Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome: Two case reports and review of literature.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient. CASE SUMMARY: Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position. CONCLUSION: The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Coexistència de la malaltia de Wilkie i la síndrome del trencanous / Coexistencia de enfermedad de Wilkie y síndrome del cascanueces / Simultaneous occurrence of Wilkie and nutcracker syndromes

Introducció. La síndrome de l’artèria mesentèrica superior,o malaltia de Wilkie, i la síndrome de compressió de lavena renal esquerra, o síndrome del trencanous, són pocfreqüents. Normalment estan provocades per una compressió extrínseca del duodè o de la vena renal esquerra, respectivament, a causa d’una disminució de l’angle entrel’artèria mesentèrica superior i l’aorta.Cas clínic. Adolescent de 15 anys que va consultar a urgències per dolor abdominal de cinc mesos d’evolució localitzata l’epigastri, acompanyat de vòmits, proteïnúria i pèrdua depes. La pacient havia consultat prèviament en altres centresi s’havien descartat patologies urgents quirúrgiques. Es vacompletar l’estudi amb una tomografia computada abdominal amb diagnòstic de síndrome de l’artèria mesentèricasuperior i síndrome del trencanous. La pacient va ingressara la planta d’hospitalització i es va tractar de forma conservadora amb una dieta hipercalòrica; el trànsit intestinal i laproteïnúria van millorar, i va poder ser remesa a domicili icontrolada ambulatòriament de forma multidisciplinària.Comentari. Els problemes secundaris a la compressió aortomesentèrica poden donar quadres compatibles amb la síndrome de l’artèria mesentèrica superior i la síndrome deltrencanous. El diagnòstic d’aquests quadres pot resultarcomplex per la incidència baixa i per la simptomatologiainespecífica que els caracteritza. El tractament conservador representa la primera línia de tractament, però en alguns casos pot no ser suficient. Per tot això és necessarifer un maneig multidisciplinari d’aquests pacients. (AU)

Introducción. El síndrome de la arteria mesentérica superior o deWilkie y el síndrome del cascanueces son poco frecuentes. Normalmente están producidos por una compresión extrínseca delduodeno o de la vena renal izquierda, respectivamente, debido a una disminución del ángulo entre la arteria mesentérica superior yla aorta.Caso clínico. Adolescente de 15 años que consultó a urgencias pordolor abdominal de cinco meses de evolución localizado en epigastrio, acompañado de vómitos, proteinuria y pérdida de peso. Lapaciente había consultado previamente en otros centros descartando patologías urgentes quirúrgicas. Se completó el estudio conuna tomografía computarizada abdominal con diagnóstico de síndrome de la arteria mesentérica superior o de Wilkie y síndrome delcascanueces. La paciente ingresó en planta de hospitalización y setrató de forma conservadora con una dieta hipercalórica con mejoría del tránsito intestinal y de la proteinuria, y pudo ser remitida adomicilio y controlada ambulatoriamente de forma multidisciplinar.Comentario. Los problemas secundarios a la compresión aortomesentérica pueden dar cuadros compatibles con el síndrome de laarteria mesentérica superior o de Wilkie y el síndrome del cascanueces. El diagnóstico de estos cuadros puede resultar complejo por subaja incidencia y por la sintomatología inespecífica que los caracteriza. El tratamiento conservador representa la primera línea de tratamiento, pero en algunos casos puede no ser suficiente. Por estosmotivos es necesario un manejo multidisciplinar de estos pacientes. (AU)

Introduction. The superior mesenteric artery syndrome or Wilkiesyndrome and the nutcracker syndrome are rare. They are normallycaused by extrinsic compression of the duodenum or the left renalvein respectively, due to a narrowing of the angle between the superior mesenteric artery and the aorta.Case report. A 15-year-old girl presented to the emergency roomwith a five-month history of abdominal pain located in the epigastrium, accompanied by vomiting, proteinuria, and weight loss. Thepatient had previously consulted in other centers, and urgent surgical conditions were ruled out. The study was completed with anabdominal computed tomography scan, which led to the diagnosisof superior mesenteric artery or Wilkie syndrome, and nutcrackersyndrome. The patient was admitted to the hospital and treatedconservatively with a hypercaloric diet with improvement in intestinal transit and proteinuria. She was discharged to continue thefollow-up with a multidisciplinary team. Comment. Problems secondary to aortomesenteric compression cangive symptoms like superior mesenteric artery or Wilkie syndromeand nutcracker syndrome. The diagnosis of these conditions canbe complex due to their low incidence and the non-specific symptomatology that characterizes them. Conservative treatment represents the first line of treatment, but in some cases it may not beenough. For these reasons, multidisciplinary management of thesepatients is necessary. (AU)

Superior mesenteric artery syndrome after colectomy: A case report and literature review.

