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Original Article |

Portomesenteric Venous Thrombosis After Laparoscopic Surgery:  A Systematic Literature Review FREE

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
[+] Author Affiliations

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.


Arch Surg. 2009;144(6):520-526. doi:10.1001/archsurg.2009.81.
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Published online

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.

Figures in this Article

Portomesenteric venous thrombosis (PVT) is an uncommon, potentially lethal condition accounting for 5% to 15% of all mesenteric ischemic events.1 Portomesenteric venous thrombosis includes a wide spectrum of clinical presentations ranging from incidental findings in an asymptomatic patient to life-threatening bowel infarction, and most of what is known about acute PVT derives from patients who did not undergo laparoscopic surgery. The etiologic factors of PVT are numerous and can be divided into local and systemic factors. Local predisposing factors to PVT include abdominal malignant neoplasm, trauma to the portal venous system, abdominal inflammatory diseases (eg, pancreatitis, appendicitis, diverticulitis, and inflammatory bowel disease), and factors that decrease portal blood flow such as ascites due to cirrhosis29 or the pressure created by pneumoperitoneum during laparoscopic procedures.1012 Systemic predisposing factors include inherited thrombophilias (eg, antithrombin III deficiency, protein C and S deficiencies, factor V Leiden deficiency, G20210A prothrombin mutation, and hyperhomocysteinemia) and various acquired prothrombotic states (including sepsis, pregnancy, oral contraceptive use, malignant neoplasm, myeloproliferative disorders, and others).4,1320 Portomesenteric venous thrombosis has been previously described after procedures that involve ligation of major portal tributaries, such as splenectomy or other surgical procedures involving the portal venous system (including liver transplantation and shunts for portal hypertension, among others)2126 but rarely after surgical procedures without injury to the portal system. Portomesenteric venous thrombosis after various laparoscopic operations without injury to the portal venous system has been described in case reports since 1991.27 The dissemination of the use of laparoscopic surgery and the greater availability of modern diagnostic imaging methods likely contribute to the observation of this possible complication. Laparoscopic approaches compare favorably with open surgery for treating most gastrointestinal tract conditions because they provide similar outcomes and offer lower complication rates, less postoperative pain, and faster recovery.28,29 However, the greater number of laparoscopic procedures performed has resulted in more complications specific to laparoscopic surgery, including complications associated with trocar insertion or pneumoperitoneum30,31 and likely the rare but potentially lethal complication described herein.

This article reviews the available literature about PVT after laparoscopic surgery. A summary of reported cases of PVT after laparoscopic surgery is presented, with description of common clinical presentations and options for diagnosis, treatment, and outcomes, as well as a discussion of possible causative factors.

We used PubMed to search MEDLINE for articles published between January 1, 1990, and December 31, 2007, using the search terms portal vein thrombosis, mesenteric venous thrombosis, pylephlebitis, laparoscopic surgery, and laparoscopy. Additional articles culled from references were obtained. The inclusion criterion was documented PVT by imaging studies (angiography, ultrasonography, computed tomography [CT], or magnetic resonance imaging) or surgery following a laparoscopic procedure other than splenectomy. We also included 2 cases at our institution, one in which the index operation was performed at the University of California, San Francisco, and another that was referred to our institution after PVT was diagnosed following a laparoscopic procedure. Age and sex of the patients, type of surgery, method of PVT detection, location and extent of thrombosis, timing of symptom onset, type of symptoms, physical findings at presentation, and abnormal laboratory test results, treatment, and outcomes were recorded.

We excluded cases of laparoscopic splenectomy because they have been thoroughly reported elsewhere in the literature and because postsplenectomy PVT is likely a distinct entity related to ligation of the splenic vessels and associated hematologic diseases.3237 Other exclusion criteria included documented PVT predating surgery or documented mechanical injury to the portal vein or its major branches.

Eighteen cases of PVT following laparoscopic surgery were reviewed (Table). Portomesenteric venous thrombosis was found after diverse laparoscopic procedures, including appendectomy (n = 1), cholecystectomy (n = 2), colectomy (n = 3), Nissen fundoplication (n = 5), and Roux-en-Y gastric bypass (n = 7). The mean patient age was 42 years (age range, 20-74 years); 7 patients were female. Perioperative pharmacologic anticoagulation therapy with low-molecular-weight heparin was reported in 7 patients. Pneumoperitoneum was established at standard pressures in all patients, the mean operative time was 100 minutes (range, 40-150 minutes), and blood loss was consistently minimal.

