PDF (5 MB) - Jurnalul de Chirurgie

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,