Persisting superior mesenteric artery syndrome following ileo-anal J pouch construction

Superior Mesenteric Artery Syndrome: Late Complication of Ileal Pouch-Anal Anastomosis

Superior mesenteric artery syndrome (SMAS) is an uncommon condition which is difficult to diagnose due to non-specificity of symptoms. The most common causes of SMAS are severe weight loss secondary to severe medical conditions, surgical history, and cancer. A 31-year-old male with a history of ulcerative colitis status-post proctocolectomy with ileal pouch-anal anastomosis 10 years prior, presented with progressively worsening weight loss and abdominal pain. Radiographic imaging was consistent with SMAS, which was subsequently confirmed intraoperatively during an emergency surgery in which a Roux-En-Y gastrojejunostomy was performed. Clinicians should be aware that SMAS is a rare but possible complication of ileal pouch-anal anastomosis. Although rare, there should be a low threshold for this diagnosis when obstructive symptoms present.

Duodenal Derotation as an Effective Treatment of Superior Mesenteric Artery Syndrome: A Thirty-Three Year Experience

We evaluated the use of duodenal derotation as a surgical option for superior mesenteric artery syndrome (SMAS) in two groups of young patients. Sixteen patients with SMAS diagnosed by barium upper gastrointestinal series (UGI) from 1974 to 2001, and six patients diagnosed by computerized tomography with three-dimensional reconstructions (3D CT) from 2001 to 2007 were referred to our surgical service, 19 of whom underwent duodenal derotation as the primary surgical treatment after a failed trial of conservative treatment. The main measured outcomes were the resolution of typical symptoms of SMAS and the development of long-term surgical complications. Of the first 16 patients, three (19%) responded to nasojejunal feedings. Of 13 patients undergoing derotation, only one (7.7%) failed derotation and required a gastrojejunostomy bypass, whereas 12 (92%) became asymptomatic after the derotation procedure. After a mean follow-up of 5.13 years (range 0.1–15), two patients (15%) presented with small bowel obstructions and were treated with a simple lysis of the adhesion. All six patients from 2001 to 2007 responded well to surgical derotation. Overall, duodenal derotations successfully relieved symptoms in 18 out of 19 (95%) patients with SMAS, with two (11%) major long-term surgical complications. No volvulus was observed in our patients at the mean follow-up of 4.37 years.

Syndrome of duodenal compression by the superior mesenteric artery following restorative proctocolectomy: a case report and review of literature

CONTEXT

Restorative proctocolectomy with anastomosis of an ileal pouch to the anal canal is a new and rare cause for triggering the syndrome of duodenal compression by the superior mesenteric artery. Restorative proctocolectomy requires assessment of the position of the duodenum in relation to aortomesenteric constriction to avoid the occurrence of duodenal compression by the superior mesenteric artery.

CASE REPORT

The authors report on a case of this syndrome in a patient with familial adenomatous polyposis and review the literature on the etiopathogenesis, diagnosis, treatment and prevention of this unusual entity.

[A rare complication of ileal pouch anal anastomosis: superior mesenteric artery syndrome]

The aim of this study was to report a new case of superior mesenteric artery syndrome following total proctocolectomy and ileal pouch-anal anastomosis for chronic ulcerative colitis. Diagnosis was made following a prolonged gastric stasis and was based on upper gastrointestinal X-ray series. Medical treatment was unefficient and gastro-jejunostomy was performed. The early outcome was good.

Lengthening of the mesentery using the marginal vascular arcade of the right colon as the blood supply to the ileal pouch

PURPOSE

Creation of a safe ileal pouch requires a tension-free anastomosis. The aim of this study was to evaluate a technical procedure that increases the length of the mesentery while preserving the blood supply to the ileal pouch.

HYPOTHESIS

Preservation of the marginal vascular arcade (MVA) of the right colon will allow ligation of more mesenteric vessels and increase the mesenteric length.

METHODS

Six fresh cadavers were dissected. Measurement of the apex of the terminal ileum was done in relation to the pubic symphysis. Measurements were taken after 1) complete mobilization of the terminal ileum, right colon, and hepatic flexure; 2) vascular ligation between colon wall and the MVA, preserving the latter from the right branch of the middle colic artery to the ileal branch of the ileocolic artery (ICA); 3) ligation of the distal third of the superior mesenteric artery; 4) ligation of the ICA at its origin; 5) ligation of the right colon artery; and 6) division of the terminal ileal mesentery.

RESULTS

This technique enabled complete division of the terminal ileal mesentery, adding a mean additional 3.6 (range, 2.5 - 5.0) cm (36.5 +/- 16.5 percent) in length to the mesentery, compared with superior mesenteric artery, ICA, and right colic artery ligation.

CONCLUSION

Patients who have a shorter mesentery and concern of excessive mesenteric tension should have colectomy performed, preserving the MVA from the middle colic artery to the ileal branch of the ICA. The preserved MVA can be a reliable alternative blood supply to the pouch if more mesenteric vessel ligations are necessary.

Superior mesenteric artery syndrome as a complication of ileal pouch-anal anastomosis. Report of a case

PURPOSE

Duodenal compression by the superior mesenteric artery following total proctocolectomy and ileal pouch-anal anastomosis is a rare occurrence. Previous surgical treatment involved duodenal division. The aim of this report was to describe a case with such a complication and to discuss an operative alternative.

METHODS

Case report.

RESULTS

Mobilization of the duodenum from its retroperitoneal attachments, without transection and reanastomosis, allowed the free passage of gas through the duodenum and recovery for the patient.

CONCLUSION

This case report suggests that a more conservative approach may be successful in managing this complication.

Ileo-anal pouch procedure: experience in the Chinese population

The ileo-anal pouch procedure is now a well-established method for dealing with ulcerative colitis and familial polyposis in many centres in the West. Experience in the Chinese population is not well documented, mainly due to the rarity of inflammatory bowel disease. This report documents the experience of a university teaching hospital in Hong Kong. Despite being a small series, the low complication rates and good functional results show that the pelvic pouch procedure has now evolved to a stage where it can be performed safely even in centres with infrequent experience.

Results of 50 ileoanal J pouch operations

Fifty ileo-anal J pouches were constructed in 26 males and 24 females for ulcerative colitis (n = 45) and familial adenomatous polyposis (n = 5). Two-thirds had proctocolectomy and pouch formation as a one-stage procedure. Thirty patients had a handsewn pouch and anastomosis and 20 were stapled. Forty-five patients had their defunctioning ileostomy closed for at least 2 months, of whom three have not been recently reviewed. One pouch was defunctioned for ischaemic stricture. The median time between pouch construction and ileostomy closure was 15 weeks and the time between closure and assessment ranged from 2 to 50 months (median 18 months). Median stool frequency was six per 24h in both the handsewn and stapled groups. Faecal incontinence occurred in 20% of patients with a handsewn anastomosis but in no patient with a stapled anastomosis (P less than 0.02). Soiling was also more common in the former group. Some 76% of patients noted an improvement in pouch function with time. In all, 67% of males and 78% of females reported unchanged or increased sexual activity since pouch surgery. Pouchitis has occurred in 20% of patients; 10% have had complications related to the pouch or anastomosis; 10% related to the ileostomy; and 6% have had small bowel obstruction. There have been no deaths. Overall, 88% of patients have had a good result, but none of the five patients with a poor result will revert to an ileostomy.