Table Graphic Jump LocationTable. Summary of Cases With Portomesenteric Venous Thrombosis

Local or systemic predispositions to PVT were commonly identified. Abdominal inflammatory processes were present in 4 patients and included appendicitis,38 cholecystitis,39,40 and diverticulitis.41 At least 1 systemic predisposition toward venous thrombosis was present in 11 patients. These include prothrombogenic factors such as morbid obesity (n = 7), oral contraceptive use (n = 2), and a history of venous thrombosis (n = 2), all of which were identified before surgery. Other systemic predisposing factors were discovered in the postoperative period, including protein S deficiency (n = 2) and anticardiolipin antibody (n = 1).

On average, symptoms of PVT manifested clinically 14 days (median, 12 days; range, 3-42 days) after surgery. The most common symptoms included abdominal pain (16 patients) with variable distribution and severity, nausea (5 patients), vomiting (3 patients), diarrhea (4 patients), and fever (3 patients). Common findings on physical examination included abdominal tenderness (8 patients), distension (3 patients), and elevated temperature (2 patients). Most important, the initial physical examination findings were normal in 7 patients. Routine laboratory test results were abnormal in only 9 patients. The most commonly found abnormalities were leukocytosis and mildly elevated liver function test results.

The diagnosis of PVT was made using CT in 14 patients, while ultrasonography, magnetic resonance imaging, and invasive angiography were used to complement CT. The Table gives the location and extent of venous thrombosis. The location of thrombosis among patients was heterogeneous. Eight patients had thrombosis of both the portal and superior mesenteric veins, while 4 patients had a clot detected more extensively throughout the portal venous system. The Figure shows contrast-medium–enhanced CT images of the abdomen in a patient with PVT after laparoscopic gastric bypass and in a healthy subject for comparison. In 4 patients, the radiographic imaging suggested intestinal ischemia (including ascites, fat stranding, bowel wall thickening, and small-intestine dilatation). The investigation, testing, and diagnosis of PVT were delayed in 7 patients (median delay in diagnosis, 7.5 days; range, 2-30 days).

Place holder to copy figure label and caption
Figure.

Contrast-medium–enhanced axial and coronal computed tomographic images of the abdomen. A and B, In a healthy subject, the main and proximal right and left portal veins are well perfused (arrows). C and D, In a patient with portomesenteric venous thrombosis after laparoscopic gastric bypass, there is a lack of enhancement in the main and right portal veins (arrowheads) due to thrombosis. A normal stomach (asterisk in A and B) and the gastric pouch with staples (asterisk in D) can be seen under the left liver lobe.

Graphic Jump Location

Sixteen patients received anticoagulation therapy on diagnosis of PVT. Of 2 patients who did not receive anticoagulation therapy, one died after an exploratory laparotomy when extensive bowel ischemia was found, and the other was treated only with hydration and bowel rest.44,49 Thirteen patients were treated with an oral vitamin K antagonist for a minimum of 6 months. More aggressive therapy was used less frequently, including interventional radiologic procedures or exploratory laparotomy. The interventional radiologic procedures included endovascular thrombolysis (n = 3) and percutaneous thrombectomy (n = 1), always in combination with anticoagulation therapy. One patient underwent placement of a transjugular intrahepatic portosystemic stent–shunt. Exploratory laparotomy was performed in 6 patients; indications for surgery included septic presentation, abdominal imaging suggestive of bowel infarction, or both. Four patients who underwent surgery required bowel resection.

Complications occurred in 6 patients and included mesenteric ischemia (n = 4), bleeding (n = 2), pancreatitis (n = 1), and pulmonary embolism (n = 1). Two patients died; both deaths were related to mesenteric ischemia.

Follow-up imaging was obtained in 12 patients. Ultrasonography and CT were commonly used (in 7 and 5 of 12 patients, respectively); follow-up imaging was obtained a mean of 2 months (range, 3 weeks to 6 months) after initial diagnosis. Complete recanalization of the portal venous system was confirmed in 8 of 12 patients. Cavernous transformation was identified in 3 of 12 patients. No sequelae of portal hypertension were reported in these patients.

