Prenatal manifestation of superior mesenteric artery syndrome

Laparascopic Ladd's procedure as treatment alternative, when parenteral or prolonged hospital nutrition is not an option for superior mesenteric artery syndrome

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.

Distal Duodenal Obstruction: a Surgical Enigma

The postbulbar segment also known as the distal duodenum is a separate clinical entity in terms of the intrinsic pathologies of this region and its varied anatomical relations. The common bile duct and the pancreatic duct open through the major papilla, which marks the beginning of this segment. Distal duodenal obstruction can be defined as a clinicoradiological entity that is characterized by features of gastric outlet obstruction with recurrent bilious vomiting and a radiological evidence of postbulbar obstruction. A Medline search for distal duodenal obstruction revealed 1409 entries, mostly in the form of case reports. In the last 10 years, 310 cases are reported. Clinical features like abdominal pain, nausea, and vomiting are non-specific and quite similar to gastric outlet obstruction. Clinical findings are also non-specific and do not aid in diagnosis. Laboratory findings also do not add much. Contrast-enhanced CT scan and MR enterography are diagnostic modalities of choice. Distal duodenal obstruction is a clinical entity that has a wide list of differential diagnosis which requires due consideration in terms of its management and follow-up. Most of these lesions require adequate workup with the help of a multidisciplinary team consisting of radiologists, gastroenterologists, and pathologists to adequately diagnose and stage the disease before a treatment plan is formulated. A thorough knowledge is a must regarding the treatment options available for each of the conditions so that the management can be personalized leading to better results.

Superior Mesenteric Artery Syndrome Diagnosed with Linear Endoscopic Ultrasound (with Video) in a Patient with Normal Body Mass Index

Superior mesenteric artery (SMA) syndrome is an uncommon disease that results from SMA compression of the third portion of the duodenum. Patients with SMA syndrome present with upper gastrointestinal symptoms, such as nausea, vomiting, and abdominal pain. The diagnosis is usually made from an upper barium study or computed tomography. Typically, SMA syndrome is caused by a decreased aortomesenteric angle of 6° to 25°. An underweight body mass index (BMI) is a risk factor for development of SMA syndrome. There are few reports of the role of linear endoscopic ultrasound (EUS) in the diagnosis of SMA syndrome. We report a case of SMA syndrome, with normal BMI, that was diagnosed with the aid of linear EUS. Although SMA syndrome is not typically within the scope of practice of endosonographers, it is useful to get familiar with the findings.

Superior mesenteric artery syndrome: where do we stand today?

BACKGROUND

Most data on large studies of superior mesenteric artery syndrome (SMAS) were published over 30 years ago. New studies are needed so that current medical progress can influence SMAS diagnosis and improve therapeutic outcomes.

METHODS

This study was conducted to report the clinical features and outcomes of SMAS. From January 2000 to December 2009, 80 cases (53 females, median age 28 years) of SMAS were collected retrospectively from seven university hospitals in South Korea.

RESULTS

The median body mass index at diagnosis was 17.4 kg/m(2), with a range of 10-22.1. Forty (50 %) of the 80 SMAS patients had co-morbid conditions including mental and behavioral disorders, infectious disorders, and disorders of the nervous system (21.3, 12.5, and 11.3 %, respectively). Computerized tomography was most commonly (93.8 %) used to diagnose SMAS. The overall medical management success and recurrence rates were 71.3 and 15.8 %, respectively. Surgical management had a high 92.9 % (13/14) success rate. The most common surgical procedure for SMAS was laparoscopic duodenojejunostomy.

CONCLUSIONS

This is the largest case series to document the clinical features and changes in diagnostic modalities, medical and surgical managements, and their outcomes in SMAS patients. Laparoscopic duodenojejunostomy is the preferred surgical procedure when medical management of the disease fails.

