Laparoscopic surgery and splanchnic vessel thrombosis

Single-Dose enoxaparin for portomesenteric venous thrombosis prophylaxis after sleeve gastrectomy

Introduction

Portomesenteric venous thrombosis (PMVT) may complicate sleeve gastrectomy. We believe that single dose of enoxaparin postoperatively can reduce the risk of PMVT.

Objective

The objective was to study the outcomes of enoxaparin single dose compared to other perioperative prophylactic doses in preventing PMVT.

Methods

Participants included 590 patients who underwent laparoscopic sleeve gastrectomy (LSG). These retrospective cohort data were collected from patient medical charts after bariatric surgery. Patients were followed up in the close postoperative period and at 1, 3, 6, 12, and 18 months. Descriptive statistical analysis was carried out. The objective was to estimate the incidence of PMVT with postoperative single 40 mg subcutaneous enoxaparin prophylactic regimen.

Results

From January 2017 to December 2021, 590 patients with obesity underwent LSG. Five patients developed PMVT with an estimate incidence of 0.85%. Three patients had unexplained tachycardia and three patients had postoperative bleeding.

Conclusions

Single-dose enoxaparin 40 mg is an effective thrombosis prophylaxis without increasing risk of bleeding.

New technique of intragastric sleeve: viability and survival in a pig model

Developing a less invasive, practical and cost-effective operative technique for obesity treatment represents a pressing need for our society. In this way, intragastric single port sleeve by endoplication was tested in six pigs during 18 weeks. Celiotomy was performed with animal placed in dorsal decubitus position. Single port gastrostomy was performed and double tobacco pouch sutures were made in fundic region, making a gastric sleeve. At the end, stomach layers and skin were closed in a conventional manner. Means and the standard deviations of surgical time were calculated. The procedure was simple and all animals survived; there were no significant blood loss and no intra and postoperative complications. The procedure was fast (67.4 minutes). The technique has the advantage of not requiring the use of mechanical sutures, making it less costly. The innovation of this procedure was the use of a single port gastrostomy device to perform an intraluminal sleeve. What made this technique less invasive were the use of a single port, nonmanipulation of the stomach intra-abdominally, ease of execution and no need of pneumoperitoneum. The new technique is acceptable and has reproducible viability, had a short procedure time without intra and postoperative complications.

Porto-mesenteric vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity: Case series and literature review

BACKGROUND

Portal vein thrombosis is a rare and a potentially lethal complication of Laparoscopic sleeve gastrectomy. In this series, we describe the presentation, treatment, and outcome of 5 cases of PMVT post-laparoscopic sleeve gastrectomy (LSG) treated successfully at our hospital.

CASE REPORT

Five patients presented to our emergency department with diffuse abdominal pain associated with anorexia, nausea and vomiting after laparoscopic sleeve gastrectomy (LSG). Computed tomography (CT) scan showed evidence of portal, mesenteric and splenic vein thrombosis and small bowel ischemia in three patients. Two patients were treated only with anticoagulant and the other three patients were treated with surgery in the form of diagnostic laparoscopy converted to laparotomy with Small bowel resection.

CONCLUSION

Portal and mesenteric venous thrombosis after laparoscopic sleeve gastrectomy is an unusual complication but it has life threatening consequences if it is not diagnosed early and treated adequately. The patients with porto-mesenteric venous thrombosis (PMVT) usually present themselves with vague abdominal symptoms. As so, the physicians should have high index of suspicion to recommend computed tomography (CT) abdomen to confirm diagnosis and start adequate treatment.

Portomesenteric Vein Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Case Series and Literature Review

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is today one of the leading procedures in bariatric surgery, and portomesenteric vein thrombosis (PMVT) has been reported as one of its rare complications. The purpose of this study is to determine the prevalence, clinical presentation, and outcomes of PMVT in patients undergoing LSG.

METHODS

A retrospective study of a database of all post-LSG patients was conducted on the patients who developed PMVT post-LSG from July 2011 to March 2016, at Amiri Hospital, Kuwait.