Portomesenteric venous thrombosis after laparoscopic surgery is an infrequently observed yet potentially life-threatening condition. Following laparoscopic surgery, PVT usually manifests as nonspecific abdominal pain similar to acute PVT in other clinical settings. However, the clinical presentation varies widely, and the diagnosis is often delayed. The wide spectrum of clinical presentations ranges from incidental findings in an asymptomatic patient to life-threatening bowel infarction. Patients may be initially seen with nonspecific abdominal pain (90% of patients), nausea (54%), vomiting (77%), or diarrhea (36%)52; other findings may include anorexia, colicky pain, or gastrointestinal tract bleeding. Most patients have had symptoms for more than 2 days before seeking medical care.53 Physical findings may be absent or may include low-grade fever (an early indicator), peritoneal signs, splenomegaly due to chronic venous congestion, or hypotension (in case of septic shock due to bowel ischemia).54 Pain out of proportion to physical findings should raise the clinical suggestion of PVT.42,49

Routine blood tests are typically not helpful in the diagnosis of acute PVT. Leukocytosis and mild elevations in liver function tests may be present, whereas metabolic acidosis is a typical late finding suggestive of bowel infarction.5,49,55 Computed tomography with intravenous contrast medium is most commonly used to diagnose PVT, is up to 90% sensitive, and can readily evaluate the extent of the disease.56 Signs on CT include a central lucency in the lumen of a dilated vein, venous collateral circulation, and signs of intestinal congestion or edema. Several studies5760 have documented a high level of agreement between findings on CT and results of other noninvasive imaging modalities, including ultrasonography and magnetic resonance imaging. Although ultrasonography is readily available and is expedient, it has the lowest specificity for PVT of available imaging techniques60 and is best used to document restoration of venous flow in a patient with known PVT. Magnetic resonance imaging is highly sensitive and specific for PVT but is not widely available.61 Invasive angiographic studies remain the standard criterion for the diagnosis.60

The development of venous thrombi in general is considered a multifactorial process,62,63 and a combination of locoregional and systemic prothombogenic factors may be causative in PVT. The increasingly described clinical scenario of PVT after laparoscopy highlights the multicausal nature of this condition.

Locoregional factors particular to laparoscopic procedures may contribute to the development of PVT. In animal and human studies,1012 insufflation of the abdomen and increased intra-abdominal pressure led to decreased mesenteric and portal venous flow via direct pressure–induced compression. Estimates of this decrease in venous flow vary from 35% to 84%.64 However, most studies find a dose-dependent relationship between insufflation pressures and venous stasis. Insufflation with carbon dioxide has been shown to cause a more substantial decrease in venous flow than insufflation with other inert gases.65,66 Transperitoneal diffusion of carbon dioxide into the circulation can cause hypercapnia, which in turn has been implicated in decreasing splanchnic blood flow related to mesenteric vasoconstriction.67 Another possible explanation is that a prolonged reverse Trendelenburg position (such as may be necessary for various laparoscopic procedures) may exacerbate laparoscopy-associated portal venous stasis, as observed in experimental models.68,69 In addition, intraoperative surgical manipulation may damage the splanchnic endothelium and lead to local thrombus formation that may then propagate throughout the portal venous system. This may be particularly true for laparoscopic splenectomy, in which ligation of the splenic vein causes endothelial damage in proximity to the portal vein, but many other procedures also lead to some manipulation of the splanchnic vasculature.

Although hereditary thrombophilia has been reported in conjunction with PVT,20,70 its reported incidence varies widely, likely because of small sample sizes and differences in baseline populations, genetic assays, and inclusion criteria.71 The factor V Leiden mutation has been observed in 3% to 30% of patients, prothrombin G20210A mutation in 3% to 40%, antithrombin III deficiency in 1% to 29%, and protein C and S deficiencies in 7% to 27% and 2% to 43%, respectively.17,62,7174 Deficiencies in proteins C and S and antithrombin III appear in greater frequency in patients with PVT than in patients with lower extremity deep venous thrombosis.75 Our review identified 2 patients with protein S deficiency.

Finally, the underlying disease process or condition leading to laparoscopic surgery may predispose to PVT. This may be true in laparoscopic splenectomy for myeloproliferative disorders, laparoscopic tumor resections for malignant neoplasm, laparoscopic gastric bypass for morbid obesity, and surgery for abdominal inflammatory conditions.

In our review, PVT occurred in 7 patients despite perioperative thromboprophylaxis with low-molecular-weight heparin. Previous findings after laparoscopic splenectomy have suggested that more aggressive perioperative anticoagulation therapy may be used for prevention of PVT.36 For other general laparoscopic surgical procedures, it is likely impracticable to develop specific guidelines to attempt prevention of PVT, as it is a rare event.

Prompt initiation of anticoagulation therapy is the current standard of care for the treatment of acute PVT. The suggested duration of anticoagulation treatment is 6 to 12 months. In a retrospective study77 of nonsurgical patients who developed acute PVT, anticoagulant therapy decreased the rate of recurrence or extension of PVT by two-thirds without increasing the rate of gastrointestinal tract bleeding. Results of another study78 showed that anticoagulation therapy with heparin or low-molecular-weight heparin led to complete or partial recanalization in 90% of patients. However, the natural history of untreated PVT is not well understood, and no randomized trials have demonstrated the best management for this rare condition, to our knowledge. Supportive measures to complement anticoagulation therapy include bowel rest, fluid resuscitation, and nasogastric suction.76 Endovascular thrombolysis has been shown to be effective in case reports and in small series,7982 but large studies are lacking. In a retrospective review, Hollingshead et al83 showed that thrombolytic therapy led to complete or partial thrombus resolution in 75% of patients with PVT that was recalcitrant to anticoagulant therapy. Therefore, in the absence of clinical improvement with anticoagulation treatment, thrombolytic therapy should be considered.

