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CASE REPORT 393Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4SUPERIOR MESENTERIC ARTERY SYNDROME - ANUNUSUAL CAUSE OF DUODENAL OBSTRUCTIONSahu SK , Singh PK, Ray J, Uniyal M, Sharma C,Sekhar C, Kapruwan H, Sachan PKDepartment of General SurgeryHimalayan Institute of Medical SciencesSUPERIOR MESENTERIC ARTERY SYNDROME - AN UNUSUAL CAUSE OFDUODENAL OBSTRUCTION. (Abstract): Superior mesenteric artery (SMA) arising from aortaat the level of first lumbar vertebra usually takes an angular downward course from ventralsurface of aorta. It is through this vascular angle that the 3rd part of duodenum passes at the levelof 4th lumbar vertebra. Fat and lymphatics around SMA maintains the angle at 25° to 60° with amean of 45 0 and provide protection against duodenal compression. In Superior Mesenteric ArterySyndrome, the SMA-aorta angle in narrowed down to 7° to 22° with a mean of 8 0 leading toentrapment of the transverse part of duodenum between the artery and the vertebral column andaorta with resultant partial or complete duodenal obstruction. We report a case of SuperiorMesenteric Artery Syndrome which was diagnosed by CECT abdomen. Duodeno-jejunostomywas done to treat this condition.KEY WORDS: SUPERIOR MESENTERIC ARTERY; DUODENUM; SUPERIORMESENTERIC ARTERY SYNDROME; DUODENO-JEJUNOSTOMY.RUNNING HEAD: Superior mesenteric artery syndromeHOW TO CITE: Sahu SK, Singh PK, Ray J, Uniyal M, Sharma C, Sekhar C, Kapruwan H, Sachan PK [Superiormesenteric artery syndrome - an unusual cause of duodenal obstruction]. Jurnalul de chirurgie (Iaşi). 2012; 8(4): 393-396.INTRODUCTIONSuperior mesenteric artery (SMA)arising from aorta at the level of first lumbarvertebra usually takes an angular downwardcourse from ventral surface of aorta.It is through this vascular angle thatthe 3 rd part of duodenum passes at the levelof 4 th lumbar vertebra.Fat and lymphatics around SMAmaintains the angle at 25° to 60° with amean of 45 o and provide protection againstduodenal compression.In Superior Mesenteric ArterySyndrome, the SMA-aorta angle is narroweddown to 7° to 22° with a mean of 8 o leadingto entrapment of the transverse part ofduodenum between the artery and thevertebral column and aorta with resultantpartial or complete duodenal obstruction.SMA-aorta distance is also reduced to2 -8 mm (normal range 10 to 28 mm) at thelevel of 4th lumbar vertebra in SuperiorMesenteric Artery Syndrome. [1-4].CASE REPORTA 58 year old female was admittedwith history of upper abdominal discomfort,recurrent bilious vomiting containingundigested food material and significantweight loss since last 8 months.The symptoms used to disappear whenthe patient used to lie in left lateral or proneposition. For the similar complaints she wasrepeatedly hospitalized and managedReceived date: 07.09.2012Accepted date: 12.11.2012Correspondence to: Shantanu Kumar Sahu, MS, Associate Professor,Department of General SurgeryHimalayan Institute of Medical SciencesSwami Ram Nagar, Post- Doiwala, DehradunUttarakhand, 248140, India.Phone: 0091 (0) 94 12 93 38 68Email: lntshantanu@yahoo.co.in
394 Sahu SK. et al.Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4conservatively for the last 8 months at localhospitals.On examination patient wasdehydrated and malnourished with a weightof 45 kg.Examination of abdomen revealedepigastric distension with a visible peristalsismoving from left to right and no palpablemass.Routine investigation revealedHemoglobin 12 mg/dL, total leukocyte count8000/mm 3 . Renal function tests were withinnormal limits. Upper GI endoscopy aftergastric lavage revealed a normal study upto2 nd part of duodenum. Sonography ofabdomen was normal.Oral and IV contrast – enhanced- CTscan of abdomen was planned whichrevealed dilatation of stomach andduodenum upto 3 rd part and narrowing of 3 rdand 4 th part of duodenum.The angle between superior mesentericartery and aorta was 20º confirming superiormesenteric artery syndrome (Fig. 1).AFig. 1 CT scanA: CECT abdomen showing dilatation of stomach and duodenumup to 3 rd part and narrowing of 3 rd and 4 th part of duodenum.B: CECT abdomen showing the 20 º angulation between superiormesenteric artery and aorta along with the duodenal compressionconfirming superior mesenteric artery syndrome.Exploratory laparotomy revealedsuperior mesenteric artery compression ofthe 3 rd part of duodenum with dilatation ofproximal duodenum and stomach.Lysis of ligament of Treitz along withside to side duodenojejunostomy with the 3 rdpart of the duodenum and a loop of jejunumBwas done. Patient had an uneventful postoperative recovery (Fig. 2, 3).DISCUSSIONSuperior Mesenteric Artery Syndrome(SMAS) was first described in literature byvon Rokitansky in 1861 on autopsy studies.The largest and most complete study of thisdisease was published by Wilkie in 1927,based on 75 cases.Chronic duodenal ileus,arteriomesenteric duodenal compression,gastromesenteric ileus, aortomesentericartery compression, duodenal vascularcompression, Wilkie’s syndrome and Castsyndrome are the various alternativenomenclatures given to this entity [3-7].Reviews of literatures have reportedthe incidence of this entity in the range of0.013–0.53%. Females are affected morecommonly than males with the age ofpresentation ranging between 10-39 years.This condition has been reported at theextremes of age with the youngest patientbeing a 35-week gestational age newborn inwhom the diagnosis was made prenatally,and the oldest patient a woman over 90 yearsof age.Lack or loss of retroperitoneal andperiduodenal fat pads is attributed to thisacute angulation resulting in the duodenal“clamping”.Severe wasting diseases such as burns,cancer and endocrine diseases; severeinjuries such as head trauma; spinal trauma,deformities like scoliosis and application ofa body cast; dietary disorders such asanorexia nervosa or malabsorptivesyndromes; and the postoperative states areassociated with this entity.Anatomical deformities resulting inthis entity includes a high insertion of theduodenum at the ligament of Treitz, acongenitally low origin of the superiormesenteric artery and compression of theduodenum caused by peritoneal adhesions,which are a results of duodenal malrotation.A surgical intervention which reducesthe width of the aortomesenteric angleincludes bariatric surgery, scoliosis surgery,
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