RESULTS

A total of 2280 patients underwent LSG during the study period. Nine (0.39%) patients were diagnosed with PMVT post-LSG. Diagnosis was confirmed by CT scan for eight patients, and one had urgent laparotomy. The median age was 34 years (20-50), and there were 7 women and 2 men. Median preoperative body mass index (BMI) was 42 kg/m² (37.5-74.6), and median operative time was 80 min (60-150). The median post-operative anticoagulation duration was 4 days (2-22). The median onset of diagnosis after the surgery was 28 days (18-453), and two patients had a positive thrombophilia study. All patients were treated medically except one patient who underwent urgent laparotomy for small bowel necrosis and eventually had small bowel transplant.

CONCLUSIONS

PMVT post-LSG is a rare but possibly dangerous complication. It should be suspected with patients presenting with unresolving abdominal pain. Treatment is mainly conservative and surgical intervention might be needed for small bowel necrosis. Extended anticoagulation prophylaxis is a hypothesis for patients after LSG, and may play a role in preventing PMVT.

Splanchnic Vein Thrombosis - an Uncommon Complication after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is an innovative and relatively safe surgical approach for weight reduction in morbidly obese people. Splanchnic vein thrombosis (SVT) is an extremely rare complication of LSG and, if not recognized, carries a high mortality rate. This paper highlights a potentially lethal condition of SVT after LSG.

CASE REPORT

A 37-year-old morbidly obese woman was referred to our institution for LSG. Three weeks after the intervention, she was readmitted with abdominal pain, vomiting, nausea, diarrhea, and fever with positive family anamnesis to viral disease. Abdominal X-ray as well as utrasonography were both normal, and no X-ray contrast medium leakage was observed. One week later, she was readmitted with septic condition. An abdominal computed tomography scan diagnosed lienal vein thrombosis along its whole length and partial thrombosis of the superior mesenteric vein.

CONCLUSION

SVT presents very heterogeneously, which makes it extremely challenging to diagnose and to make an appropriate treatment decision. With regard to the high prevalence of obesity and the increasing frequency of LSG, prompt diagnosis and management are crucial.

Acute aortic occlusion presenting as paraplegia: a catastrophic complication in an elective surgical patient

Acute aortic occlusion by massive thoracoabdominal thrombi has been reported as a serious complication in patients undergoing major vascular or cardiac surgical procedures. However, this complication occurs rarely after ambulatory procedures. In this case report, we describe a patient who experienced paraplegia after an elective laparoscopic cholecystectomy in whom acute aortic thromboembolic occlusion was subsequently diagnosed. We emphasize the importance of accurate neurologic and cardiovascular history taking and examination throughout the perioperative period along with the appropriate diagnostic studies to expeditiously arrive at a diagnosis of such a rare complication.

Intestinal ischemia following laparoscopic surgery: a case series

Introduction

Intestinal ischemia is a rare complication of laparoscopic surgery. Its prognosis depends on a high index of suspicion and effective early treatment.

Case presentation

In the present report, we describe three cases where intestinal ischemia developed following laparoscopic surgery. Case 1 concerns a 52-year-old Caucasian man who developed large bowel ischemia following laparoscopic adjustable gastric band surgery. Case 2 concerns an 82-year-old Caucasian woman who developed fatal intestinal ischemia following laparoscopic cholecystectomy. Case 3 concerns a 58-year old Caucasian woman who developed right-sided lower intestinal ischemia following open cholecystectomy.

Conclusions

Intestinal ischemia is a rare complication of laparoscopic surgery. The identification of high-risk patients is an essential primary preventive measure. A high index of suspicion is required to make an early diagnosis, which may help improve outcomes.

Understanding Intra-Abdominal Hypertension

Received November 10, 2009. Received Revised June 17, 2010. Submitted June 21, 2010. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are highly morbid conditions that are common and underrecognized in the intensive care unit. Intra-abdominal hypertension affects the critically ill patient population and is not solely limited to the trauma and surgical subgroups. The recognition of IAH and ACS as distinct clinical states has become more apparent. Extensive bench and clinical research has shed significant light into the definition, incidence, etiology, physiology, clinical manifestations, and treatment strategies. Although further research into this morbid condition is needed, improvement in recognition is a critical first step. This review aims to scrutinize the basic science and clinical literature available on this condition in a surgically focused, organ-system-based approach.

