Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome:Two case reports and review of literature

BACKGROUND Superior mesenteric artery(SMA)syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta(SMA-Ao).Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome,individual variations in the optimal patient position have been noted.In this report,we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient.CASE SUMMARY Case 1:A 90-year-old man with nausea and vomiting.Following diagnosis of SMA syndrome by computed tomography(CT),ultrasonography(US)revealed the SMA-Ao distance in the supine position(4 mm),which slightly improved in the lateral position(5.7–7.0 mm)without the passage of duodenal contents.However,in the sitting position,the SMA-Ao distance was increased to 15 mm accompanied by improved content passage.Additionally,US indicated enhanced passage upon abdominal massage on the right side.By day 2,the patient could eat comfortably with the optimal position and massage.Case 2:An 87-year-old woman with vomiting.After the diagnosis of SMA syndrome and aspiration pneumonia by CT,dynamic US confirmed the optimal position(SMA-Ao distance was improved to 7 mm in forward-bent position,whereas it remained at 5 mm in the supine position).By day 7 when her pneumonia recovered,she could eat with the optimal position.CONCLUSION The optimal position for SMA syndrome varies among individuals.Dynamic US appears to be a valuable tool in improving patient outcomes.

Comprehensive interventions for adult cyclic vomiting syndrome complicated by superior mesenteric artery syndrome:A case report

BACKGROUND Cyclic vomiting syndrome(CVS)is a chronic functional gastrointestinal disorder involving the gut–brain interaction that is characterized by recurring episodes of nausea,vomiting,abdominal pain,and interspersed complete normal periods.Superior mesenteric artery(SMA)syndrome(SMAS)is a vascular condition in which the horizontal portion of the duodenum is compressed due to a reduced angle between the aorta and the SMA.This condition presents with symptoms similar to CVS,posing challenges in distinguishing between the two and often resulting in misdiagnosis or inappropriate treatment.CASE SUMMARY A 20-year-old female patient presented with recurrent episodes of vomiting and experienced a persistent fear of vomiting for the past 2 years.She adopted conscious dietary restrictions,which led to severe malnutrition.Initially,she was diagnosed with SMAS,as revealed by computed tomography angiography.Despite efforts to increase the angle between the aorta and the SMA through weight gain,her vomiting did not improve.Finally,she was diagnosed with comorbidities including CVS,SMAS and anxiety disorder.She underwent comprehensive interventions,including enteral and parenteral nutritional supplementation,administration of antiemetic and anti-anxiety agents,and participation in mindfulness-based cognitive therapy.The patient eventually experienced a notable improvement in both body weight and clinical symptoms.CONCLUSION We present a rare case of CVS in an adult complicated with SMAS and propose additional treatment with nutritional support,pharmacological intervention,and psychotherapy.

Superior Mesenteric Artery Syndrome, a Rare Complication of Severe Malnutrition: Two Cases from a Subsaharian Endocrinology Department

Introduction: Superior mesenteric artery syndrome (SMAS), a rare diagnosis due to compression of the third duodenum between the superior mesenteric artery (SMA) and the aorta resulting in bowel obstruction, may lead to severe malnutrition. We report two cases of patients hospitalised in the Internal Medicine, Endocrinology, Diabetology, and Nutrition Department of the National Hospital Center (NHC) of Pikine. Observations: Patient 1: A 35-year-old female was referred for an aetiological diagnosis due to a rapid weight loss of 15 kilograms in one month, accompanied by persistent vomiting, following an appendectomy performed a month before admission. Upon clinical examination, she presented severe malnutrition (Buzby index of 76%), early post-prandial chronic vomiting, and a poor general condition. An abdominal CT scan revealed aortomesenteric clamp syndrome (AMCS) with an angulation between the aorta and the SMA of 13˚. The underlying cause in this patient was severe malnutrition. Fortunately, her condition improved with medical treatment. Patient 2: We report the case of a 30-year-old female hospitalized due to unusual weight-bearing post-prandial epigastric pain and intermittent vomiting over the past six months. Upon physical examination at admission, she exhibited severe malnutrition with a body mass index (BMI) of 14 kg/m2, a Buzby index of 71%, trophic disorders, and a stage IV general condition assessment according to the World Health Organization (WHO). An abdominal CT scan revealed AMCS with an angle between the aorta and the SMA of 22˚ and an aortomesenteric space of 4 mm. The outcome was poor with medical treatment failure and, unfortunately, the patient died before surgery. Conclusion: SMAS is rarely evoked in clinical practice despite the presence of contributing factors and suggestive clinical signs. The prognosis depends on management time.