The treatment of PVT after laparoscopic surgery is also not fully delineated. Anticoagulation treatment alone has been shown to be of therapeutic benefit in acute PVT.77,84,85 Anticoagulation therapy speeds recanalization of the portal venous system27 and decreases the risk of further thrombotic events.77 Therefore, anticoagulation therapy is recommended for 6 to 12 months.76 Our review found 1 case of spontaneous resolution of portal and superior mesenteric venous thrombosis without anticoagulation therapy.44 More tenuous are the indications for chemical and mechanical thrombolysis. Although thrombolysis has been shown to be effective in resolving thrombus and in avoiding bowel resection, it is associated with a high complication rate.83 Therefore, thrombolysis should be reserved for patients with extensive thrombosis of the portal venous system and for patients whose clinical condition warrants aggressive thrombolytic treatment.

This review indicates that preoperative strategies to identify populations that may be at particularly high risk for PVT have not been well elucidated, although certain hereditary thrombophilias may disproportionately increase the risk for the condition. Signs and symptoms of PVT vary widely, and the diagnosis is often delayed. Treatment should include anticoagulation therapy; additional measures should be individualized based on the extent of the thrombosis and the presence of bowel ischemia. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation, or damage to the splanchnic endothelium and systemic thrombophilic states may contribute to the development of this potentially lethal condition.

Correspondence: Guilherme M. Campos, MD, PhD, Department of Surgery, University of California, San Francisco, 521 Parnassus Ave, Room C-341, San Francisco, CA 94143-0790 (G.Campos@ucsfmedctr.org).

Accepted for Publication: April 15, 2008.

Author Contributions:Study concept and design: Campos. Acquisition of data: James, Rabl, Westphalen, and Campos. Analysis and interpretation of data: James, Rabl, Fogarty, Posselt, and Campos. Drafting of the manuscript: James, Posselt, and Campos. Critical revision of the manuscript for important intellectual content: Rabl, Westphalen, Fogarty, Posselt, and Campos. Statistical analysis: James. Obtained funding: Campos. Administrative, technical, and material support: James, Rabl, Westphalen, Fogarty, and Campos. Study supervision: Posselt and Campos.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by grant KL2 RR024130 from the National Center for Research Resources (Dr Campos).

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Center for Research Resources or the National Institutes of Health.

