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Chapter 51
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Case on Splenic and Portal Vein Thrombosis
After Splenectomy
Miguel A. Cuesta and H. Jaap Bonjer
Keywords Splenectomy • Giant spleen • Myelofi brosis • Portal vein thrombosis •
Portal hypertension
First Patient
Diagnosis and Indication for Surgery
A 65-year-old man was diagnosed 10 years before with myelofi brosis involving a
signifi cantly enlarged spleen. Patient was treated by the internist and hematologist
conservatively. The only treatment options had been largely supportive without an
alteration of the disease, including folic acid , allopurinol , blood transfusions , and
dexamethasone . He underwent a progressive growth of the spleen, occupying his
entire abdomen, having produced important scoliosis with deformity that impeded
him in walking properly. Moreover, there was an important depression of the bone
marrow function and changes in fi brosis. Indication for splenectomy was considered because of the mechanical complaints with rest dyspnea . On the US and CT
scan, a splenomegaly of 30 by 25 cm was seen with enlarged veins around the
spleen (Fig. 51.1 ). No portal hypertension was observed and neither were esopha-
geal varices seen on the gastroscopy.
M. A. Cuesta , M.D. () • H. J. Bonjer, M.D., Ph.D., F.R.C.S.C.
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; j.bonjer@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_51,
© Springer International Publishing Switzerland 2014
273
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Fig. 51.1 Splenomegaly on
the US
Fig. 51.2 View of operative
fi eld during open
splenectomy for a giant
spleen
M.A. Cuesta and H.J. Bonjer
Operation
At laparotomy, 1 l of ascites was found, and the liver was hard on palpation and
enlarged; moreover the spleen was giant, larger than 30 cm. After careful mobilization and division of short vessels, the hilar vessels, fi rst the artery and then the vein,
30 mm in size, were taken down by ligatures (Fig. 51.2 ). Platelet suspension was
transfused once the enlarged splenic vein was divided. The spleen weighed 8.2 kg.
The splenorenal and phrenosplenic ligaments were already calcifi ed and this
disturbed the course of the operation.
51 Case on Splenic and Portal Vein Thrombosis After Splenectomy
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Fig. 51.3 Two days
postoperative US-Doppler,
portal vein open
Fig. 51.4 Portal vein
thrombosis and ascites
275
Postoperative Course: Identifi cation
and Treatment of Complication
Postoperative course of the patient was initially undisturbed, yet thrombocytosis
came about and he was then treated with double doses of sc Fraxiparin ® . Because
of abdominal distention an Echo-Doppler was performed showing an open portal
vein (Fig. 51.3 ). Seven days after operation the patient developed important ascites
and abdominal distension. On a CT scan, thrombosis of the splenic and portal vein
was seen (Fig. 51.4 ). Treatment was started with iv heparin in therapeutic doses and
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adequate feeding. Apparently the situation stabilized, and partial reopening of the
portal vein was seen on the CT scan. After 2 weeks, the situation of the patient worsened; he became septic, refused surgical treatment, and died. At autopsy, mesenteric
ischemia/necrosis was found.
M.A. Cuesta and H.J. Bonjer
Second Patient
Diagnosis and Indication for Surgery
A 33-year-old patient with morbid obesity and a BMI of 50 had been operated in
other hospital by means of a laparoscopic gastric bypass.
Operation
According to surgeon, the operation went from the technical point of view without
incidences, but patient had to be reoperated immediately after the initial operation
because of hypovolemic shock and low hemoglobin rate. By laparotomy, postoperative bleeding appeared that was caused by a splenic bleeding and splenectomy was
performed.
Postoperative Course: Identifi cation
and Treatment of Complication
Patient developed important ascites after operation. On the CT scan at postoperative
day three, thrombosis of the splenic portal vein was observed with some thickness
of small bowel loops (Fig. 51.5 ). Leukocyte rate was normal and the lactate
increased to 2.6 mmol/l. The day of the transfer to our department and suspecting
some grade of mesenteric ischemia, a relaparotomy was performed. Bowels were
found to be normal and the surgeon decided not to perform thrombectomy of the
thrombosed superior mesenteric and portal vein and hence treated the patient conservatively by anticoagulation in the form of iv heparin (Fig.
ered completely and went home.
Discussion
Van ‘t Riet et al. reviewed 563 splenectomies and found nine (2 %) that were
complicated by symptomatic portal vein thrombosis (Illustration 51.1a, b ) [ 1 ]. All
the patients of these cases had either fever or abdominal pain. Two of 16 patients
51.6 ). Patient recov-
51 Case on Splenic and Portal Vein Thrombosis After Splenectomy
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Fig. 51.5 Thrombosis vena
porta, superior mesenteric
vein and splenic vein
277
Fig. 51.6 Aspect of the
bowels during explorative
laparotomy
with a myeloproliferative disorder developed portal vein thrombosis after splenectomy ( P = 0.03) and 4 of 49 patients with hemolytic anemia ( P = 0.005). Portal
vein thrombosis should be suspected in a patient with fever or abdominal pain
after splenectomy. Prophylactic anticoagulants should be given. Patients with
a myeloproliferative disorder or hemolytic anemia are at higher risk; they
might benefi t from early detection by a routine Doppler ultrasonography after
splenectomy.
