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Postsplenectomy thrombosis of splenic, mesenteric, and portal vein (PST-SMPv): A single institutional series, comprehensive systematic review of a literature and suggested classification. Am J Surg 2018; 216:1192-1204. [DOI: 10.1016/j.amjsurg.2018.01.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 01/22/2018] [Accepted: 01/30/2018] [Indexed: 12/21/2022]
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Murphy RX, Holko GA, Khoury AA, Bleznak AD. Progressive wound necrosis associated with postoperative thrombocytosis in mastectomy and immediate breast reconstruction surgery: report of a case. EPLASTY 2009; 9:e34. [PMID: 19768118 PMCID: PMC2742396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 37-year-old who underwent splenectomy for motor vehicle accident-related injuries was diagnosed with stage IIA carcinoma of left breast 12 years later. She underwent bilateral mastectomy and bilateral immediate unipedicle TRAM flap reconstruction. Her preoperative platelet counts ranged from 332 to 424 K/cmm. Intraoperative fluorescein confirmed mastectomy flap viability. On postoperative day 1, platelet count was 374 K/cmm and all suture lines appeared benign. The patient was discharged 3 days later with healthy appearing tram flaps and slight epidermolysis in the abdominal region. Over the next 2 weeks, both the mastectomy flaps and the abdominal region underwent progressive necrosis as the platelet count increased to 1390 K/cmm. Aspirin therapy was instituted at this time. The TRAM flaps remained completely viable. Eighteen days later, the patient required wound debridement with secondary closure of the breast wounds. Platelet count peaked at 1689 K/cmm 2 days later (postoperative day 38). The wounds deteriorated again and were managed conservatively. Two months after mastectomy, the first area of spontaneous healing was documented (platelet count 758 K/cmm). Ultimately, wounds healed as platelet count reached its preoperative baseline. We hypothesize that an abnormal secondary thrombocytosis at subdermal plexus level caused problematic healing in this patient's mastectomy and abdominal flaps.
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Acute myocardial infarction after treatment of thrombocytopenia in a young woman with systemic lupus erythematosus. J Clin Rheumatol 2009; 14:350-2. [PMID: 19086148 DOI: 10.1097/rhu.0b013e31817de0fb] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We describe a case of an acute myocardial infarction (MI) coincident with correction of severe thrombocytopenia in a 23-year old African American woman with systemic lupus erythematosus (SLE) in the absence of coronary artery disease on angiography. Despite a history of anticardiolipin and beta(2)-glycoprotein I antibodies, she had no prior thromboembolic events. The occurrence of an acute MI after rapid normalization in the platelet count suggests the need for close monitoring of possible cardiovascular events during and after treatment of severe thrombocytopenia in the presence of antiphospholipid antibodies.
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Brink JS, Brown AK, Palmer BA, Moir C, Rodeberg DR. Portal vein thrombosis after laparoscopy-assisted splenectomy and cholecystectomy. J Pediatr Surg 2003; 38:644-7. [PMID: 12677588 DOI: 10.1053/jpsu.2003.50144] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A 12-year-old girl underwent laparoscopy-assisted splenectomy and cholecystectomy with removal of her spleen through a small Pfannenstiel incision. She had an unremarkable postoperative course but returned 16 days later because of increasing right-sided abdominal pain. The pain was constant, sharp, and stabbing without radiation. Abdominal examination showed diffuse right upper quadrant and epigastric tenderness without peritoneal irritation. Laboratory test results included white blood cell count, 14.4 x 10(9)/mm3; hemoglobin, 8.5 g/dL; platelets, 1,483,000; and normal values for lipase, amylase, aspartate transaminase, and alanine transaminase. Evaluation with ultrasonography and vessel Doppler studies showed an occlusive thrombus throughout the portal and splenic veins. The patient underwent intravenous heparin anticoagulation therapy. Her symptoms resolved completely over the next 2 days. The patient is currently receiving warfarin and anagrelide as an outpatient (international normalized ratio, 2). There were no long-term complications caused by portal vein thrombosis. This is the first reported case of portal vein thrombosis after laparoscopic splenectomy in the pediatric population.