RATIONALE: Superior mesenteric artery (SMA) syndrome, also known as Wilkie syndrome, is a rare benign disease characterized by small bowel obstruction due to compression of the third portion of the duodenum by the SMA and the abdominal aorta. However, SMA syndrome after colectomy is extremely rare, establishing a clear diagnosis and formulating a treatment plan may be challenging for surgeons. PATIENT CONCERNS: A 64-year-old male with multiple colon polyposis and constipation underwent laparoscopic subtotal colectomy with cecal-rectal anastomosis. On the seventh postoperative day, he started vomiting and complained of abdominal bloating. DIAGNOSIS: An upper gastrointestinal series, computed tomography scan and computed tomography angiography confirmed the diagnosis of SMA syndrome. INTERVENTIONS: Gastric decompression, nasojejunal tube feeding and parenteral nutrition were performed. OUTCOMES: After 3 weeks of conservative treatment, the patient showed no clinical improvement in symptoms. Subsequently, he suffered from gastrointestinal hemorrhage, deep venous thrombosis of the lower extremity and cerebral hemorrhage successively. Unfortunately, the patient eventually died. LESSONS: Surgeons should be aware of the fact that SMA syndrome can occur after colectomy. Every attempt should be made to correct and avoid any predisposing factors perioperatively. Prompt diagnosis of SMA syndrome after colectomy and appropriate early intervention reduce mortality.

Point-of-care ultrasound findings in the diagnosis and management of Superior Mesenteric Artery (SMA) syndrome.

Superior mesenteric artery (SMA) syndrome is a potentially fatal condition that can be difficult to diagnose for emergency medicine physicians due to its rarity and vague gastrointestinal symptom presentation. Patients arriving at the emergency department (ED) with this condition may encounter delays in proper supportive care and treatment. We present the case of a 21-year-old female who was seen in the ED for nausea, non-bloody vomiting, and rapid weight loss. Through point-of-care ultrasound (POCUS) findings, she was diagnosed with SMA syndrome and received appropriate, supportive care for her condition before catastrophic complications could occur. This case demonstrates the utility of POCUS in SMA syndrome and the importance of considering this diagnosis despite its rarity.

[Superior mesenteric artery syndrome in gastric cancer: a case report]. / Syndrome de la pince aorto-mésentérique sur cancer gastrique: à propos d'un cas.

Superior mesenteric artery syndrome or Wilkie syndrome is due to the compression of the third duodenum between the superior mesenteric artery and the aorta. It causes acute or chronic upper bowel occlusion. Abdominal CT scan facilitates the diagnosis. Severe malnutrition is its main etiological factor. Medical treatment can be based on aspiration of gastric contents and parenteral nutrition. If this fails, surgery is necessary. We here report the case of a 46-year-old patient, with a history of smoking, presenting with profuse postprandial bile and food vomiting. He had had weight loss of 7% over a period of 6 months. Upper GI endoscopy revealed non-stenotic antro-pyloric tumour mass. Histological examination showed poorly differentiated tubular gastric adenocarcinoma. Staging was without any peculiarity and allowed for the detection of superior mesenteric artery syndrome at an angle of 8°C. The patient received parenteral nutrition for 10 days, followed by inferior pole gastrectomy and gastrojejunal anastomosis (omega loop). The postoperative course was uneventful. Adjuvant chemotherapy was indicated.

Duodenoyeyunostomía laparoscópica en el Síndrome de la Arteria Mesentérica Superior / Laparoscopic duodenojejunostomy for Superior Mesenteric Artery Syndrome

Introducción: El Síndrome de la Arteria Mesentérica Superior es causa poco frecuente de obstrucción duodenal. Los síntomas varían desde una obstrucción leve hasta emergencias agudas. El examen físico no siempre ayuda al diagnóstico, que se basa en los hallazgos imagenológicos. Objetivo: preconizar, recomendar el uso de las técnicas mínimamente invasivas en el manejo quirúrgico del Síndrome de la Arteria Mesentérica Superior. Presentación del caso: Mujer de 49 años de edad, antecedentes de pérdida de peso después de quimioterapia con náuseas, vómitos y dolor abdominal posprandial de dos años de evolución. Tratada exitosamente con duodenoyeyunostomía laparoscópica. El tratamiento inicial suele ser conservador. Publicaciones recientes respaldan que la duodenoyeyunostomía laparoscópica es un método seguro y efectivo para su tratamiento. Conclusiones: El tratamiento quirúrgico es cada vez más exitoso, la mayoría de los pacientes no presenta síntomas después de la cirugía(AU)

