Superior mesenteric artery (SMA) syndrome is an uncommon but well-recognized clinical entity. It can lead to proximal small bowel obstruction and severe morbidity and mortality in lieu of late diagnosis and concomitant existing comorbidities. We report a 54-year-old female, with SMA syndrome which manifested itself after Nissen fundoplication along with two major complications. The diagnosis of SMA was established by clinical symptoms and radiological findings

Estrada, JJ

Giuliani, S

Mason, RJ

Petrosyan, M

Rosen, H

Williams, M

Case Reports in Medicine

English

PubMed

St George's Online Research Archive

Hindawi Publishing CorporationCase Reports in MedicineVolume 2009, Article ID 426162, 4 pagesdoi:10.1155/2009/426162Case ReportGastric Perforation and Pancreatitis Manifesting after anInadvertent Nissen Fundoplication in a Patient with SuperiorMesenteric Artery SyndromeMikael Petrosyan, Joaquin J. Estrada, Stefano Giuliani, Monica Williams,Heather Rosen, and Rodney J. MasonDivision of Emergency Surgery, Department of Surgery, Keck School of Medicine, University of Southern California Medical Centerand Los Angeles County Hospital, Los Angeles, CA 90033, USACorrespondence should be addressed to Mikael Petrosyan, mpetrosyan@surgery.usc.eduReceived 13 March 2009; Accepted 13 July 2009Recommended by Kent-Man ChuSuperior mesenteric artery (SMA) syndrome is an uncommon but well-recognized clinical entity. It can lead to proximal smallbowel obstruction and severe morbidity and mortality in lieu of late diagnosis and concomitant existing comorbidities. We reporta 54-year-old female, with SMA syndrome whichmanifested itself after Nissen fundoplication along with twomajor complications.The diagnosis of SMA was established by clinical symptoms and radiological findings.Copyright © 2009 Mikael Petrosyan et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.1. IntroductionSuperior mesenteric artery syndrome (SMAS), which is alsoknown as Cast syndrome or Wilkie syndrome, was firstdescribed in 1861 by Wilkie [1]. SMAS syndrome is charac-terized by compression of the third, or transverse, portion ofthe duodenum against the aorta by the superior mesentericartery (SMA) secondary to a narrowing of the angle betweenthese two vessels. It leads to chronic, intermittent, acute com-plete and/or partial duodenal obstruction [2, 3]. The preciseincidence of this entity is unknown; however literature sug-gests that approximately 0.013–0.3% of upper gastrointesti-nal tract barium studies support a diagnosis of SMAS [4, 5].2. Case ReportA 54-year-old Caucasian female presented to the clinic withepigastric pain and bloating after meals. Seven monthsago she underwent a laparoscopic Nissen fundoplicationfor refractory gastroesophageal reflux disease in her nativecountry. Her reflux symptoms started 2 years ago whichincluded severe heartburn, retrosternal crampy pains as wellglobus sensation. She was initially treated with PPIs for aperiod of 4 months with only minimal improvement of hersymptoms. She underwent laparoscopic Nissen Fundoplica-tion with unremarkable hospital course and was dischargedhome in the stable condition on the third postoperativeday. Shortly after her surgery she left her country andtraveled to Los Angeles, only to find herself in an urgentcare clinic few days later where she was evaluated forher daily bloating episodes lasting 2-3 hours, inability tobelch, and intermittent nausea. After thorough evaluation,which included laboratory work and abdominal X-ray, itwas concluded that her complaints were most likely relatedto a normal post-Nissen fundopication symptoms. She wasreassured and subsequently discharged home. However, shecontinued to have similar symptoms and several weeks latershe represented to a local hospital with severe abdominalpain and fevers of 101 F. Her laboratory work revealed ele-vated WBC 18000 cells/µL (normal, 4500–10 500 cells/µL).She had sinus tachycardia with the systolic blood pressureof 90 and abdominal examination consisting of generalizedperitonitis. She was taken emergently to the operating roomfor exploratory laparotomy. Intraoperative findings revealedan acute gastric linear tear on the anterior portion of thebody of the stomach, 10 centimeters distal to the intactfundoplication wrap. The gastric tear appeared traumaticin origin without any other gastric pathology. Two-layer2 Case Reports in MedicineFigure 1: Abdominal X-ray demonstrating abrupt cut oﬀ signat the 3rd portion of duodenum. Dilated stomach and proximalduodenum. Black arrow shows the cut-oﬀ sign.Figure 2: Upper GI demonstrates obstruction at the 3rd portion ofthe duodenum. Arrow indicates the cut-oﬀ sign.primary closure of the defect was performed. She remainedstable during her hospital stay and was discharged home on5th postoperative day tolerating regular diet. Two monthsafter her second surgery, she represented again to theemergency department with severe epigastric pain radiatingto the back. She was diagnosed with acute pancreatitis on thebasis of her symptoms and laboratory values of amylase andlipase 800UL (normal 60–180U/L) and 1200U/L (normal<190U/L), respectively. Ultrasound and endoscopic retro-grade cholangiopancreatography on the admission revealedno evidence of gallstones or choledocholithiasis. Her pan-creatitis responded to conservative treatment and she wassubsequently discharged home 6 days after her admissionwith complete resolution of symptoms.During her surgical follow-up visit she continued tocomplain of postprandial pain with an early satiety andepisodic nausea. She appeared weak and malnourished. Shenoted a 20 lbs weight loss since her initial antireflux proce-dure. Her abdomen was slightly distended with hyperactiveFigure 3: Upper GI shows the relief of obstruction by contrastmoving distally, once the patient was placed in prone position.bowel sounds. She had moderate epigastric pain duringpalpation. She was admitted to the hospital for a work-upof her ongoing symptoms and as well as for poor nutritionalstatus. Her work-up included plain abdominal films, whichdemonstrated air in a dilated stomach and duodenum withan abrupt vertical cut oﬀ and no evidence of air in thesmall intestine distal to the 3rd portion of the duodenum(Figure 1). Upper Gastrointestinal series obtained subse-quently revealed contrast in the dilated duodenum withan abrupt cut oﬀ at the level of the superior mesentericartery pedicle in a supine position (Figure 2). Obstructionwas relieved once patient was placed in the prone position(Figure 3). Based on her clinical signs as well as classic radi-ological findings, a diagnosis of superior mesenteric arterysyndrome was made. Patient was taken to the operatingroom where she underwent duodenojejunostomy. Her post-operative hospital course was uneventful. She was toleratingregular diet and was subsequently discharged home on the5th postoperative day. Patient remains asymptomatic at oneyear followup.3. DiscussionSuperior mesenteric artery syndrome (SMAS) has beenreported as one of the numerous causes of proximal bowelobstruction. Its existence however remains controversialsince the presenting symptomsmay be similar to other causesof bowel obstruction [2]. Therefore, careful and thoroughwork-up is required to exclude other causes of bowelobstruction before the diagnosis of SMAS can be made.SMAS has been associated with tumors, peptic ulcer disease,pancreatitis, and intra-abdominal inflammation [3]. Manystill question whether SMAS is a true entity while othersfeel that the syndrome maybe overdiagnozed [4, 5]. The trueetiology of this syndrome is related to the anatomical relationof duodenum and superior mesenteric artery (SMA). Thedisease manifests itself when mechanical compression ofCase Reports in Medicine 3duodenum occurs between SMA and its origin, aorta.Various predisposing factors have been described includingsevere weight loss, prolonged immobilization, pressure andlack of retroperitoneal fat cushion at the SMA, and aorticbufircation [6, 7].We believe that in our patient the precipitating factorwas her initial antireflux procedure. The mechanics of Nissenfundoplication with coexisting SMAS in our patient resultedin a closed loop obstruction which led to two subsequentlife threatening complications: gastric perforation and pan-creatitis.Patients with SMAS usually suﬀer from nonspecificsymptoms such as abdominal pain, postprandial fullness,weight loss, bloating, epigastric pain, nausea, and vomiting[7]. Similar symptoms have been described after Nissenfundoplication and therefore led to a misdiagnosis in ourcase [8]. Moreover, we speculate that her initial refluxsymptoms might have been exacerbated or even causedby her proximal duodenal obstruction. Thus, her initialtreatment with PPIs was deemed to be a failure, giventhe inherent mechanics and fluid dynamics of proximalduodenal obstruction.Nonspecific findings of SMAS on a physical examinationmake the diagnosis even more challenging. Significant com-plications have been reported in the literature, with fatalitiesdue to severe electrolyte abnormalities, gastric dilatationwith subsequent perforation, gastric pneumatosis, portalvenous gas, and pancreatitis [9–11]. These complicationsare all consequences of an increased intraluminal pressure.Although Nissen fundoplication restores the mechanicalproperties of the stomach cardia and gastroesophagealjunction, in our patient, this increased pressure gradient atthe cardia together with the duodenal obstruction distally bySMA caused significant increase in the intraluminal pressureboth in the stomach and the duodenum. Furthermore,patients with GERD usually swallow more air than normalsubjects [12]. This aerophagia can persists for a few monthafter Nissen Fundoplication and together with decreasedability to belch can lead to gas bloat syndrome. All thesefactors, including her significant weight loss, might have ledto an increased intraluminal pressure with resultant spon-taneous gastric perforation. This was due to a closed loopobstruction, which resulted from obstruction proximally byesophageal wrap and distally by SMA. This rare entity hasalso been described in a patient after laparoscopic Roux-en-Y procedure, most likely from fast and significant weightloss creating