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PubMed Link to Article
Cohen  JEdelman  RRChopra  S Portal vein thrombosis: a review. Am J Med 1992;92 (2) 173- 182
PubMed Link to Article
Brown  KMKaplan  MMDonowitz  M Extrahepatic portal venous thrombosis: frequent recognition of associated diseases. J Clin Gastroenterol 1985;7 (2) 153- 159
PubMed Link to Article
Bradbury  MSKavanagh  PVBechtold  RE  et al.  Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics 2002;22 (3) 527- 541
PubMed Link to Article
Cakmak  OElmas  NTamsel  S  et al.  Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography. Abdom Imaging 2008;33 (1) 65- 71
PubMed Link to Article
Erden  AErden  IYağmurlu  BKarayalçin  SYurdaydin  CKarayalçin  K Portal venous system: evaluation with contrast-enhanced 3D MR portography. Clin Imaging 2003;27 (2) 101- 105
PubMed Link to Article
Harward  TRGreen  DBergan  JJRizzo  RJYao  JS Mesenteric venous thrombosis. J Vasc Surg 1989;9 (2) 328- 333
PubMed Link to Article
Pieters  PCMiller  WJDeMeo  JH Evaluation of the portal venous system: complementary roles of invasive and noninvasive imaging strategies. Radiographics 1997;17 (4) 879- 895
PubMed Link to Article
Haddad  MCClark  DCSharif  HSal Shahed  MAideyan  OSammak  BM MR, CT, and ultrasonography of splanchnic venous thrombosis. Gastrointest Radiol 1992;17 (1) 34- 40
PubMed Link to Article
Denninger  MHChaït  YCasadevall  N  et al.  Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors. Hepatology 2000;31 (3) 587- 591
PubMed Link to Article
Rosendaal  FR Venous thrombosis: a multicausal disease. Lancet 1999;353 (9159) 1167- 1173
PubMed Link to Article
Schäfer  MKrähenbühl  L Effect of laparoscopy on intra-abdominal blood flow. Surgery 2001;129 (4) 385- 389
PubMed Link to Article
Ho  HSSaunders  CJGunther  RAWolfe  BM Effector of hemodynamics during laparoscopy: CO2 absorption or intra-abdominal pressure? J Surg Res 1995;59 (4) 497- 503
PubMed Link to Article
Schmandra  TCKim  ZGGutt  CN Effect of insufflation gas and intraabdominal pressure on portal venous flow during pneumoperitoneum in the rat. Surg Endosc 2001;15 (4) 405- 408
PubMed Link to Article
Epstein  RMWheeler  HOFrumin  MJHabif  DVPapper  EMBradley  SE The effect of hypercapnia on estimated hepatic blood flow, circulating splanchnic blood volume, and hepatic sulfobromophthalein clearance during general anesthesia in man. J Clin Invest 1961;40592- 598
PubMed Link to Article
Gutt  CNSchmedt  CGSchmandra  THeupel  OSchemmer  PBüchler  MW Insufflation profile and body position influence portal venous blood flow during pneumoperitoneum [published correction appears in Surg Endosc. 2004;18(2):351]. Surg Endosc 2003;17 (12) 1951- 1957
PubMed Link to Article
Junghans  TBöhm  BGründel  KSchwenk  WMüller  JM Does pneumoperitoneum with different gases, body positions, and intraperitoneal pressures influence renal and hepatic blood flow? Surgery 1997;121 (2) 206- 211
PubMed Link to Article
Bonariol  LVirgilio  CTiso  E  et al.  Spontaneous superior mesenteric vein thrombosis (SMVT) in primary protein S deficiency: a case report and review of the literature. Chir Ital 2000;52 (2) 183- 190
PubMed
Harmanci  OErsoy  OGurgey  A  et al.  The etiologic distribution of thrombophilic factors in chronic portal vein thrombosis. J Clin Gastroenterol 2007;41 (5) 521- 527
PubMed Link to Article
Chamouard  PPencreach  EMaloisel  F  et al.  Frequent factor II G20210A mutation in idiopathic portal vein thrombosis. Gastroenterology 1999;116 (1) 144- 148
PubMed Link to Article
Egesel  TBüyükasik  YDündar  SVGürgey  AKirazli  SBayraktar  Y The role of natural anticoagulant deficiencies and factor V Leiden in the development of idiopathic portal vein thrombosis. J Clin Gastroenterol 2000;30 (1) 66- 71
PubMed Link to Article
Janssen  HLMeinardi  JRVleggaar  FP  et al.  Factor V Leiden mutation, prothrombin gene mutation, and deficiencies in coagulation inhibitors associated with Budd-Chiari syndrome and portal vein thrombosis: results of a case-control study. Blood 2000;96 (7) 2364- 2368
PubMed
Bombeli  TBasic  AFehr  J Prevalence of hereditary thrombophilia in patients with thrombosis in different venous systems. Am J Hematol 2002;70 (2) 126- 132
PubMed Link to Article
Kumar  SSarr  MGKamath  PS Mesenteric venous thrombosis. N Engl J Med 2001;345 (23) 1683- 1688
PubMed Link to Article
Condat  BPessione  FHillaire  S  et al.  Current outcome of portal vein thrombosis in adults: risk and benefit of anticoagulant therapy. Gastroenterology 2001;120 (2) 490- 497
PubMed Link to Article
Condat  BPessione  FHelene Denninger  MHillaire  SValla  D Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy. Hepatology 2000;32 (3) 466- 470
PubMed Link to Article
Aytekin  CBoyvat  FKurt  AYologlu  ZCoskun  M Catheter-directed thrombolysis with transjugular access in portal vein thrombosis secondary to pancreatitis. Eur J Radiol 2001;39 (2) 80- 82
PubMed Link to Article
Kercher  KWSing  RFWatson  KWMatthews  BDLeQuire  MHHeniford  BT Transhepatic thrombolysis in acute portal vein thrombosis after laparoscopic splenectomy. Surg Laparosc Endosc Percutan Tech 2002;12 (2) 131- 136
PubMed Link to Article
Ozkan  UOğuzkurt  LTercan  FTokmak  N Percutaneous transhepatic thrombolysis in the treatment of acute portal venous thrombosis. Diagn Interv Radiol 2006;12 (2) 105- 107
PubMed
Sze  DYO’Sullivan  GJJohnson  DLDake  MD Mesenteric and portal venous thrombosis treated by transjugular mechanical thrombolysis. AJR Am J Roentgenol 2000;175 (3) 732- 734
PubMed Link to Article
Hollingshead  MBurke  CTMauro  MAWeeks  SMDixon  RGJaques  PF Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol 2005;16 (5) 651- 661
PubMed Link to Article
Brunaud  LAntunes  LCollinet-Adler  S  et al.  Acute mesenteric venous thrombosis: case for nonoperative management. J Vasc Surg 2001;34 (4) 673- 679
PubMed Link to Article
Sheen  CLLamparelli  HMilne  AGreen  IRamage  JK Clinical features, diagnosis and outcome of acute portal vein thrombosis. QJM 2000;93 (8) 531- 534
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Contrast-medium–enhanced axial and coronal computed tomographic images of the abdomen. A and B, In a healthy subject, the main and proximal right and left portal veins are well perfused (arrows). C and D, In a patient with portomesenteric venous thrombosis after laparoscopic gastric bypass, there is a lack of enhancement in the main and right portal veins (arrowheads) due to thrombosis. A normal stomach (asterisk in A and B) and the gastric pouch with staples (asterisk in D) can be seen under the left liver lobe.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Summary of Cases With Portomesenteric Venous Thrombosis

