Portomesenteric vein thrombosis following laparoscopic sleeve gastrectomy in a Chinese patient

Abstract

A 51-year-old morbidly obese Chinese man was scheduled for laparoscopic sleeve gastrectomy in October 2016. He had a body mass index of 34 kg/m 2 complicated by metabolic syndrome. He had no history of thromboembolism. Surgery was performed using a 5-port technique. A liver retractor was inserted under direct vision. The greater curvature was mobilised up to the angle of His and the gastric sleeve was created. The operation lasted 125 minutes. The patient was mobile on postoperative day 2 and was discharged on day 5.On day 6 postoperatively, he presented to the surgical ward with nausea, vomiting, and epigastric pain. No peritoneal signs were elicited during physical examination. White cell count had increased to 10.1 x 10 9 /L (reference range, 4-11 x 10 9 /L), and serum creatinine level to 248 µmol/L (reference range, 67-109 µmol/L). He was kept nil by mouth and prescribed broad-spectrum antibiotics. A computed tomographic (CT) scan of the abdomen and pelvis with intravenous contrast was performed on postoperative day 8. The portal vein was not opacified and a wedge-shaped hypoenhancing area was seen at subcapsular S4 of the liver. These were attributed by the radiologist to the timing of acquisition and perfusion artefacts. Ascites was also identified on the CT scan.His condition deteriorated and he was transferred to the intensive care unit on postoperative day 9. A repeat contrast-enhanced CT on the same day, arranged in view of his rapid deterioration and the presence of unexplained ascites, revealed extensive thrombosis of the superior mesenteric vein, splenic vein, portal trunk, and portal veins (Fig). A long segment of small bowel appeared ischaemic. Hypoenhancement in the liver and spleen was evident and likely related to impaired perfusion. Emergent laparotomy was performed immediately and revealed small bowel gangrene extending from the proximal jejunum to mid-ileum with mesenteric vein thrombosis. The distal ileum showed venous