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Superior mesenteric artery syndrome
Superior
Mesenteric
1
Arterv
J
DOUGLAS A. MCKINNON, M.D. AND J. ROBERT SPENCER,
From tbe Surgical Service, Presbyterian Hospital, Denver, Colorado.
HE SUPERIOR mesenteric artery syndrome is a rather unusual form of high intestina1 obstruction which was first described by Rokitansky over IOO years ago [r,z]. Definitive surgery in the form of duodenojejunostomy was suggested frfty years later by Bloodgood [J], and was successfully performed by StaveIy soon thereafter. During the 1920’s and earIy 1930’s, the syndrome gained diagnostic popularity as evidenced by over IOO case reports in the literature. Interest waned, however, and there were only seven cases reported in the literature between 1944 and 1944 [4]. Several recent reports of large series of cases seem to indicate a renewed interest in the condition [1,5,6]. This, along with recent persona1 contact with three such patients, Ied us to review the cases surgicahy treated at Presbyterian Hospita1 in Denver during the past ten years. Eight cases were encountered and constitute the subject of this report. Patients who were treated medicaIIy are not included in this study.
of the Southwestern 19%
American
Journal
of Surgery.
Volume
106, October
1963
Denver,
Colorado
DIAGNOSIS
The typicai patient with this syndrome in its chronic form presents a history of postprandial distension, pain, nausea and vomiting of bile-stained material. Often food ingested twenty-four hours previousIy may be noted in the vomitus. As these patients Iearn to recognize the reIationship of their symptoms to meaIs, they may tend to eat Iess, thereby adding maInutrition and its attendant symptoms to the clinica picture. Some of these patients may have found some measure of relief by Iying on their Ieft side or assuming the knee chest position foIlowing meals. The patient with superior mesenteric artery syndrome in its acute form presents a clinica picture of high intestina1 obstruction with gastric diIatation and vomiting of biIe-stained materia1. Roentgenograpbic Examination. The typica roentgenogram of this disease incIudes diIatation of the duodenum through the second portion with a sharp demarcation of the contrast medium at the midIine. (Fig. I .) Positioning the patient on the Ieft side during ffuoroscopic examination may show churning of the barium in the duodenum, as we11 as sIow pas-
The superior mesenteric artery syndrome consists of compression of the fixed, third portion of the duodenum by the superior mesenteric neurovascular bundIe anteriorly and the aorta and vertebra1 coIumn posteriorIy. The upright posture of man predisposes to this anatomica “nut cracker,” whereas quadrupeds are free of this potentia1 obstruction due to their smaI1 boweI mesentery being suspended anteriorIy rather than inferiorIy [5,7]. WhiIe the erect posture certainIy contributes to potentia1 obstruction, Strong notes that evoIution wouId have stopped short of the biped Annual Meeting
M.D.,
SYMPTOMSAND
CAUSE
at the Fifteenth
J
human if erect posture in itseIf resuIted in duodenal occlusion [a]. Many factors have been mentioned which act to close or tighten the vascuIar vise encIosing the third portion of the duodenum. Among these are: Ioss of weight, prolonged bed rest, various generalized systemic diseases, previous surgica1 procedures, acute inflammatory Iesions of the bowe1, increased Iordosis (as can occur with the appIication of a body cast), and Ioss of muscle tone of the abdomina1 waI1 leading to visceroptosis [1,2,4,5,8,g].
T
* Presented
Svndrome*
552
Surgical Congress,
Mexico,
D. F., April zz--2~,
Superior
FIG.
I. TypicaI roentgenographic
Mesenteric
appearance
Artery
Syndrome
of mesenteric compression
symptoms, relief [fi].
sage of the media through the compressed portion of the bowel. Diagnosis at Luparotomy. If the clear cut picture of proximal duodenal dilatation with mesenteric compression is in doubt at laparotomy, further diagnostic aids may be used. Air insufhation of stomach and duodenum with a Levine tube proved to be a valuable tool in our series. It readily demonstrated the potential distensibility of the first and second portions of the duodenum with obstruction at the mesenteric crossing.
and,
of duodenum.
at best,
(Case VII.)
