Superior mesenteric artery syndrome in a healthy active adolescent.

This report discusses a case of superior mesenteric artery (SMA) syndrome in a previously healthy 15-year-old boy with no weight loss or other common risk factors. The patient presented to the emergency department with acute bilious vomiting and epigastric pain after acute consumption of a meal and excessive quantities of water. The patient was diagnosed with SMA syndrome based on the findings of contrasted CT of the abdomen. In early puberty, boys have a significant increase in lean body mass and a concomitant loss of adipose tissues. These pubertal changes lead to a narrowing of the aortomesenteric space. The acute consumption of food and water caused a transient obstruction at the already-narrowed space, which resulted in the manifestation of SMA syndrome. This case demonstrates that pubertal growth spurt is a risk factor for SMA syndrome, and acute excessive ingestion can trigger SMA syndrome among those in puberty.

The two sides of superior mesenteric artery syndrome treatment: conservative or surgical management? / Las dos caras del tratamiento del síndrome de la arteria mesentérica superior: ¿manejo conservador o quirúrgico?

Introduction: Superior mesenteric artery syndrome (SMAS) is a rare condition characterized by vascular compression of the duodenum. There is controversy regarding the optimal treatment. Case report: In case 1, we describe the case of a 21-year-old woman (body mass index [BMI] 16.9 kg/m2) with high-level obstructive symptoms three months prior, with computed tomography scan (TC) showing a superior mesenteric artery aorta angle (SMAA) of 13° and compression of the third portion of the duodenum (D3), for this reason a nasojejunal tube was placed for enteral feeding. In case 2, enteral nutrition was initiated for feeding a 17-year-old female with anorexia nervosa (BMI 8.3 kg/m2). She presented macrohematuria, vomiting, epigastralgia, abdominal distension and acute abdomen when oral feeding was reinitiated. TC reported a SMAA of 15°, in addition to compression of the left renal vein (Nutcracker syndrome) and gastro duodenal expansion, surgical management was necessary. Discussion: Both cases had favorable evolution, being the nutritional support fundamental. SMAS should be suspected in all people with high-level obstructive symptoms and recent weight loss (AU)

Introducción: el síndrome de la arteria mesentérica superior (SAMS) es una condición rara caracterizada por la compresión vascular del duodeno, y existe controversia acerca de su tratamiento. Caso clínico: en el caso 1, presentamos a una mujer de 21 años (índice de masa corporal [IMC] 16,9 kg/m2) con datos de obstrucción alta y epigastralgia durante los tres meses previos, con tomografía computarizada (TC) que reporta ángulo de la arteria mesentérica superior (AAMS) de 13° y compresión de D3. Se colocó sonda nasoyeyunal para alimentarla. En el caso 2, se inició alimentación enteral por sonda nasogástrica en una mujer de 17 años con anorexia nerviosa (IMC 8,3 kg/m2). Al reiniciar la vía oral presentó hematuria, vómito, epigastralgia, distensión abdominal y abdomen agudo. La TC reportó AAMS 15°, compresión de la vena renal izquierda (síndrome de Nutcracker) y distensión gastroduodenal. Requirió tratamiento quirúrgico. Discusión: ambas pacientes tuvieron evolución favorable, siendo fundamental el soporte nutricional. Se debe sospechar el SAMS en los pacientes con datos de obstrucción intestinal alta y pérdida de peso reciente (AU)

Low body mass index: a risk factor for superior mesenteric artery syndrome in adolescents undergoing spinal fusion for scoliosis.

STUDY DESIGN: Five cases of superior mesenteric artery (SMA) syndrome occurred at our institution over a 4-year period in adolescents undergoing spinal fusion surgery for scoliosis. All patients had in common a very slender body habitus. The measurement of body mass index (BMI) was low in all patients and an age-matched control group of patients undergoing similar surgery without this complication was assessed with this Index to determine its utility as a screening tool for this postoperative condition. OBJECTIVE: The goal was to determine if BMI is a useful parameter to assess the relative risk of patients undergoing spinal fusion surgery for developing the complication of SMA syndrome. BACKGROUND DATA: SMA syndrome is a serious and potentially fatal complication of spinal fusion surgery for scoliosis. Significant curve correction and slender body habitus have been cited in the literature as potential risk factors for this disorder. METHODS: BMI and the amount of scoliosis curve correction in the 5 patients developing SMA syndrome after spinal fusion were calculated and compared with those values in a group of 18 age-matched patients undergoing spinal fusion during the same time period. RESULTS: Absolute curve correction was comparable between the 2 groups. All 5 patients who developed SMA syndrome had a BMI of less than 18. CONCLUSIONS: Patients undergoing spinal fusion surgery for scoliosis with a BMI of less than 18 are at risk to develop SMA syndrome postoperatively.

[Analysis of complications in scoliosis surgery].