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Affiliation(s)
- Jeromy S Brink
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Parker HH, Bynoe RP, Nottingham JM. Thrombosis of the portal venous system after splenectomy for trauma. THE JOURNAL OF TRAUMA 2003; 54:193-6. [PMID: 12544919 DOI: 10.1097/00005373-200301000-00027] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Harris H Parker
- Department of Surgical Education, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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van't Riet M, Burger JW, van Muiswinkel JM, Kazemier G, Schipperus MR, Bonjer HJ. Diagnosis and treatment of portal vein thrombosis following splenectomy. Br J Surg 2000; 87:1229-33. [PMID: 10971433 DOI: 10.1046/j.1365-2168.2000.01514.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Portal vein thrombosis is a rare but potentially fatal complication of splenectomy. The aim of this study was to assess the incidence, risk factors, treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients. METHODS All patients who had undergone a splenectomy in the University Hospital, Rotterdam, between 1984 and 1997 were reviewed retrospectively. Splenectomy that was followed by symptomatic portal vein thrombosis was selected for analysis. Risk factors for portal vein thrombosis were sought. RESULTS Of 563 splenectomies, nine (2 per cent) were complicated by symptomatic portal vein thrombosis. All these patients had either fever or abdominal pain. Two of 16 patients with a myeloproliferative disorder developed portal vein thrombosis after splenectomy (P = 0.03), and four of 49 patients with haemolytic anaemia (P = 0.005). Treatment within 10 days after splenectomy was successful in all patients, while delayed treatment was ineffective. CONCLUSION Portal vein thrombosis should be suspected in a patient with fever or abdominal pain after splenectomy. Patients with a myeloproliferative disorder or haemolytic anaemia are at higher risk; they might benefit from early detection and could have routine Doppler ultrasonography after splenectomy.
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Affiliation(s)
- M van't Riet
- Departments of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Cappell MS. Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy. Gastroenterol Clin North Am 1998; 27:783-825, vi. [PMID: 9890114 DOI: 10.1016/s0889-8553(05)70033-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, New York State Health Science Center, Brooklyn, New York, USA
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Skarsgard E, Doski J, Jaksic T, Wesson D, Shandling B, Ein S, Babyn P, Heiss K, Hu X. Thrombosis of the portal venous system after splenectomy for pediatric hematologic disease. J Pediatr Surg 1993; 28:1109-12. [PMID: 8308671 DOI: 10.1016/0022-3468(93)90141-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Splenic, portal, or mesenteric venous thrombosis after splenectomy for hematologic disease has not been reported in the pediatric literature. It is a rare complication associated with significant morbidity and mortality in adult reports. Between 1981 and 1991, 3 patients (13-year-old boy with hereditary elliptocytosis [HE], 13-year-old boy with thalassemia intermedia [TI], and 18-year-old girl with idiopathic thrombocytopenic purpura [ITP]) presented with abdominal pain, nausea, with or without fever, at 4, 11, and 13 days postsplenectomy, respectively. Abdominal Doppler ultrasound (US) and/or computed tomography (CT) showed: (1) an intraluminal filling defect with partial obstruction to flow in the right branch of the portal vein with the remaining vessels patent (HE); (2) splenic vein thrombosis with complete occlusion of the main portal vein and proximal superior mesenteric vein (TI); and (3) complete thrombosis of the splenic vein, proximal superior mesenteric vein and portal vein (including central radicles), with retrogastric collateralization (ITP). Subsequent imaging showed either complete resolution of vascular obstruction on no treatment (patient 1), or portal venous cavernomatous transformation with hepatofugal flow after 6 months of systemic anticoagulation (patients 2 and 3), and all 3 patients are currently asymptomatic. Postoperative sonographic evaluation of a consecutive series of pediatric splenectomies for hematologic disease (n = 16), was performed at a median of 51 days (range, 3 to 124). This demonstrated one case of asymptomatic left portal venous thrombosis with subsequent recanalization in the absence of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- E Skarsgard
- Department of Surgery, Hospital For Sick Children, Toronto, Ontario, Canada
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Abstract
Thrombosis of the portal vein and its splanchnic tributaries is often unsuspected clinically and may be recognized only after imaging studies of the abdomen are performed for other reasons. Radiologists should be aware of the clinical situations that predispose a patient to portal or mesenteric vein thrombosis and should also be able to recognize the sequelae of chronic thrombosis. Different modalities can be used to image the patient with portal vein thrombosis; each has its strengths and drawbacks. This paper discusses the conditions that predispose to portal and mesenteric vein thrombosis, differentiating intrahepatic portal vein occlusion secondary to liver disease from extrahepatic portal vein occlusion associated with a normal liver. The imaging features of portal vein thrombosis, its associated causes and sequelae will be reviewed as demonstrated on computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), angiography, and plain film.
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Affiliation(s)
- P L Abbitt
- Department of Radiology, University of Florida College of Medicine, Gainesville
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Abstract
Four patients under 45 years old presented with small bowel infarction secondary to superior mesenteric venous thrombosis. Diagnosis was not made pre-operatively in three patients and delay to operation of over 4 days occurred in two patients. In each case infarcted bowel was resected and a primary anastomosis fashioned. A further resection of infarcted small bowel was necessary in three patients. Each patient was discharged on long-term warfarin therapy. Two patients required permanent total parenteral nutrition, one of whom died of liver failure at one year. The remaining patients remain well.