give Iittle or no
MATERIAL
Ages of the eight cases colIected ranged from twenty to seventy years. Six were women. Predisposing factors were present in five of the cases with no demonstrabIe associated disease in the remaining three. (TabIe I.) CASE
REPORTS
CASE I. A thirty-four year oId white woman was admitted with a four month history of cramping pain in the epigastrium and right upper quadrant. She aIso comptained of intermittent vomiting and distension. Past history revealed four previous surgical explorations, the first for a ruptured appendix, foIIowed by three subsequent explorations for Iysis of adhesions. Physical examination was unremarkabIe except for some evidence of maInutrition. Roentgenographic examination of the upper gastrointestina1 tract showed some duodena1 dilatation, but was not interpreted as significant mesenteric vesseI compression. Surgical expIoration
TREATMENT
The surgical treatment of choice for this condition is duodenojejunostomy. If peptic ulcer disease is present, other procedures may be considered in combination with duodenojejunostomy. These incIude: vagotomy and pyIoropIasty; sIeeve resection; or Bilroth I type of gastric resection. A BiIroth II resection or a vagotomy and pyloropIasty without duodenojejunostomy can aggravate the obstructive 553
McKinnon
and Spencer
TABLE
I
MATERIAL Case No., Age and Sex
fConservative
Predisposing or Associated Factors
Therapy
-
Dehnitive Surgery
ResuIts
-r.939.F ri.,47,F
None Generalized
4 mo. scIeroderma
I yr.
~rr.,zo,F
None
6 mo.
rv.,g6,F
Lymphoma-para-aortic nodes None
4 weeks
Generalized arteriosclerosis Vagotomy and pyloroplasty with hiatus hernia repair Bihoth I subtota1 gastric resection for gastric uIcer
1 yr.
v.,3o,F vr.,-/o,F vr1.,3z,M
v111.,41,M
5 mo.
8 mo.
4 mo.
Duodenojejunostomy Gastro enterostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy
Asymptomatic,
5 yr. postoperative
MaIabsorption secondary to primary ease, relief of obstructive symptoms Asymptomatic I 34 yr. postoperative
dis-
Died four weeks postoperative of primary disease Asymptomatic, I +i yr. postoperative ReIief of obstructive symptoms, 235 yr. postoperative Continued regurgitation and deIayed gastric emptying, “vagotomy effect,” now improved DeIayed emptying of duodenojejunostomy stoma, now improved
Further in vestigation reveaIed systemic scleroderma with demonstrabre invoIvement of hands and gastrointestina1 tract. This patient is stiI1 free of obstructive symptoms, but is pursuing a sIow downhi course due to the primary disease.
reveaIed many operative adhesions of the small bowe1 which were believed to have been sites of potential intermittent obstruction. There was also considerable diIatation of the stomach and duodenum through the second portion with definite compression of the third portion by the superior mesenteric vessels. It was decided to try conservative therapy and the abdomen was closed after freeing the adhesions. The patient’s postoperative course was unsatisfactory; she had troublesome distension and continuous pain. Three weeks Iater expIoratory surgery was done again. A duodenojejunostomy was performed. The patient is asymptomatic five years postoperativeIy.
CASE III. A twenty year old white woman was admitted with a history of gradual onset of pain in the upper part of the abdomen, during a one year period. The pain always occurred immediately after meals and lasted for three to four hours. Vomiting occurred on numerous occasions with some relief. The patient had aIso noted some rehef of symptoms on assuming the knee-chest position folIowing meaIs. The physical examination was unremarkabIe as were aI1 studies except for the upper gastrointestinal series which reveared obstruction of the third portion of the duodenum consistent with superior mesenteric artery compression. ExpIoration confirmed the roentgenographic findings, and a duodenojejunostomy was performed. The patient is reportedIy asymptomatic at this time, one and one-half years following surgery.
CASE II. A forty-seven year old white woman was admitted with a one year history of postprandial epigastric pain, excessive eructation and distension. She had been treated for peptic ulcer and gastritis but continued to have symptoms associated with a weight loss of thirty pounds during the year prior to admission. Physical examination was unrevealing except for obvious recent weight loss. An upper gastrointestina1 series demonstrated dilatation of the first and second portions of the duodenum with compression at the third portion. Surgical expIoration confirmed the diagnosis and a gastroenterostomy aIong with shortening of the transverse mesocoIon were performed. The patient subsequently did we11 for ten months with a sIow weight gain and reIief of pain. At that point, however, marked weakness of the neck muscuIature and Raynaud’s phenomena of the hands deveIoped.
CASE IV. A tifty-six year oId white woman was admitted with a four week history of intractabIe nausea, vomiting and epigastric pain. Four years earlier, a diagnosis of Iymphosarcoma had been made; however, she had been doing we11 fohowing radiation and chemotherapy. PhysicaI examination reveaIed a chronically debiIitated middIe aged woman with generaIized adenopathy and abdominat fuIIness. Upper gastro-
554
Superior
Mesenteric
Artery
intestinal series showed delayed gastric emptying with a partial high intestina1 obstruction. At exploratory surgery, the third portion of the duodenum was found to be obstructed between the mesenteric vessek and enIarged para-aortic Iymph nodes. A duodenojejunostomy afforded reIief of symptoms, but the patient died primary disease four weeks postoperatively.
