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Pappalardo G, Pola E, Bertini FA, Nasto LA, Eschweiler J, Schäfer L, Migliorini F. Superior mesenteric artery syndrome following spine surgery in idiopathic adolescent scoliosis: a systematic review. Eur J Med Res 2024; 29:410. [PMID: 39118170 PMCID: PMC11308422 DOI: 10.1186/s40001-024-02002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
Superior mesenteric artery syndrome (SMAS) is a rare and unpredictable complication after correction spine surgery for adolescent idiopathic scoliosis (AIS). The management of this condition is poorly investigated, with controversial outcomes. This investigation systematically reviewed current evidence on pathogenesis, risk factors, management, and outcomes of SMAS following correction spine surgery for AIS. The present systematic review was conducted according to the 2020 PRISMA statement. All the included investigations reported SMAS presentation following scoliosis correction surgery in AIS. 29 articles with 61 eligible patients were included in this review. The mean age of the patients was 15.8 ± 7.2 years. The mean weight was 45.3 ± 8.0 kg, the mean height 159.6 ± 13.6 cm, and the mean BMI 16.5 ± 2.9 kg/m2. The mean duration of the treatment for SMAS was 21.6 ± 10.3 days. The mean interval between spine surgery and symptoms of SAMS was 69 days, with high between-studies variability (3 days to 4 years). Prompt identification of risk factors and an early diagnosis are necessary to manage SMAS and reduce the risk of complications. Additional investigations are required to establish risk factors and diagnostic criteria.Level of evidence Level IV, systematic review.
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Affiliation(s)
| | - Enrico Pola
- Orthopaedics and Traumatology Division, Multidisciplinary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli" School of Medicine, 80138, Naples, Italy
| | - Fracesca Alzira Bertini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
| | - Luigi Aurelio Nasto
- Orthopaedics and Traumatology Division, Multidisciplinary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli" School of Medicine, 80138, Naples, Italy
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, BG Hospital Bergmannstrost Halle, Halle, Germany
- Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Luise Schäfer
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Life Sciences, Health, and Health Professions, Link Campus University, Rome, Italy.
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Navandhar PS, Shinde RK, Gharde P, Nagtode T, Badwaik N. Understanding Superior Mesenteric Artery Syndrome: Etiology, Symptoms, Diagnosis, and Management. Cureus 2024; 16:e61532. [PMID: 38957238 PMCID: PMC11218894 DOI: 10.7759/cureus.61532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, poses a diagnostic challenge due to its rarity and varied clinical manifestations. This review explores the syndrome's etiology, symptoms, diagnostic challenges, and management strategies. Symptoms range from early satiety to severe abdominal pain, often leading to malnutrition. Diagnosis involves a thorough gastrointestinal evaluation and various imaging modalities. Management includes medical interventions like nasogastric decompression and nutritional support, along with surgical interventions such as duodenojejunostomy. A thorough understanding of SMA syndrome's complexities is crucial for its timely diagnosis and effective management, especially considering its potential overlap with other gastrointestinal disorders or eating disorders. Further research is needed to enhance understanding and improve patient outcomes.
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Affiliation(s)
- Pratik S Navandhar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raju K Shinde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tushar Nagtode
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nitesh Badwaik
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Rathod T, Ved YP, Jain D, Patel A. Delayed presentation of Wilkie's syndrome after scoliotic curve correction surgery: a case report. BMC Musculoskelet Disord 2024; 25:329. [PMID: 38658916 PMCID: PMC11044465 DOI: 10.1186/s12891-024-07462-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare but serious complication following scoliosis correction surgery. It occurs as a result of mechanical compression of third part of duodenum between the SMA and aorta. This condition occurs most commonly in significantly underweight patients with deformities, and usually during the first week following spinal deformity corrective surgeries. The angle between the abdominal aorta and the SMA gets reduced following spinal lengthening during deformity correction surgery causing compression of third part of duodenum resulting in development of SMA syndrome. CASE PRESENTATION We present a case of 17-year-old male with congenital scoliosis with a 70-degree scoliotic curve who underwent spinal deformity correction surgery with posterior instrumented fusion. Post-operative course was uneventful and the patient was discharged after suture removal on post-operative day 15. The patient presented after 21-days of symptom onset on post-operative-day 51, with a 3 week history of post-prandial vomiting, abdominal pain and distension which resulted in rapid weight loss of 11 kg. A CT-angiogram showed obstruction at third part of duodenum. After reviewing clinical and radiological profile of the patient, a diagnosis of SMA syndrome was made. Conservative management was tried, but due to rapid deterioration of patient condition and symptoms of complete intestinal obstruction, the patient was treated surgically by gastro-jejunostomy and side-to-side jejuno-jejunostomy, which improved his condition. CONCLUSION SMA syndrome can occur much later than previously reported cases and with potentially life-threatening symptoms following scoliosis correction. Having a high index of suspicion, early recognition of condition and institution of appropriate treatment are essential to prevent occurrence of severe complications including risk of intestinal perforation and mortality. This case highlights management of delayed onset of SMA syndrome, with presentation further delayed after symptom onset, as is common in developing parts of the world, due to limited availability and accessibility of resources, and low socio-economic status of large segments of the population.
