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Incidence and Risk Factors of Portomesenteric Venous Thrombosis

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Incidence and Risk Factors of Portomesenteric Venous Thrombosis Manigrasso et al. World Journal of Surgical Oncology (2019) 17:195 https://doi.org/10.1186/s12957-019-1739-9 RESEARCH Open Access Incidence and risk factors of portomesenteric venous thrombosis after colorectal surgery for cancer in the elderly population Michele Manigrasso1, Marco Milone1,2*, Nunzio Velotti3, Sara Vertaldi1, Pietro Schettino1, Mario Musella3, Giovanni Aprea1, Nicola Gennarelli1, Francesco Maione1, Giovanni Sarnelli1, Pietro Venetucci3, Giovanni Domenico De Palma1 and Francesco Milone3 Abstract Background: Although it is known that portomesenteric venous thrombosis (PMVT) is associated with total colectomy and proctocolectomy in young patients with inflammatory bowel disease, little is known about incidence and risk factors of PMVT among the elderly population undergoing colorectal surgery for cancer. Methods: Data of elderly patients (> 70 years) undergoing surgery for colorectal cancer were retrospectively registered. The occurrence of PMVT was correlated with the patients’ characteristics and operative variables. Data collected included age, sex, obesity, ASA score, tumor degree, type of surgical resection, surgical approach (laparoscopic or open), and duration of surgery (from skin incision to the application of dressings). Results: A total of 137 patients > 70 years who underwent surgery for colorectal cancer and developed an acute intraabdominal process with suggestive symptoms, needing a CT scan, were included. Three of these patients (2.1%) had portomesenteric venous thrombosis during the study period, which was proved with CT scan. There were no significant patients’ characteristics or operative variables between patients with or without the occurrence of PMVT after surgery. Of interest, only operative time was significantly higher in patients with PMVT after surgery (256 ± 40 vs 140 ± 41, p < 0.001). Conclusions: PMVT as a cause of abdominal pain after colorectal surgery for cancer in the elderly population is uncommon. An index of suspicion for PMVT in an elderly postoperative colorectal cancer patient with sudden onset of abdominal pain must be maintained. Keywords: Portomesenteric, Venous thrombosis, Colorectal, Surgery Background procedures, have been recently studied [1, 2]. The inci- Portomesenteric venous thrombosis (PMVT) is an un- dence of postoperative PMVT has been reported to common, potentially life-threatening, condition. Data range from 2.8 to 9%. Although it is known that about PMVT in broader surgical population are scarce. splanchnic venous thrombosis is associated with total Incidence and risk factors for PMVT development after colectomy and proctocolectomy in young patients with major abdominal surgery, in particular colon and rectal inflammatory bowel disease [3–5], little is known about incidence and risk factors of PMVT among the elderly population undergoing colorectal surgery for cancer. * Correspondence: [email protected] 1Department of Clinical Medicine and Surgery, University “Federico II” of The incidence of postoperative PMVT after colorectal Naples, Naples, Italy surgery has been reported to range from 2.8 to 9%. 2Department of Gastroenterology, Endocrinology and Surgical Endoscopy, Factors reported to be associated with the development University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy Full list of author information is available at the end of the article of PMVT include manipulation of mesenteric vessels, © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Manigrasso et al. World Journal of Surgical Oncology (2019) 17:195 Page 2 of 5 postoperative septic complications, and various under- Patients’ characteristics and operative variables of en- lying diseases. tire study population and of the patients with PMVT are The aim of this study is to evaluate the incidence of respectively shown in Tables 1 and 2. PMVT after colorectal surgery in the elderly as well as Considering thrombosis risk factors, none of the three the presence of risk factors, presenting symptoms, and patients with PMVT had any alteration of coagulation the treatment. profile. All three patients recovered from the acute event, with Methods no need for further surgical intervention. They have Data of patients collected during a 12-year period (from been discharged from the hospital with long-term sys- September 2002 to July 2014) with diagnosis of colorectal temic oral anticoagulation for a minimum of 6 