Syndrome
the superior mesenteric artery. This was further confirmed by air insufnation through a Levine tube; a duodenojejunostomy was performed. The patient had some postoperative vomiting and regurgitation with deIayed gastric emptying. Now, nearIy a year postoperative, he reports a weight gain and is markedIy improved.
of the
CASE VIII. A forty-one year old white man was admitted with a four month history of postprandial cramps and vomiting. One month prior to admission the patient was said to have vomited about thirty minutes after every meal. Past history disclosed that the patient had been subjected to BiIroth I type subtota1 gastric resection five months prior to admission. Physical examination revealed recent weight loss and epigastric tenderness to paJpation but was otherwise unremarkable. Roentgenograms demonstrated compression at the third portion of duodenum with dilatation of the proximal Ioop. Laparotomy corroborated the roentgenographic observations; a duodenojejunostomy was performed. PostoperativeIy the patient was troubIed by delayed emptying of the duodenojejunostomy stoma; however, now, six months later, he is reported to be gaining weight and is melI.
CASE v. A thirty year old white woman was admitted with a five month history of epigastric pain and fullness. The pain would occur up to two hours after meaIs without nausea or vomiting. The patient received no rdief of symptoms from change of position or antacid therapy. The physical examination was unremarkabIe; however, roentgenograms of the upper part of the gastrointestinal tract revealed a classic picture of superior mesenteric artery compression of the duodenum. SurgicaI expIoration confirmed the roentgenographic diagnosis, and a duodenojejunostomy was performed. The patient is asymptomatic at this time, two years later. CASE VI. A seventy year oId white woman was admitted with a one year history of epigastric pain with radiation to mid-back. Physical examination reveaIed a very thin, frai1, eIderIy woman with occasiona epigastric cramps. DuodenaI compression by the superior mesenteric artery was suspected on roentgenographic examination, and exploratory surgery was undertaken. At operation, a definite obstruction was found at the point where the neurovascuIar bundle crossed the duodenum. The superior mesenteric artery at this point was hard and scIerotic suggesting that this might have been a causative factor in producing the obstruction. The obstruction was further demonstrated with air insufllation of the stomach and duodenum; a duodenojejunostomy was performed. The patient’s postoperative course was uneventful, and she is reported to be free of gastrointestina1 symptoms two and one-half years Iater.
COMMENTS
authors have suggested that acute gastric dilatation, a serious and poorIy understood postoperative compIication, is due to unrecognized mesenteric obstruction of the duodenum [7,10]. Little evidence is offered in Several
support of this suggestion, however. An acute form of the superior mesenteric artery syndrome, recognized radiographicaIly, has been reported in association with pancreatitis and other intraperitoneal inflammatory lesions [q. It is interesting that onIy thirteen cases have been reported in infants and children. One, a twenty-two month old girl, was found at surgery to have enlarged mesenteric Iymph nodes as a possible cause, a mechanism perhaps comparable to that encountered in one of our patients (Case IV) [2]. Duodenal diverticula
CASE VII. A thirty-two year old white man was admitted with an eight month history of postprandial vomiting and regurgitation. The patient reported a ten pound weight Ioss during this period. Past history revealed that he had a hiata1 herniorrhaphy with vagotomy and pyIoropIasty three months prior to the onset of symptoms. Physical examination was unremarkabIe except for evidence of recent weight loss. An upper gastrointestina1 series showed a dilated duodenum through the second portion with an abrupt cutoff of contrast media at the region of the right psoas shadow. ExpIoration revealed definite compression by
have been reported in association with the superior mesenteric artery syndrome, one of the cases was a twelve year old girl [r r]. The occurrence is probabIy secondary to the increased duodena1 pressure resuking from the mesenteric obstruction and not, as has been suggested, a cause of the obstruction. Duodenal diverticula were not found in any of the eight cases herein reported. Absence of the myenteric 555
McKinnon
and Spencer
TABLE II WEIGHT LOSS No. of Cases
tone in the upper gastrointestina1 tract may have precipitated the Iatter. Another had had a subtota1 gastric resection, BiIroth I, which may have disturbed motility of the upper part of the intestine. The third patient had a rigid arterioscIerotic superior mesenteric artery which was thought to be a contributing factor. The patient with scIeroderma had roentgenographic evidence of hypomotiIity of the intestina tract; the patient with Iymphoma had Iarge invoIved para-aortic lymph nodes to expIain the cause. In onIy three patients, did the superior mesenteric artery syndrome have no apparent causaIIy reIated factor.