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Affiliation(s)
- Tushar Rathod
- Department of Orthopaedics, Seth G. S. Medical College and K. E. M. Hospital, Mumbai, Maharashtra, India
| | - Yash Prakash Ved
- Department of Orthopaedics, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.
| | - Deepika Jain
- Department of Orthopaedics, Senior Resident Seth G. S. Medical College and K. E. M. Hospital, Mumbai, Maharashtra, India
| | - Altamash Patel
- Department of Orthopaedics, Senior Resident Seth G. S. Medical College and K. E. M. Hospital, Mumbai, Maharashtra, India
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Bajour D, Haddad S, Marina S, Zoukar S, Haddad S, Martini N, Khouri L. Co-occurrence of ectopic pancreas and superior mesenteric artery syndrome in a child: A case report and literature review. SAGE Open Med Case Rep 2023; 12:2050313X231220830. [PMID: 38162423 PMCID: PMC10757443 DOI: 10.1177/2050313x231220830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
Ectopic pancreas refers to pancreatic tissue that lacks vascular or anatomical connection with the main body of the pancreas. Superior mesenteric artery syndrome involves the compression of the third part of the duodenum between the aorta and the superior mesenteric artery. We present a case of a 12-year-old female with a 4-year history of recurrent episodes of severe epigastric pain, improved by sitting and leaning forward, and occurred monthly for nearly 48 h. Radiological findings confirmed the diagnosis of superior mesenteric artery syndrome. However, further investigation revealed the presence of ectopic pancreas. Surgical intervention successfully treated both conditions. The patient presented with severe abdominal pain, and although there was a diagnosis of superior mesenteric artery syndrome, the pain was not entirely attributable to this condition, as there was no correlation with food intake, and the degree of obstruction was mild. Further investigations revealed the presence of ectopic pancreas, which provided an explanation for the severity of the pain. This case highlights the need for further research on the potential association between superior mesenteric artery syndrome and ectopic pancreas.
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Affiliation(s)
- Dina Bajour
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Salim Haddad
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Sliman Marina
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Sham Zoukar
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Sultaneh Haddad
- Aleppo University, Faculty of Medicine, Aleppo, Syrian Arab Republic
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Nafiza Martini
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Lina Khouri
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
- Departement of Pediatrics at Children’s Hospital, Damascus, Syrian Arab Republic
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Tang J, Zhang M, Zhou Y, Cao G, Li S, Zhang X, Tang S. Laparoscopic lateral duodenojejunostomy for pediatric superior mesenteric artery compression syndrome: a cohort retrospective study. BMC Surg 2023; 23:365. [PMID: 38049799 PMCID: PMC10694871 DOI: 10.1186/s12893-023-02274-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
PURPOSE There are only a few case reports of laparoscopic lateral duodenojejunostomy (LLDJ) in children with Wilkie's syndrome, also known as superior mesenteric artery compression syndrome (SMAS). We aimed to describe our laparoscopic technique and evaluate its outcomes for SMAS in children. METHODS From January 2013 to May 2021, SMAS children who received LLDJ were included. The procedure was carried out utilizing the four-trocar technique. The elevation of the transverse colon allows good exposure of the dilated and bulging second and third sections of the duodenum. Using a linear stapler, we established a lateral anastomosis connecting the proximal jejunum with the third part of the duodenum. Following that, a running suture was used to intracorporeally close the common enterotomy. Clinical data on patients was collected for analysis. The demographics, diagnostic findings, and postoperative outcomes were analyzed retrospectively. RESULTS We retrospectively analyzed 9 SMAS patients (6 females and 3 males) who underwent LLDJ, aged between 7 and 17 years old. The mean operative time was 118.4 ± 16.5 min and the mean estimated blood loss was 5.6 ± 1.4 ml. There were no conversion, intraoperative complications or immediate postoperative complications. The mean postoperative hospital stay was 6.8 ± 1.9 days and the mean follow-up time was 5.4 ± 3.0 years. During follow-up, seven patients (77.8%) experienced complete recovery of symptoms prior to surgery. One patient (11.1%) still had mild vomiting, which resolved with medication. Another patient (11.1%) developed psychological-induced nausea, which significantly improved after treatment with education, training and diet management. CONCLUSIONS LLDJ represents a feasible and safe treatment option for SMAS in well-selected children. Further evaluation with more cases and case-control studies is required for the real benefits.
