Superior mesenteric venous thrombosis as a first manifestation of Antithrombin III deficiency in the postoperative course of laparoscopic sleeve gastrectomy: a case study of 2 patients from 1211 bariatric patients

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Abstract

Superior mesenteric venous thrombosis (SMVT) following laparoscopic sleeve gastrectomy (LSG) is a rare, potentially life-threatening complication, which presents either isolated, or as a part of portal/mesenteric/splenic vein thrombosis. Distinction between them possibly confers an important clinical and prognostic value. Antithrombin III (ATIII) deficiency causes an hypercoagulable state which predisposes to SMVT. We report the clinical presentation and treatment of two patients among 1211 LSGs (incidence = 0.165%) that presented with isolated SMVT and ATIII deficiency in an Academic Bariatric Center. Both patients had an unremarkable past medical history; none was smoker or had a previously known thrombophillic condition/thrombotic episode. Mean time of presentation was 15.5 days after LSG. Despite aggressive resuscitative and anticoagulation measures, surgical intervention was deemed necessary. No mortalities were encountered. Coagulation tests revealed ATIII deficiency in both patients.

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Mesenteric venous thrombosis.

Ashwani K. Singal, Patrick Kamath, Ayalew Tefferi (2013)

The prevalence of mesenteric venous thrombosis has increased over the past 2 decades with the routine use of contrast-enhanced computed tomography (CT) in patients presenting with abdominal pain and those with portal hypertension. Concurrent with increasing recognition, routine and frequent use of anticoagulation has reduced the need for surgical intervention and improved outcome in these patients. Acute thrombosis often presents with abdominal pain, whereas chronic disease manifests either as an incidental finding on CT or with features of portal hypertension. Contrast-enhanced CT diagnoses about 90% of cases. The presence of collateral circulation and cavernoma around a chronically thrombosed vein differentiates chronic from acute disease. The superior mesenteric vein is often involved, whereas involvement of the inferior mesenteric vein is rare. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Thrombophilia and local abdominal inflammatory conditions are common causes. Management is aimed at preventing bowel infarction and recurrent thrombosis. Anticoagulation, the mainstay of management, has also been safely used in patients with cirrhosis and portal hypertension. This review discusses the pathogenesis of thrombosis of mesenteric veins, the diagnosis and differentiation from arterial ischemia, the emergence of the JAK2 (Janus kinase 2) sequence variation as a marker of thrombophilia and myelodysplastic neoplasms, and new anticoagulants. Algorithms for the management of acute and chronic mesenteric venous thrombosis are provided to help readers understand and remember the approach to the management of acute and chronic mesenteric venous thrombosis.

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Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use.

Morteza Abdollahi, Mary Cushman, Frits Rosendaal (2003)

Deep vein thrombosis (DVT) is a common disease with an annual incidence of about 1 in 1000. Many risk factors have already been studied, both genetic and acquired. It is unclear whether obesity affects thrombotic risk in unselected patients. Obesity is common, with a prevalence of 20-25% and may therefore have a considerable impact on the overall incidence of thrombosis. We evaluated the risk of thrombosis due to overweight and obesity using data from a large population based case-control study. Four hundred and fifty-four consecutive patients with a first episode of objectively diagnosed thrombosis from three Anticoagulation Clinics in the Netherlands were enrolled in a case-control study. Controls were matched on age and sex to patients and were introduced by the patients. All patients completed a standard questionnaire and interview, with weight and height measured under standard conditions. The associations of obesity with clotting factor levels were studied to investigate possible mechanisms. Obesity (BMI >/=30 kg/m(2)) increased the risk of thrombosis twofold (CI95: 1.5 to 3.4), adjusted for age and sex. Obese individuals had higher levels of factor VIII and factor IX, but not of fibrinogen. The effect on risk of obesity was not changed after adjustment for coagulation factors levels (fibrinogen, F VIII, F IX, D-dimer). The relative risk estimates were similar in different age groups and in both sexes, indicating a larger absolute effect in older age groups. Evaluation of the combined effect of obesity and oral contraceptive pills among women aged 15-45 revealed that oral contraceptives further increased the effect of obesity on the risk of thrombosis, leading to 10-fold increased risk amongst women with a BMI greater than 25 kg/m(2) who used oral contraceptives. Obesity is a risk factor for deep vein thrombosis. Among women with a BMI greater than 25 kg/m(2) the synergistic effect with oral contraceptives should be considered when prescribing these.

