Title : Stuck in the middle: A case of superior mesenteric artery syndrome on a 68 yearold male
Abstract:
Superior mesenteric artery (SMA) syndrome, also called Wilkie's syndrome or Cast syndrome, reported to have an incidence of 0.1-0.3% of a population, is a rare disorder in which acute angulation of the SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction.
The patient presented in this case is a 68-year-old male who presented with a 1 year history of chronic bilious post-prandial vomiting, associated with intermittent abdominal pain, weight loss and early satiety. This prompted him to seek consultation where numerous diagnostic procedures were done. All of which were inconclusive of the patient’s presenting symptoms. Upper GI Endoscopy revealed Severe Esophagitis, To Consider Partial Intestinal Obstruction. Colonoscopy was then done, only revealing a solitary rectal polyp and Grade I Internal Hemorrhoids. CT Scan of the Whole Abdomen done at another institution was read to be unremarkable save for Atherosclerosis and Sponylosis Deformans. The patient was then managed conservatively and was given due medications to relieve him of his symptoms.
Despite medical management, the patients symptoms still persisted and was maintained on soft diet since then, hence the patient decided to seek for consult in our institituion. His previous CT-Scan images were then reviewed in our instituition and was read as Upper GI Obstruction likely secondary to Superior Mesentric Artery Syndrome with Inflammatory Changes in the Duodenal Junction at the Level of the Ligament of Treitz. The patient was then advised for nutritional build-up and referred to General Surgery service, and was scheduled for Open Duodenojejunostomy.
Intraoperatively, abdominal exploration was done where in no masses were palpated on the small and large intestines, the liver and no peritoneal signs of carcinomatosis were evident. The transverse colon was retracted superiorly to visualize the duodenum. The stomach, 1st and 2nd part of the duodenum were noted to be dilated, while the 3rd part of the duodenum was identified to be compressed by the superior mesenteric artery and the duodenum and was noted to have a smaller diameter in comparson with D1 and D2.
Post-operatively the patient’s course in the ward was unremarkable. His diet was progressed slowly. He was maintained on nothing per orem and NGT was kept open to drain with minimal gastric ouput on post-op day 1-2 . He was started on sips of water on post op day 3. On post op day 4, his diet was then progressed to general liquids and was tolerated. On post op day 5, NGT was removed and his diet was progressed to soft diet. The patient was then progressed to full diet and discharged on post-op day 6, with no postoperative complications, no episodes episodes of bilious vomiting, abdominal distention or abdominal pain.
Audience Take Away Notes:
- SMA Syndrome or Wilkie’s syndrome is a rare case that a general surgeon doesn’t see everyday. Through this case report, the author aims to ellucidate and shed knowledge on the clinical picture, management and postoperative course of patients with this disease. Additionally, the author further supports the efficiency of surgical correction through a duodenojejunostomy as for SMA Syndrome In this patient, there was a delay in diagnosis due to its rarity and unremarkable initial work up. Initial medical management was not beneficial to the patient as evidenced by persistence of his symptoms
- It was only upon further probing and review of the CT-scan images was the diagnosis clinched and considered. Surgical management was then done by creating a side-side duodenojejunostomy. The intraoperative and post-operative course of the patient was unremarkable. Follow up clinical picture showed no recurrence of symptoms with improved nutrition. In hindsight, it is important for a surgeon to consider such entities in patients with obstructive symptoms with poor response to initiated medical therapy. Through this learning experience, the author hopes to enlighten the surgical community on the importance of high index of suspicion and careful case dissection to arrive on the correct diagnosis, and therefore, correct management
