Weight loss as a potential trigger for nutcracker syndrome after a complex surgery: About a case report.

ABSTRACT

INTRODUCTION: Nutcracker syndrome results from the compression of the left renal vein between the aorta and the superior mesenteric artery. The Nutcracker syndrome is rare and occurs in specific contexts such in patients who have lost significant weight. Our case presents an infrequent instance of nutcracker syndrome following a complicated biliary surgery. CASE PRESENTATION A 32-year-old patient presented with symptomatic cholelithiasis. Laparoscopic cholecystectomy was complicated by an injury in the right hepatic artery necessitating a biliary reconstruction. After three months, the BMI was 18 Kg/m2.The patient was operated on, he had a hepaticojejunal anastomosis on the left hepatic duct. Right hepatectomy was unnecessary due to complete atrophy of the right liver. Postoperatively, persistent low back pain prompted a CT scan. It revealed compression of the left renal vein in the aortomesenteric clamp indicating a nutcracker syndrome. The patient was put on anticoagulants with a good evolution. DISCUSSION: The Nutcracker syndrome is categorized into three types the anterior form, the posterior form and the posterolateral form. The aortomesenteric angle could be subject to variation depending on the body mass index (BMI). Significant weight loss could induce nutcracker syndrome by decreasing the Aorto- superior mesenteric artery angle due to reduced retroperitoneal and perivascular fat (D'Souza et al., n.d.). In our case, the patient's BMI dropped from 25 to 18 kg/m2 contributing to the syndrome. Radiological examinations should assess not only the anatomy of the aorto-mesenteric angle but to identify an eventual associated thrombosis. Conservative treatment is sufficient in most cases with a resolution of symptoms in 60 to 80 % of cases. CONCLUSION: We aimed to bring attention to Nutcracker syndrome, especially in patients who have experienced significant weight loss after a complicated surgery.