a closed loop obstruction [13]. Moreover,pancreatitis in our patient was most likely secondary toabnormal pancreatico-duodenal reflux within the closedloop of the intestine.Symptoms such as bloating, inability to belch, and nauseacan be early symptoms of post-Nissen Fundoplication. Thesesymptoms are mostly gastric in origin and are due tomechanical alterations in the cardia of the stomach. Ifthese symptoms persist work-up is warranted. The work-up should include a barium swallow with small bowelfollow through and upper endoscopy, therefore evaluatingesophageal function, wrap viability, and anatomical visual-ization of proximal intestine. Moreover, initial work-up ofGERD should include Barium swallow, upper endoscopyand 24-hour pH monitoring. If delayed films are obtainedafter Barium swallow, the proximal duodenal anatomy canbe visualized and incidental SMAS can be diagnosed on theinitial work-up of GERD.Diagnostic evaluation in suspected SMAS should startwith a plain abdominal film. Findings such as abrupt verticalor oblique compression of the third part of the duodenum,dilatation of the second part of duodenum as well as gastricdilation are indicative of this syndrome [14]. To visualizevascular anatomy and the degree of compression of theduodenum, contrast enhanced spiral CT also has beenrecommended [15, 16].Initial treatment should consist of resuscitation anddecompression of the stomach and proximal duodenumwitha nasogastric tube. Fast and significant weight loss, which isusually seen in these patients, should be reversed. Surgeryis reserved for the patients who fail conservative treatment.Open or laparoscopic duodenojejunostomy is indicated [9].In conclusion SMAS may often be overlooked as thecause of bowel obstruction. Establishing diagnosis early isvery important for fast and eﬀective treatment to improve thepatient’s condition and prevent subsequent morbidity andmortality associated with this disease entity.References[1] D. Wilkie, “Chronic duodenal ileus,” British Journal of Surgery,vol. 9, no. 34, pp. 204–214, 1921.[2] J. R. Cohen, J. Leal, G. Pillari, J. B. Chang, and C. Ilardi,“Superior mesenteric artery balloon occlusion. A nonoper-ative model of small bowel ischemia in dogs,” InvestigativeRadiology, vol. 22, no. 11, pp. 871–874, 1987.[3] D. Wilson-Storey and G. A. MacKinlay, “The superior mesen-teric artery syndrome,” Journal of the Royal College of Surgeonsof Edinburgh, vol. 31, no. 3, pp. 175–178, 1986.[4] C. V. Cimmino, “Arteriomesenteric occlusion of the duode-num: an entity?” Radiology, vol. 76, pp. 828–829, 1961.[5] J. R. Hines, R. M. Gore, and G. H. Ballantyne, “Superiormesenteric artery syndrome. Diagnostic criteria and therapeu-tic approaches,” American Journal of Surgery, vol. 148, no. 5,pp. 630–632, 1984.[6] J. B. Barnes andM. Lee, “Superior mesenteric artery syndromein an intravenous drug abuser after rapid weight loss,”Southern Medical Journal, vol. 89, no. 3, pp. 331–334, 1996.[7] P. Ylinen, J. Kinnunen, and K. Hockerstedt, “Superior mesen-teric artery syndrome. A follow-up study of 16 operatedpatients,” Journal of Clinical Gastroenterology, vol. 11, no. 4,pp. 386–391, 1989.[8] T. R. DeMeester, L. Bonavina, and M. Albertucci, “Nissenfundoplication for gastroesophageal reflux disease. Evaluationof primary repair in 100 consecutive patients,” Annals ofSurgery, vol. 204, no. 1, pp. 9–20, 1986.[9] K. S. Gersin and B. T. Heniford, “Laparoscopic duode-nojejunostomy for treatment of superior mesenteric arterysyndrome,” Journal of the Society of Laparoendoscopic Surgeons,vol. 2, no. 3, pp. 281–284, 1998.[10] L. G. Cremonte and E. Mantellini, “An association of acutepancreatitis and intestinal infarct due to superior mesentericartery occlusion,” Minerva Medica, vol. 80, no. 5, pp. 505–506,1989.4 Case Reports in Medicine[11] T. J. de Koning, C. van Schie, and J. J. J. Waelkens, “Acute gas-tric dilatation and superior mesenteric artery syndrome in thementally retarded,” Nederlands Tijdschrift voor Geneeskunde,vol. 140, no. 39, pp. 1960–1963, 1996.[12] A. J. Bredenoord, B. L. A. M. Weusten, R. Timmer, and A. J. P.M. Smout, “Air swallowing, belching, and reflux in patientswith gastroesophageal reflux disease,” American Journal ofGastroenterology, vol. 101, no. 8, pp. 1721–1726, 2006.[13] M. T. Baker, M. D. Lara, and S. N. Kothari, “Superiormesenteric artery syndrome after laparoscopic Roux-en-Ygastric bypass,” Surgery for Obesity and Related Diseases, vol.2, no. 6, p. 667, 2006.[14] I. Laﬀont, D. Bensmail, C. Rech, G. Prigent, G. Loubert,and O. Dizien, “Late superior mesenteric artery syndrome inparaplegia: case report and review,” Spinal Cord, vol. 40, no. 2,pp. 88–91, 2002.[15] L. Gustafsson, A. Falk, P. J. Lukes, and R. Gamklou, “Diagnosisand treatment of superior mesenteric artery syndrome,”British Journal of Surgery, vol. 71, no. 7, pp. 499–501, 1984.[16] G. R. Applegate and A. J. Cohen, “Dynamic CT in superiormesenteric artery syndrome,” Journal of Computer AssistedTomography, vol. 12, no. 6, pp. 976–980, 1988.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Diagnosis and treatment of superior mesenteric artery syndrome,”

