A rare complication with superior mesenteric vein thrombosis after laparoscopic sleeve gastrectomy: A case report

Abstract

Laparoscopic sleeve gastrectomy (LSG) has become a frequent procedure to reduce weight and morbid obesity. The procedure involves laparoscopic resection of more than 75% of the greater curvature of the stomach, resulting in early satiety and neuro-hormonal changes that collectively promote effective weight loss. We present a rare case of complication of superior mesenteric vein thrombosis (SMVT) and splenic vein after LSG, with consequent bowel ischemia that was treated with open laparotomy and appropriate anticoagulation therapy. A 56-year-old obese woman (BMI of 42.5 kg/m²), smoker for 30 years, presented to the emergency department with symptoms such as abdominal pain, fever, nausea and vomiting, 2 weeks after LSG intervention. Her white blood cell count was 15.5 (normal values: 3.8-10.4 × 10³ /µL), while C- reactive protein level was 193 (normal values: 0.0-6.0 mg/L) and her D-Dimer level 4.69 (normal values: 0-0.50 mg/L). Abdominal CT with contrast showed a filling defect in the superior mesenteric and splenic vein, free perihepatic and Douglas pouch fluid, as well as small bowel thickening. An open laparotomy was performed and the necrotic segment of bowel of 80 cm was removed. The postoperative period went relatively well, despite the diarrhea that continued for the next 4 months after the intervention. The most common causes leading the development of this complication include: hypercoagulable state, dehydration, increased intra-abdominal pressure during the procedure and other secondary factors. The main symptom is abdominal pain, followed by nausea, vomiting, diarrhea and bleeding from the gastrointestinal tract. SMVT and SVT should be considered as a possible complication in patients with abdominal pain and increased inflammatory parameters after LSG. Early diagnosis through CT imaging and rapid anticoagulation therapy is considered to reduce further complications such as intestinal infarction and portal hypertension.

Keywords: Anticoagulation therapy; Intestinal ischemia and necrosis; Laparoscopic sleeve gastrectomy; Superior mesenteric vein thrombosis.

Fig. 1

Abdominal and pelvic CT on postcontrast axial image show the stomach after performing the laparoscopic sleeve gastrectomy, resulting in reduction of the stomach lumen in a shape of sleeve. White arrows show the operative hyper-dense suture materials.

Fig. 2

(A, B, C, D): Abdominal and pelvic CT axial and reformatted images, in late phase after the administration of the iodine contrast dye, portal phase abdominal CT shows the filling defect - thrombosis inside the enlarged superior mesenteric vein (white arrows) in A) the upper segment image, in B) the lower segment image, and C) with sagittal reformatting.

Fig. 3

(A and B): Abdominal and pelvic CT coronal (A) and axial (B) images show the edematous and thickened small bowel walls annotated with white arrows in both postcontrast images. In the (B) image, presence of inter intestinal free liquid annotated with yellow arrows, and the dirty fatty tissue nearby the SMV - with the red arrows.

Fig. 4

Abdominal and pelvic CT axial images show the partial thrombosis of the splenic vein annotated with white arrows.

Fig. 5

(A and B): Abdominal CT, axial postcontrast images show the presence of the free fluid: perihepatic (A) and (B) subhepatic.

Fig. 6

(A and B): Abdominal and pelvic CT, axial postcontrast images show the presence of the free fluid: (A) interintestinal and (B) in the Douglas pouch.

Fig. 7

Abdominal and pelvic CT, coronal reconstruction, shows restored functionality of SMV (white arrows) with slight postintraluminal irregularity (red arrow) and fully re-canalized SV (yellow arrow).

Fig. 8

(A and B) Gastro duodenography image and small bowel enema show reduced volume and cylinder shape of the stomach, as well as appropriate propagation of barium, respectively.