References

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PubMed
Fichera  ACicchiello  LAMendelson  DSGreenstein  AJHeimann  TM Superior mesenteric vein thrombosis after colectomy for inflammatory bowel disease: a not uncommon cause of postoperative acute abdominal pain. Dis Colon Rectum 2003;46 (5) 643- 648
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Sanabria  JRHiruki  TSzalay  DATandan  VGallinger  S Superior mesenteric vein thrombosis after the Whipple procedure: an aggressive, combined treatment approach. Can J Surg 1997;40 (6) 467- 470
PubMed
Stieber  ACZetti  GTodo  S  et al.  The spectrum of portal vein thrombosis in liver transplantation. Ann Surg 1991;213 (3) 199- 206
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Rotstein  LEMakowka  LLanger  BBlendis  LMStone  RMColapinto  RF Thrombosis of the portal vein following distal splenorenal shunt. Surg Gynecol Obstet 1979;149 (6) 847- 851
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Siddiqui  ALivingston  EHuerta  S A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model. Am J Surg 2006;192 (5) e1- e7
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PubMed
Schäfer  MLauper  MKrähenbühl  L Trocar and Veress needle injuries during laparoscopy. Surg Endosc 2001;15 (3) 275- 280
PubMed Link to Article
Brink  JSBrown  AKPalmer  BAMoir  CRodeberg  DR Portal vein thrombosis after laparoscopy-assisted splenectomy and cholecystectomy. J Pediatr Surg 2003;38 (4) 644- 647
PubMed Link to Article
Franciosi  CRomano  FCaprotti  R  et al.  Splenoportal thrombosis as a complication after laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A 2002;12 (4) 273- 276
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Harris  WMarcaccio  M Incidence of portal vein thrombosis after laparoscopic splenectomy. Can J Surg 2005;48 (5) 352- 354
PubMed
Miniati  DNPadidar  AMKee  STKrummel  TMMallory  B Portal vein thrombosis after laparoscopic splenectomy: an ongoing clinical challenge. JSLS 2005;9 (3) 335- 338
PubMed
Pietrabissa  AMoretto  CAntonelli  GMorelli  LMarciano  EMosca  F Thrombosis in the portal venous system after elective laparoscopic splenectomy. Surg Endosc 2004;18 (7) 1140- 1143
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Abdelrazeq  ASDwaik  MAAldoori  MILund  JNLeveson  SH Laparoscopy-associated portal vein thrombosis: description of an evolving clinical syndrome. J Laparoendosc Adv Surg Tech A 2006;16 (1) 9- 14
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Preventza  OAHabib  FAYoung  SCPenney  DOppat  WMittal  VK Portal vein thrombosis: an unusual complication of laparoscopic cholecystectomy. JSLS 2005;9 (1) 87- 90
PubMed
Baixauli  JDelaney  CPSenagore  AJRemzi  FHFazio  VW Portal vein thrombosis after laparoscopic sigmoid colectomy for diverticulitis: report of a case. Dis Colon Rectum 2003;46 (4) 550- 553
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Poultsides  GALewis  WCFeld  RWalters  DLCherry  DARuby  ST Portal vein thrombosis after laparoscopic colectomy: thrombolytic therapy via the superior mesenteric vein. Am Surg 2005;71 (10) 856- 860
PubMed
Millikan  KWSzczerba  SMDominguez  JM McKenna  RRorig  JC Superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy: report of a case. Dis Colon Rectum 1996;39 (10) 1171- 1175
PubMed Link to Article
Davies  MSatyadas  TAkle  CA Spontaneous resolution of a superior mesenteric vein thrombosis after laparoscopic Nissen fundoplication. Ann R Coll Surg Engl 2002;84 (3) 177- 180
PubMed
García Díaz  RARodríguez-Sanjuán  JCDomínguez Díez  RA  et al.  Fatal portal thrombosis after laparoscopic Nissen fundoplication. Rev Esp Enferm Dig 2005;97 (9) 666- 669
