Pylephlebitis Complicating Intra Gastric Migration
1
PYLEPHLEBITIS COMPLICATING INTRA GASTRIC MIGRATION
OF ADJUSTABLE SILICONE GASTRIC BANDING
Olivier Detry, Arnaud De Roover, Carla Coimbra, Etienne Hamoir,
Pierre Honoré, Michel Meurisse
Dpt of Abdominal Surgery and Transplantation
University of Liège
CHU Sart Tilman B35
B4000 Liège, Belgium
Correspondence:
Dr Olivier Detry
Dpt of Abdominal Surgery and Transplantation
CHU Sart Tilman B35, B4000 Liège, Belgium
Email:
Running Title: Pylephlebitis complicating ASGB
Abstract
Pylephlebitis, or septic thrombophlebitis of the portal vein, is an infrequent but severe complication of abdominal septic events. In this report the authors described the occurrence of pylephlebitis and multiple liver abscesses induced by neglected intra gastric migration of an adjustable silicone gastric banding. The patient was successfully treated by broad-spectrum antibiotics and total gastrectomy with Roux-in-Y oesphago- jejunostomy. Postoperative recovery was marked by acute liver failure that was managed conservatively. The patient is alive and well at one-year follow-up. This case emphasizes the interest of early removal of the banding when intra gastric migration is diagnosed.
Introduction
Pylephlebitis, or septic thrombophlebitis of the portal vein, is an infrequent but severe complication of abdominal septic events, as colon diverticulitis, necrotizing pancreatitis, acute appendicitis, acute cholecystitis, inflammatory bowel disease or bowel perforation1. Pylephlebitis has a high morbidity and mortality and its management is mainly based on intravenous broad-spectrum antibiotic therapy and surgical removal of the septic focus that initiated the process2. In this report the authors described the occurrence of pylephlebitis and multiple liver abscesses induced by intra gastric migration of an adjustable silicone gastric banding (ASGB).
Case report
A woman born in 1945 suffered from morbid obesity and underwent vertical banded gastroplasty (VBG) in 1989 and VBG redo in 1994. In addition, she underwent ASGB in another institution in 1996. Eight years later a gastroscopy was performed and demonstrated intra gastric migration of the device that was not removed, as decided by the surgeon who performed the ASGB procedure.
Eight months later she was admitted in our emergency department for sepsis and right upper abdomen pain. Blood tests showed major inflammation and moderate liver enzymes elevation and abdominal computed tomography showed thrombosis of the portal vein and left gastric vein, with multiple liver abscesses (Fig 1 and Fig 2). Pylephlebitis secondary to intragastric migration of the adjustable gastric banding, was diagnosed. The patient was treated by broad-spectrum antibiotics. Two days later she underwent explorative laparotomy that confirmed the intra gastric migration of the silicone banding. Culture of both abscesses and removed banding showed Streptococcus viridans and Escherichia coli infections, proving the link between the intra gastric banding migration and pylephlebitis and liver abscesses. No other abdominal potential cause of pylephlebitis was demonstrated during the procedure. Total gastrectomy had to be performed, with a Roux-in-Y esophago-jejunostomy for bowel reconstruction. The liver abscesses were surgically drained. The early postoperative period was complicated by severe acute liver failure that was successfully managed conservatively3. The patient slowly recovered under antibiotherapy and left the ward at postoperative day 57. One-year follow-up was clinically uneventful and control computed tomography demonstrated portal vein thrombosis with disappearance of the liver abscesses.
Discussion
Laparoscopic ASGB is a common and effective surgical procedure for severe obesity. Complications of this procedure are common and quite well described, mainly pouch dilatation, port-related complications, intra-operative gastric perforation and band erosion or intra gastric migration4. It is generally recommended to remove the banding as soon as intra gastric migration is diagnosed.
To the author’s knowledge this report is the first description of pylephlebitis and liver abscesses as a severe complication of intra gastric migration of ASGB. This case emphasizes the interest of early removal of the banding when intra gastric migration is diagnosed. Management of pylephlebitis includes aggressive antibiotic therapy targeted to cover the probable organisms, and early surgical intervention. Outcome depends on multiple factors, including the patient’s host defences, the virulence of the offending organisms and delays in medical and surgical therapy. Mortality is not rare2. The role of anticoagulation is unclear. Anticoagulation could be used in cases of acute extensive pylethrombosis, progression of thrombus after initial diagnosis, persistent fever under treatment and enteric resection for pylethrombosis induced ischemia5. Anticoagulant therapy is not without risks and there is no guarantee that it will prevent the development of portal hypertension2.
References
1. Van De Wauwer C, Irvin TT. Pylephlebitis due to perforated diverticulitis. Acta Chir Belg 2005; 105: 229-30.
2. Plemmons RM, Dooley DP, Longfield MS. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21: 1114-20.
3. Detry O, Honoré P, Meurisse M, et al. Management of fulminant hepatic failure. Acta Chir Belg 1998; 98: 235-40.
4. Vella M, Galloway DJ. Laparoscopic adjustable gastric banding for severe obesity. Obes Surg 2003; 13: 642-8.
5. Duffy FJ Jr, Millan MT, Schoetz D, et al. Suppurative pylephlebitis and pylethrombosis: the role of anticoagulation. Am Surg 1995; 61: 1041-4.
Figures
Fig 1: Abdominal computed tomography showing the adjustable silicone gastric banding and an abscess in the right liver lobe (white arrow).
Fig 2: Abdominal computed tomography showing extensive portal vein pylephlebitis (black arrow) with involvement of the right (Fig 2A) and the left (Fig 2B) intra hepatic branches of the portal vein and an abscess in the left liver lobe (white arrow).