JRSM >
Volume 96, Number 7 >
Pp. 350-351
Academic Surgical Unit, St Mary's Hospital, London W2 1NY, UK
1
Department of Radiology, St Mary's Hospital, London W2 1NY, UK
Correspondence to: Mr Tushar Agarwal, Academic Surgical Unit, 10th Floor QEQM Wing, St Mary's Hospital, Praed Street, London W2 1NY, UKE-mail: atushar13{at}hotmail.com
One of the contributing factors in superior mesenteric artery syndrome is severe wasting.
CASE HISTORY
A man of 27 with established AIDS was referred with a diagnosis of cerebral toxoplasmosis and clinical features of high gastrointestinal obstruction. He had been vomiting profusely for six weeks and was unable to retain anything orally. He now weighed just 30 kg. Inability to retain his antiviral medication had led to worsening immunosuppression, and severe oral and oesophageal candidiasis prevented him swallowing his own saliva. The cerebral toxoplasmosis had resulted in mild left sided hemiparesis. On examination of the abdomen there was epigastric fullness with a positive succussion splash.
Ultrasound showed the stomach to be massively distended, and CT demonstrated obstruction of the third part of the duodenum by extrinsic compression. A narrow aorto-mesenteric angle in the sagittal section was highly suggestive of superior mesenteric artery (SMA) syndrome (Figure 1) and hypotonic duodenography showed typical cut-off at the third part of the duodenum.
|
An attempt was made at conservative management, initially with total parenteral nutrition and later with nasogastric feeding. However, weight loss continued and the nasogastric aspirate remained greater than 1L/day. Enteral access was necessary for administration of his antiviral and antitoxoplasmosis medication. Surgical intervention was therefore required. The options included a feeding jejunostomy alone (to improve the patient's nutritional and immune status) or a definitive procedure for SMA syndrome. The latter was chosen. Intraoperative findings confirmed the presence of SMA syndrome. The stomach and proximal duodenum were distended and there was visible compression of the third part of the duodenum, the site of block being confirmed by nasogastric air insufflation. Because of anatomical and technical considerations, a gastrojejunostomy was performed instead of the more commonly advocated duodenojejunostomy. Postoperatively, the nasogastric aspirate decreased rapidly and from day 2 the patient started tolerating oral fluids. His weight increased and his viral load decreased when antiviral medication was restarted. The toxoplasmosis and oesophageal candidiasis resolved.
COMMENT
SMA syndrome (also known as Wilkie's syndrome1) has many causes including high insertion of the duodenum at the ligament of Treitz, a congenitally low origin of the superior mesenteric artery and compression of the duodenum due to peritoneal adhesions as a result of duodenal malrotation.2,3 However, the most common cause is thought to be narrowing of the aorto-mesenteric angle causing extrinsic compression of the third part of the duodenum.4
Predisposing factors include severe wasting diseases such as burns or malignancy, severe trauma (especially head injuries), spinal trauma (cast syndrome), eating disorders and the postoperative state. The condition is difficult to diagnose as it mimics gastric outlet obstruction. Hypotonic duodenography and CT scan can be helpful.
Treatment includes an attempt at feeding to improve nutrition. If this fails, various surgical procedures have been advocated. Duodenojejunostomy is the definitive procedure of choice. However, other procedures including gastrojejunostomy, Roux-en-Y duodenojejunostomy and anterior transposition of the third part of the duodenum have been reported.
In the present patient, the development of SMA syndrome exacerbated the wasting of AIDS by preventing oral antiretroviral therapy. When conservative measures proved unsuccessful, decisions on surgical management had to take account of the risks to operating personnel. Standard precautions in high risk patients include the use of impermeable gowns, double gloving and eye protection and immediate disposal of sharps in a sharps bin. Only the necessary number of assistants, who should have an appropriate level of experience, are allowed to scrub for the surgical procedure. Surgical staplers are used in preference to sutures. In the present case the gastrojejunostomy could have been done laparoscopically. This would have greatly lessened the exposure risk from sharps injury, though a theoretical risk is aerosolization of infected material through the laparoscopic ports during instrument changes. We decided against a laparoscopic procedure because we had planned to do a duodenojejunostomy (a technically demanding procedure when done laparoscopically). If we had originally intended to do a gastrojejunostomy, laparoscopic surgery would probably have been our choice.
REFERENCES
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