PubMed Link to Article
Kemppainen  EKokkola  ASirén  JKiviluoto  T Superior mesenteric and portal vein thrombosis following laparoscopic Nissen fundoplication. Dig Surg 2000;17 (3) 279- 281
PubMed Link to Article
Noh  KWWolfsen  HCBridges  MDHinder  RA Mesenteric venous thrombosis following laparoscopic antireflux surgery. Dig Dis Sci 2007;52 (1) 273- 275
PubMed Link to Article
Steele  SRMartin  MJGarafalo  TKo  TMPlace  RJ Superior mesenteric vein thrombosis following laparoscopic Nissen fundoplication. JSLS 2003;7 (2) 159- 163
PubMed
Swartz  DEFelix  EL Acute mesenteric venous thrombosis following laparoscopic Roux-en-Y gastric bypass. JSLS 2004;8 (2) 165- 169
PubMed
Denne  JLKowalski  C Portal vein thrombosis after laparoscopic gastric bypass. Obes Surg 2005;15 (6) 886- 889
PubMed Link to Article
Johnson  CMde la Torre  RAScott  JSJohansen  T Mesenteric venous thrombosis after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1 (6) 580- 583
PubMed Link to Article
Boley  SJKaleya  RNBrandt  LJ Mesenteric venous thrombosis. Surg Clin North Am 1992;72 (1) 183- 201
PubMed
Rhee  RYGloviczki  PMendonca  CT  et al.  Mesenteric venous thrombosis: still a lethal disease in the 1990s. J Vasc Surg 1994;20 (5) 688- 697
PubMed Link to Article
Cohen  JEdelman  RRChopra  S Portal vein thrombosis: a review. Am J Med 1992;92 (2) 173- 182
PubMed Link to Article
Brown  KMKaplan  MMDonowitz  M Extrahepatic portal venous thrombosis: frequent recognition of associated diseases. J Clin Gastroenterol 1985;7 (2) 153- 159
PubMed Link to Article
Bradbury  MSKavanagh  PVBechtold  RE  et al.  Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics 2002;22 (3) 527- 541
PubMed Link to Article
Cakmak  OElmas  NTamsel  S  et al.  Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography. Abdom Imaging 2008;33 (1) 65- 71
PubMed Link to Article
Erden  AErden  IYağmurlu  BKarayalçin  SYurdaydin  CKarayalçin  K Portal venous system: evaluation with contrast-enhanced 3D MR portography. Clin Imaging 2003;27 (2) 101- 105
PubMed Link to Article
Harward  TRGreen  DBergan  JJRizzo  RJYao  JS Mesenteric venous thrombosis. J Vasc Surg 1989;9 (2) 328- 333
PubMed Link to Article
Pieters  PCMiller  WJDeMeo  JH Evaluation of the portal venous system: complementary roles of invasive and noninvasive imaging strategies. Radiographics 1997;17 (4) 879- 895
PubMed Link to Article
Haddad  MCClark  DCSharif  HSal Shahed  MAideyan  OSammak  BM MR, CT, and ultrasonography of splanchnic venous thrombosis. Gastrointest Radiol 1992;17 (1) 34- 40
PubMed Link to Article
Denninger  MHChaït  YCasadevall  N  et al.  Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors. Hepatology 2000;31 (3) 587- 591
PubMed Link to Article
Rosendaal  FR Venous thrombosis: a multicausal disease. Lancet 1999;353 (9159) 1167- 1173
PubMed Link to Article
Schäfer  MKrähenbühl  L Effect of laparoscopy on intra-abdominal blood flow. Surgery 2001;129 (4) 385- 389
PubMed Link to Article
Ho  HSSaunders  CJGunther  RAWolfe  BM Effector of hemodynamics during laparoscopy: CO2 absorption or intra-abdominal pressure? J Surg Res 1995;59 (4) 497- 503
PubMed Link to Article
Schmandra  TCKim  ZGGutt  CN Effect of insufflation gas and intraabdominal pressure on portal venous flow during pneumoperitoneum in the rat. Surg Endosc 2001;15 (4) 405- 408
PubMed Link to Article
Epstein  RMWheeler  HOFrumin  MJHabif  DVPapper  EMBradley  SE The effect of hypercapnia on estimated hepatic blood flow, circulating splanchnic blood volume, and hepatic sulfobromophthalein clearance during general anesthesia in man. J Clin Invest 1961;40592- 598
PubMed Link to Article