PossibIe ReIated Causes ~_____
3 I I
I I I
None demonstrated Vagotomy and pyIoropIasty with hiatus hernia repair* Gastric resection for gastric ulcer* Mesenteric arterioscIerosis* ScIeroderma Lymphoma
TotaI 8 * Antecedent
weight 10s~. SUMMARY
pIexus
of Auerbach in the waII of the duodenum (so caIIed megaduodenum) may rarely simuIate superior mesenteric artery syndrome and can be distinguished from it by a duodenaI biopsy
In recent years several reports of obstruction of the third portion of the duodenum due to compression by the superior mesenteric artery have appeared in the Iiterature. The increasing recognition of this probIem Ied us to review the cases encountered at the Presbyterian Hospital in the past ten years. Five of the eight cases were associated with other diseases which appeared to be causaIIy reIated to the obstruction. One foIIowed vagotomy and pyIoropIasty in conjunction with hiatus hernia repair; another occurred in a case of diffuse scleroderma with involvement of the gastrointestina1 tract; the third case was associated with Iymphosarcoma invoIving paraortic Iymph nodes; the fourth foIIowed BiIroth I gastrectomy for gastric uIcer; and the fifth had arterioscIerosis of the mesenteric artery. The reIativeIy high incidence of associated diseases encountered in this type of obstruction warrants a carefu1 search for any causaIIy reIated disease which may be more pertinent cIinicaIIy than the obstruction itseIf.
[r21. OnIy one of our patients had an associated peptic uIcer. Such an association has been reported in as high as 25 per cent of cases, and suggests that stasis resuIting from duodenal distention may be a factor contributing to peptic uIceration [5,13]. The incidence of the superior mesenteric artery syndrome may be higher than is curIn a recent study of over rently reaIized. 2,000 upper gastrointestinal roentgenographic studies, the incidence was found to be one in 300 [6]. In our hospita1 the eight surgica1 cases occurred in a series of 8,904 upper gastrointestina1 roentgenograms representing Iess than one in a 1,000. The two series are not, however, comparable as our Iower incidence represents onIy the cases operated upon. Cases demonstrated by roentgenograms but treated medicaIIy and others which showed transitory deIay in emptying of the duodenum but without symptoms of obstruction were not incIuded in our series. AIthough weight Ioss, particuIarIy in the asthenic person, is a frequent finding in conjunction with superior mesenteric artery syndrome, this was an inconsistent finding in our cases, occurring in only three of eight patients. (TabIe II.) In addition to weight loss, each of the three had other findings of possible etioIogic significance. One had had a vagotomy in conjunction with hiatus hernia repair just prior to onset of symptoms attributabIe to duodena1 obstruction, suggesting that Ioss of muscIe
REFERENCES I. KAISER, G. J., MCCAIN, J. M. and SCHUMACHER, H. B. The suoerior mesenteric arterv svndrome. Surg. Gynec. & Obst., IIO: 133, 1960: * 2. RABINOVITCH, J., PINES, B. and FELTON, M. Superior mesenteric artery syndrome. J. A. M. A., Ij’g: 257, 1963. 3. BLOODGOOD,J. C. Acute dilation of the stomach: gastromesenteric ileus. Ann. Surg., 46: 736, ,907. 4. BERLEY, F. V. and BROWN, R. B. Arteriomesenteric obstruction of the duodenum. U. S. Armed Forces M. J., 5: 1044, rg54. 5. JONES, S. A., CARTER, R., SOUTH, L. L. and JOERGENSON, E. J. Arteriomesenteric duodena1 compression. Am. J. Surg., 100: 262, 1960. 6. GOIN, L. S. and WELK, S. P. Intermittent arterio-
556
Superior
Mesenteric
mesenteric occIusion of the duodenum. Radiology, 67: 729. 1956. 7. CONNOR, L. A. Acute dilation of the stomach and its reIation to mesenteric obstruction of the duodenum. Tr. Assoc. Am. Physicians, 21: 57~~ 1906. 8. STRONG, E. K. Mechanics of arteriomesenteric duodenat obstruction and direct surgical attack upon etiology. Ann. Surg., 148: 725, 1958. 9. SIMOK, M. and LERNER, M. Duodenal compression of the mesenteric root in acute pancreatitis and inflammatory conditions of the bowel. Radiology, 79: 75, 1962. IO. KAUFFMAN, R.
R.
and
GERBODE, F.