Superior mesenteric artery syndrome:Diagnosis and management

Superior mesenteric artery(SMA)syndrome(also known as Wilkie's syndrome,cast syndrome,or aorto-mesenteric compass syndrome)is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta.The median age of patients is 23 years old(range 0-91 years old)and predominant in females over males with a ratio of 3:2.The symptoms are variable,consisting of postprandial abdominal pain,nausea and vomiting,early satiety,anorexia,and weight loss and can mimic anorexia nervosa or functional dyspepsia.Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis,early diagnosis is required.The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography,which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage.The initial treatment is usually conservative,including postural change,gastroduodenal decompression,and nutrient management(success rates:70%-80%).If conservative therapy fails,surgical treatment(i.e.,laparoscopic duodenojejunostomy)is recommended(success rates:80%-100%).

Causes of epigastric pain and vomiting after laparoscopic-assisted radical right hemicolectomy-superior mesenteric artery syndrome

BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition causing functional obstruction of the third portion of the duodenum.Postoperative SMAS following laparoscopic-assisted radical right hemicolectomy is even less prevalent and can often be unrecognized by radiologists and clinicians.AIM To analyze the clinical features,risk factors,and prevention of SMAS after laparoscopic-assisted radical right hemicolectomy.METHODS We retrospectively analyzed clinical data of 256 patients undergoing laparoscopicassisted radical right hemicolectomy in the Affiliated Hospital of Southwest Medical University from January 2019 to May 2022.The occurrence of SMAS and its countermeasures were evaluated.Among the 256 patients,SMAS was confirmed in six patients(2.3%)by postoperative clinical presentation and imaging features.All six patients were examined by enhanced computed tomography(CT)before and after surgery.Patients who developed SMAS after surgery were used as the experimental group.A simple random sampling method was used to select 20 patients who underwent surgery at the same time but did not develop SMAS and received preoperative abdominal enhanced CT as the control group.The angle and distance between the superior mesenteric artery and abdominal aorta were measured before and after surgery in the experimental group and before surgery in the control group.The preoperative body mass index(BMI)of the experimental group and the control group was calculated.The type of lymphadenectomy and surgical approach in the experimental and control groups were recorded.The differences in angle and distance were compared preoperatively and postoperatively in the experimental group compared.The differences in angle,distance,BMI,type of lymphadenectomy and surgical approach between the experimental and control groups were compared,and the diagnostic efficacy of the significant parameters was assessed using receiver operating characteristic curves.RESULTS In the experimental group,the aortomesenteric angle and distance after surgery were significantly decreased than those before surgery(P<0.05).The aortomesenteric angle,distance and BMI were significantly higher in the control group than in the experimental(P<0.05).There was no significant difference in the type of lymphadenectomy and surgical approach between the two groups(P>0.05).CONCLUSION The small preoperative aortomesenteric angle and distance and low BMI may be important factors for the complication.Over-cleaning of lymph fatty tissues may also be associated with this complication.

Superior mesenteric artery syndrome following scoliosis surgery: Its risk indicators and treatment strategy

AIM: To investigate the risk indicators, pattern of clinical presentation and treatment strategy of superior mesenteric artery syndrome (SMAS) after scoliosis surgery.METHODS: From July 1997 to October 2003, 640 patients with adolescent scoliosis who had undergone surgical treatment were evaluated prospectively, and among them seven patients suffered from SMAS after operation. Each patient was assigned a percentile for weight and a percentile for height. Values of the 5th、 10th、 25th、 50th、 75th、 and 95thpercentiles were selected to divide the observations. The sagittal Cobb angle was used to quantify thoracic or thoracolumbar kyphosis. All the seven patients presented with nausea and intermittent vomiting about 5 d after operation.An upper gastrointestinal barium contrast study showed a straight-line cutoff at the third portion of the duodenum representing extrinsic compression by the superior mesenteric artery (SMA).RESULTS: The value of height in the seven patients with SMAS was above the mean of sex- and age-matchednormal population, and the height percentile ranged from 5% to 50%. On the contrary, the value of weight was below the mean of normal population with the weight percentile ranging from 5% to 25%. Among the seven patients, four had a thoracic hyperkyphosis ranging from 55° to 88°(average 72°), two had a thoracolumbar kyphosis of 25° and 32° respectively. The seven patients were treated with fasting, antiemetic medication, and intravenous fluids infusion. Reduction or suspense of traction was adopted in three patients with SMAS during halo-femoral traction after anterior release of scoliosis. All the patients recovered completely with no sequelae. No one required operative intervention with a laparotomy.CONCLUSION: Height percentile＜50% , weight percentile ＜25%, sagittal kyphosis, heavy and quick halo-femoral traction after spinal anterior release are the potential risk indicators for SMAS in patients undergoing correction surgery for adolescent scoliosis.