Superior mesenteric artery syndrome: a rare cause of complete intestinal obstruction in neonates

Superior mesenteric artery syndrome (SMAS) is an uncommon cause of high intestinal obstruction in neonates; it is owing to incomplete obstruction in the third part of the duodenum caused by compression between the SMA and abdominal aorta. In neonates, complete intestinal obstruction owing to SMAS has been very rarely reported in the literature .We present a 7-day-old previously healthy male infant with a short history of gastroenteritis and sepsis followed by progressive abdominal distension and persistent bilious vomiting that resulted in hypovolemic shock. The patient was aggressively resuscitated, and a gastrografin study showed a hugely distended stomach with an abrupt narrowing at the third part of the duodenum. Exploratory laparotomy unexpectedly revealed a high insertion of the duodenum at the ligament of Treitz, with upward displacement and SMA compression leading to duodenal obstruction. The ligament of Treitz was divided, and the duodenum, mobilized. The postoperative course was uneventful. Although extremely rare, SMAS should be considered as one of the differential diagnoses in newborns presenting with complete intestinal obstruction, especially if preceded by gastroenteritis or sepsis-like symptoms.

Robotic duodenojejunostomy for superior mesenteric artery syndrome in a teenager

Superior mesenteric artery syndrome (SMAS) involves vascular compression of the third part of the duodenum, eventually leading to gastrointestinal obstruction. Duodenojejunostomy is indicated after failure of conservative management and in chronic cases. We report a case of a cachetic 16-year-old girl with dyskeratosis congenita who suffered from SMA syndrome for 18 months. Upper endoscopy and preoperative imaging (upper GI series and abdominal CT scan) confirmed the diagnosis. A da Vinci-assisted duodenojejunostomy was performed after obtaining informed consent from the patient and her parents. Intraoperatively, a dilated duodenum to the level of D3 was noted. A side-to-side two-layer handsewn anatomosis was performed. The patient was discharged home on postoperative day #3. She gained 1.4 kg within 1 month. Twenty-one months later, she remains asymptomatic with a total weight gain of 3.2 kg. To our knowledge, this is the first reported case of a robot-assisted duodenojejunostomy for SMAS.

Superior mesenteric artery syndrome in an infant: case report and literature review

Superior mesenteric artery syndrome (SMAS) is an obstruction at the third portion of the duodenum by compression between the superior mesenteric artery and the aorta. In infancy, SMAS is extremely rare; and for its diagnosis, other duodenal obstructive diseases including congenital duodenal stenosis and intestinal malrotation must be ruled out. We present the case of a 7-month-old girl with frequent bilious vomiting after the resolution of acute gastroenteritis. Superior mesenteric artery syndrome was finally diagnosed at laparotomy, and duodenojejunostomy was performed. Vomiting disappeared postoperatively, and she gained weight. Although SMAS is an extremely rare syndrome in infants, it should be considered as a possible cause of incomplete duodenal obstruction.

Incomplete duodenal obstruction in a newborn

A case of newborn with incomplete duodenal obstruction caused by superior mesenteric artery syndrome has been presented with this report. A full term, 1-day-old baby girl was referred to our hospital because of recurrent bilious vomiting since birth and upper gastrointestinal barium study revealed the incomplete obstruction at the 3rd part of the duodenum with a vertical abrupt cutoff. The diagnosis of superior mesenteric artery syndrome was made with ultrasonography and duodenojejunostomy was carried out. Although it is extremely rare, superior mesenteric artery syndrome should also be considered as one of the rare cause of incomplete duodenal obstruction in newborn period.

[Superior mesenteric artery syndrome: a cause of vomiting in children. Report of 3 cases]

Duodenal obstruction by Superior Mesenteric Artery (SMA) is a misdiagnosed vomiting syndrome in children. Several factors are involved, including rapid weight loss, rapid statural growth without weight augmentation. Diagnosis is suspected when an improvement is achieved by ventral decubitus and it is confirmed by plain films of the abdomen, GI study with barium and echography, measuring the aortomesenteric angle (inferior to 25-30 degrees ). Patients must at first be treated conservatively. Surgery is indicated for occlusive episodes with unsuccessful conservative therapy. The authors report 3 cases with different clinical presentation. However, all the patients presented important weight loss and vomiting.