“ Less is more ”: Non operative management of short term superior mesenteric artery syndrome

Abstract

IntroductionSuperior mesenteric artery (SMA) syndrome is a relatively rare aetiology of proximal intestinal obstruction. This is caused by narrowing of vascular angle of SMA and aorta compressing the third part of the duodenum (D3). Predisposing factors may include precipitous weight loss, corrective spinal surgery or repair of an aortic aneurysm.Presentation of caseA 53 year old male presented to our department with worsening post-prandial vomiting and epigastric pain for last three months. One examination, epigastric region was distended with succussion splash on abdominal auscultation. History did not include any predisposing factor. CT scan showed narrow angle of 12.77° between SMA and aorta owing to the compression of D3. Since onset of vomiting and resultant poor oral intake, he had lost 11 kg of his usual body weight. After gastric decompression, nasojejunal enteral feeding was started. Diet was progressed to oral feedings gradually and following return to his baseline weight, he continued to be free of symptoms in follow-up visits.DiscussionAlthough there are recognised predisposing factors but sometimes aetiology remains idiopathic. SMA syndrome should initially be managed non-operatively with gastric decompression, correction of water and electrolyte imbalance, and hemodynamic instability. Regaining weight helps increasing vascular space between SMA and D3 thus relieving obstruction. Persistence of symptoms beyond 3–4 weeks warrants surgical intervention.ConclusionNon operative management with nutritional supplementation remains the first line of therapy.

Superior Mesenteric Artery Syndrome Secondary to Anorexia Nervosa and Methamphetamine Use

“…The most prominent diagnostic finding of SMA syndrome is when the aortomesenteric angle is below 25 degrees. CT imaging typically results in the best view, although endoscopy or endoscopic ultrasound can also play a role [12][13][14]. CT has the added benefit of demonstrating the transition point of obstruction in relation to the superior mesenteric vessels and the aorta [11].…”

Tratamiento mínimamente invasivo del síndrome de Wilkie

“…En la mayoría de casos el tratamiento se inicia de manera conservadora y en caso de que falle se continúa con el manejo quirúrgico 17 . En este caso la decisión se inclinó hacia la cirugía, dado que se había hecho varios intentos de manejo médico multimodal sin obtener mejoría y la estancia hospitalaria fue prolongada.…”

“…El manejo médico conservador se basa en dos pautas principales, mejorar los síntomas obstructivos y reversar los factores precipitantes, para lo que se utilizan tres estrategias: descompresión gástrica, corrección de trastornos hidroelectrolíticos y soporte nutricional 1,16,17 . El componente más importante es el soporte nutricional.…”

The Two Sides of Superior Mesenteric Artery Compression Treatment: Conservative or Surgical Management?

“…The angle between the AMS and the aorta measures between 38-65° (6,8). An angle < 25° is more likely to cause obstruction and gastric distension (the angle in the first case measured 11.7° and in the second case, 14°).…”

“…However, those cases in which there is no improvement after 3-4 weeks with conservative management should be considered as unmanageable, particularly in patients with chronic SMAS with duodenal stasis or complicated peptic acid disease (10). In this type of situation, surgical procedures such as duodenal-jejunal anastomosis or division of the Treitz ligament with mobilization of the duodenum (Strong's operation) could be required (8). The patient in case 2 required two surgical procedures that included partial gastrectomy and gastrojejunal anastomosis.…”