Article Commentary: Laparoscopy Associated Mesenteric Vascular Complications

Since the first reported case in 1994, a small but significant number of patients have developed major mesenteric arterial and venous thromboses after laparoscopy, usually with catastrophic outcomes. The basic science data in both animal and human models suggest that these events were due in part to specific predisposing patient factors, combined with the physiologic changes in splanchnic hemodynamics that occur during induction and maintenance of pneumoperitoneum. The following manuscript examines the science of this phenomenon in detail and the features of the reported cases to date, with the goal being to increase awareness of this serious and likely underreported phenomenon.

Massive intestinal infarction following retroperitoneoscopic right lumbar sympathectomy

The adverse physiological effects of pneumo and retro-peritoneum are relatively well known. However, the clinical implications of compromised mesenteric circulation through several mechanical and physiological mechanisms are not as well recognized. We describe a fatal case of intestinal infarction following an elective retroperitoneoscopic right sympathectomy. The patient was a 88-year-old man who died 30 hours after an uneventful anesthesia and right endoscopic lumbar sympathectomy. An emergency explorative laparotomy revealed a massive intestinal infarction due to thrombosis of the superior mesenteric artery. We reviewed the literature on laparoscopic procedures and mesenteric ischemia. To our knowledge, this is the first reported case of intestinal infarction following retro-pneumoperitoneum. We conclude that the presence of a severe multidistrectual? arteriopathy may represent a major risk factor in retroperitoneoscopic procedures.

Randomized comparison of conventional carbon dioxide insufflation and abdominal wall lifting for laparoscopic cholecystectomy

BACKGROUND

Gasless laparoscopy using abdominal wall lifting (AWL) has been developed in an attempt to avoid the adverse effects of carbon dioxide pneumoperitoneum that may occur in conventional laparoscopy. However, lifting has been criticized for its poor operative space and surgical invasiveness. This study compared the AWL method with conventional CO2 pneumoperitoneum for laparoscopic cholecystectomy with respect to operation performance, postoperative course, and stress response.

PATIENTS AND METHODS

During a 6-month period, 95 patients with symptomatic gallstones were randomly assigned to receive laparoscopic cholecystectomy with conventional CO2 pneumoperitoneum (CO2 group; N = 47) or the AWL method (AWL group; N = 48). Operative results and operative time were recorded. Cardiopulmonary functions were assessed, and arterial blood gases were analyzed during surgery. Urinary cortisol, vanillylmandelic acid, metanephrines, and nitrogen loss; serum complement 3, C-reactive protein, and interleukin-6; postoperative pain; and the presence of nausea and vomiting were assessed for 48 hours after surgery. Postoperative time to recovery of flatus, tolerance of a full oral diet, and full activity were also determined.

RESULTS

Only three significant differences were found. First, intraoperative ventilatory function deteriorated significantly less in the AWL group. Second, arterial blood gas determinations and capnography showed a greater decrease in intraoperative arterial pH and compliance with CO2 retention and an increase in peak airway pressure in the CO2 group (P < 0.05), reflecting poorer ventilatory performance. Third, preparation time and total operating time were significantly greater with the AWL method (P < 0.05).

CONCLUSIONS

Although AWL required a longer operation time, our results suggest that the technique may still have value in high-risk patients with cardiorespiratory diseases.

Complications of laparoscopic antireflux surgery

Over the last decade, the laparoscopic approach to antireflux surgery has been widely applied, resulting in improved early outcomes and greater patient acceptance of surgery for gastroesophageal reflux disease. However, although short-term outcomes are probably better overall than those following open surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications, and as well as the occurrence of new complications specific to the laparoscopic approach. Significant complications include acute paraesophageal hiatus herniation, severe dysphagia, pneumothorax, vascular injury, and perforation of the gastrointestinal tract. The incidence of some of these complications decreases as surgeons gain experience; others can be minimized by using an appropriate operative technique. In addition, laparoscopic reintervention is usually straightforward in the 1st postoperative week. For this reason, the surgeon should have a low threshold for early laparoscopic reexploration, facilitated by early radiological contrast studies, in order to reduce the likelihood that problems will arise later.