Superior Mesenteric Artery Syndrome Improved by Enteral Nutritional Therapy: A Retrospective Case-Series Study in a Single Institution

Duodenojejunostomy following failed gastrojejunostomy in superior mesenteric artery syndrome: A case report

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare duodenal-vascular anatomic disorder leading to external compression on the duodenum. The first step of treatment usually is conservative, and in the case of failure, surgical management is the treatment choice. Treatment success with duodenojejunostomy after failure in gastrojejunostomy can show the uniqueness of this article.

CASE PRESENTATION

A 14-year-old boy came to our hospital with a complaint of epigastric pain, nausea, bilious vomiting, and weight loss since 6 months ago. Conservation therapy and laparotomic Braun anastomosis and gastrojejunostomy was performed due to the SMA syndrome diagnosis 2.5 months before the admission. At our hospital, an alteration of gastrojejunostomy by duodenojejunostomy employing a diamond-shaped anastomosis between the third portion of the duodenum (D3) and a part of jejunum that was placed 15 cm away from the ligament Treitz was done. A significantly dilated stomach and the first three parts of the duodenum were observed during the procedure. After the second surgical intervention, the general condition of the patient dramatically improved.

CLINICAL DISCUSSION

Conservative treatment, including nasogastric tube decompression, postural changes, and nutritional support with hyperalimentation, has a variable success rate. However, in some cases, surgery may be necessary. Surgeons prefer laparoscopic duodenojejunostomy due to its outstanding success rate, ranging from 80 % to 100 %. But, in some case reports it is suggested that gastrojejunostomy could be done in cases with severe duodenal dilation instead of duodenojejunostomy. The initial gastrojejunostomy failed because of ongoing symptoms, which was finally revised with a duodenojejunostomy.

CONCLUSION

It is suggested to use duodenojejunostomy after failure of gastrojejunostomy or it can be employed as the first surgical option even in cases with severe dilation. Because it is a more efficient correction with fewer complications than gastrojejunostomy.

Aorto-mesenteric compass syndrome (Wilkie's syndrome) in the differential diagnosis of chronic abdominal pain

A woman in her 40s was admitted to hospital with weight loss, asthenia, persistent abdominal pain and post-prandial nausea and vomiting. Other comorbidities were anxiety-depressive disorder, gastro-oesophageal reflux disease and fibrocystic mastopathy. On admission her body mass index (BMI) was 15.57 kg/m2 with a reported weight loss of 6 kg during the last 3 months. The patient underwent a double contrast abdominal CT scan, which showed that the third portion of the duodenum appeared to be compressed between the superior mesenteric artery and the abdominal aorta. After a multidisciplinary evaluation, a conservative approach and nutritional supplementation was decided upon and administered. At the 1-year follow-up the symptoms had greatly improved; the epigastric pain, although persistent, was reduced, also due to the weight gain to 50 kg (BMI 19.5 kg/m2). Wilkie's syndrome, in its acquired form, predominantly affects young women after rapid weight loss. In the diagnostic work-up, case history, physical examination and radiological findings play a key role.

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%).

Clinical applications of body composition and functional status tools for nutrition assessment of hospitalized adults: A systematic review

BACKGROUND

No global consensus exists on diagnostic criteria for malnutrition. Muscular deficits and functional impairments are major components of available malnutrition diagnostic frameworks because these facets of nutrition status significantly impact outcomes. The purpose of this review is to explore which body composition assessment (BCA) and functional status assessment (FSA) tools are being used for nutrition assessment (NA) and monitoring the response to nutrition interventions (RNIs) in adult inpatients.

METHODS

A literature search of Embase, Medline (Ovid), Web of Science, and Cochrane Central was performed to identify studies that used BCA and/or FSA tools for NA (along with an accepted NA diagnostic framework) and/or for monitoring RNI in adult inpatients.