OBJECTIVE: To analyze the complications occurred in scoliosis surgery and evaluate its prevention strategy. METHODS: From June 2002 to May 2007, 86 cases of idiopathic scoliosis were treated. There were 21 male and 65 female with an average age of 17.8 years(range, from 8 to 22 years). According to Lenke classification, 33 cases were type 1, 10 type 2, 18 type 3, 5 type 4, 10 type 5 and 10 type 6. Five cases were Risser 0 to I, 20 cases II to III, 61 cases 1V to V. Cobb angles were from 45 degrees to 85 degrees (mean 60.35 degrees). The pedicle screw technique was used to correct all the scoliasis, and the results and complications were studied. RESULTS: The average operation time was 3.2 hours and average blood loss volume was 1000 ml (800-2400 ml), 924 pedicle screws were inserted and the average postoperative Cobb angle was 18.46 degrees. All the patients were followed up for 5 to 40 months(mean 20.5 months). The complications were as following: 1 case of spinal cord injury; 25 screws misplaced; 2 cases of nerve root injury; 1 case of pleura injury; 1 case of superior mesenteric artery syndrome; 3 cases of wound infection; 2 cases of trunk decompensation; 1 case of junction kyphosis; 3 cases of implant loosening; 2 cases of pseudarthrosis; 1 case of crankshaft phenomenon; 2 cases of flatback syndrome. CONCLUSION: Many kinds of complications may occur in scoliosis surgery. Exactitude procedures of diagnosis and surgery for the scoliosis are the key to decrease and prevent the complications related to the operation.

Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy.

From July 1997 to October 2003, 640 patients with adolescent scoliosis who had undergone surgical treatment were evaluated prospectively, 7 patients of whom suffered from SMAS post-operatively. The height of the 7 patients who developed SMAS was above the mean of sex- and age-matched normal population, with the height percentile ranging from 5% to 50%. On the contrary, their weight was below the mean of the normal population with a weight percentile ranging from 5% to 25%. Among the 7 patients, 4 had a thoracic hyperkyphosis ranging from 55 degrees to 88 degrees (average 72 degrees ) and 2 had a thoracolumbar kyphosis of 25 degrees and 32 degrees respectively. The 7 patients were all treated with fasting, antiemetic medication and intravenous fluids, a nasogastric tube was passed and aspirations commenced. Reduction or suspense of traction was adopted in three patients who had SMAS during Halo-femoral traction after anterior release of scoliosis. All the patients recovered completely with no sequelae.

Revascularization to prevent postoperative bowel infarction after surgery for acute superior mesenteric artery thromboembolism.

PURPOSE: Postoperative bowel infarction is a major contributing factor to the high mortality rate associated with acute thromboembolism of the superior mesenteric artery (SMA). This study was conducted to evaluate the prophylactic role of thrombectomy to prevent postoperative mesenteric infarction. METHODS: An autologous fibrin clot (1 cm3) was implanted into the SMA of beagle dogs. The animals in group I (n = 7) underwent only resection of the ischemic intestine 120 min after insertion of the thrombus. In group IIa (n = 6), the intestine was removed before thrombectomy of the SMA, and revascularization was performed 30 min prior to resection in group IIb (n = 6). The postoperative outcomes were compared among the three groups. RESULTS: Postoperative bowel infarction developed in four (57.1%) of the group I dogs, three (42.8%) of which died within 5 days postoperatively. The SMA was patent in the group IIa and IIb dogs, none of which died throughout the observation period. Performing thrombectomy before the resection reduced the length of resected intestine. CONCLUSION: Arterial revascularization is not only an essential procedure for mesenteric infarction due to SMA thromboembolism, but it also prevents the postoperative bowel infarction caused by the extension of thrombus in the mesentery.

[The prevention of the aorto-mesenteric compression syndrome in interventions for ileoanal anastomoses]. / Prevenzione della sindrome del compasso aorto-mesenterico negli interventi di ileo-ano-anastomosi.

Restorative proctocolectomy with ileal-anal anastomosis can induce a duodenal stenosis due to the compression between superior mesenteric artery (SMA) and aorta when the ileum is pulled-down to the anus stretching the SMA. This situation may require prolonged nasogastric intubation or even surgery. In our experience this occurred in 10% of pts. Aiming to avoid this complication we have performed an intestinal derotation just before ileal-anal anastomosis abolishing any possibility of duodenal compression. Comparing this latter group of patients to those who didn't receive intestinal derotation, we observed a significant reduction of nasogastric tube drainage and of the nasogastric intubation time. We think that intestinal derotation could be effective in preventing SMA syndrome after restorative proctocolectomy and ileal-anal anastomosis.

[Observation of the superior mesenteric artery by ultrasonography: for prediction of the superior mesenteric artery syndrome].

Superior mesenteric artery (SMA) syndrome is a major complication after scoliosis surgery. The author reports an ultrasonic observation of the SMA in normal and scoliotic individuals. There are three patterns of the SMA anatomy: Type I in which the SMA runs very close and parallel to the aorta, Type II in which the SMA branches off the aorta at a certain angle and Type III in which the SMA runs parallel to the aorta. Dynamic observation revealed that passage of food displaces the SMA anteriorly and to the left and that turning to the left from a supine position displaces the SMA from just anterior to the left of the aorta in normal individuals and from the right to the left side of the aorta in scoliosis cases. AMA itself has no significance in the occurrence of SMA syndrome because the SMA moves rather freely with the passage of food or position change. When this natural movement of the SMA is disturbed, one should carefully look for the possibility of SMA syndrome.