Superior mesenteric artery syndrome in a diabetic patient with acute weight loss

Superior mesenteric artery(SMA)syndrome is an un- common disease resulting compression of the third portion of the duodenum from the superior mesenteric artery.This disease shares many common manifestations with diabetic gastroparesis,including postprandial fullness,nausea,vomiting,and bloating.Therefore,it is often overlooked in diabetic patients.Here,we report a 41-year-old man with poorly controlled diabetic mellitus who developed SMA syndrome due to rapid weight loss. The diagnosis was confirmed by computed tomography and an upper gastrointestinal series.His condition improved after parenteral nutrient,strict sugar control, and gradual weight gain.

Assessment of duodenal circular drainage in treatment of superior mesenteric artery syndrome

AIM： To assess the clinical value of duodenal circular drainage for superior mesenteric artery syndrome （SMAS）. METHODS： Forty-seven cases of SMAS were treated with duodenal circular drainage from 1959 to 2001. Clinical data were analyzed retrospectively. RESULTS： In this group, good effects were achieved in 39 cases treated with duodenal circular drainage after 2-15 years of follow-up. The other eight cases were first treated with anterior repositioning of the duodenum （two cases）, duodenojejunostomy （five cases）, subtotal gastrectomy and billroth I gastrojejunostomy （one case）, but vomiting was not relieved until duodenal circular drainage was performed again. A follow-up study of 8-10 years revealed satisfactory results in these eight patients. CONCLUSION： In SMAS, if the reversed peristalsis is strong and continuous, and vomiting occurs frequently, the symptom can not be relieved even if the obstruction of duodenum is removed surgically. The key treatment is the relief of reversed peristalsis. The duodenal circular drainage can resolve the drainage direction of duodenal content, thus relieving the symptom of vomiting.

Prof. Zhou Xuewen's Experience in Treating Superior Mesenteric Artery Syndrome

Prof. Zhou Xuewen (周学文), a veteran TCM doctor,is an expert in treating miscellaneous internaldiseases. I have the honor to follow him and havebenefited from his teaching. The following is hisexperience in treating superior mesenteric arterysyndrome that I would like to introduce below.

Superior mesenteric artery syndrome in a patient with esophageal stenosis: A case report

BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition,characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery(SMA).Most cases of SMAS are associated with weight loss,and the most frequent clinical manifestations are nausea,vomiting,postprandial fullness,and abdominal pain.Treatment of SMAS is usually conservative,consisting mainly of adequate nutritional support,but in refractory cases surgery may be necessary,with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.CASE SUMMARY We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion,who suffered significant weight loss after replacement of his jejunostomy tube.He was admitted to the hospital due to pain and abdominal distension.A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery,thus establishing the diagnosis of SMAS.Due to the presence of the esophageal stricture,the patient was incapable of emesis;however,passage of a nasogastric tube for decompression was not possible.Considering the risk of gastric perforation due to distention,we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSION Diagnosis of SMAS can be challenging in patients with esophageal stenosis,and risk of gastric perforation may preclude conservative treatment.

Laparoscopic lysis of duodenum for superior mesenteric artery syndrome： how and why we do it？

Superior mesenteric artery syndrome （SMAS） is a rare etiology of duodenal obstruction resulting from the compression of the third part of the duodenum between the superior mesenteric artery and the aorta. The typical clinical presentation of SMAS is persistent postprandial abdominal distention, vomiting and weight loss.

Superior mesenteric artery syndrome caused by weight loss in a malnourished Syrian man

Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal obstruction in which the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta,and the compression of the duodenum is caused by a narrowed aortomesenteric angle.We report in this case a 35-year-old patient who came with features of small bowel obstruction,weight loss and had a history of malnutrition because of war.Multi-slice computerized tomography showed a narrowed aortomesenteric angle and distance.Conservative treatment was presented and,after 3 months of observation,the patient gained weight.