Superior Mesenteric Artery Syndrome Research Articles

Superior Mesenteric Artery Syndrome: A Vicious Cycle?

CASE REPORT Superior mesenteric artery syndrome (SMAS) is a rare syndrome where the third part of the duodenum is compressed between the abdominal aorta and the superior mesenteric artery (SMA).1 The loss of the intervening mesenteric fat pad causes the aortomesenteric angle to decrease from its normal value of 38°–65° to less than 25°, decreasing the aortomesenteric distance to less than 10 mm and causing duodenal compression. Its incidence in the general population is between 0.1% and 0.3% with a female predominance.2 A 22-year-old woman presented to the emergency department of our hospital with complaints of vomiting and a marked decrease in appetite for the past 4 months. The vomiting was nonbilious and nonprojectile and would only occur postprandially. She also reported past episodes of watery diarrhea associated with anorexia and experienced intermittent episodes of fever, documented at 101°F–102°F. Since the start of her symptoms, she had lost 27 kg. An upper abdominal computed tomography scan in both plain and contrast films revealed significant gastric distention, distention of the duodenum up to the second and third parts, and a relatively collapsed small bowel distal to the presumed crossing of SMA (Figure 1). The computed tomography scan displayed downward inclination of SMA and significant compression of the left renal vein between the abdominal aorta and SMA, confirming the existence of left renal vein entrapment syndrome in our case (Figure 2). In addition, there was a reduced aortomesenteric angle of 11.8°, and a distance of 8 mm was observed (Figure 3). In lieu of the above findings, SMAS was suspected. The patient initially received conservative treatment and was started on nasogastric feeding tube. Owing to intolerance, a total parenteral nutrition regimen was used to stabilize the patient's weight. Only 2 kg were gained by the patient over the course of 4 weeks. Her symptoms continued to worsen despite her slight weight gain. Having failed to achieve a satisfactory outcome with conservative management, an exploratory laparotomy was performed. The peritoneal cavity was exposed through a midline skin incision. There was gross distention of the second part of the duodenum, and the third part of the duodenum was compressed. Owing to grossly dilated duodenum, the decision was taken to perform gastrojejunostomy instead of duodenojejunostomy. Stapled posterior gastrojejunostomy was performed to bypass the compressed duodenum, and an anastomosis was made between the stomach and the proximal loop of the jejunum (Figure 4). The intraperitoneal drain was kept in place. An uneventful recovery followed the patient's extubation.Figure 1.: Computed tomography scan showing compression of the third part of the duodenum. Arrow is pointing toward the compressed duodenum.Figure 2.: Computed tomography scan showing compression of the left renal vein. Arrow is pointing towards the compressed left renal vein.Figure 3.: Computed tomography scan showing compression of the third part of the duodenum. Angle denoting a reduced aortomesenteric angle value of 11° (normally>38°).Figure 4.: Computed tomography scan after gastrojejunostomy displaying the anastomosis made between the stomach and the proximal loop of the jejunum. Arrow pointing towards the anastomotic site.This case report presents an early preoperative diagnosis of a rare disease entity based on its radiological presentations. When women with a low body mass index present with chronic, refractory symptoms of the upper digestive system, SMAS should be suspected. It can also often be confused with other etiologies of mega duodenum such as diabetes mellitus, systemic lupus erythematosus, amyloidosis, myotonic dystrophy, scleroderma, and chronic idiopathic intestinal pseudo-obstruction. This necessitates the need of a multidisciplinary approach based on symptoms to diagnose SMAS by clinicians. DISCLOSURES Author contributions: A. Jawed collected patient information and followed up after discharge and wrote the manuscript. A. Jawed wrote the manuscript. ME Anis identified the case and treated the patient, revised the manuscript, and is the article guarantor. MA Qadeer and Z. Abbas revised the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.

Superior mesenteric artery syndrome

Superior mesenteric artery syndrome

Surgical therapy of celiac axis and superior mesenteric artery syndrome

IntroductionCompression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome.MethodsA systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up.ResultsTwenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0–217) and 31 ml (21–50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1–12) for CAS and 5 days (1–10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms.ConclusionFailure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.

Wilkie syndrome, changing perspectives in image visualization

The superior mesenteric artery syndrome is an uncommon entity included in the spectrum of vascular syndromes. The low presentation, variety of in specific symptoms and shortage of bibliography presents a challenging diagnosis for both clinicians and radiologists.