Introduction: Superior Mesenteric Artery Syndrome is an uncommon cause of duodenal obstruction. Symptoms may vary from mild obstruction to acute life-threatening emergencies. Physical examination does not always help in establishing the diagnosis which is based on findings from imaging studies. Objective: To recommend the laparoscopic approach for the surgical treatment of this entity. Case presentation: A 49-year old female patient with prior history of weight loss after chemotherapy and a two-year history of postprandial nausea, vomiting, and abdominal pain who was successfully treated by laparoscopic duodenojejunostomy is presented. Discussion: Initial treatment is usually conservative. Recently published studies support that laparoscopic duodenojejunostomy is a safe and effective method of treatment. Conclusions: Surgical treatment is becoming more successful and the majority of patients are symptom-free after surgery(AU)

Superior Mesenteric Artery Syndrome Following Scoliosis Surgery: A Systematic Review of Case Reports.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a well-recognized, rare complication of undergoing surgical correction of a spinal deformity. The objective of this study was to summarize the best available evidence on SMA syndrome treatment after scoliosis surgery. To identify differences, special attention was paid to scoliosis pathology, intervention and SMA syndrome presentation. METHODS: A systematic review of the literature was performed on SMA syndrome following scoliosis surgery. The Web of Science, PubMed, Wanfang (Chinese) and EMBASE databases were systematically searched for articles from January 1971 to October 2020. The main subjects discussed are scoliosis pathology, intervention and SMA syndrome presentation. RESULTS: A total of 32 articles with 52 cases were included in our report. The mean age of patients with SMA syndrome following scoliosis surgery was 14.7 ± 2.9 years and the majority (n = 42, 80.8%) were girls. The most frequently reported scoliosis type was adolescent idiopathic scoliosis (n = 34, 65.4%). The mean postoperative days (POD) (interval between the surgical treatment and the onset of symptoms) was 9.6 ± 9.5 days. Different treatment methods were analyzed in 46 patients. We noted a trend toward a higher percentage of patients with POD < 48 hr in the group with surgical treatment than in the conservative treatment group (P = 0.002). CONCLUSION: In summary, in this systematic review, for the first time, we found that the time of onset of postoperative symptoms can be used as an important reference index for surgical intervention. We also believe that recommendations about the treatment of SMA syndrome following scoliosis surgery should include this finding. Given the lack of robust clinical evidence, these findings warrant verification in a prospective multicenter screening trial.

Unusual presentation of superior mesenteric artery syndrome after trauma.

Superior mesenteric artery (SMA) syndrome is a rare but severe condition. SMA syndrome's association with trauma has been reported to present weeks to months after significant weight loss due to head or spinal cord injury. We present an unusual case of SMA syndrome presenting with obstructive symptoms, which developed immediately after clavicle fracture and was not associated with weight loss. CT of the abdomen showed small bowel obstruction in the third part of the duodenum. CT angiogram of the abdomen confirmed SMA syndrome. The patient was managed conservatively with enteral nutrition via jejunostomy tube. He was discharged after symptoms resolved, and repeat imaging revealed resolution of obstruction. This case emphasises the importance of having SMA syndrome as one of the differential diagnoses for patients presenting with obstructive symptoms after trauma because early diagnosis can be managed with conservative treatment.

Combined Superior Mesenteric Artery Syndrome and Nutcracker Syndrome in a Young Patient: A Case Report and Review of the Literature.

BACKGROUND Superior mesenteric artery syndrome is the compression of the third portion of the duodenum between the superior mesenteric artery and the aorta causing abdominal pain and vomiting. Nutcracker syndrome is the compression of the left renal vein between the superior mesenteric artery and the aorta causing symptoms related to renal congestion. Both entities, although well described in the literature, are individually rare, and even though they might share a common etiology, their co-existence has been reported in only a few case reports. CASE REPORT An 18-year-old male, previously healthy, presented with postprandial abdominal pain relieved by bilious vomiting that started shortly after he lost weight fasting. Our investigation revealed superior mesenteric artery syndrome as well as a compressed left renal vein. He was started on an enriched fluid diet which was progressed gradually as he regained weight. His left renal vein compression at the time was asymptomatic; it will be followed up for possible resolution after the patient's weight returns to normal. CONCLUSIONS Superior mesenteric artery syndrome is to be suspected in patients with abdominal pain following weight loss. Conservative treatment with a focus on weight regain will cure most cases. Asymptomatic or mildly symptomatic nutcracker syndrome is treated conservatively. For patients requiring intervention, laparoscopic extravascular titanium stent placement seems to be the least invasive promising option today, awaiting further definitive studies.

