腹腔镜袖状胃切除术后门静脉-肠系膜静脉血栓形成1例报道及文献复习_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

张雪涛 , 赵英志 , 杜书祥 , 李玉龙 , 晋新峰 , 陈紫来 , 王尚鑫 , 张伟 ,  吴刚

郑州大学人民医院/河南大学人民医院/河南省人民医院胃肠外科（郑州 450003）;

Corresponding author：

吴刚, Email: wugang006123@163.com

Keywords：

腹腔镜袖状胃切除术; 门静脉-肠系膜静脉血栓; 减重手术; 肥胖症

DOI：

10.7507/1007-9424.202210044

Video：

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目的报道1例腹腔镜袖状胃切除术（laparoscopic sleeve gastrectomy，LSG）后并发门静脉-肠系膜静脉血栓形成（portal-mesenteric vein thrombosis，PMVT）病例，并做相关文献复习，为PMVT的诊断、治疗和预防提供参考。方法报道1例LSG术后并发PMVT的临床案例，并检索2009–2022年期间谷歌Scholar、PubMed、Web of Science、中国知网、万方医学网、中华医学期刊网和迈特思创数据库，收集LSG术后PMVT研究的相关文献资料并进行归纳总结。结果结合文献报道的196例和本病例共197例病态肥胖患者在减重手术后发生了PMVT，患者以女性居多（122例，61.9%），年龄14～68岁、平均年龄为39.4岁，体质量指数33.2～74.6 kg/m²、平均42.2 kg/m²。临床表现以腹痛最多见（180例，91.4%）。凝血功能障碍常见的原因依次是因子Ⅷ升高20例（10.2%），抗凝血酶缺乏16例（8.1%），蛋白C和（或）S缺乏13例（6.6%）。减重手术以LSG最多（190例，96.4%），术中气腹压力12～20 mmHg（1 mmHg=0.133 kPa），中位气腹压力15 mmHg；手术时间30～156 min，中位手术时间60 min。减重术后发生PMVT的时间为术后1～2 569 d，中位时间为14 d；经增强CT检查确诊者最多（178例，90.4%）。有110例（55.8%）患者术前给予了预防性抗凝治疗；161例（81.7%）患者术后给予了抗凝治疗，其中146例（90.7%）的用药时间 ≤10 d。随访时间为1～87 个月，平均随访时间为13个月，血管再通（部分或完全） 72例（36.5%），血管未通9例（4.6%），有116例（58.9%）血管再通情况不详；有3例死亡，病死率为1.5%。结论 PMVT是减重手术后一种少见但致命的并发症。PMVT最常见的表现为腹痛，增强CT是诊断PMVT重要方式，抗凝是PMVT的主要治疗方式。LSG术后应考虑使用低分子肝素抗凝治疗至少1个月，以降低PMVT发生的风险。对于有糖尿病、吸烟及非酒精性脂肪肝病患者，由于存在高凝状态的风险高，应更加注意PMVT的防治。

Citation： 张雪涛, 赵英志, 杜书祥, 李玉龙, 晋新峰, 陈紫来, 王尚鑫, 张伟, 吴刚. 腹腔镜袖状胃切除术后门静脉-肠系膜静脉血栓形成1例报道及文献复习. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2023, 30(4): 471-475. doi: 10.7507/1007-9424.202210044 Copy