months. cancer were retrospectively reviewed. The inclusion cri- In details, to all subjects were given intravenous fluids, teria were patients > 70 years who underwent surgical prophylactic antibiotic therapy (3rd generation cephalo- intervention and needed CT scan for the new onset of ab- sporin–ceftriaxone- 1 g e.v. twice daily) and low molecu- dominal pain. CT scans were performed using a spiral CT lar weight heparin (LMWH) therapy (100 UI/Kg s.c. scanner with intravenously administered contrast. twice/day). A week later, 2 patients were given warfarin Our perioperative prophylaxis routinely included sub- with a target PT INR value ≥ 2. The other patient under- cutaneous heparin administration and perioperative hand- went percutaneous transhepatic thrombolysis and mech- ling of antiplatelet drugs according to the current literature anical thrombectomy prior to starting warfarin with a [6–9]. A complete coagulation profile was performed when- target PT INR value ≥ 2. In both cases, LMWH was ever a diagnosis of portomesenteric venous thrombosis was stopped when PT INR reached values of INR ≥ 2[10]. made. The coagulation profile included platelet count, All the three cases of PMVT were successfully resolved. thrombin time, antithrombin III, plasminogen, protein C, After a median follow-up of 24 months, all three pa- protein S, homocysteine level, factor V Leiden mutation, tients had discontinued taking their oral anticoagulants and prothrombin G20210A mutation, but no cases of recurrent thrombotic events have been Data collected included age, sex, obesity, ASA score, reported. During the follow-up period, no death was tumoral stage, type of surgical resection, surgical ap- reported. proach (laparoscopic or open), and duration of surgery There were no significant patients’ characteristics or (from skin incision to the application of dressings). operative variables between patients with or without the The occurrence of portomesenteric venous thrombosis occurrence of PMVT after surgery. Of interest, only was correlated with the patients’ characteristics and op- Table 1 Patients characteristics and operative variables of the erative variables. 137 patients with abdominal pain Statistical analysis was performed with SPSS 16.0. The Age (years) 75.5 ± 7.1 Yates corrected χ2 test was used to evaluate differences in categorical variables, and the independent samples t Male gender (pts) 70 (51%) test was used to analyze continuous variables. To adjust Obesity (pts) 27 (19.7%) for covariates and to make predictions, logistic regres- ASA score sion model was used. Statistical significance was ac- II 61 (44.5%) cepted when the p value was less than 0.05. III 53 (38.6%) Results IV 23 (16.7%) A total of 137 patients > 70 years who underwent surgery Tumor grade for colorectal cancer with a postoperative onset of symp- I 36 (26.2%) toms suggestive of an acute intraabdominal process, who II 58 (42.2%) therefore needed a CT scan were identified. III 29 (21.1%) Three of these patients (2.1%) had portomesenteric IV 14 (10.2%) venous thrombosis during the study period, which was Surgery (pts) 25 (18.2%) proved with CT scan. In all three cases, splanchnic ven- ous thrombosis could be identified by CT scan. In most Right colectomy 78 (56.9%) cases, the main symptom was the new-onset of acute ab- Left colectomy 23 (16.7%) dominal pain. Other signs and symptoms included fever Rectal resection 11 (8%) in two patients, of which one presented an elevated Miles intervention white blood cell count, and nausea in one patient. The Laparoscopy (pts) 34 (24.8%) intercurrent time between surgery and the acute event Operative time (min) 143.3 ± 44.8 was respectively 35, 62, and 80 days. Manigrasso et al. World Journal of Surgical Oncology (2019) 17:195 Page 3 of 5 Table 2 Patients with PMVT Age Sex Obesity ASA Tumor grade Surgery Approach Operative time Patient 1 75 Male No II III Right colectomy Open 250 Patient 2 77 Female NO II I Miles Open 220 Patient 3 82 Male Yes III II Rectal resection Laparoscopic 300 operative time was significantly higher in the group of It is well known that less invasive approach reached in patients with PMVT after surgery (256 ± 40 vs 140 ± 41, the last decades increased popularity in each surgical p < 0,001). After adjusting for patients’ characteristics field and it is considered the best surgical approach to and operative variables in a multivariate logistic regres- colorectal and gastric malignancy [22–32]: shorter recov- sion, operative time showed a clear trend toward a ery and hospitalization, lower postoperative pain, and
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