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Affiliation(s)
- Jingfeng Tang
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengxin Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Zhou
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaotao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Vellingiri B, Aishwarya SY, Benita Jancy S, Sriram Abhishek G, Winster Suresh Babu H, Vijayakumar P, Narayanasamy A, Mariappan S, Sangeetha R, Valsala Gopalakrishnan A, Parthasarathi R, Iyer M. An anxious relationship between Autism Spectrum Disorder and Gut Microbiota: A tangled chemistry? J Clin Neurosci 2022; 99:169-189. [PMID: 35286970 DOI: 10.1016/j.jocn.2022.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 12/27/2022]
Abstract
Autism spectrum disorder (ASD) is a serious multifactorial neurodevelopmental disorder often accompanied by strained social communication, repetitive behaviour, immune dysregulation, and gastrointestinal (GI) issues. Recent studies have recorded a link between dysbiosis in the gut microbiota (gm) and the primary stages of ASD. A bidirectional connection (also called microbiota-gut-brain-axis) exchanges information between the gut bacteria and central nervous system. When the homeostasis of the microenvironment of the gut is dysregulated, it causes oxidative stress, affecting neuronal cells and neurotransmitters, thereby causing neurodevelopmental disorders. Studies have confirmed a difference in the constitution of gut bacteria among ASD cases and their controls. Numerous studies on animal models of ASD have shown altered gm and its association with abnormal metabolite profile and altered behaviour phenotype. This process happens due to an abnormal metabolite production in gm, leading to changes in the immune system, especially in ASD. Hence, this review aims to question the current knowledge on gm dysbiosis and its related GI discomforts and ASD behavioural symptoms and shed light on the possible therapeutic approaches available to deal with this situation. Thereby, though it is understood that more research might be needed to prove an association or causal relationship between gm and ASD, therapy with the microbiome may also be considered as an effective strategy to combat this issue.
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Affiliation(s)
- Balachandar Vellingiri
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India.
| | - S Y Aishwarya
- Department of Biotechnology, Sri Shakthi Institute of Engineering and Technology, Coimbatore 641062, Tamil Nadu, India
| | - S Benita Jancy
- Department of Biotechnology, Sri Shakthi Institute of Engineering and Technology, Coimbatore 641062, Tamil Nadu, India
| | - G Sriram Abhishek
- Department of Biotechnology, Sri Shakthi Institute of Engineering and Technology, Coimbatore 641062, Tamil Nadu, India
| | - Harysh Winster Suresh Babu
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India; Disease Proteomics Laboratory, Department of Zoology, Bharathiar University, Coimbatore 641046, Tamil Nadu, India
| | - Padmavathi Vijayakumar
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India
| | - Arul Narayanasamy
- Disease Proteomics Laboratory, Department of Zoology, Bharathiar University, Coimbatore 641046, Tamil Nadu, India
| | - Sujitha Mariappan
- Department of Biotechnology, Sri Shakthi Institute of Engineering and Technology, Coimbatore 641062, Tamil Nadu, India
| | - R Sangeetha
- Department of Zoology and Wild Life Biology, Government Arts College, Udhagamandalam 643002, India
| | - Abilash Valsala Gopalakrishnan
- Department of Biomedical Sciences, School of Biosciences and Technology, Vellore Institute of Technology, Vellore 632014 Tamil Nadu, India
| | - Ramakrishnan Parthasarathi
- Computational Toxicology Facility, Centre for Innovation and Translational Research, Environmental Monitoring and Intervention Hub (DSIR-CRTDH), CSIR-Indian Institute of Toxicology Research, Lucknow 226001 Uttar Pradesh, India
| | - Mahalaxmi Iyer
- Livestock Farming and Bioresource Technology, Tamil Nadu, India.