Artery
Syndrome
mesenteric duodenal ileus. Stanford M. Bull., 9: 262, 1951. I I. LAMBERT, C. J., FITTS, F. 0. and TUHK, R. Duodena diverticulum: an unusua1 cause of “secondary superior mesenteric artery syndrome.” Am. J. Surg., IOI : 805, 1961. 12. BARNETT, W. 0. and WALL, L. Megaduodenum resuIting from absence of the parasympathetic ganglion ceIIs and Auerbach’s pIexus. Ann. Surg., 141 : 527, 1955. 13. WILLIAMS, L. F. and BOWERS, W. F. Arteriomesenteric duodenat obstruction associated with severe peptic ulcer disease. Ann. Sure., 153: 250, 1961.
Arterio-
557
Mesenteric
1
Arterv
J
DOUGLAS A. MCKINNON, M.D. AND J. ROBERT SPENCER,
From tbe Surgical Service, Presbyterian Hospital, Denver, Colorado.
HE SUPERIOR mesenteric artery syndrome is a rather unusual form of high intestina1 obstruction which was first described by Rokitansky over IOO years ago [r,z]. Definitive surgery in the form of duodenojejunostomy was suggested frfty years later by Bloodgood [J], and was successfully performed by StaveIy soon thereafter. During the 1920’s and earIy 1930’s, the syndrome gained diagnostic popularity as evidenced by over IOO case reports in the literature. Interest waned, however, and there were only seven cases reported in the literature between 1944 and 1944 [4]. Several recent reports of large series of cases seem to indicate a renewed interest in the condition [1,5,6]. This, along with recent persona1 contact with three such patients, Ied us to review the cases surgicahy treated at Presbyterian Hospita1 in Denver during the past ten years. Eight cases were encountered and constitute the subject of this report. Patients who were treated medicaIIy are not included in this study.
of the Southwestern 19%
American
Journal
of Surgery.
Volume
106, October
1963
Denver,
Colorado
DIAGNOSIS
The typicai patient with this syndrome in its chronic form presents a history of postprandial distension, pain, nausea and vomiting of bile-stained material. Often food ingested twenty-four hours previousIy may be noted in the vomitus. As these patients Iearn to recognize the reIationship of their symptoms to meaIs, they may tend to eat Iess, thereby adding maInutrition and its attendant symptoms to the clinica picture. Some of these patients may have found some measure of relief by Iying on their Ieft side or assuming the knee chest position foIlowing meals. The patient with superior mesenteric artery syndrome in its acute form presents a clinica picture of high intestina1 obstruction with gastric diIatation and vomiting of biIe-stained materia1. Roentgenograpbic Examination. The typica roentgenogram of this disease incIudes diIatation of the duodenum through the second portion with a sharp demarcation of the contrast medium at the midIine. (Fig. I .) Positioning the patient on the Ieft side during ffuoroscopic examination may show churning of the barium in the duodenum, as we11 as sIow pas-
The superior mesenteric artery syndrome consists of compression of the fixed, third portion of the duodenum by the superior mesenteric neurovascular bundIe anteriorly and the aorta and vertebra1 coIumn posteriorIy. The upright posture of man predisposes to this anatomica “nut cracker,” whereas quadrupeds are free of this potentia1 obstruction due to their smaI1 boweI mesentery being suspended anteriorIy rather than inferiorIy [5,7]. WhiIe the erect posture certainIy contributes to potentia1 obstruction, Strong notes that evoIution wouId have stopped short of the biped Annual Meeting
M.D.,
SYMPTOMSAND
CAUSE
at the Fifteenth
J
human if erect posture in itseIf resuIted in duodenal occlusion [a]. Many factors have been mentioned which act to close or tighten the vascuIar vise encIosing the third portion of the duodenum. Among these are: Ioss of weight, prolonged bed rest, various generalized systemic diseases, previous surgica1 procedures, acute inflammatory Iesions of the bowe1, increased Iordosis (as can occur with the appIication of a body cast), and Ioss of muscle tone of the abdomina1 waI1 leading to visceroptosis [1,2,4,5,8,g].
T
* Presented
Svndrome*
552
Surgical Congress,
Mexico,
D. F., April zz--2~,
Superior
FIG.