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2.	Blüher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol, 2019, 15(5): 288-298.
3.	Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol, 2017, 14(3): 160-169.
4.	Angrisani L, Santonicola A, Iovino P, et al. IFSO worldwide survey 2016: primary, endoluminal, and revisional procedures. Obes Surg, 2018, 28(12): 3783-3794.
5.	Han Y, Jia Y, Wang H, et al. Comparative analysis of weight loss and resolution of comorbidities between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis based on 18 studies. Int J Surg, 2020, 76: 101-110.
6.	Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis, 2016, 12(4): 750-756.
7.	Alenazi NA, Ahmad KS, Essa MS, et al. Porto-mesenteric vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity: case series and literature review. Int J Surg Case Rep, 2019, 63: 59-64.
8.	Tan SBM, Greenslade J, Martin D, et al. Portomesenteric vein thrombosis in sleeve gastrectomy: a 10-year review. Surg Obes Relat Dis, 2018, 14(3): 271-275.
9.	中华医学会内分泌学分会, 中华中医药学会糖尿病分会, 中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 等. 基于临床的肥胖症多学科诊疗共识(2021年版). 中华肥胖与代谢病电子杂志, 2021, 7(4): 211-226.
10.	Rajani R, Björnsson E, Bergquist A, et al. The epidemiology and clinical features of portal vein thrombosis: a multicentre study. Aliment Pharmacol Ther, 2010, 32(9): 1154-1162.
11.	Karaman K, Aziret M, Bal A, et al. Porto-mesenteric venous thrombosis after laparoscopic sleeve gastrectomy: a case report and systematic review of the 104 cases. Obes Res Clin Pract, 2018, 12(3): 317-325.
12.	Shoar S, Saber AA, Rubenstein R, et al. Portomesentric and splenic vein thrombosis (PMSVT) after bariatric surgery: a systematic review of 110 patients. Surg Obes Relat Dis, 2018, 14(1): 47-59.
13.	Caruso F, Cesana G, Lomaglio L, et al. Is portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy related to short-course prophylaxis of thromboembolism? A monocentric retrospective analysis about an infrequent but not rare complication and review of the literature. J Laparoendosc Adv Surg Tech A, 2017, 27(10): 987-996.
14.	Patti G, Cavallari I, Andreotti F, et al. Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs. Nat Rev Cardiol, 2019, 16(2): 113-130.
15.	Marco A, Marco P. Improvement in the cardiovascular profile of patients with morbid obesity following bariatric surgery: Effect on hypercoagulability. Medicine (Baltimore), 2021, 100(12): e25280. doi: 10.1097/MD.0000000000025280.
16.	Giorgi-Pierfranceschi M, Monreal M, Di Micco P, et al. Prognostic impact of active cigarette smoking on mortality in patients with acute venous thromboembolic events, findings from real world data. Medicina (Kaunas), 2022, 58(2): 295. doi: 10.3390/medicina58020295.
17.	Ciavarella A, Gnocchi D, Custodero C, et al. Translational insight into prothrombotic state and hypercoagulation in nonalcoholic fatty liver disease. Thromb Res, 2021, 198: 139-150.
18.	Godoroja D, Hainarosie D, Zaharencu A, et al. Portal vein thrombosis a rare but life-threatening complication after laparoscopic sleeve gastrectomy: a 5 years study in a Bariatric Center of Excellence. Chirurgia (Bucur), 2019, 114(6): 711-724.
19.	El Lakis MA, Pozzi A, Chamieh J, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a 36-case series. Surg Endosc, 2017, 31(3): 1005-1011.
20.	Bucheeri MM, Abulsel AY. Case series: portomesenteric venous thrombosis complicating laparoscopic bariatric procedures. Int J Surg Case Rep, 2019, 62: 126-131.
21.	Muneer M, Abdelrahman H, El-Menyar A, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: 3 case reports and a literature review. Am J Case Rep, 2016, 17: 241-247.
22.	Shaheen O, Siejka J, Thatigotla B, et al. A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy. Surg Obes Relat Dis, 2017, 13(8): 1422-1431.
23.	Nakashima MO, Rogers HJ. Hypercoagulable states: an algorithmic approach to laboratory testing and update on monitoring of direct oral anticoagulants. Blood Res, 2014, 49(2): 85-94.
24.	Raj PP, Gomes RM, Kumar S, et al. Role of routine pre-operative screening venous duplex ultrasound in morbidly obese patients undergoing bariatric surgery. J Minim Access Surg, 2017, 13(3): 205-207.
25.	Alsina E, Ruiz-Tovar J, Alpera MR, et al. Incidence of deep vein thrombosis and thrombosis of the portal-mesenteric axis after laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A, 2014, 24(9): 601-605.
26.	Parikh M, Somoza E, Chopra A, et al. Thrombophilia prevalence in patients seeking laparoscopic sleeve gastrectomy: extended chemoprophylaxis may decrease portal vein thrombosis rate. Surg Obes Relat Dis, 2020, 16(7): 839-843.
27.	Aminian A, Andalib A, Khorgami Z, et al. Who should get extended thromboprophylaxis after bariatric surgery?: A risk assessment tool to guide indications for post-discharge pharmacoprophylaxis. Ann Surg, 2017, 265(1): 143-150.

