Spontaneous resolution of a superior mesenteric vein thrombosis after laparoscopic nissen fundoplication

A previously fit 37-year-old man developed superior mesenteric venous thrombosis after undergoing a laparoscopic Nissen fundoplication. Despite receiving thrombo-embolic prophylaxis on postoperative day 16, he presented with a gradual onset of vague, but severe, umbilical and epigastric pains. Laboratory tests, abdominal ultrasound scan and gastroscopy were all unremarkable. Contrast enhanced abdominal spiral computerised tomography (CT) revealed a partial occlusion of the superior mesenteric and portal vein due to a thrombus; abnormal flow was confirmed on colour Doppler ultrasound. A predisposing hyper-coagulable condition was excluded. The patient responded rapidly to expectant management and a repeat spiral CT scan, 3 weeks after the initial presentation, demonstrated complete re-canalisation of the vessel. Although rare, superior mesenteric venous thrombosis is probably underdiagnosed due to the vague nature of the symptoms, the lack of clinical signs, a low index of suspicion on the part of the clinician, and then subsequent failure to request the optimal investigation--namely contrast enhanced abdominal spiral CT scan. We discuss the possible mechanisms by which laparoscopic surgery may increase the risks of developing superior mesenteric venous thrombosis, the pitfalls in diagnosis and treatment options.