I. TypicaI roentgenographic
Mesenteric
appearance
Artery
Syndrome
of mesenteric compression
symptoms, relief [fi].
sage of the media through the compressed portion of the bowel. Diagnosis at Luparotomy. If the clear cut picture of proximal duodenal dilatation with mesenteric compression is in doubt at laparotomy, further diagnostic aids may be used. Air insufhation of stomach and duodenum with a Levine tube proved to be a valuable tool in our series. It readily demonstrated the potential distensibility of the first and second portions of the duodenum with obstruction at the mesenteric crossing.
and,
of duodenum.
at best,
(Case VII.)
give Iittle or no
MATERIAL
Ages of the eight cases colIected ranged from twenty to seventy years. Six were women. Predisposing factors were present in five of the cases with no demonstrabIe associated disease in the remaining three. (TabIe I.) CASE
REPORTS
CASE I. A thirty-four year oId white woman was admitted with a four month history of cramping pain in the epigastrium and right upper quadrant. She aIso comptained of intermittent vomiting and distension. Past history revealed four previous surgical explorations, the first for a ruptured appendix, foIIowed by three subsequent explorations for Iysis of adhesions. Physical examination was unremarkabIe except for some evidence of maInutrition. Roentgenographic examination of the upper gastrointestina1 tract showed some duodena1 dilatation, but was not interpreted as significant mesenteric vesseI compression. Surgical expIoration
TREATMENT
The surgical treatment of choice for this condition is duodenojejunostomy. If peptic ulcer disease is present, other procedures may be considered in combination with duodenojejunostomy. These incIude: vagotomy and pyIoropIasty; sIeeve resection; or Bilroth I type of gastric resection. A BiIroth II resection or a vagotomy and pyloropIasty without duodenojejunostomy can aggravate the obstructive 553
McKinnon
and Spencer
TABLE
I
MATERIAL Case No., Age and Sex
fConservative
Predisposing or Associated Factors
Therapy
-
Dehnitive Surgery
ResuIts
-r.939.F ri.,47,F
None Generalized
4 mo. scIeroderma
I yr.
~rr.,zo,F
None
6 mo.
rv.,g6,F
Lymphoma-para-aortic nodes None
4 weeks
Generalized arteriosclerosis Vagotomy and pyloroplasty with hiatus hernia repair Bihoth I subtota1 gastric resection for gastric uIcer
1 yr.
v.,3o,F vr.,-/o,F vr1.,3z,M
v111.,41,M
5 mo.
8 mo.
4 mo.
Duodenojejunostomy Gastro enterostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy Duodenojejunostomy
Asymptomatic,
5 yr. postoperative
MaIabsorption secondary to primary ease, relief of obstructive symptoms Asymptomatic I 34 yr. postoperative
dis-
Died four weeks postoperative of primary disease Asymptomatic, I +i yr. postoperative ReIief of obstructive symptoms, 235 yr. postoperative Continued regurgitation and deIayed gastric emptying, “vagotomy effect,” now improved DeIayed emptying of duodenojejunostomy stoma, now improved
Further in vestigation reveaIed systemic scleroderma with demonstrabre invoIvement of hands and gastrointestina1 tract. This patient is stiI1 free of obstructive symptoms, but is pursuing a sIow downhi course due to the primary disease.
reveaIed many operative adhesions of the small bowe1 which were believed to have been sites of potential intermittent obstruction. There was also considerable diIatation of the stomach and duodenum through the second portion with definite compression of the third portion by the superior mesenteric vessels. It was decided to try conservative therapy and the abdomen was closed after freeing the adhesions. The patient’s postoperative course was unsatisfactory; she had troublesome distension and continuous pain. Three weeks Iater expIoratory surgery was done again. A duodenojejunostomy was performed. The patient is asymptomatic five years postoperativeIy.
CASE III. A twenty year old white woman was admitted with a history of gradual onset of pain in the upper part of the abdomen, during a one year period. The pain always occurred immediately after meals and lasted for three to four hours. Vomiting occurred on numerous occasions with some relief. The patient had aIso noted some rehef of symptoms on assuming the knee-chest position folIowing meaIs. The physical examination was unremarkabIe as were aI1 studies except for the upper gastrointestinal series which reveared obstruction of the third portion of the duodenum consistent with superior mesenteric artery compression. ExpIoration confirmed the roentgenographic findings, and a duodenojejunostomy was performed. The patient is reportedIy asymptomatic at this time, one and one-half years following surgery.
CASE II. A forty-seven year old white woman was admitted with a one year history of postprandial epigastric pain, excessive eructation and distension. She had been treated for peptic ulcer and gastritis but continued to have symptoms associated with a weight loss of thirty pounds during the year prior to admission. Physical examination was unrevealing except for obvious recent weight loss. An upper gastrointestina1 series demonstrated dilatation of the first and second portions of the duodenum with compression at the third portion. Surgical expIoration confirmed the diagnosis and a gastroenterostomy aIong with shortening of the transverse mesocoIon were performed. The patient subsequently did we11 for ten months with a sIow weight gain and reIief of pain. At that point, however, marked weakness of the neck muscuIature and Raynaud’s phenomena of the hands deveIoped.