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Kim J, Yang S, Im YC, Park I. Superior mesenteric artery syndrome treated successfully by endoscopy-assisted jejunal feeding tube placement. BMJ Case Rep 2021; 14:14/11/e245104. [PMID: 34785514 PMCID: PMC8596032 DOI: 10.1136/bcr-2021-245104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We report the case of a 31-year-old man with superior mesenteric artery syndrome after reoperation due to postoperative complications from rectal cancer. Although initial total parenteral nutrition (TPN) therapy failed, he underwent endoscopy-assisted feeding tube placement without complications instead of surgery. After 2 weeks of dual feeding (enteral feeding and TPN), he improved, gaining 6 kg; and an oral diet was advanced.
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Affiliation(s)
- Jongkuk Kim
- Department of General Surgery, University of Ulsan College of Medicine and Ulsan University Hospital, Ulsan, Republic of Korea
| | - Songsoo Yang
- Department of General Surgery, University of Ulsan College of Medicine and Ulsan University Hospital, Ulsan, Republic of Korea
| | - Yeong Cheol Im
- Department of General Surgery, University of Ulsan College of Medicine and Ulsan University Hospital, Ulsan, Republic of Korea
| | - Inkyu Park
- Department of General Surgery, University of Ulsan College of Medicine and Ulsan University Hospital, Ulsan, Republic of Korea
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Fan Y, Cai M, Wang J, Xia L. Superior Mesenteric Artery Syndrome Following Scoliosis Surgery: A Systematic Review of Case Reports. Ann Vasc Surg 2021; 76:514-535. [PMID: 33905850 DOI: 10.1016/j.avsg.2021.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/19/2020] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Superior mesenteric artery (SMA) syndrome is a well-recognized, rare complication of undergoing surgical correction of a spinal deformity. The objective of this study was to summarize the best available evidence on SMA syndrome treatment after scoliosis surgery. To identify differences, special attention was paid to scoliosis pathology, intervention and SMA syndrome presentation. METHODS A systematic review of the literature was performed on SMA syndrome following scoliosis surgery. The Web of Science, PubMed, Wanfang (Chinese) and EMBASE databases were systematically searched for articles from January 1971 to October 2020. The main subjects discussed are scoliosis pathology, intervention and SMA syndrome presentation. RESULTS A total of 32 articles with 52 cases were included in our report. The mean age of patients with SMA syndrome following scoliosis surgery was 14.7 ± 2.9 years and the majority (n = 42, 80.8%) were girls. The most frequently reported scoliosis type was adolescent idiopathic scoliosis (n = 34, 65.4%). The mean postoperative days (POD) (interval between the surgical treatment and the onset of symptoms) was 9.6 ± 9.5 days. Different treatment methods were analyzed in 46 patients. We noted a trend toward a higher percentage of patients with POD < 48 hr in the group with surgical treatment than in the conservative treatment group (P = 0.002). CONCLUSION In summary, in this systematic review, for the first time, we found that the time of onset of postoperative symptoms can be used as an important reference index for surgical intervention. We also believe that recommendations about the treatment of SMA syndrome following scoliosis surgery should include this finding. Given the lack of robust clinical evidence, these findings warrant verification in a prospective multicenter screening trial.
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Affiliation(s)
- Yonggang Fan
- Institute of Spinal Deformity, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
| | - Mandi Cai
- Institute of Spinal Deformity, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
| | - Jie Wang
- Institute of Spinal Deformity, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
| | - Lei Xia
- Institute of Spinal Deformity, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China.