Superior Mesenteric Artery Syndrome Improved by Enteral Nutritional Therapy: A Retrospective Case-Series Study in a Single Institution.

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is a relatively rare cause of chronic duodenal obstruction, owing to the compression of the third portion of the duodenum. OBJECTIVES: This retrospective study aims to discuss the efficacy of enteral nutrition (EN) therapy in nutritional status and symptom improvement at a short-term follow-up for SMAS patients. METHODS: We retrospectively analyzed clinical data of patients diagnosed as SMAS and treated with EN from September 2012 to January 2019. RESULTS: Twenty-six patients were included (16 women; mean age 24.96 ± 11.77 years), none was excluded, and one was lost to follow-up. The patients' mean body weight was 40.94 ± 10.16 kg, mean weight loss 11.73 ± 7.58 kg, and mean body mass index (BMI) 14.82 ± 2.52 kg/m2. The mean duration of EN therapy was 10.10 ± 4.66 months. Serum level of nutritional indicators, BMI and body weight increased after EN therapy. During a median follow-up of 24 months (9-44) after EN therapy, the mean symptom score decreased from 24.28 ± 9.57 to 8.06 ± 8.29 (p < 0.0001), and 65% of patients' symptoms resolved and 15% of patients' symptoms improved. In total, 16 complications occurred, including tube blockage, peristomal wound infections, peristomal leakage, granulomas, and nasopharyngeal pain. CONCLUSION: EN therapy may be an effective option for SMAS patients. While it might not remove all symptoms, it can improve the nutritional status to support subsequent treatments.

[Diagnosis and treatment of superior mesenteric artery compression syndrome secondary to chronic constipation (Lee's triad syndrome)].

Objective: To summarize the experience of diagnosis and treatment of superior mesenteric artery compression syndrome (SMACS) secondary to chronic constipation according to the concept of Lee's triad syndrome. Methods: The concept of Lee's triad syndrome: (1) clinical symptoms: triad of constipation, malnutrition, upper gastrointestinal obstruction (vomiting, difficulty in eating); (2) anatomical manifestations: with triple anatomy anomaly of transverse colon sagging, elevated spleen flexure, and mesentery arterial compression; (3) treatment: with triple treatment of enteral nutrition support, chest-knee posture and fecal microbiota transplantation. A descriptive cohort study was performed. According to Lee's triad syndrome criteria, clinical data of 78 patients with superior mesenteric artery compression syndrome secondary to chronic constipation in the Tenth People's Hospital of Tongji University and General Hospital of Eastern Theater Command from June 2004 to November 2018 were prospectively collected, including basic information, symptoms and signs, imaging findings, nutritional indicators, gastrointestinal quality of life index (GIQLI) and Wexner defecation score. The above parameters based on Lee's triad syndrome criteria were followed up and recorded at 1, 3, 6, 12 months after comprehensive treatment. Results: All the patients had Lee's triple symptoms of constipation, malnutrition, upper gastrointestinal obstruction (vomiting, eating difficulties), and triple anatomy anomaly of transverse colon sagging, elevated spleen curvature, and mesentery arterial compression before treatment. After triple treatment of enteral nutrition support, chest-knee posture, and fecal microbiota transplantation, 69 (88.5%) patients had a significant improvement of symptoms, and 9 patients had no significant improvement of symptoms and then eventually received surgery. The 69 cases without operation received follow-up for 12 months. All the patients eventually returned to normal eating, and upper gastrointestinal angiography and superior mesenteric artery imaging showed duodenal compression disappeared. After 1 month, the constipation-related indexes were improved. After 12 months, the number of autonomous defecation per week increased from 1.0±0.8 to 5.0±1.6 (P<0.001). The GIQLI score increased from 52.7±8.5 to 93.2±7.5 (P<0.001), and the Wexner score decreased from 19.1±2.5 to 6.2±2.1 (P<0.001). After 1 month, nutritional indexes were improved gradually. After 12 months, the BMI increased from (17.9±1.8) kg/m(2) to (21.0±1.3) kg/m(2), total protein increased from (65.2±5.7) g/L to (68.3±4.2) g/L, albumin increased from (32.1±5.1) g/L to (40.4±3.0) g/L, prealbumin increased from (163.2±53.7) mg/L to (259.1±45.6) mg/L, fibrinogen increased from (1.9±0.5) g/L to (2.4±0.5) g/L, whose differences were statistically significant (all P<0.001). Upper gastrointestinal angiography and superior mesenteric artery imaging showed duodenal compression were relieved. The angle between superior mesenteric artery and abdominal aorta increased from (17.4±3.8)° to (37.8±5.8)° (t=-22.26, P<0.001). Conclusion: When patients with SMACS secondary to chronic constipation have Lee's triple symptoms and triple anatomy anomaly, the triple combination treatment of enteral nutrition support, chest-knee posture and fecal microbiota transplantation should be applied.

