Case presentation
37 years old Iranian female, a known case of hypothyroidism and class
III obesity, admitted to our hospital for laparoscopic gastric sleeve
surgery (150 cm, 95 kg, and BMI: 42.2 kg/m2). She had a previous
surgical history of three caesarian sections; the last one was almost 7
years earlier than this admission. She was on levothyroxine and
metformin (self-prescribed in order to lose weight) and did not use
birth control. She had no family history of inheritable coagulopathies,
and her social history was unremarkable.
Laboratory and clinical pre-operative evaluations were unremarkable,
including anesthesia, endocrinology, and cardiology. For
thromboprophylaxis, compression stockings were applied, and she received
a single dose (5000 IU) of subcutaneous heparin one hour before the
surgery, according to the local guidelines. Her operation was
uneventful, and sleeve gastrectomy was conducted in 100 minutes with six
60 mm purple endostaplers. At the end of the surgery, a Jackson-Pratt
(JP) drain was inserted at the surgery site. She recovered, returned to
the ward, and prophylactic enoxaparin (60 mg/day subcutaneously) started
within 6 hours after surgery. The patient was ambulated as soon as she
became conscious and hemodynamically stable. The first post-operative
night was uneventful, but she fainted the next morning after ambulation.
She was tachycardic (pulse rate 140 bpm) and hypotensive (systolic blood
pressure 80 mmHg). JP drain did not contain bloody discharge. After
primary resuscitation, considering myocardial infarction, anastomotic
leakage, and PE as top differential diagnoses, the following evaluations
were initiated:
- Abdominopelvic sonography: minimal free fluid in the abdominal cavity
- Echocardiography: dilated right ventricle and atrium (pulmonary
acceleration time: 60 msec)
- Spiral Computed Tomography (CT) scan of abdomen and pelvis with
Intravenous contrast: (1) liver slightly edematous, which could be due
to right side heart failure, and (2) mild free fluid in the
abdominopelvic cavity
- Spiral CT Angiography of pulmonary vessels with contrast (PE
protocol): multiple filling defects in the bifurcation of main
bilateral pulmonary arteries which extended to segmental and lobar
branches of both sides (confirmatory of massive PE) (Figure)