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Superior Mesenteric Artery Syndrome: A Potentially Fatal but Reversible Gastrointestinal Manifestation of Systemic Sclerosis. Case Rep Rheumatol 2020; 2020:8831417. [PMID: 32695548 PMCID: PMC7355361 DOI: 10.1155/2020/8831417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/24/2022] Open
Abstract
Superior mesenteric artery syndrome (SMAS) is a rare gastrointestinal disorder characterised by vascular compression of the third part of the duodenum, in the angle between the superior mesenteric artery (SMA) and the abdominal aorta. It presents as an uncommon cause of upper gastrointestinal obstruction. In patients with systemic sclerosis (SSc), gastrointestinal involvement may result in oesophageal dysmotility, gastroesophageal reflux disease (GERD), gastroparesis, small intestinal bacterial overgrowth (SIBO), chronic intestinal pseudoobstruction (CIPO), and fecal incontinence. Malnutrition may thus result in weight loss and reduced mesenteric and retroperitoneal adipose tissue, decreasing the angle between the SMA and aorta causing SMAS. Enteral or parenteral feeding can potentially reverse SMAS in SSc. We report a case of SMAS in an elderly female with SSc and concurrent gastrointestinal involvement, and discuss the important management considerations and potential adverse outcomes when untreated.
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Dekonenko C, Hill JA, Sobrino JA, Snyder CL, St Peter SD, Oyetunji TA. Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome. J Surg Res 2020; 254:91-95. [PMID: 32422431 DOI: 10.1016/j.jss.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/26/2020] [Accepted: 04/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. MATERIALS AND METHODS We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. RESULTS Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. CONCLUSIONS Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Joshua A Hill
- School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Justin A Sobrino
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri; Department of Surgery, Quality Improvement and Surgical Equity Research (QISER) Center, Children's Mercy Kansas City, Kansas City, Missouri.
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SMA syndrome: management perspective with laparoscopic duodenojejunostomy and long-term results. Surg Endosc 2020; 35:2029-2038. [PMID: 32342220 DOI: 10.1007/s00464-020-07598-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Superior mesentery artery syndrome (SMAS) is a rare vasculo-anatomic occlusive pathologic entity for which a period of conservative medical management is advocated with surgery reserved for nonresponsive cases. We present our management plan that entails a single admission approach and complete rendering of medical and surgical treatment to the patient on a background of the socioeconomic and cultural trends prevalent in this geographic region. METHODS A retrospective analysis of 22 cases of SMAS admitted in our health care system who underwent a period of preoperative conditioning followed by laparoscopic duodenojejunostomy from September 2009 to June 2019 was performed. Patients were followed up at regular intervals. RESULTS The mean follow-up of the cohort was 41.2 months (2-108 months). The median length of stay was 6 days. The mean postoperative stay was 4.13 days. A subgroup of six patients who had severe physiological depletion required a period of preoperative optimisation. Five of the 22 (22.7%) patients suffered from postoperative complications in the form of delayed return of bowel functions. None of the patients had complications more than Clavien-Dindo grade 2 with no mortality. Long-term data are available for 19 patients (86.3%) which showed no symptom recurrence. CONCLUSION Management of SMAS that entails an antecedent medical therapy followed by surgery can be accomplished in a single admission with good to excellent results in the intermediate and long-term follow-up. Physiologically depleted patients do require a period of intensive preconditioning but on long-term follow-up, they have excellent results.
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Bing L, Shun-Lin X, Ji-Hua O, Wei-Bing C, Ye-Bo W. Laparascopic Ladd's procedure as treatment alternative, when parenteral or prolonged hospital nutrition is not an option for superior mesenteric artery syndrome. J Pediatr Surg 2020; 55:554-557. [PMID: 30376960 DOI: 10.1016/j.jpedsurg.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Superior mesenteric artery syndrome (SMAS) is an uncommon cause of duodenal obstruction in pediatric patients. It is extremely rare in young infants. The classic treatment for SMAS has been an open or laparoscopic duodenojejunostomy when conservative medical therapy failed to resolve the obstruction. We herein reported 3 cases of SMAS in infants treated by laparoscopic Ladd's procedure. The advantages and feasibility of laparoscopic Ladd's procedure applied for SMAS in infants were discussed. METHODS Three cases of infants with SMAS subjected to laparoscopic Ladd's procedure in our hospital were collected from January 2014 to December 2015. The patients' age, operative time, postoperative hospital observation, resumption of full diet, and postoperative complications were analyzed. RESULTS The median age at operation was 8 months (range, 6-9 months). The mean body weight was 7.9 kg (range, 6.5-8.8 kg). The mean operative time was 66.7 min (range, 65-75 min). The mean postoperative hospital stay was 4.3 days (range, 4-5 days) and the follow-up was 20.7 months (range, 12-34 months) without any specific postoperative complications. CONCLUSION Based on our reports, laparoscopic Ladd's procedure is a reliable and practicable minimally invasive surgery for in infants with SMAS.
