Ann Thorac Surg 2006;82:e37-e38
© 2006 The Society of Thoracic Surgeons
Case Reports
Superior Mesenteric Artery Syndrome After Esophagectomy With Cervical Esophagogastrostomy
Ku Ran Cho, MD, PhDa,
Won-Min Jo, MD, PhDb,*
a Department of Radiology, Anam Hospital, Korea University, Seongbuk-ku, Seoul
b Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University, Ansan-si, Kyonggi-do, Republic of Korea
Accepted for publication June 19, 2006.
* Address correspondence to Dr Jo, Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University, Gojan-1-dong, Danwon-ku, Ansan-si, Kyonggi-do, Republic of Korea 425-707. (Email: jowonmin{at}korea.ac.kr).
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Abstract
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A 50-year-old man who underwent esophagectomy with cervical esophagogastrostomy for esophageal cancer presented with superior mesenteric artery syndrome. He had severe diffuse and dull abdominal pain and frequent vomiting that began within 10 days after the operation. He also complained of indigestion and early fullness, and lost more than 5 kg of body weight during the period. The symptoms were initiated by poor oral intake and weight loss, and were relieved by nutritional support. Although it is very rare, we conclude that surgeons and radiologists should be aware of the possibility of superior mesenteric artery syndrome as one of the complications after esophagectomy.
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Introduction
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Superior mesenteric artery (SMA) syndrome, or Wilkie disease, is a rare condition characterized by SMA compression of third portion of the duodenum as it passes over this portion of the duodenum. It was first described by Rokitansky [1] in 1861 and later by Wilkie [2]. This compression is thought to occur as the mesentery loses its fat, which allows the SMA to collapse on the duodenum, compressing it between the SMA anteriorly and the aorta posteriorly. An alternate cause may be that the loss of supporting fat in the second and third portions of the duodenum allows the duodenum to collapse against the spine. In this article, we present a case of SMA syndrome after esophagectomy with cervical esophagogastrostomy at about 1 month after the operation.
A 50-year-old man visited our hospital for intermittent dysphagia and weight loss of 7 kg of 2 month's duration. An endoscopic examination revealed a mass in the mid esophagus, and he was histopathologically diagnosed as having squamous cell carcinoma. On preoperative computed tomography (CT) scan, no metastatic mass or lymph node enlargement was found, and the tumor staging was IIA (T2N0M0). There was no abnormal dilatation of the duodenum (Fig 1).
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Fig 1. In the initial preoperative computed tomography scan at the level of the duodenum crossing between the superior mesenteric artery and the aorta, the distance between the superior mesenteric artery (single arrow) and aorta is 1.7 cm. There is no evidence of duodenal dilatation (double arrow).
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Surgical resection of esophageal cancer was performed by transthoracic esophagectomy and cervical esophagogastrostomy. According to our protocol, the pylorus fracture was performed instead of pyloromyotomy, and jejunostomy for tube feeding was not conducted. He recovered without any adverse events and was discharged on postoperative day 21.
The patient visited the hospital again 10 days after discharge because of severe epigastric and periumbilical pain, early fullness, and frequent vomiting. His body weight was reduced by more than 5 kg since his discharge. Endoscopic examination and CT scan revealed that the second portion of the duodenum was much dilated and the third portion was narrowed and the SMA compressed the duodenum at this portion (Fig 2). There was no constricting lesion at the level of the pylorus allowing free passage of the endoscope. The esophagogastrography failed due to intolerance of the patient.
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Fig 2. Postoperative computed tomography scan shows beak-like compression of the third part of the duodenum between superior mesenteric artery (single arrow) and the aorta. The proximal (second portion) duodenum is much dilated (double arrow), but the distance between the aorta and the superior mesenteric artery distance is still 1.5 cm.
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The patient was diagnosed with SMA syndrome. The symptoms were gradually relieved after parenteral nutrition and high caloric diet. After a 3-week admission, the patient gained about 4 kg of body weight and symptoms were relieved.