Rare bowel emphysema with superior mesenteric artery syndrome after surgery.

Superior mesenteric artery syndrome, a rare cause of duodenal obstruction, occasionally requires surgery. Bowel emphysema might also require surgery and might be an ominous sign of a serious condition. We report the case of a 69-year-old Japanese man with left pneumothorax who was also diagnosed as having bowel emphysema and superior mesenteric artery syndrome simultaneously without serious infection after surgery for the pneumothorax. Following gastric decompression via a nasogastric tube, his general condition resolved quickly with no need for surgical intervention. Prompt and precise diagnosis by computed tomography and both adequate judgment and treatment can avoid surgery in such cases.

The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old.

This review is directed at increasing awareness of two diverse rare upper gastrointestinal problems that occur at opposite ends of the age spectrum and are difficult to diagnose and treat. The Superior Mesenteric Artery Syndrome (SMAS) likely involves a young patient, especially female, and is especially associated with rapid weight loss, resulting in relative strangulation of the duodenum by a narrowing of the angle between the Superior Mesenteric Artery (SMA) and the aorta. On the other hand, atherosclerosis of the SMA is associated most likely with postprandial upper intestinal ischemia and abdominal pain occurs in the elderly at high risk for cardiovascular (CV) disease. Medical management of the SMAS in the young involves good alimentation and weight gain to overall increase the intestinal fat pad. Medical management of SMA atherosclerotic ischemia in the elderly is directed at marked lipid lowering with atherosclerotic plaque stabilization or even regression. If needed, surgery for SMAS can be attempted laparoscopically with duodenojejunoscopy which is the most popular procedure but there are also more conservative possibilities that avoid division of the duodenum. In addition, sometimes direct vision is needed to successfully operate on SMAS. If surgery is needed for SMA atherosclerotic ischemia, it is usually attempted endoscopically with angioplasty and stent placement. Most important, in the case of these two rare clinical entities, is that the clinician have a suspicion of their presence when indicated so that the young or old patient can be spared unnecessary suffering and return to good health in a timely fashion.

Superior Mesenteric Artery Syndrome Following Augmentation Cystoplasty.

Superior mesenteric artery syndrome (SMAS) is a rare condition of external duodenal compression in the angle between the superior mesenteric artery and aorta. We report a case of SMAS following augmentation cystoplasty in a young patient.

Superior mesenteric artery syndrome coexists with Nutcracker syndrome in a female: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome or Benign duodenal stasis, is a rare benign disease. It could threaten the life if the manifestation is severe and the treatment is inappropriate. In the patients with SMA syndrome, the third portion (transverse part) of the duodenum is compressed externally between the SMA and abdominal aorta (AA) leading to duodenal stasis and gastrointestinal obstruction. SMA syndrome may rarely combine with Nutcracker syndrome when left renal vein (LRV) was compressed between SMA and AA. CASE PRESENTATION: A 32-year-old female patient presented with complaints of gradually severe bloating, epigastric pain, left flank ache, nausea and occasional vomiting of 1 month's duration. The epigastric and left flank ache was aggravated when the patient was supine and relieved in a prone or left lateral decubitus. The abdominal bloating was associated with early satiety. The vomiting always started 40 min after meal. The patient gave a history of urine stone with drotaverine hydrochloride tablets treatment for two weeks before the gastrointestinal symptoms arising. The patient had no significant surgical history, but had a rapid weight loss of approximately 10 kg with a body mass index (BMI) from 21 kg/m2 to less than 18 kg/m2 over the last two months. An abdominal examination revealed upper abdominal tenderness and distention. The urine routine examination showed no significant abnormality. The findings of initial blood tests and other laboratory investigations were unremarkable. CONCLUSIONS: This case reports a female patient with SMA syndrome with Nutcracker syndrome predisposed by Antispasmodics. We highlight the importance of the combination therapy of long-term nutritional supporting and prokinetic agents. Rehabilitating practice after discharge is beneficial to reduce recurrence.