title: Portal vein thrombosis after laparoscopic sleeve gastrectomy: presentation and management.
abstract: BACKGROUND
  Portal vein thrombosis (PVT) is a serious problem with a high morbidity and mortality, often exceeding 40% of affected patients. Recently, PVT has been reported in patients after laparoscopic sleeve gastrectomy (LSG). The frequency is surprisingly high compared with other abdominal operations.
  
  
  OBJECTIVE
  We present a series of 5 patients with PVT after LSG. The treatment was not restricted simply to anticoagulation alone, but was determined by the extent of disease. A distinction is made among nonocclusive, high-grade nonocclusive, and occlusive PVT. We present evidence that systemic anticoagulation is insufficient in occlusive thrombosis and may also be insufficient in high-grade nonocclusive disease.
  
  
  METHODS
  Single private institution, United States.
  
  
  METHODS
  We present a retrospective analysis of 646 patients who underwent LSG between 2012 and 2015. In all patients, the diagnosis was established with an abdominal computed tomography (CT) scan as well as duplex ultrasound of the portal venous system. All patients received systemic anticoagulation. Depending on the extent of disease, thrombolytic therapy and portal vein thrombectomy were utilized. All patients received long-term anticoagulation.
  
  
  RESULTS
  Four patients with PVT were identified. A fifth patient with PVT after LSG was referred from another center. The mean age of all patients was 49 years. One patient had a history of deep vein thrombosis (DVT). No complications were identified intraoperatively or during the hospital stay, and all patients were discharged by postoperative day 2. The patients presented with PVT at an average of 20 days (range: 10-35) post-LSG. The CT scan was positive for PVT in all patients. In stable noncirrhotic patients with nonocclusive disease, we administered therapeutic anticoagulation. One patient with high-grade, nonocclusive PVT received anticoagulation alone. Patients with occlusive disease were treated with operative thrombectomy including intraoperative and postoperative thrombolysis (tissue plasminogen activator) with subsequent therapeutic anticoagulation, followed by oral warfarin or a factor Xa inhibitor. There was 1 death from multisystem organ failure in the patient who was referred from another institution with occlusive disease, initially managed only with an anticoagulation infusion.
  
  
  CONCLUSIONS
  We maintain that portal vein patency is essential to normal gastrointestinal physiology and should be the treatment goal in all patients with PVT. In these patients, the therapeutic option should be guided by the extent of the thrombosis. In view of currently available approaches, we propose that operative portal vein thrombectomy, in conjunction with fibrinolysis and anticoagulation, offers the best long-term success in patients with occlusive PVT.
authors.affiliation: Bariatric Medicine Institute, Salt Lake City, Utah.
authors.forename: LeGrand
authors.initials: L
authors.lastname: Belnap
authors.affiliation: Huntsman Cancer Hospital, Hematology Clinic, Salt Lake City, Utah.
authors.forename: George M
authors.initials: GM
authors.lastname: Rodgers
authors.affiliation: Bariatric Medicine Institute, Salt Lake City, Utah. Electronic address: drdanielcottam@yahoo.com.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cottam
authors.affiliation: Bariatric Medicine Institute, Salt Lake City, Utah.
authors.forename: Hinali
authors.initials: H
authors.lastname: Zaveri
authors.affiliation: Bariatric Medicine Institute, Salt Lake City, Utah.
authors.forename: Cara
authors.initials: C
authors.lastname: Drury
authors.affiliation: Bariatric Medicine Institute, Salt Lake City, Utah.
authors.forename: Amit
authors.initials: A
authors.lastname: Surve
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D004630:Emergencies; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011169:Portal Vein; D011183:Postoperative Complications / Q000188:drug therapy / Q000209:etiology / Q000601:surgery; D012189:Retrospective Studies; D017131:Thrombectomy / Q000379:methods; D015912:Thrombolytic Therapy; D020246:Venous Thrombosis / Q000188:drug therapy / Q000209:etiology* / Q000601:surgery
chemical_list: D000925:Anticoagulants
keywords: LSG; PVT; Portal vein thrombosis; Sleeve gastrectomy; Thrombolysis; Thrombosis