Portomesenteric Vein Thrombosis Following Sleeve Gastrectomy: A Case Report and Literature Review

Abstract

BACKGROUND The prevalence of obesity has more than doubled since 1980. Consequently, bariatric surgery rates have risen significantly, increasing the need to address its complications. Portomesenteric venous thrombosis is a rare but potentially life-threatening complication, accounting for 5% to 15% of all mesenteric ischemic events. This case highlights the importance of considering portomesenteric vein thrombosis as a potential complication in bariatric surgery, especially in patients at high risk. CASE REPORT A 28-year-old woman with grade II obesity underwent elective laparoscopic sleeve gastrectomy. On postoperative day 7, she presented with diarrhea and vomiting (over 10 episodes in a weekend), dry mucosa, vague abdominal pain radiating to the lumbar region, and intolerance to oral intake. After 48 h with no improvement, a contrast-enhanced abdominal and pelvic computed tomography scan (January 7, 2024) revealed intravascular defects in the portal vein, superior mesenteric vein, and splenic vein, suggesting thrombosis. CONCLUSIONS The etiology of portomesenteric vein thrombosis following bariatric surgery is likely multifactorial. While the relationship between venous thromboembolism and obesity is well established, debates persist regarding the optimal duration of medical therapy after discharge, despite the existing preventive measures in the literature. Some 95% of surgeons administer anticoagulants for at least 10 to 14 days postoperatively, while 50% extend prophylaxis for up to 30 days, depending on individual risk factors. While gastric sleeve surgery offers substantial benefits for patients with obesity, the rising incidence of portal mesenteric thrombosis underscores the importance of proactive prevention and early detection strategies.

Figure 1

Axial contrast-enhanced computed tomography scan of the abdomen showing a hypodense intravascular filling defect within the anatomical course of the splenic vein, consistent with acute splenic vein thrombosis. The hypodense thrombus is clearly demarcated against the enhanced vessel lumen, due to intravenous contrast administration.

Figure 2

Axial contrast-enhanced CT scan showing portal vein thrombosis. The thrombus appears as a non-enhancing area within the normally opacified vessel lumen, clearly contrasting with the surrounding contrast-enhanced blood.

Figure 3

Axial contrast-enhanced CT scan showing superior mesenteric vein thrombosis with extension into the splenic vein. Axial contrast-enhanced CT scan of the abdomen reveals a hypodense intravascular filling defect within the superior mesenteric vein (SMV), extending into the splenic vein. The thrombus appears as a non-enhancing region within the contrast-filled vessel lumen, indicating obstruction of venous flow. The involvement of multiple major mesenteric vessels suggests an extensive thrombotic event, which significantly increases the risk of intestinal ischemia.

Figure 4

Diagnostic laparoscopy highlighting necrosis of small intestinal loops (ileum). The affected bowel segments display hallmark features of transmural necrosis, including dark discoloration, lack of peristalsis, friability, and thinning of the bowel wall. Surrounding loops are edematous and distended, and turbid intraperitoneal fluid is noted, suggesting secondary peritonitis.

Figure 5

Intraoperative view obtained during diagnostic laparoscopy demonstrates the early onset of transmural necrosis affecting a segment of the ileum, approximately 50 cm proximal to the ileocecal valve. The affected bowel segment shows signs of dusky discoloration, loss of peristalsis, and thinning of the intestinal wall, all indicative of ischemic injury.

Figure 6

A lateral-to-lateral anastomosis between the jejunum and ileum is performed using a linear laparoscopic stapler. This technique involves aligning the lateral borders of both intestinal segments and creating an enterotomy in each to establish a common opening. The linear stapler is then introduced through the laparoscopic ports to simultaneously staple and seal the adjacent edges, forming the internal suture line of the anastomosis. After firing the stapler, the enterotomy defect is closed manually.