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M.A. Cuesta and H.J. Bonjer
a
b
Oesophagus
varices
Illustration 51.1 ( a , b ) Postoperative thrombosis of the splenic and portal vein is a frequent
complication after splenectomy for giant spleens. It should always be considered and prevented by
prophylactic anticoagulation. Turbulence in the fl ow and postoperative thrombocytosis may be the
cause. Portal thrombosis can lead to portal hypertension
Reference
1. Van ‘t Riet M, Burger JW, van Muiswinkel JM, et al. Diagnosis and treatment of portal vein
thrombosis following splenectomy. Br J Surg. 2000;87:1229–33.
vena porta thrombose
(and splenic Vein)
Chapter 52
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Case on Rebleeding After Initial Coiling
of Spleen Trauma
Rutger J. Lely and Miguel A. Cuesta
Keywords Spleen • Splenic trauma • Angiography and coiling • Rebleeding
Diagnosis and Indication for Angiography
A 48-year-old male patient was admitted to the hospital after a scooter-to-car
accident. Patient had abdominal pain, the physical and radiological examinations
revealed his two lowest ribs broken, the CT scan showed the spleen ruptured
(Fig. 52.1 ), hemoglobin was low 6.5, and the patient became hemodynamically
stable after fl uid reposition. A decision was taken to perform angiographic examination and coiling. On CT-angiography, a blush was seen in the splenic artery, it being
coiled successfully on angiography (Fig. 52.2a, b ). Patient recovered and went
home 3 days later, being stable and having adequate pain treatment.
Follow-Up: Identifi cation and Treatment of Complication
Two months later, he was acutely readmitted on to the ward, because of a large mass
in the left upper abdomen and abdominal pain. On the CT scan, some sort of splenic
fl uid collection or cyst of 15 cm was observed that was attached to the inferior aspect
of the spleen (Fig. 52.3 ). Patient was hemodynamically stable, but his hemoglobin
R. J. Lely , M.D.
Radiology , VU University Medical Centre , Amsterdam , The Netherlands
e-mail: r.lelij@vumc.nl
M. A. Cuesta , M.D. (
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_52,
© Springer International Publishing Switzerland 2014
*)
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Fig. 52.1 CT-angiography
scan on admission, bleeding
splenic rupture
a
R.J. Lely and M.A. Cuesta
b
Fig. 52.2 Angiography pre- ( a ) and post-coiling ( b ) splenic artery
Fig. 52.3 CT scan on
readmission, showing the
hemorrhagic cyst
52 Case on Rebleeding After Initial Coiling of Spleen Trauma
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281
Fig. 52.4 Pre- ( a ) and post-coiling ( b ) short vessel with blush
Fig. 52.5 Percutaneous
drainage of the splenic cyst
ba
was 7.3. A new angiography was performed, and it revealed a large branch of the
short vessels going to the splenic old ruptured surface. This was considered the cause
for the bleeding and it was subsequently coiled (Fig. 52.4a, b ). In retrospect, at the
fi rst angiography this short vessel had been seen producing a blush. The next day,
the cyst was drained by means of a percutaneous drain, evacuating 1.5 l old blood
52.5 ). After 2 days, the drain was retired and patient could go home.
(Fig.
Discussion
Angiographic coiling is becoming the standard approach for this blunt abdominal
trauma. Only those hemodynamic unstable patients who are not reacting to fl uid
reposition or having associated traumatic lesions should be considered for explorative laparotomy. During angiography, all blush should be coiled. In the present
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R.J. Lely and M.A. Cuesta
Illustration 52.1 Spleen trauma is frequently conservatively treated. CT-angiography scan
showing a blush should be treated by angiography and coiling. In the case that patient is hemodynamically unstable and does not react to fl uids, surgical approach is indicated. Moreover if multitrauma patient, surgical treatment of the splenic trauma should be done
Spleen
Coiling
Short vessel
bleeding coiled
case, only the splenic artery bleeding had been initially coiled, whereas in
retrospection also a blush was present at one short vessel. Patient developed a slow
bleeding with a hemorrhagic cyst. During the second admission a new angiography
showed the bleeding. This was coiled and the cyst percutaneously drained
(Illustration 52.1 ) [ 1 ].
Cyst
Reference
1. Bhullar IS, Frykberg ER, Siraqusa D, et al. Selective angiographic embolization of blunt
splenic traumatic injuries in adults decreases failure rate of nonoperative management.
J Trauma Acute Care Surg. 2012;72:1127–34.
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