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Mesenteric venous thrombosis: a changing clinical entity.

J Matsumura, A Chiou, J Ebaugh … (2001)

Mesenteric venous thrombosis (MVT) and its clinical spectrum have become better defined following improvements in diagnostic imaging. Historically, MVT has been described as a morbid clinical entity, but this may not necessarily be true. Often, an underlying disease process that predisposes a patient to MVT can be found and potentially treated. This study was designed to evaluate the diagnostics and management of MVT and to review long-term results of treatment. Thirty-one patients in whom MVT was diagnosed between 1985 and 1999 were retrospectively reviewed. Survivors were contacted for follow-up. There were 15 men and 16 women. Ages ranged from 22 to 80 years (mean, 49.1 years). Thirteen patients had documented hypercoagulability, 10 had a history of previous abdominal surgery, 6 had a prior thrombotic episode, and 4 had a history of cancer. MVT presented as abdominal pain (84%), diarrhea (42%), and nausea/vomiting (32%). Computed tomography (CT) was considered diagnostic in 18 (90%) of 20 patients who underwent the test. CT diagnosed MVT in 15 (100%) of 15 patients presenting with vague abdominal pain or diarrhea. Angiography demonstrated MVT in only five (55.5%) of nine patients. Seven of 31 patients died within 30 days (< 30-day mortality rate, 23%). Twenty-two patients (72%) were initially treated with heparin. Nine patients were not heparinized: four of them died, and two were later given warfarin sodium (Coumadin). Of the 31 patients, only one received lytic therapy. Three patients became symptom free without anticoagulation. Ten patients (32%) underwent bowel resection. Overall, 19 (79%) of 24 survivors were treated with long-term warfarin therapy. Long-term follow-up was obtained in 24 patients (mean, 57.7 months). Twenty-one (88%) of 24 survived in follow-up. The diagnosis of MVT should be suspected when acute abdominal symptoms develop in patients with prior thrombotic episodes or a documented coagulopathy. CT scanning appears to be the primary diagnostic test of choice. Anticoagulation is recommended. If diagnosed and treated early, MVT is not likely to progress to gangrenous bowel. Recent mortality rates for MVT are lower than previously published, perhaps because of earlier diagnosis and aggressive treatment or possibly because we now readily diagnose a more benign form of the disease, which is due to widespread use of CT scanning.

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Author and article information

Journal

Journal ID (nlm-ta): J Surg Case Rep

Journal ID (iso-abbrev): J Surg Case Rep

Journal ID (publisher-id): jscr

Title: Journal of Surgical Case Reports

Publisher: Oxford University Press

ISSN (Electronic): 2042-8812

Publication date Collection: November 2019

Publication date (Electronic): 20 November 2019

Publication date PMC-release: 20 November 2019

Volume: 2019

Issue: 11

Electronic Location Identifier: rjz306

Affiliations

[1] Department of Surgery , 5th Surgical Clinic, Evgenidion Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

Author notes

Correspondence address. Department of Surgery, 5th Surgical Clinic, Evgenidion Hospital, National and Kapodistrian University of Athens, School of Medicine, Papadiamantopoulou 20 Str, PO Box 11528, Athens, Greece. Tel: +30-2107208175; Fax: +30-2107233623; E-mail: andykirian@ 123456gmail.com

Article

Publisher ID: rjz306

DOI: 10.1093/jscr/rjz306

PMC ID: 6865349

SO-VID: f322abe6-f683-45d9-ad12-ee428801c837

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 23 July 2019

Date revision received : 15 September 2019

Date accepted : 1 October 2019

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Pages: 4

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Superior mesenteric venous thrombosis as a first manifestation of Antithrombin III deficiency in the postoperative course of laparoscopic sleeve gastrectomy: a case study of 2 patients from 1211 bariatric patients

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European Journal of Medical Case Reports (EJMCR)

Most cited references 10

Mesenteric venous thrombosis.

Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use.

Mesenteric venous thrombosis: a changing clinical entity.

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