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Superior mesenteric artery syndrome 395Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4ileoanal pouch anastomosis, and aorticaneurysm disease as well as its repair isassociated with this entity [8-17].Fig. 2 Intraoperative viewExploratory laparotomy showing superior mesenteric arterycompression of the 3 rd part of duodenum along with dilatation ofthe proximal duodenumFig. 3 Intraoperative viewDuodenojejunostomy with the 3 rd part of proximal duodenum and aloop of jejunum done in the SMA syndromePostprandial upper abdominal pain andfullness, voluminous bilious vomiting andrapid weight loss are the most characteristicsymptoms of presentation of superiormesenteric artery syndrome. Certain posturaladjustments like left lateral, knee chest orprone position may relieve these abdominalsymptoms.Epigastric distension and a tympaniticand tender upper abdomen are usuallypresent. Laboratory findings will showevidence of dehydration and electrolyteabnormalities [4,7].Plain abdominal radiography maysuggest the diagnosis if it shows a dilatationof the first and second portions of theduodenum, with or without gastric dilatation.Barium studies may show abruptvertical and oblique compression of themucosal folds; antiperistaltic flow of bariumproximal to the obstruction, producing toand-fromovement; delay of 4 to 6 hours intransit through the gastroduodenal regionand relief of obstruction when the patient isplaced in a position (prone or knee-chest).Contrast enhanced CT scan abdomenand MRI abdomen is helpful in estimation ofthe actual aortomesenteric gap as well asvisualization of the retroperitoneal andmesenteric fat and the level of duodenalcompression. Selective SMA arteriographyagainst a barium-filled duodenum willdemonstrate the extrinsic compression andmeasure the aortomesenteric angle and thedistance from the aorta [17].Conservative management includesrest to GI tract, fluid and electrolyteresuscitation, parenteral nutrition and lyingin left decubitus or knee chest position.Efforts to induce weight gain with highcalories liquid diet in left decubitus or kneechest position have been tried with varyingresults.Aggressive nutritional support using anasojejunal tube placed past the point ofobstruction via endoscopic or radiographicguidance may be necessary if the patientdoes not tolerate or achieve adequate oralintake.Surgery is indicated if there is a longhistory of vomiting, progressive weight loss,pronounced dilatation and stasis of theduodenum.Open or laparoscopic approach can beadopted with equal success. Loop duodenojejunostomyfrom the third portion of theduodenum to the jejunum is the procedure ofchoice with 80% success rate.Gastro-jejunostomy, Roux–en-Yduodeno-jejunostomy, anterior transpositionof the third part of the duodenum above theSMA and lysis of ligament of Treitz(Strong’s operation) and mobilization ofduodenum have been tried with varyingresults [8,18,19].
396 Sahu SK. et al.Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4CONFLICT OF INTERESTSNone to declareREFERENCES1. Pleşa A, Constantinescu C, Crumpei F,Cotea E. Superior mesenteric artery syndrome:an unusual case of intestinal obstruction. JGastrointestin Liver Dis. 2006; 15(1): 69-72.2. Applegate GR, Cohen AJ. Dynamic CT insuperior mesenteric artery syndrome.J Comput Assist Tomogr. 1988; 12: 976-980.3. Unal B, Aktaş A, Kemal G, Bilgili Y, GüliterS, Daphan C, Aydinuraz K. Superiormesenteric artery syndrome: CT andultrasonography findings. Diagn Interv Radiol.2005; 11(2): 90-95.4. Baltazar U, Dunn J, Floresguerra C,Schimidt L, Browder W. Superior mesentericartery syndrome: an uncommon cause ofintestinal obstruction. South Med J. 2000;93(6): 606-608.5. Von Rokitansky C. Lehrbuch derpathologischen Anatomie.Vienna: Braumuller& Seidel. 1861.6. Wilkie DP: Chronic duodenal ileus. Am J MedSci. 1927; 173: 643-649.7. Ahmed AR, Taylor I. Superior mesentericartery syndrome. Postgrad Med J. 1997; 73:766-768.8. Ylinen P, Kinnunen J, Hockerstedt K. Superiormesenteric artery syndrome. A follow up studyof 16 operated patients. J Clin Gastroenterol1989; 11: 386-391.9. Elbadawy MH. Chronic superior mesentericartery syndrome in anorexia nervosa. Br JPsychiatry. 1992; 160: 552-554.10. McClenathan JH. Hyperthyroidism as a causeof superior mesenteric artery syndrome. Am JDis Child. 1988; 142: 685-686.11. Milner EA, Cioffi WG, McManus WF,Pruitt BA Jr. Superior mesenteric arterysyndrome in a burn patient. Nutr Clin Pract.1993; 8: 264-266.12. Philip PA. Superior mesenteric arterysyndrome in a child with brain injury. Casereport. Am J Phys Med Rehabil. 1981; 70:280-282.13. Ramos M. Recurrent superior mesentericartery syndrome in a quadriplegic patient.Arch Phys Med Rehabil. 1975; 56: 86-88.14. Roth EJ, Fenton LL, Gaebler-Spira DJ, FrostFS, Yarkony GM.Superior mesenteric arterysyndrome in acute traumatic quadriplegia:casereports and literature review. Arch Phys MedRehabil. 1991; 72: 417-420.15. Cohen LB, Field SP, Sachar DB. The superiormesenteric artery syndrome: the disease thatisn't, or is it? J Clin Gastroenterol. 1985; 7:113-116.16. Strong EK. Mechanics of arteriomesentericduodenal obstruction and direct surgical attackupon etiology. Ann Surg. 1958; 148: 725-730.17. Hearn JB. Duodenal ileus with specialreference to superior mesenteric arterycompression. Radiology. 1966; 86: 305-310.18. Gustafasson L, Falk A, Lukes PJ, Gam Klour,Diagnosis and treatment of superiormesenteric artery syndrome. Br. J Surg. 1984;71: 499-501.19. Neto PRF, Paiva RDA, Filho AL, QuerirozFLD, Noronha T. Superior mesenteric arterycompression syndrome - case report. JColoproctol. 2011; 31(4): 401-404.
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