Dynamic CT in superior mesenteric artery syndrome,”

Gastric perforation and pancreatitis manifesting after an inadvertent nissen fundoplication in a patient with superior mesenteric artery syndrome.

Mikael Petrosyan

Joaquin J. Estrada

Stefano Giuliani

Monica Williams

Heather Rosen

Rodney J. Mason

Directory of Open Access Journals

Gastric Perforation and Pancreatitis Manifesting after an Inadvertent Nissen Fundoplication in a Patient with Superior Mesenteric Artery Syndrome

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A .J .B r e d e n o o r d

Acute gastric dilatation and superior mesenteric artery syndrome in the mentally retarded,” Nederlands Tijdschrift voor Geneeskunde,

An association of acute pancreatitis and intestinal infarct due to superior mesenteric artery occlusion,”

Arteriomesenteric occlusion of the duodenum: an entity?”

Chronic duodenal ileus,”

D e M e e s t e r ,L .B o n a v i n a ,a n dM .A l b e r t u c c i ,“ N i s s e n fundoplication for gastroesophageal reﬂux disease. Evaluation of primary repair in 100 consecutive patients,”

J.B.BarnesandM.Lee,“Superiormesentericarterysyndrome in an intravenous drug abuser after rapid weight loss,”

L.Gustafsson,A.Falk,P.J.Lukes,andR.Gamklou,“Diagnosis and treatment of superior mesenteric artery syndrome,”

Laparoscopic duodenojejunostomy for treatment of superior mesenteric artery syndrome,”JournaloftheSocietyofLaparoendoscopicSurgeons,

Late superior mesenteric artery syndrome in paraplegia: case report and review,”

Superior mesenteric artery balloon occlusion. A nonoperative model of small bowel ischemia in dogs,”

Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass,” Surgery for Obesity and Related Diseases,

Superior mesenteric artery syndrome. A follow-up study of 16 operated patients,”

Superior mesentericarterysyndrome.Diagnosticcriteriaandtherapeutic approaches,”

The superior mesenteric artery syndrome,”

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2734930

Gastric perforation and pancreatitis manifesting after an inadvertent nissen fundoplication in a patient with superior mesenteric artery syndrome.

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