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A Systematic Literature Review

Aaron W. James, BA; Charlotte Rabl, MD; Antonio C. Westphalen, MD; Patrick F. Fogarty, MD; Andrew M. Posselt, MD, PhD; Guilherme M. Campos, MD, PhD

Arch Surg. 2009;144(6):520-526.

Background  Portomesenteric venous thrombosis (PVT) is an uncommon but potentially lethal condition reported after several laparoscopic procedures. Its presentation, treatment, and outcomes remain poorly understood, and possible etiologic factors include venous stasis from increased intra-abdominal pressure, intraoperative manipulation, or damage to the splanchnic endothelium and systemic thrombophilic states.

Design  Systematic literature review.

Setting  Academic research.

Subjects  We summarized the clinical presentation and outcomes of PVT after laparoscopic surgery other than splenectomy in 18 subjects and reviewed the treatment strategies.

Main Outcome Measures  Systematic review of the literature on PVT after laparoscopic procedures other than splenectomy.

Results  Eighteen cases of PVT following laparoscopic procedures were identified after Roux-en-Y gastric bypass (n = 7), Nissen fundoplication (n = 5), partial colectomy (n = 3), cholecystectomy (n = 2), and appendectomy (n = 1). The mean patient age was 42 years (age range, 20-74 years). Systemic predispositions toward venous thrombosis were identified in 11 patients. Clinical symptoms consisted primarily of abdominal pain manifested, on average, 14 days (range, 3-42 days) after surgery. Thrombus location varied, but 8 patients had a combination of portal and superior mesenteric venous thrombosis. Sixteen patients were treated with anticoagulation therapy. Ten patients underwent major interventions, including exploratory laparotomy in 6 patients and thrombolytic therapy in 4 patients. Six patients had complications, and 2 patients died.

Conclusions  Portomesenteric venous thrombosis following laparoscopic surgery usually manifests as nonspecific abdominal pain. Computed tomography can readily provide the diagnosis and demonstrate the extent of the disease. Treatment should be individualized based on the extent of thrombosis and the presence of bowel ischemia but should include anticoagulation therapy. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation of splanchnic vasculature, and systemic thrombophilic states likely converges to produce this potentially lethal condition.

Author Affiliations: Departments of Surgery (Mr James and Drs Rabl, Posselt, and Campos), Radiology (Dr Westphalen), and Medicine (Dr Fogarty), University of California, San Francisco.

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