Faculty Bibliography

Introduction: Portomesenteric vein thrombosis (PMVT) is a rare but serious postoperative complication following bariatric surgery, with an incidence rate ranging from 0.3 to 1%. Due to the nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. If left untreated, PMVT can progress to intestinal ischemia, perforation and peritonitis. Case Presentation: A 51-year-old female presented to the Emergency Department five days after laparoscopic sleeve gastrectomy (LSG) complaining of worsening abdominal pain and low grade fevers. A CT scan and upper GI series were performed with no evidence of leak or abscess, and the patient was admitted for observation. On hospital day two, the patient had worsening abdominal pain, and an episode of emesis. An ultrasound revealed a new moderate amount of intraperitoneal free fluid. A CT scan was repeated which revealed a thrombus in the splenic and superior mesenteric veins. Upon further discussion, the patient admitted to a previous diagnosis of antithrombin III deficiency and non compliance with anticoagulation. The patient was subsequently started on therapeutic anticoagulation with resolution of her abdominal pain. The remainder of the hospitalization was uncomplicated and she was discharged home on oral anticoagulation.
Discussion(s): It has been well established that morbid obesity is a significant prothrombotic factor for patients undergoing bariatric procedures. There has been increasing interest in identifying other factors which may contribute to hypercoagulability during these procedures. Possible etiologies for PMVT following LSG include thrombophilia, venous stasis from increased intra-abdominal pressure or patient positioning, and intraoperative manipulation of vasculature. Increasing interest has turned toward identifying patients who may be predisposed to PMVT following LSG. In a recent multicenter review of 40 patients who developed PMVT after LSG, 92% had a hematologic abnormality. The most common abnormality identified was elevation of Factor VIII (76%). Other significant abnormalities included deficiencies in antithrombin III, factor V leiden, and protein C/S.
Conclusion(s): Patients undergoing LSG have an increased risk of developing PMVT. A high index of suspicion is important for prompt diagnosis and expeditious treatment. Up to 90% of PMVT after LSG can be successfully treated with therapeutic anticoagulation alone

Background: Median arcuate ligament syndrome (MALS) is a rare and complex disease requiring various lab tests, CT abdominal scans, and abdominal ultrasounds in order to diagnose. Located near the first lumbar vertebra, the median arcuate ligament is a fibrous arch that usually crosses superior to the proximal portion of the celiac artery. In 10-24% of the general population this ligament originates from a more inferior position than normal, causing it to compress the celiac artery. This could possibly lead to mesenteric ischemia and abdominal pain in some of the population affected with this abnormality. The presentation of this syndrome is vague abdominal pain and in order to diagnose MALS, common disorders affecting other organs in the GI must be ruled out first. Case Report: The patient is an 80 year old Caucasian woman with refractory abdominal pain and weight loss for several months. Her pain presented 1 hour after meals causing her to eat less and lose weight. An abdominal ultrasound was performed and revealed several small stones in the gall bladder, but no wall thickening or other indications of cholecystitis. Initially she was diagnosed with biliary colic and was going to be managed with an elective laparoscopic cholecystectomy. However due to the excessive weight loss from food aversion and absence of specific right upper quadrant pain, an abdominal CT was done which showed extrinsic compression of the celiac artery with luminal narrowing in a manner consistent with MALS. A laparoscopic operation was performed to skeletonize the celiac artery and completely release it from the constricting median arcuate ligament. 10 days after the surgery the patient did not complain of any abdominal pain. Her only complication was due to dehydration and fatigue which required hospitalization with administration of IV fluids.
Conclusion(s): Skeletonization of the celiac artery by releasing the low lying median arcuate ligament via laparoscopic surgery is a highly effective treatment for MALS patients. This laparoscopic technique provides a quicker recovery time and is more efficacious in providing early symptom relief than having an open surgery

A 76-year-old woman with surgical history of Roux-en-Y gastric bypass presented with recurrent choledocholithiasis. Double balloon enteroscopy was unsuccessful in cannulating the biliary tree, thus, requiring surgically assisted endoscopic retrograde cholangiopancreaticogram (ERCP) access. Due to her stable clinical status, the non-urgent indication and multiple anticipated ERCPs for definitive biliary clearance, a more durable port of access to the ampulla was desired. A modified laparoscopic Janeway gastrostomy of the gastric remnant was performed and served as access for multiple subsequent endoscopic procedures with successful clearance of the biliary tree.