JAMA Surgery: Vascular Medicine Topic Collection

Portomesenteric Thrombosis Following Laparoscopic Bariatric Surgery Incidence, Patterns of Clinical Presentation, and Etiology in a Bariatric Patient Population Portomesenteric Thrombosis Following LBS

Goitein D, Matter I, Raziel A, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Objective

To describe the incidence of, the patterns of clinical presentation of, and the reasons for portomesenteric vein thrombosis among patients who underwent laparoscopic bariatric surgery.

Design

Retrospective, multicenter study.

Setting

Six academic bariatric centers.

Patients

Morbidly obese patients diagnosed with portomesenteric vein thrombosis following laparoscopic bariatric surgery between January 2007 and June 2012.

Main Outcome Measures

Clinical presentation, diagnostic measures used, treatments employed, outcome, and hematologic workup of patients.

Results

Of 5706 patients who underwent laparoscopic bariatric surgery, 17 (0.3%) had portomesenteric vein thrombosis, 16 after sleeve gastrectomy and 1 following adjustable gastric banding. Seven patients were women, the mean age was 38 years, and the mean body mass index was 44.3. The median time to presentation was 10.1 days, and the median time to diagnosis was 11.7 days. New-onset epigastric pain was present in all patients, whereas other signs and symptoms were sporadically found. Computed tomography was performed and was diagnostic in 16 cases. Ultrasonography was used for 9 patients, and positive results were found for 8 of these patients. Patients were treated by anticoagulation with subcutaneous low-molecular-weight heparin (n = 15) or intravenous heparin (n = 2), followed by warfarin sodium. One patient underwent transhepatic portal infusion of streptokinase. Three patients required surgery: laparoscopic splenectomy due to infarct and abscess for 1 patient and laparotomy for 2 patients (with necrotic small-bowl resection for 1 of these patients). There were no deaths.

Conclusions

Portomesenteric vein thrombosis is rare after laparoscopic bariatric surgery. Familiarity with this dangerous entity is important. Prompt diagnosis and care, initiated by a high index of suspicion, is crucial.

Variations on a Theme Comment on “Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies” Variant Venous Adrenal Anatomy at Work

Sadowski SM, Kebebew E. — Mon, 01 Apr 2013 00:00:00 GMT

The number of adrenalectomies performed in the last 2 decades has almost doubled, and many of these procedures are being performed laparoscopically because of the improved patient outcomes associated with this surgical technique. Thus, knowledge of adrenal venous anatomy and its variations is important to avoid one of the common complications of an adrenalectomy, bleeding. Furthermore, in patients with pheochromocytoma, early identification and division of the adrenal vein(s) are often emphasized to minimize intraoperative hemodynamic instability.

Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies Variant Adrenal Venous Anatomy in Adrenalectomy

Scholten A, Cisco RM, Vriens MR, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Importance

Knowing the types and frequency of adrenal vein variants would help surgeons identify and control the adrenal vein during laparoscopic adrenalectomy.

Objectives

To establish the surgical anatomy of the main vein and its variants for laparoscopic adrenalectomy and to analyze the relationship between variant adrenal venous anatomy and tumor size, pathologic diagnosis, and operative outcomes.

Design, Setting, and Patients

In a retrospective review of patients at a tertiary referral hospital, 506 patients underwent 546 consecutive laparoscopic adrenalectomies between April 22, 1993, and October 21, 2011. Patients with variant adrenal venous anatomy were compared with patients with normal adrenal venous anatomy regarding preoperative variables (patient and tumor characteristics [size and location] and clinical diagnosis), intraoperative variables (details on the main adrenal venous drainage, any variant venous anatomy, duration of operation, rate of conversion to hand-assisted or open procedure, and estimated blood loss), and postoperative variables (transfusion requirement, reoperation for bleeding, duration of hospital stay, and histologic diagnosis).

Intervention

Laparoscopic adrenalectomy.

Main Outcomes and Measures

Prevalence of variant adrenal venous anatomy and its relationship to tumor characteristics, pathologic diagnosis, and operative outcomes.

Results

Variant venous anatomy was encountered in 70 of 546 adrenalectomies (13%). Variants included no main adrenal vein identifiable (n = 18), 1 main adrenal vein with additional small veins (n = 11), 2 adrenal veins (n = 20), more than 2 adrenal veins (n = 14), and variants of the adrenal vein drainage to the inferior vena cava and hepatic vein or of the inferior phrenic vein (n = 7). Variants occurred more often on the right side than on the left side (42 of 250 glands [17%] vs 28 of 296 glands [9%], respectively; P = .02). Patients with variant anatomy compared with those with normal anatomy had larger tumors (mean, 5.1 vs 3.3 cm, respectively; P < .001), more pheochromocytomas (24 of 70 [35%] vs 100 of 476 [21%], respectively; P = .02), and more estimated blood loss (mean, 134 vs 67 mL, respectively; P = .01). For patients with variant anatomy vs those with normal anatomy, the rates of transfusion requirement (2 of 70 [3%] vs 10 of 476 [2%], respectively; P = .69) and reoperation for bleeding (1 of 70 [1%] vs 3 of 476 [1%]; P = .46) were similar between groups.

Conclusions and Relevance

Understanding variant adrenal venous anatomy is important to avoid bleeding during laparoscopic adrenalectomy, particularly in patients with large tumors or pheochromocytomas. Surgeons should anticipate a higher probability of adrenal vein variants when operating on pheochromocytomas and larger adrenal tumors.