Case Presentation: A 39 year old female presented on day 10, status post (s/p) laparoscopic gastric sleeve, with nausea, vomiting, abdominal pain and loose mucoid stools intermittently since surgery. She had history of rheumatoid arthritis, morbid obesity, with provoked lower extremity deep venous thrombosis (DVT) and pulmonary embolism (PE) who had previous IVC filter and was on anticoagulation. Her father died of “clot” in brain, mother had history of pancreatic cancer, and she did not smoke or drink. MRI abdomen revealed splenic and portal vein thrombosis. A hypercoagulable work up was done during the time of admission which revealed a heterozygous Methylenetetrahydrofolate reductase (MTHFR) mutation with borderline homocysteine levels. These levels could be low due to acute nature of thrombus and tests were to be repeated at a later date. Patient was started on heparin and transitioned to rivaroxaban with resolution of symptoms. As the patient had recurrent thromboembolic event, lifelong anticoagulation was in consideration.

Discussion: Porto-mesenteric and splenic vein thrombosis (PMSVT) is a rare but potentially serious complication after bariatric surgery. PMSVT usually occurs within the first postoperative month. The purpose of this case report is to identify thrombotic risk and identification of surgical methods (laparoscopic vs open bariatric surgery) in specific patient population. When laparoscopic bariatric surgery is contemplated, physicians and patients should be aware of the risk of splanchnic vessel thrombosis, especially when certain pre-existing conditions are present (e.g., impairment of splanchnic vessel flow, hypercoagulable states, etc.). Experimental and clinical data indicate that PMSVT is predisposed by carbon dioxide pneumoperitoneum, reducing splanchnic blood flow and venous stasis. Our patient highlights the likely increased thrombotic risk of laparoscopic surgery, although negative hypercoagulable work up.

Conclusions: The mentioned case is an example of the need for reassessing high risk patients prone to developing clots. When the planned laparoscopic procedure may be lengthy, gasless or low-pressure laparoscopic surgery, reversion to traditional open surgery can be considered. Going back in time to consider open bariatric surgery may or may not be ideal, but there are not many studies comparing thrombotic outcomes of such procedures. Preventive measures and methods like, intermittent decompression of the abdomen when the procedure is lengthy may have a potential to prevent this complication, although it has not been completely clear. Incidence of PMSVT is rare but it is becoming one of the frequently seen complications in laparoscopic gastric sleeve and has been reported in many other abdominal laparoscopic surgeries.