Gutt  CNSchmedt  CGSchmandra  THeupel  OSchemmer  PBüchler  MW Insufflation profile and body position influence portal venous blood flow during pneumoperitoneum [published correction appears in Surg Endosc. 2004;18(2):351]. Surg Endosc 2003;17 (12) 1951- 1957
PubMed Link to Article
Junghans  TBöhm  BGründel  KSchwenk  WMüller  JM Does pneumoperitoneum with different gases, body positions, and intraperitoneal pressures influence renal and hepatic blood flow? Surgery 1997;121 (2) 206- 211
PubMed Link to Article
Bonariol  LVirgilio  CTiso  E  et al.  Spontaneous superior mesenteric vein thrombosis (SMVT) in primary protein S deficiency: a case report and review of the literature. Chir Ital 2000;52 (2) 183- 190
PubMed
Harmanci  OErsoy  OGurgey  A  et al.  The etiologic distribution of thrombophilic factors in chronic portal vein thrombosis. J Clin Gastroenterol 2007;41 (5) 521- 527
PubMed Link to Article
Chamouard  PPencreach  EMaloisel  F  et al.  Frequent factor II G20210A mutation in idiopathic portal vein thrombosis. Gastroenterology 1999;116 (1) 144- 148
PubMed Link to Article
Egesel  TBüyükasik  YDündar  SVGürgey  AKirazli  SBayraktar  Y The role of natural anticoagulant deficiencies and factor V Leiden in the development of idiopathic portal vein thrombosis. J Clin Gastroenterol 2000;30 (1) 66- 71
PubMed Link to Article
Janssen  HLMeinardi  JRVleggaar  FP  et al.  Factor V Leiden mutation, prothrombin gene mutation, and deficiencies in coagulation inhibitors associated with Budd-Chiari syndrome and portal vein thrombosis: results of a case-control study. Blood 2000;96 (7) 2364- 2368
PubMed
Bombeli  TBasic  AFehr  J Prevalence of hereditary thrombophilia in patients with thrombosis in different venous systems. Am J Hematol 2002;70 (2) 126- 132
PubMed Link to Article
Kumar  SSarr  MGKamath  PS Mesenteric venous thrombosis. N Engl J Med 2001;345 (23) 1683- 1688
PubMed Link to Article
Condat  BPessione  FHillaire  S  et al.  Current outcome of portal vein thrombosis in adults: risk and benefit of anticoagulant therapy. Gastroenterology 2001;120 (2) 490- 497
PubMed Link to Article
Condat  BPessione  FHelene Denninger  MHillaire  SValla  D Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy. Hepatology 2000;32 (3) 466- 470
PubMed Link to Article
Aytekin  CBoyvat  FKurt  AYologlu  ZCoskun  M Catheter-directed thrombolysis with transjugular access in portal vein thrombosis secondary to pancreatitis. Eur J Radiol 2001;39 (2) 80- 82
PubMed Link to Article
Kercher  KWSing  RFWatson  KWMatthews  BDLeQuire  MHHeniford  BT Transhepatic thrombolysis in acute portal vein thrombosis after laparoscopic splenectomy. Surg Laparosc Endosc Percutan Tech 2002;12 (2) 131- 136
PubMed Link to Article
Ozkan  UOğuzkurt  LTercan  FTokmak  N Percutaneous transhepatic thrombolysis in the treatment of acute portal venous thrombosis. Diagn Interv Radiol 2006;12 (2) 105- 107
PubMed
Sze  DYO’Sullivan  GJJohnson  DLDake  MD Mesenteric and portal venous thrombosis treated by transjugular mechanical thrombolysis. AJR Am J Roentgenol 2000;175 (3) 732- 734
PubMed Link to Article
Hollingshead  MBurke  CTMauro  MAWeeks  SMDixon  RGJaques  PF Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol 2005;16 (5) 651- 661
PubMed Link to Article
Brunaud  LAntunes  LCollinet-Adler  S  et al.  Acute mesenteric venous thrombosis: case for nonoperative management. J Vasc Surg 2001;34 (4) 673- 679
PubMed Link to Article
Sheen  CLLamparelli  HMilne  AGreen  IRamage  JK Clinical features, diagnosis and outcome of acute portal vein thrombosis. QJM 2000;93 (8) 531- 534
PubMed Link to Article

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
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