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Background: Portomesenteric venous thrombosis (PMVT) is a rare, but serious, complication of abdominal surgery with no agreed standard of care. Management options include observation, anticoagulation, and thrombectomy. Our study aims to characterize a large series of patients with PMVT after abdominal surgery with a focus on management and outcomes.Methods: We performed a retrospective analysis of more than 4000 patients having abdominal surgery at an academic medical center between January 2007 and August 2010. Patients with postoperative thrombosis of the portal, superior mesenteric, and/or splenic veins were reviewed. Transplant patients and those with preexisting PMVT were excluded. The diagnosis was established by computed tomography (CT), magnetic resonance imaging (MRI), and/or duplex ultrasound.Results: Forty-four patients had PMVT (23 isolated portal, 19 combined portal and mesenteric and/or splenic, 1 isolated mesenteric, 1 isolated splenic). Average patient age was 59 years, and 55% were male. Four patients (9%) were on preoperative anticoagulation that was held for surgery, and 25 patients (57%) had a malignancy. Operations performed included pancreas resection (21), liver resection (5), colorectal resection (5), pancreas debridement (4), splenectomy (3), major biliary surgery (2), combined pancreas and colon resection (2), palliative gastrojejunostomy (1), gastrectomy (1), and abdominal wall reconstruction (1). Median time from operation to PMVT diagnosis was 14 days, and 23 patients were diagnosed after discharge from the original hospitalization. Diagnostic modalities included computed tomography (35), duplex ultrasound (8), and magnetic resonance imaging (1). Treatment included observation in 15 patients, anticoagulation in 24 patients (20 continued as outpatients), and operative thrombectomy in 5 patients. All patients who underwent operative thrombectomy developed PMVT on postoperative day 1 after their initial operation, and four of these patients had a portomesenteric venous resection and reconstruction as part of their initial operation. PMVT-induced liver abscess occurred in 1 patient. Small bowel and/or colon resection for ischemia occurred in 2 patients. Seventeen (40%) patients were readmitted within 30 days of discharge from the PMVT admission. Only one patient died five days after a liver resection complicated by portal vein thrombosis requiring operative thrombectomy and enterectomy.Conclusions: Portomesenteric venous thrombosis (PMVT) is an uncommon complication following abdominal surgery which may present early postoperatively, but often presents after discharge. While the morbidity associated with PMVT is high, the mortality is low (2%). Management should be tailored to individual patient characteristics with respect to timing and severity of presentation.