Decrease in aorto-mesenteric angle and distance diagnosis and treatment: case report

Background: Wilkie syndrome (WS) is a pathological manifestation caused by an abnormal disorder of the superior mesenteric artery (SMA). It is a branch of the abdominal part of the aorta. As a result, the distal part of the duodenum is compressed between the abdominal aorta, spine, and SMA, which creates a hindrance for the passage of chyme in the duodenum, creating a mechanical obstruction, and thus, gives rise to the WS. It is commonly due to the loss of fatty tissue. Case Presentation: We hereby discuss the case report of a 28-year-old patient diagnosed with the same at the initial stage of WS. The patient had been suffering from the symptoms of WS since 2018 but wasn't able to identify the disease when he came to our department. Based on the results of abdominal sonography, Computed tomography (CT)-scan with contrast, and angiography, we confirmed the diagnosis of WS. The patient was treated with the duodenojejunostomy (laparoscopic Strong's operation), and after the surgery, the patient was treated symptomatically. Conclusion: WS is a rare and fatal manifestation that if delayed can cause severe life-threatening complications and even death, but diagnosis in the initial stages, especially with contrast CT/magnetic resonance imaging angiography, and timely management can save the life and prevent fatal complications. WS can be a fatal manifestation if not diagnosed on time, but early and accurate diagnosis can unleash the diseased state of WS, and treatment on time can avoid severe and deadly complications.

Superior mesenteric artery syndrome treatment strategies: A case report

Superior mesenteric artery syndrome is a rare manifestation of small bowel obstruction caused by the compressed third part of the duodenum between the superior mesenteric artery and the abdominal aorta. We present the case of an 18-year-old female and presented with symptoms of duodenal outflow obstruction. Upon investigation, her cross-sectional imaging revealed partial obstruction of the distal duodenum at the crossing of superior mesenteric artery forming an acute angle between the superior mesenteric artery and aorta. Failing initial attempts at conservative management, the patient underwent laparotomy and duodenojejunostomy with complete relief of symptoms. Superior mesenteric artery syndrome is a rare but a sinister diagnosis in patients presenting with features of duodenal outflow obstruction. Cross-sectional imaging plays an important role in diagnosis.

Síndrome da artéria mesentérica superior em combinação com síndrome de quebra-nozes manifestando-se como pancreatite aguda: relato de caso

Abstract Superior mesenteric artery syndrome designates compression of the third part of the duodenum between the superior mesenteric artery and the aorta. This condition has a low incidence, being more common in thin young women. Nutcracker syndrome is compression of the left renal vein between the superior mesenteric artery and the aorta. Both entities are rare, and their coexistence has been reported in a few cases. Conservative treatment targeting weight gain is sufficient in most cases. An association between the superior mesenteric artery syndrome and acute pancreatitis has rarely been reported. We intend to describe the case of an 18-year-old girl who was admitted to the emergency room with epigastric pain and emesis. Our investigation revealed acute acalculous pancreatitis. During work-up, we discovered superior mesenteric artery syndrome and a compressed left renal vein. The patient is on conservative treatment, and her symptoms have improved.

Evaluation of Abdominopelvic Vascular Compression Syndromes using Computed Tomography

Introduction: Various abdominopelvic vascular compression syndromes can cause a wide spectrum of symptoms which can be diagnosed incidentally in asymptomatic patients or in patients in which imaging was done for other indications. The purpose of this study is to evaluate the typical imaging findings of superior mesenteric artery syndrome, median arcuate ligament syndrome, nutcracker syndrome, and May-Thurner syndrome using computed tomography and correlating with clinical symptoms. Methods: This observational, cross-sectional study was performed on patients who were referred for computed tomography of the abdomen and pelvis for various indications. Different measurements, ratios, and common symptoms for superior mesenteric artery syndrome, median arcuate ligament syndrome, nutcracker syndrome, and May-Thurner syndrome are discussed separately under each heading. Result: A total of 35 patients were included in this study with 10 patients each with superior mesenteric artery syndrome, median arcuate ligament syndrome, and nutcracker syndrome with five patients of May-Thurner syndrome. Out of 35, 24(68.5%) were female and 11(31.5%) were male. SMAS: The mean age of individuals was 32.7 ± 17.5 years with a mean aortomesenteric angle of 18.3º and aortomesenteric distance of 6.2 mm. MALS: The mean age of patients was 34.3± 15.8 years and the mean thickness of the median arcuate ligament was 5.4 mm. NCS: The mean age of patients was 37 ± 22 years and the mean compression ratio was 3.9. MTS: Mean age was 45± 14.2 years with mean diameter of LCIV 2.4 mm. Conclusion: Abdominopelvic compression syndromes are rare and often underdiagnosed because of a lack of awareness among clinicians and radiologists. Contrast-enhanced triple-phase computed tomography is performed to maximize the visibility of involved vessels in different planes and allow the identification of typical imaging features and possible complications.