RESULTS

The search yielded 3667 articles; 94 were included in the review. The number of studies using BCA and/or FSA tools for NA was 47 and also 47 for monitoring RNI. Seventy-nine percent of studies used bioimpedance for BCA, and 97% that included FSA utilized handgrip strength. When compared against sets of diagnostic criteria, many of the BCA and FSA tools showed promising associations with nutrition status.

CONCLUSION

Bioimpedance methods are the most widely used bedside BCA tools, and handgrip strength is the most widely used FSA tool; however, these methods are being used with a variety of protocols, algorithms, and interpretation practices in heterogeneous populations. To create a standardized nutrition status assessment process there is a need for validation studies on bedside methods and the development of globally standardized assessment protocols in clinical inpatient settings.

Wilkie’s syndrome as a cause of anxiety-depressive disorder: A case report and review of literature

BACKGROUND

Superior mesenteric artery syndrome is a disease with a complex diagnosis, and it is associated with complications that make it even harder to identify. Currently, a frequent association with psychiatric disorders has been noted. Despite numerous case reports and case series, the variability of the disease has not allowed the development of protocols regarding diagnosis and management.

CASE SUMMARY

A 33-year-old woman presented with abdominal pain, nausea, and bile vomiting over the last 15 mo, associated with a 15-kg weight loss over the last three months. After the onset of the symptoms, the patient was diagnosed with anxiety-depressive disorder and treated appropriately. Standard examinations excluded an organic cause, and the cause of the symptoms was considered psychogenic. The persistence of symptoms, even under treatment, prompted a computer tomography angiography examination of the abdomen and pelvis. The examination identified emergence at a sharp angle of 13.7° of the superior mesenteric artery, with a reduced distance between the artery and the anterior wall of the aorta up to a maximum of 8 mm. A diagnosis of aortomesenteric clamp was established. Surgical treatment by laparoscopic duodenojejunostomy was performed. Postoperative evolution was marked by a patent anastomosis at 1 mo, with a 10-kg weight gain and improvement of the associated anxiety.

CONCLUSION

This case report underlines two major aspects. One aspect refers to the predisposition of patients with superior mesenteric artery syndrome to develop psychiatric disorders, with an excellent outcome when proper treatment is administered. The second aspect underlines the key role of a multidisciplinary approach and follow-up.

Effect of a Novel, Energy-Dense, Low-Volume Nutritional Food in the Treatment of Superior Mesenteric Artery Syndrome

Superior mesenteric artery syndrome (SMAS) is an intermittent or persistent passage obstruction that occurs in the third portion of the duodenum between the aorta and the superior mesenteric artery. After symptoms stabilize, the nutritional intake is started by ingesting a small amount. Recently, an energy-dense, low-volume nutritional food, Terumeal uplead^® (Terumo Corporation, Tokyo, Japan) with an energy density of 4.0 kcal/mL, was launched. We report a case of a postoperative SMAS patient who was successfully treated using Terumeal uplead^® through gastrostomy. An 83-year-old man who developed adhesive intestinal obstruction underwent right hemicolectomy, lysis of adhesion, and partial small bowel resection. Gastric distension persisted after surgery; thus, gastrostomy was performed for decompression and enteral nutrition on the 21st postoperative day, and enteral feeding was started on the 23rd postoperative day. However, fluoroscopy showed obstruction in the third portion of the duodenum, which was considered to be SMAS. To reduce the administration volume, enteral nutrition was replaced with Terumeal uplead^® from the 28th postoperative day (intermittent administration thrice a day, 300 mL, 1,200 kcal per day). From the 34th postoperative day, the gastrostomy tube was clamped for two hours after administration, and no drainage was observed. Oral intake was resumed from the 36th postoperative day, and it was used in combination with enteral nutrition. Three months later, the patient was discharged home and continued oral ingestion with occasional decompression from the gastrostomy tube. Thus, Terumeal uplead^® may be useful during the conservative treatment of SMAS by initiation with small amounts.