Management Of Nutcracker Syndrome Research Articles

Nutcracker Sendromlu Hastalarda Klinik Deneyimlerimiz

INTRODUCTION: Nutcracker syndrome (NCS) is a rare condition caused by the compression of the left renal vein between the abdominal aorta and superior mesenteric artery. The purpose of the study was to evaluate our management of NCS. METHODS: Patients were retrospectively reviewed and sex, age, main symptoms at application, physical examination, radiological findings, laboratory examinations, and treatment were recorded. RESULTS: 23 patients (16 girls, 7 boys; age range, 5 to 16) diagnosed with NCS. Microhematuria was detected with 14 (60.8%) patients before diagnosis. And four of 9 (39.1%) were determined after diagnosis. Microhematuria was not detected in 5 (21.7%) of the patients. All patients (100%) had orthostatic proteinuria. 17 (73.9%) patients had mild, 3 (13.0%) patients had moderate and 3 (13.0%) had severe proteinuria. The mean diameter of the left renal vein (LRV) at the aortomesenteric (AM) portions and the hilar were 1.69mm±0.70 and 8.01mm±2.27. The mean angle between the superior mesenteric artery and LRV was 25.26º±7.98. DISCUSSION AND CONCLUSION: In the case of especially colic flank pain, hematuria, and proteinuria NCS should keep in mind in the differential diagnosis. Surgical management may supply more enough clinic improvement when the patient has a response to medical therapy.

A systematic review on management of nutcracker syndrome.

Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for intervention. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.

Gonadal Vein Transposition in the Treatment of Nutcracker Syndrome

The favored approach in the management of nutcracker syndrome (NCS) has traditionally been renal vein transposition (RVT), with more recent efforts at endovascular therapies as well. Gonadal vein transposition (GVT) has been infrequently used and chiefly in special circumstances. GVT has the potential to reduce operative complexity and to improve safety of the left renal vein. In this study, we compare the safety and efficacy of GVT and RVT as the operative approach of choice in the treatment of NCS. Six patients who underwent open repair for NCS between January 2008 and March 2016 were identified from the medical record. Primary outcomes were symptom resolution and patency of the reconstruction, and secondary outcomes were the need for reintervention and occurrence of major morbidity. During the study period, four patients underwent repair of NCS by GVT; one patient required renal autotransplantation and one underwent RVT. The patients' mean age was 31 years, their mean body mass index was 24.9 kg/m2, and 83% were female. All presented with symptoms of flank pain. In addition, one-third had varicosities, and half had gross or microscopic hematuria. All patients had evidence of renal vein compression (one posterior, five anterior) and significant pelvic venous congestion on cross-sectional imaging. Average operative times and estimated blood loss for the non-GVT and GVT cohorts were 220 minutes and 108.5 minutes, respectively, and 125 mL and 450 mL, respectively. There were no major perioperative complications, including acute kidney injury, renal failure necessitating dialysis, prolonged ventilation, hemorrhage, or wound infection, among others. During an average follow-up of 572 days, all patients had either clinical (three) or radiographically proven (three) patency as well as complete (four) or partial (two) symptomatic relief, and no patient has required reintervention. In this series, GVT is as effective as RVT in reported series and offers the benefit of shorter operative times, lower blood loss, and avoidance of manipulation of the renal vein.