Laparoscopic duodeno jejunostomy a minimaly invasive surgery in the management of Wilkie syndrome a case report cas clinique

The superior mesenteric artery syndrome (SMAS), also known as Wilkie’s syndrome, is a duodenal obstruction caused by the compression of the third part of the duodenum between the superior mesenteric artery (SMA) and the aorta. This condition often arises due to the disappearance of perivascular fatty tissue, as well as advanced stages of malnutrition and weight loss. Patients typically experience symptoms such as vomiting, fullness, and postprandial epigastric pain. While initial management involves conservative measures, surgery becomes necessary if symptoms do not improve. Here, we present the case of a 25-year-old man diagnosed with SMAS. Despite undergoing conservative management for three months, the symptoms did not regress. Subsequently, a laparoscopic duodeno-jejunostomy was performed, resulting in an uneventful postoperative period, disappearance of vomiting and epigastric pain, and a weight gain of 14 kg after one year.

Surgery for supplementary motor area gliomas—Controversies and rationale for surgical approach: A perspective

Abstract Supplementary motor area (SMA) has a role in planning and coordinating motor movements as well as in speech (dominant SMA). SMA gliomas are complex tumors to operate on and sufficient knowledge regarding connection fibers is needed to plan and prevent complications, the most important being SMA syndrome. Development of SMA syndrome causes significant morbidity and although SMA syndrome is transient and the majority of symptoms are relieved over time some symptoms persist that may lead to loss of quality of life in these patients. A thorough review of the literature was done to expand on the white matter tracts connecting SMA to other eloquent regions, SMA syndrome, best surgical practices for SMA gliomas (addressing the dilemma of awake vs. asleep craniotomy), and intraoperative monitoring techniques being used currently. An attempt has been made to address the debate regarding outcomes and controversies in the treatment of SMA region gliomas and we have also presented our experience through three case illustrations, which include two cases of SMA gliomas operated under asleep monitoring and one case operated under awake monitoring.

Acute gastric dilatation with superior mesenteric artery syndrome after binge eating.

Acute gastric dilatation with superior mesenteric artery syndrome after binge eating.

Superior mesenteric artery syndrome as a rare clinical observation

Superior mesenteric artery syndrome as a rare clinical observation

Transposition of superior mesenteric artery in arteriomesenteric obstruction of the duodenum (Wilkie syndrome)

Transposition of superior mesenteric artery in arteriomesenteric obstruction of the duodenum (Wilkie syndrome)

Gastric Pneumatosis and Its Gastrofibroscopic Findings in Life-Threatening Superior Mesenteric Artery Syndrome Complicated by Anorexia Nervosa in a Child.

A 14-year-old girl was admitted to the emergency department for excessive bile-containing vomiting and severe abdominal pain. She had been healthy until she intentionally lost 25 kg over a 6-month period. Thick, bloody bile-mixed food particles were drained from the stomach through a nasogastric tube. Abdominal computed tomography revealed huge stomach dilatation with extensive gastric pneumatosis, possible near rupture, acute pancreatitis, and a very narrow third of the duodenum, indicating superior mesenteric syndrome. Gastrofibroscopy revealed multiple hemorrhagic ulcers and numerous bead-like cystic lesions in the stomach. Laboratory examination results were notable for severe deficiencies in critical nutrients, including iron, zinc, proteins, and prealbumin, as well as undernutrition-associated endocrine complications such as hypothyroidism and hypogonadotropic hypogonadism. Excessive vomiting ceased after the endoscopic removal of stagnant gastric contents. Gastric pneumatosis improved after 3 days of supportive care.