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Affiliation(s)
- Li Bing
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China.
| | - Xia Shun-Lin
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Ou Ji-Hua
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Chen Wei-Bing
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Wang Ye-Bo
- Department of General Surgery, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu 223300, PR China
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Molina Proaño GA, Cobo Andrade MM, Guadalupe Rodríguez RA, Gálvez Salazar PF, Cadena Aguirre DP, González Poma GV, Gutierrez Granja BM. Wilkie's syndrome, a missed opportunity. J Surg Case Rep 2018; 2018:rjy246. [PMID: 30254733 PMCID: PMC6149230 DOI: 10.1093/jscr/rjy246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/19/2018] [Accepted: 09/03/2018] [Indexed: 12/31/2022] Open
Abstract
Wilkie’s syndrome is a rare cause of duodenal obstruction that can easily be missed at clinical practice. It is characterized by nausea, abdominal pain and vomit. It usually affects young adults, and it’s caused by a low aortomesenteric angle resulting in vascular compression of the duodenum. Symptoms could resemble many of the symptoms presented in a patient with a suspected eating disorder. The non-specificity of the clinical signs and symptoms can confuse, delay the diagnosis and expose the patient to potentially hazardous therapies. We report a case of a 20-year-old patient who presented to the emergency room with a history of intermittent vomiting and abdominal pain. He had been previously misdiagnosed with an eating disorder and received physiological therapy. Nonetheless, his pain persisted. After further evaluation with the use of imaging techniques, a low aortomesenteric angle was discovered. He underwent surgery and completely recovered. On follow up controls patient is well and he no longer had episodes of vomiting.
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Khodear Y, Al-Ramli W, Bodnar Z. Laparoscopic management of a complicated case of Wilkie's syndrome: A case report. Int J Surg Case Rep 2017; 37:177-179. [PMID: 28688313 PMCID: PMC5501890 DOI: 10.1016/j.ijscr.2017.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/18/2017] [Accepted: 06/18/2017] [Indexed: 11/16/2022] Open
Abstract
Surgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management. Successful management of a complicated case of Wilkie’s Syndrome via duodenojeujenostomy is feasible using a laparoscopic approach. Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.
Introduction Superior mesenteric artery (SMA) syndrome also known as Wilkie’s syndrome is a rare condition caused by the entrapment of the third part of the duodenum between the aorta and the SMA. The incidence of Wilkie’s syndrome range between 0.013% and 0.3%. The normal angle between the aorta and SMA has been described to range between 38° and 65°, whereas in Wilkie’s syndrome this angle is reduced to less than 20° causing gastric outlet obstruction. Case presentation We report a case of a previously diagnosed 43 year-old male with SMA syndrome, whom had been conservatively managed for 5-years for recurrent admissions with symptoms of gastric outlet obstruction. During his last admission, CT abdomen demonstrated gastric pneumatosis and portal venous gas requiring urgent surgical intervention. Duodenojejunostomy was successfully performed using laparoscopic technique. Discussion SMA syndrome is thought to occur secondary to the rapid and excessive weight loss leading to the reduction of the mesenteric fat around the aorta and SMA, thereby reducing the normal angle between the two arteries. Conservative medical management is usually the first line of treatment in uncomplicated cases. Surgical management is usually reserved only after failed conservative management or complicated cases, at which time either an open or laparoscopic surgical approach is undertaking. Conclusion Surgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management. Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.
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Affiliation(s)
- Yehya Khodear
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Co. Donegal, Ireland.
| | - Wisam Al-Ramli
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Co. Donegal, Ireland.
| | - Zsolt Bodnar
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Co. Donegal, Ireland
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