1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2 416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet, 2017, 390(10113): 2627-2642.
2. Blüher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol, 2019, 15(5): 288-298.
3. Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol, 2017, 14(3): 160-169.
4. Angrisani L, Santonicola A, Iovino P, et al. IFSO worldwide survey 2016: primary, endoluminal, and revisional procedures. Obes Surg, 2018, 28(12): 3783-3794.
5. Han Y, Jia Y, Wang H, et al. Comparative analysis of weight loss and resolution of comorbidities between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis based on 18 studies. Int J Surg, 2020, 76: 101-110.
6. Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis, 2016, 12(4): 750-756.
7. Alenazi NA, Ahmad KS, Essa MS, et al. Porto-mesenteric vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity: case series and literature review. Int J Surg Case Rep, 2019, 63: 59-64.
8. Tan SBM, Greenslade J, Martin D, et al. Portomesenteric vein thrombosis in sleeve gastrectomy: a 10-year review. Surg Obes Relat Dis, 2018, 14(3): 271-275.
9. 中华医学会内分泌学分会, 中华中医药学会糖尿病分会, 中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 等. 基于临床的肥胖症多学科诊疗共识(2021年版). 中华肥胖与代谢病电子杂志, 2021, 7(4): 211-226.
10. Rajani R, Björnsson E, Bergquist A, et al. The epidemiology and clinical features of portal vein thrombosis: a multicentre study. Aliment Pharmacol Ther, 2010, 32(9): 1154-1162.
11. Karaman K, Aziret M, Bal A, et al. Porto-mesenteric venous thrombosis after laparoscopic sleeve gastrectomy: a case report and systematic review of the 104 cases. Obes Res Clin Pract, 2018, 12(3): 317-325.
12. Shoar S, Saber AA, Rubenstein R, et al. Portomesentric and splenic vein thrombosis (PMSVT) after bariatric surgery: a systematic review of 110 patients. Surg Obes Relat Dis, 2018, 14(1): 47-59.
13. Caruso F, Cesana G, Lomaglio L, et al. Is portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy related to short-course prophylaxis of thromboembolism? A monocentric retrospective analysis about an infrequent but not rare complication and review of the literature. J Laparoendosc Adv Surg Tech A, 2017, 27(10): 987-996.
14. Patti G, Cavallari I, Andreotti F, et al. Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs. Nat Rev Cardiol, 2019, 16(2): 113-130.
15. Marco A, Marco P. Improvement in the cardiovascular profile of patients with morbid obesity following bariatric surgery: Effect on hypercoagulability. Medicine (Baltimore), 2021, 100(12): e25280. doi: 10.1097/MD.0000000000025280.
16. Giorgi-Pierfranceschi M, Monreal M, Di Micco P, et al. Prognostic impact of active cigarette smoking on mortality in patients with acute venous thromboembolic events, findings from real world data. Medicina (Kaunas), 2022, 58(2): 295. doi: 10.3390/medicina58020295.
17. Ciavarella A, Gnocchi D, Custodero C, et al. Translational insight into prothrombotic state and hypercoagulation in nonalcoholic fatty liver disease. Thromb Res, 2021, 198: 139-150.
18. Godoroja D, Hainarosie D, Zaharencu A, et al. Portal vein thrombosis a rare but life-threatening complication after laparoscopic sleeve gastrectomy: a 5 years study in a Bariatric Center of Excellence. Chirurgia (Bucur), 2019, 114(6): 711-724.
19. El Lakis MA, Pozzi A, Chamieh J, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a 36-case series. Surg Endosc, 2017, 31(3): 1005-1011.
20. Bucheeri MM, Abulsel AY. Case series: portomesenteric venous thrombosis complicating laparoscopic bariatric procedures. Int J Surg Case Rep, 2019, 62: 126-131.
21. Muneer M, Abdelrahman H, El-Menyar A, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: 3 case reports and a literature review. Am J Case Rep, 2016, 17: 241-247.
22. Shaheen O, Siejka J, Thatigotla B, et al. A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy. Surg Obes Relat Dis, 2017, 13(8): 1422-1431.
23. Nakashima MO, Rogers HJ. Hypercoagulable states: an algorithmic approach to laboratory testing and update on monitoring of direct oral anticoagulants. Blood Res, 2014, 49(2): 85-94.
24. Raj PP, Gomes RM, Kumar S, et al. Role of routine pre-operative screening venous duplex ultrasound in morbidly obese patients undergoing bariatric surgery. J Minim Access Surg, 2017, 13(3): 205-207.
25. Alsina E, Ruiz-Tovar J, Alpera MR, et al. Incidence of deep vein thrombosis and thrombosis of the portal-mesenteric axis after laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A, 2014, 24(9): 601-605.
26. Parikh M, Somoza E, Chopra A, et al. Thrombophilia prevalence in patients seeking laparoscopic sleeve gastrectomy: extended chemoprophylaxis may decrease portal vein thrombosis rate. Surg Obes Relat Dis, 2020, 16(7): 839-843.
27. Aminian A, Andalib A, Khorgami Z, et al. Who should get extended thromboprophylaxis after bariatric surgery?: A risk assessment tool to guide indications for post-discharge pharmacoprophylaxis. Ann Surg, 2017, 265(1): 143-150.

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腹腔镜袖状胃切除术后门静脉-肠系膜静脉血栓形成1例报道及文献复习

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