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Comment
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The third or transverse portion of the duodenum is the most immobile portion of the gastrointestinal tract. It lies between the SMA anteriorly and the aorta and spine posteriorly, and is held fixed by the ligament of Treitz. In rare cases, an abrupt reduction of mesenteric fat causes obstruction of the duodenum between the SMA and the aorta. This phenomenon was earlier called "cast syndrome" or Wilkie syndrome and, more recently, as SMA syndrome. Although SMA syndrome is most commonly seen in young asthenic individuals, any condition that decreases the angle between the SMA and the aorta predisposes the duodenum to compression [3].
Diagnosis is based on clinical suspicion with radiologic confirmation. Clinical suspicion is raised in a patient with postprandial epigastric pain and fullness relieved by emesis. Radiologic diagnosis is made by a barium upper gastrointestinal series or hypotonic duodenography that reveals abrupt or nearly total cessation of flow of barium from the duodenum to the jejunum [4]. CT scan has been suggested to be a useful diagnostic aid because it may provide clues for the diagnosis of SMA syndrome, including close aorta-SMA distance, characteristic duodenal distension, and the amount of intraabdominal and retroperitoneal fat [5]. In addition, a CT scan can exclude conditions such as gastric volvulus, duodenal obstruction, and internal hernia and can help to exclude gastric gangrene, conditions that require immediate exploration [6].
In our patient, the aorta-SMA distance was within the normal range of 1.5 cm, so the diagnosis of SMA syndrome could not be made from this criterion alone. Although the CT scan did not reveal the typical findings, the fact that marked dilatation of the second portion of duodenum followed the weight loss led us to consider SMA syndrome radiologically, and the poor oral intake with abrupt loss of body weight after discharge might have induced the SMA syndrome clinically.
Conservative treatments are initially tried and have increasingly been shown to be successful as definitive treatment [7]. Typically, symptoms improve after restoration of lost weight or removal of the body cast [8]. Surgery is necessary only rarely, and duodenojejunostomy may relieve the symptoms [8].
The symptoms are relieved gradually after intravenous hyperalimentation, liquid diet, and weight gain in this case, which helps to diagnose this case as a SMA syndrome.
Our protocol reserves the jejunostomy procedure to select patients who are of old age, present with more than 10 kg of weight loss preoperatively, or require immediate postoperative adjuvant therapy. We believe that a jejunostomy might have prevented the SMA syndrome in this patient and recognize that our protocol may need modifications to extend indications for jejunostomy in cases of profound preoperative weight loss.
We conclude that surgeons and radiologists should remember the SMA syndrome as one of the complications after esophagectomy, although an incidence is extremely rare.
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References
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- Rokitansky C. Lehrbuch der Pathologishen Anotmie. Vienna: Braumuller & Seidel; 1861. pp. 187.
- Wilkie P. Chronic duodenal ileus Br J Surg 1921;9:204-214.
- Gustafsson L, Falk A, Lukes PJ, Gamklou R. Diagnosis and treatment of superior mesenteric artery syndrome Br J Surg 1984;71:499-501.[Medline]
- Reckler JM, Bruck HM, Munster AM, Curreri PW, Pruitt Jr BA. Superior mesenteric artery syndrome as a consequence of burn injury J Trauma 1972;12:979-985.[Medline]
- Santer R, Young C, Rossi T, Riddlesberger MM. Computed tomography in superior mesenteric artery syndrome Pediatr Radiol 1991;21:154-155.[Medline]
- Martin RJ, Khor TS, Vermeulen T, Hall J. Wilkie's syndrome may be due to poor motility ANZ J Surg 2005;75:1027.[Medline]
- Waseem M, Salvatore C. Abdominal pain—an uncommon cause Pediatr Emerg Care 2004;20:531-533.[Medline]
- Feldman LS. Sleisenger & Fordtran's gastrointestinal and liver disease. 7th ed.. Philadelphia: Saunders; 2002. pp. 2533.
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Abstract
Introduction