CASE IV. A tifty-six year oId white woman was admitted with a four week history of intractabIe nausea, vomiting and epigastric pain. Four years earlier, a diagnosis of Iymphosarcoma had been made; however, she had been doing we11 fohowing radiation and chemotherapy. PhysicaI examination reveaIed a chronically debiIitated middIe aged woman with generaIized adenopathy and abdominat fuIIness. Upper gastro-
554
Superior
Mesenteric
Artery
intestinal series showed delayed gastric emptying with a partial high intestina1 obstruction. At exploratory surgery, the third portion of the duodenum was found to be obstructed between the mesenteric vessek and enIarged para-aortic Iymph nodes. A duodenojejunostomy afforded reIief of symptoms, but the patient died primary disease four weeks postoperatively.
Syndrome
the superior mesenteric artery. This was further confirmed by air insufnation through a Levine tube; a duodenojejunostomy was performed. The patient had some postoperative vomiting and regurgitation with deIayed gastric emptying. Now, nearIy a year postoperative, he reports a weight gain and is markedIy improved.
of the
CASE VIII. A forty-one year old white man was admitted with a four month history of postprandial cramps and vomiting. One month prior to admission the patient was said to have vomited about thirty minutes after every meal. Past history disclosed that the patient had been subjected to BiIroth I type subtota1 gastric resection five months prior to admission. Physical examination revealed recent weight loss and epigastric tenderness to paJpation but was otherwise unremarkable. Roentgenograms demonstrated compression at the third portion of duodenum with dilatation of the proximal Ioop. Laparotomy corroborated the roentgenographic observations; a duodenojejunostomy was performed. PostoperativeIy the patient was troubIed by delayed emptying of the duodenojejunostomy stoma; however, now, six months later, he is reported to be gaining weight and is melI.
CASE v. A thirty year old white woman was admitted with a five month history of epigastric pain and fullness. The pain would occur up to two hours after meaIs without nausea or vomiting. The patient received no rdief of symptoms from change of position or antacid therapy. The physical examination was unremarkabIe; however, roentgenograms of the upper part of the gastrointestinal tract revealed a classic picture of superior mesenteric artery compression of the duodenum. SurgicaI expIoration confirmed the roentgenographic diagnosis, and a duodenojejunostomy was performed. The patient is asymptomatic at this time, two years later. CASE VI. A seventy year oId white woman was admitted with a one year history of epigastric pain with radiation to mid-back. Physical examination reveaIed a very thin, frai1, eIderIy woman with occasiona epigastric cramps. DuodenaI compression by the superior mesenteric artery was suspected on roentgenographic examination, and exploratory surgery was undertaken. At operation, a definite obstruction was found at the point where the neurovascuIar bundle crossed the duodenum. The superior mesenteric artery at this point was hard and scIerotic suggesting that this might have been a causative factor in producing the obstruction. The obstruction was further demonstrated with air insufllation of the stomach and duodenum; a duodenojejunostomy was performed. The patient’s postoperative course was uneventful, and she is reported to be free of gastrointestina1 symptoms two and one-half years Iater.
COMMENTS
authors have suggested that acute gastric dilatation, a serious and poorIy understood postoperative compIication, is due to unrecognized mesenteric obstruction of the duodenum [7,10]. Little evidence is offered in Several
support of this suggestion, however. An acute form of the superior mesenteric artery syndrome, recognized radiographicaIly, has been reported in association with pancreatitis and other intraperitoneal inflammatory lesions [q. It is interesting that onIy thirteen cases have been reported in infants and children. One, a twenty-two month old girl, was found at surgery to have enlarged mesenteric Iymph nodes as a possible cause, a mechanism perhaps comparable to that encountered in one of our patients (Case IV) [2]. Duodenal diverticula
CASE VII. A thirty-two year old white man was admitted with an eight month history of postprandial vomiting and regurgitation. The patient reported a ten pound weight Ioss during this period. Past history revealed that he had a hiata1 herniorrhaphy with vagotomy and pyIoropIasty three months prior to the onset of symptoms. Physical examination was unremarkabIe except for evidence of recent weight loss. An upper gastrointestina1 series showed a dilated duodenum through the second portion with an abrupt cutoff of contrast media at the region of the right psoas shadow. ExpIoration revealed definite compression by
have been reported in association with the superior mesenteric artery syndrome, one of the cases was a twelve year old girl [r r]. The occurrence is probabIy secondary to the increased duodena1 pressure resuking from the mesenteric obstruction and not, as has been suggested, a cause of the obstruction. Duodenal diverticula were not found in any of the eight cases herein reported. Absence of the myenteric 555
McKinnon
and Spencer
TABLE II WEIGHT LOSS No. of Cases
tone in the upper gastrointestina1 tract may have precipitated the Iatter. Another had had a subtota1 gastric resection, BiIroth I, which may have disturbed motility of the upper part of the intestine. The third patient had a rigid arterioscIerotic superior mesenteric artery which was thought to be a contributing factor. The patient with scIeroderma had roentgenographic evidence of hypomotiIity of the intestina tract; the patient with Iymphoma had Iarge invoIved para-aortic lymph nodes to expIain the cause. In onIy three patients, did the superior mesenteric artery syndrome have no apparent causaIIy reIated factor.