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Affiliation(s)
- H C Umpleby
- University Surgical Unit, Southampton General Hospital, UK
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Abstract
Clinical and morphologic findings are described in a 22 year old man with prolonged thromboyctosis, and coronary and splenic arterial thrombi causing myocardial and splenic infarcts. The absence of preexistent extensive coronary atherosclerosis, the presence of thrombus in more than one epicardial artery and in multiple intramural coronary arteries, the presence of arterial thrombosis in a noncoronary artery (splenic) and the absence of another apparent cause of the arterial thromboses are evidences that the intraarterial clotting in this patient was related to the severe thrombocytosis. A reveiw of the reported cases of vascular occlusion associated with thrombocytosis indicates that thrombi have infrequently been confirmed as the mechanism of the vascular occlusion. Although the frequency of vascular thrombi in patients with thrombocytosis has not been established, it is clear that vascular thrombosis can be a consequence of thrombocytosis and, as demonstrated by the present patient, that the coronary artery may be the site of the vascular occlusion, a heretofore unconfirmed event.
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Nagasue N, Inokuchi K, Kobayashi M, Saku M. Mesenteric venous thrombosis occurring late after splenectomy. Br J Surg 1977; 64:781-3. [PMID: 588970 DOI: 10.1002/bjs.1800641107] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Two patients with mesenteric venous thrombosis which occurred late after splenectomy are reported. In the first case the thrombosis was seen, with preceding thrombocytosis, 3 years after splenectomy. In the second case the thrombosis occurred 2 years and 5 months postoperatively. Platelet counts had not been obtained before the mesenteric thrombosis in this case. In both instances persistent severe anaemia for several weeks preceded the symptoms and signs of mesenteric venous thrombosis. Both patients were treated by extended resection of the affected small bowel. Thus, dangerous thrombocytosis may occur in the presence of persistent severe anaemia even late after splenectomy. Thrombocytosis occurring immediately after splenectomy, which is almost inevitable, should be treated with heparin or other anticoagulants. In the late period the avoidance of persistent severe anaemia seems to be important in the prevention of thrombotic complications due to reactive thrombocytosis in splenectomized patients.
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Peters TG, Lewis JD, Flip DJ, Morris L. Antithrombin III deficiency causing postsplenectomy mesenteric venous thrombosis coincident with thrombocytopenia. Ann Surg 1977; 185:229-31. [PMID: 65157 PMCID: PMC1396096 DOI: 10.1097/00000658-197702000-00017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The most commonly recognized cause of mesenteric venous thrombosis following splenectomy is hypercoagulation secondary to reactive thrombocytosis. A case is reviewed in which hypercoagulation followed splenectomy for idiopathic thrombocytopenic purpura (ITP) in spite of persistent thrombocytopenia. Episodic mesenteric venous occlusion occurred due to antithrombin III deficiency. This hypercoagulable state may be the cause of primary acute mesenteric venous occlusive disease. Symptoms and signs suggesting thrombosis in the portal circulation demand immediate coagulation studies since even in the thrombocytopenic patient thrombotic proglems can occur. Surgical intervention is the treatment of choice for segmental small bowel ischemia; warfarin therapy is indicated when there is evidence of antithrombin III deficiency.
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Rossi P, Passariello R, Simonetti G. Portal thrombosis: high incidence following splenectomy for portal hypertension. GASTROINTESTINAL RADIOLOGY 1976; 1:225-7. [PMID: 1052464 DOI: 10.1007/bf02256370] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The authors report the incidence of portal thrombosis in their experience, of patients who have been operated on for splenectomy as treatment for portal hypertension with splenomegaly and hypersplenism without a portal systemic shunt. In 161 patients studied angiographically for portal hypertension due to cirrhosis, portal thrombosis was shown in 19 patients. Of these 19 patients 13 previously splenectomized. Only 6 were never operated upon.
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Abstract
Three cases of postsplenectomy mesenteric thrombosis, two associated with thrombocytosis, are presented. Experience has shown that persistent thrombocytosis, accompanied by abnormal platelet function, is not a benign condition and may be associated with thrombosis. When encountered, postsplenectomy thrombocytosis of greater than 800,000 per mm-3 must be evaluated by platelet function studies and anticoagulation begun. Post-prandial cramping abdominal pain may be an early symptom of thrombosis, demanding immediate anticoagulation. Low-dose heparin, ASA, and dipyridamole are three of the more commonly used treatment modalities. Small bowel resection is indicated if thrombosis occurs.
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