袖状胃切除术并发近期肠系膜上静脉血栓、肠坏死一例报道

Superior mesenteric vein thrombosis and bowel necrosis after sleeve gastrectomy:a case report

报告1例特殊病史肥胖症患者在LSG术后近期并发罕见肠系膜上静脉血栓(SMVT)、肠切除的诊疗经过。患者女性,41岁,身高1.61 m,体重130 kg,BMI 50.15 kg/m^(2),既往病史(肺动脉栓塞病史,下肢静脉血栓,易栓体质)。2021年9月15日以主诉"呼吸喘憋3月余"入住哈尔滨市第一医院肥胖症与代谢病多学科诊疗中心。LSG术后第7天患者自诉近日隐约腹痛,当日明显加重,疼痛呈持续性,难以忍受,诊断为肠系膜上静脉血栓,给予抗凝(低分子肝素钙4100 U)、溶栓(尿激酶25 U)治疗,病情未见缓解,在全麻腹腔镜下探查、中转开腹手术。术中切除坏死肠段约80 cm,行近远端小肠侧侧吻合,同时行肠系膜上静脉取栓术。术后继续抗凝治疗,患者恢复良好,顺利出院,口服利伐沙班3月。至今随访13月余,患者无再发血栓疾病,减重约57 kg,凝血相关指标正常范围。针对高危VTE患者(既往VTE病史、易栓体质、BMI>50 kg/m^(2)等),减重与代谢外科手术后VTE风险仍会持续存在,出院后应延续抗凝治疗方案和定期复查凝血指标。

A special history of a patient with obesity was reviewed for the diagnosis and treatment of rare superior mesenteric vein thrombosis(SMVT)and bowel necrosis after LSG surgery.The patient was a 41-year-old female with a height of 1.61 m,weight of 130 kg,BMI of 50.15 kg/m^(2),and past medical history(pulmonary embolism,lower extremity venous thrombosis and embolism-prone body).On September 15,2021,she was admitted to the Multidisciplinary Diagnosis and Treatment Center for Obesity and Metabolic Diseases of the First Hospital of Harbin with the main complaint of"breathing and wheezing for more than 3 months".On the 7th day after LSG surgery,the patient complained of vague abdominal pain in recent days,which was significantly aggravated on the same day.The pain became persistent and unbearable,and she was diagnosed with superior mesenteric vein thrombosis.She was treated with anticoagulation(low molecular weight heparin calcium 4100 U)and thrombolysis(urokinase 25 U).The condition did not improve,and she was explored laparoscopically under general anesthesia and transferred to open surgery.The necrotic intestinal segment was resected about 80 cm during the operation,the lateral anastomosis of the proximal and distal small intestine was performed,and the superior mesenteric vein embolectomy was performed.Anticoagulation was continued after surgery,and the patient recovered well,was successfully discharged from the hospital,and took oral rivaroxaban for 3 months.Since the follow-up for more than 13 months,the patient has had no recurrent thrombotic disease,lost about 57 kg,and the coagulation-related indexes are within the normal range.For patients with high-risk VTE(previous history of VTE,embolism-prone body,BMI>50 kg/m^(2),etc.),the risk of VTE after weight loss and metabolic surgery will persist,and anticoagulation regimens should be continued.Coagulation indexes should be reviewed regularly after discharge.