PossibIe ReIated Causes ~_____
3 I I
I I I
None demonstrated Vagotomy and pyIoropIasty with hiatus hernia repair* Gastric resection for gastric ulcer* Mesenteric arterioscIerosis* ScIeroderma Lymphoma
TotaI 8 * Antecedent
weight 10s~. SUMMARY
pIexus
of Auerbach in the waII of the duodenum (so caIIed megaduodenum) may rarely simuIate superior mesenteric artery syndrome and can be distinguished from it by a duodenaI biopsy
In recent years several reports of obstruction of the third portion of the duodenum due to compression by the superior mesenteric artery have appeared in the Iiterature. The increasing recognition of this probIem Ied us to review the cases encountered at the Presbyterian Hospital in the past ten years. Five of the eight cases were associated with other diseases which appeared to be causaIIy reIated to the obstruction. One foIIowed vagotomy and pyIoropIasty in conjunction with hiatus hernia repair; another occurred in a case of diffuse scleroderma with involvement of the gastrointestina1 tract; the third case was associated with Iymphosarcoma invoIving paraortic Iymph nodes; the fourth foIIowed BiIroth I gastrectomy for gastric uIcer; and the fifth had arterioscIerosis of the mesenteric artery. The reIativeIy high incidence of associated diseases encountered in this type of obstruction warrants a carefu1 search for any causaIIy reIated disease which may be more pertinent cIinicaIIy than the obstruction itseIf.
[r21. OnIy one of our patients had an associated peptic uIcer. Such an association has been reported in as high as 25 per cent of cases, and suggests that stasis resuIting from duodenal distention may be a factor contributing to peptic uIceration [5,13]. The incidence of the superior mesenteric artery syndrome may be higher than is curIn a recent study of over rently reaIized. 2,000 upper gastrointestinal roentgenographic studies, the incidence was found to be one in 300 [6]. In our hospita1 the eight surgica1 cases occurred in a series of 8,904 upper gastrointestina1 roentgenograms representing Iess than one in a 1,000. The two series are not, however, comparable as our Iower incidence represents onIy the cases operated upon. Cases demonstrated by roentgenograms but treated medicaIIy and others which showed transitory deIay in emptying of the duodenum but without symptoms of obstruction were not incIuded in our series. AIthough weight Ioss, particuIarIy in the asthenic person, is a frequent finding in conjunction with superior mesenteric artery syndrome, this was an inconsistent finding in our cases, occurring in only three of eight patients. (TabIe II.) In addition to weight loss, each of the three had other findings of possible etioIogic significance. One had had a vagotomy in conjunction with hiatus hernia repair just prior to onset of symptoms attributabIe to duodena1 obstruction, suggesting that Ioss of muscIe
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556
Superior
Mesenteric
mesenteric occIusion of the duodenum. Radiology, 67: 729. 1956. 7. CONNOR, L. A. Acute dilation of the stomach and its reIation to mesenteric obstruction of the duodenum. Tr. Assoc. Am. Physicians, 21: 57~~ 1906. 8. STRONG, E. K. Mechanics of arteriomesenteric duodenat obstruction and direct surgical attack upon etiology. Ann. Surg., 148: 725, 1958. 9. SIMOK, M. and LERNER, M. Duodenal compression of the mesenteric root in acute pancreatitis and inflammatory conditions of the bowel. Radiology, 79: 75, 1962. IO. KAUFFMAN, R.
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and
GERBODE, F.
Artery
Syndrome
mesenteric duodenal ileus. Stanford M. Bull., 9: 262, 1951. I I. LAMBERT, C. J., FITTS, F. 0. and TUHK, R. Duodena diverticulum: an unusua1 cause of “secondary superior mesenteric artery syndrome.” Am. J. Surg., IOI : 805, 1961. 12. BARNETT, W. 0. and WALL, L. Megaduodenum resuIting from absence of the parasympathetic ganglion ceIIs and Auerbach’s pIexus. Ann. Surg., 141 : 527, 1955. 13. WILLIAMS, L. F. and BOWERS, W. F. Arteriomesenteric duodenat obstruction associated with severe peptic ulcer disease. Ann. Sure., 153: 250, 1961.
Arterio-
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