sequel, it didn't resolve completely. Due to incomplete recovery of pain, for further investigations, she underwent diagnostic laparoscopy and fortunately, there was no evidence or sign of bowel ischemia. Abdominal CT angiography was done four days after onset of pain, and it showed thrombosis of left branch of portal vein in portal venous phase (Fig. 2).

Fig. 2.

Thrombosis of left branch of portal vein in portal venous phase.

After three days, the patient was discharged without any symptoms, and prescription of Tab rivaroxaban 15 mg two times a day for three months.

Written informed consent had been obtained from the patient.

3. Discussion

Among different methods of surgery, in recent decades OAGB is one of the developing and ongoing methods [9], which is as effective as Roux-en-Y gastric bypass (RYGB), and it seems to cause more weight loss than RYGB in long term [10].

Among all the post-operative complications like leakage from anastomosis, pulmonary thrombosis emboli (PTE), insufficient weight loss, and malnutrition, venous thromboembolism (VTE) are the known and important complications following bariatric surgery [11,12]. PMVT is one of the uncommon and infrequent yet lethal complications after bariatric surgery that can lead to gastrointestinal tract ischemia [13].PMVT is reported to be seen mostly after procedures that include thermal ligation of major portal branches. It has been seen frequently after sleeve gastrectomy, due to thermal ligation of blood vessels near the greater curvature, followed by roux-en-Y gastric bypass and less in gastric banding [14]. In this case, although the patient underwent OAGB, she developed PMVT.

There are some predicting factors for VTE like past medical history or familial history of VTE or coagulopathy, male gender, long operation time (more than 3 h), type of surgery, history of using OCP, active smoking, BMI, and age [14,15]. It is also noticeable that lab tests are not helpful in the diagnosis of PMVT and leukocytosis and abnormal LFT are not always seen but in the case of bowel ischemia due to PMVT, abnormal blood gas profile could be seen as late findings. Abdominal CT scan with IV contrast is highly recommended to diagnose PMVT [16,17]. In this case, the patient has no significant predisposing factors except high BMI, and her lab tests were normal and evidence of PMVT was seen in her abdominal CT scan.

Due to the increased risk of VTE incidence in obese and post-bariatric surgery patients to prevent VTE, extended thromboprophylaxis for example with heparin (5000 units TDS) or enoxaparin (30–40 mg BD) especially in high-risk patients (BMI >55 kg/m2 and age > 55, history of VTE, hypercoagulability, sleep apnea or pulmonary hypertension) has been recommended as safe and effective choice beside early physical activity to decrease the risk of VTE; although the risk of VTE is reported to be relatively moderate [18]. In this case, despite using subcutaneous heparin two times a day, she developed PMVT. Also based on previous studies, it is expected that clot removal happens at least three weeks to three months after anticoagulation therapy [19].

4. Conclusion

This case report showed the possibility of PMVT after OAGB even in low-risk patients without any significant familial history with anticoagulant therapy. More studies to evaluate the incidence of PMVT after OAGB is necessary.

Consent

A signed written informed consent was obtained from the patient.

Also this study was conducted in accordance with the ethical standards of the ethics committee of Iran university of medical sciences (approval number: IR.IUMS.REC.1402.272), and with the 2013 Helsinki declaration and its later amendments or comparable ethical standards.

Ethical approval

This study was conducted in accordance with the ethical standards of the ethics committee of Iran university of medical sciences (approval number: IR.IUMS.REC.1402.272), and with the 2013 Helsinki declaration and its later amendments or comparable ethical standards. A signed written informed consent was obtained from participant involved in the study.

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CRediT authorship contribution statement

Delaram Moosavi and Mahsa Taherzadeh: primary drafted

Abdolreza pazouki, Somayeh Mokhber and Sajedeh Riazi: critical revision

All authors contributed to conception and design of the study, revising g it critically for important intellectual content or drafting the manuscript and final approval of the version to be submitted.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guarantor

Sajedeh Riazi

Declaration of competing interest

N/A.