Complaint of Persistent Nausea Resulting with Superior Mesenteric Artery Syndrome Diagnosis: A Case Report

Complaint of Persistent Nausea Resulting with Superior Mesenteric Artery Syndrome Diagnosis: A Case Report

A case of superior mesenteric artery syndrome after atrial fibrillation catheter ablation in which abdominal ultrasound was useful

症例は58歳男性．心房細動に対するカテーテルアブレーション（radiofrequency catheter ablation：RFCA）後から食欲不振，体重減少（10 kg/2か月），繰り返す嘔吐を認め当科受診．CTで著明な胃拡張と十二指腸水平脚の部分的拡張および虚脱を認めた．十二指腸水平脚は上腸間膜動脈（superior mesenteric artery：SMA）と大動脈（aorta：Ao）により圧迫され，SMA症候群と診断した．体位変換を活用した超音波検査でSMA-Ao間の距離は，大きく変化し，十二指腸の圧迫は左側臥位で最も軽減された．入院の上，モサプリドクエン酸塩投与，分割食，食後左側臥位の指導により嘔吐は消失し，食事も全量摂取可能となり退院した．近年，SMA症候群の一因に，心房細動に対するRFCAが指摘されている．RFCAによる焼灼エネルギーが心臓外に放射され，胃周囲迷走神経叢の損傷により胃の蠕動機能障害が起こり，食思不振から体重減少ひいてはSMA症候群を生ずるとされる．本例では体位変換による超音波検査でSMA周囲腸管を観察したところ，左側臥位でSMAが大きく偏位するに伴い，十二指腸狭窄部が開放される状態をリアルタイムに観察できた．体位変換を活用した超音波検査は，SMA症候群の診断および最適な発症予防体位の同定に有用である．

The Wilkie's Syndrome which Disguised As Anorexia Nervosa: A Case Report

Abstract Wilkie's Syndrome (WS), Superior Mesenteric Artery Syndrome or aortomesenteric clamp is an infrequent cause of high intestinal obstruction that is produced by an angular constriction (< 25º) between the superior mesenteric artery and abdominal aorta, resulting in a compression of the third duodenal portion. Its incidence is estimated around 0.013-0.3% in general population, as it is more common in women between 10-39-years. This pathology produces unspecific gastrointestinal symptoms, turning diagnostic suspicion really important, due to its critical complications. The case of a 15-year old woman is presented, who is admitted in an acute child psychiatric hospitalisation unit because she displays eating disorder symptomatology in the previous months. Initially she is suspected for suffering Anorexia Nervosa (AN) but according to the rapid general deterioration that she suffers the case is profoundly studied and eventually diagnosed as a Wilkie's Syndrome case, based on an exhaustive complementary test battery. This case shows the importance of the diagnostic suspicion of this entity and the relevance of making a proper differential diagnosis in Eating Disorders (ED).

WASTING AWAY – SUPERIOR MESENTERIC ARTERY SYNDROME IN A YOUNG GIRL – A CASE REPORT

The case of an 18-year-old girl with Superior Mesenteric Artery syndrome is presented here. She presented to us with complaints of anorexia, nausea, vomiting, and weight loss for the past year. She was cachectic and volume-depleted. All investigations and preliminary imaging were inconclusive. Upper GI endoscopy revealed normal structure up to the second part of the duodenum. Contrast-enhanced Computerized Tomography of the abdomen and pelvis did not reveal any intra- or extra-luminal pathology. The patient was unwilling to undergo surgical correction and opted for conservative treatment. This case highlights the importance of considering SMA syndrome in the differential diagnosis of patients presenting with anorexia and weight loss and emphasizes the changing epidemiology of SMA syndrome.

Superior Mesenteric Artery and Nutcracker Syndromes in a Healthy 14-Year-Old Girl Requiring Surgical Intervention after Failed Conservative Management

This case report presents the diagnosis of superior mesenteric artery and nutcracker syndromes in a previously fit and well 14-yearold girl. Although these two entities usually occur in isolation, despite their related aetiology, our patient was a rare example of their occurrence together. In this case the duodenal compression of superior mesenteric artery syndrome caused intractable vomiting leading to weight loss, and her nutcracker syndrome caused severe left-sided abdominal pain and microscopic haematuria without renal compromise. Management of the superior mesenteric artery syndrome can be conservative by increasing the weight of the child which leads to improvement of retroperitoneal fat and hence the angle of the artery. The weight can be improved either by enteral feeds or parenteral nutrition. This conservative management initially helped but not in the long-term as the child started losing weight again. The next step in management is surgery (duodenojejunostomy – if the conservative management fails), which the child went through, remarkably improving their symptoms.

Thyrotoxicosis Masquerading as Superior Mesenteric Artery Syndrome in An Adolescent

Thyrotoxicosis Masquerading as Superior Mesenteric Artery Syndrome in An Adolescent