Prenatal manifestation of superior mesenteric artery syndrome

Intestinal obstruction is not a rarity in the newborn. Its etiology is diverse. Superior mesenteric artery syndrome (SMAS) is a phenomenon in which the duodenum is obstructed by the SMA. This causes bowel obstruction accompanied by duodenal dilatation. It has previously been described in adults and children but rarely in infants. We report for the first time on an intrauterine manifestation of SMAS.     

Nonobstructive dilatation of the fetal bowel in twin gestations. A possible sonographic marker for fetal compromise

OBJECTIVE: To assess the possible association of in-utero bowel dilatation and circulatory changes with fetal compromise. METHODS: A retrospective survey of all ultrasound examinations was performed at the Chaim Sheba Medical Center (n approximately 10,000) between 1995 and 1999. Cases with ultrasonographic evidence of bowel dilatation, but without evidence of obstruction, were recruited. In utero Doppler studies of umbilical, splenic, superior mesenteric arteries, and middle cerebral artery (MCA) were performed: systolic/diastolic ratio (S/D), pulsatility index (PI) and resistance index (RI) were calculated in the above arteries and compared with those of normal fetuses. Nonstress test and cord blood pH were also assessed. Neonatal medical records were procured. RESULTS: Four fetuses, all of who were products of twin gestations, showed bowel dilatation without evidence for obstruction. Three of the four fetuses were small-for-gestation-age (SGA) and of bichorionic gestation, while one was of monochorionic twin gestation, with twin transfusion syndrome. In all three SGA fetuses, Doppler studies revealed increased peripheral resistance in the umbilical artery and adaptive peripheral vasodilatation in the fetal midcerebral, splenic and superior mesenteric arteries. In all cases, an abnormal nonstress test led to prompt delivery. CONCLUSIONS: Acute fetal bowel dilatation in a twin gestation is associated with abnormal splanchnic and gut perfusion that may lead to fetal compromise.     

Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.     

Superior mesenteric artery syndrome as a complication in hip spica application for immobilization: report of a case.

A 10-year-old girl who had a pelvic and femoral osteotomy for congenital dislocation of her right hip was immobilized with a hip spica. On the 28th postoperative day, she had upper abdominal pain, distention and bilious vomiting. An upper GI series demonstrated complete obstruction of the duodenum at the third portion of the duodenum in a supine position; however, the barium passed the obstruction site slowly when the patient assumed a lateral or prone position. She was successfully treated conservatively with nasogastric decompression, fluid replacement, proper positioning and hyperalimentation. Superior mesenteric artery syndrome is a rare complication in patients immobilized in a body cast or hip spica. Early diagnosis and proper treatment usually leads to an uneventful convalescence.     

Fetal superior mesenteric artery blood flow velocimetry in normal and high-risk pregnancy

THE AIM: To record blood flow velocimetry in the fetal superior mesenteric artery in normal pregnancy and to evaluate if blood flow recordings in the vessel might predict adverse outcome in high-risk pregnancy. METHODS: The fetal superior mesenteric artery blood velocimetry was recorded in a cross sectional manner in 75 normal pregnancies between 27 and 41 weeks of gestation. Reference curves were performed for pulsatility and resistance indices. The superior mesenteric artery was also located in 48 singleton pregnancies complicated by pregnancy-induced hypertension and/or intra-uterine growth retardation. Middle cerebral artery, umbilical artery and vein and uterine artery velocimetry were also recorded. RESULTS: Superior mesenteric artery PI and RI values expressed an increase in resistance to blood flow with gestational age after 32 weeks of gestation. In all except eight high-risk pregnancies the fetal mesenteric artery PI values were within normal range. Among the pregnancies with absent or reversed blood flow in the umbilical artery, all had abnormal mesenteric artery pulsatility index (PI) (> 97.5th percentiles), one fetus died intrauterine and two others died after delivery due to prematurity, growth retardation and necrotizing enterocolitis. In the remaining fetuses with increased mesenteric artery PI, necrotizing enterocolitis was diagnosed in three cases. CONCLUSIONS: Increased vascular resistance in the mesenteric artery might be a late sign of fetal circulation redistribution and frequently related to necrotizing enterocolitis in the newborn.     

The examination of superior mesenteric artery circulation in fetus during pregnancy

Objective: The aim of the study was a comprehensive examination of the circulation of superior mesenteric artery in different weeks of pregnancy using Doppler ultrasound examination.

Methods: The study was conducted at the Clinic of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University, Slovakia between the years 2008 and 2012. Dynamics and changes in superior mesenteric artery circulation were studied in 856 women. Results of Doppler examination were processed and subsequently evaluated for each gestational week separately.

Results: We found that changes in resistance index of superior mesenteric artery are slower and have a tendency to decrease as a consequence of a gradual decrease in vascular resistance. The changes in pulsatility index are different in nature; there is a tendency for there are to be repeating periods of higher and then lower values, which are subject to a more pronounced dependence on flow rate, especially end diastolic velocity, and Vmean.

Conclusions: This article and its results bring a new, comprehensive view not only of physiological changes in the splanchnic circulation, but also of changes that may be subject to a certain extent, not only to the sex, but primarily to the weight of the fetus, which, of course, indirectly reflects its metabolic and respiratory demands.     

Echogenic bowel in intrauterine growth restriction fetuses: does this jeopardize the gut?

OBJECTIVE: To investigate the association between intrauterine growth restriction (IUGR) fetuses with echogenic bowel and high resistance in the umbilical artery and increased risk of developing neonatal necrotizing enterocolitis. METHODS: We analyzed two groups: group 1, singleton IUGR fetuses with echogenic bowel or reversed diastolic flow in the umbilical artery, and group 2, neonates who were diagnosed as having neonatal necrotizing enterocolitis. In group 1, the pulsatility index of the superior mesenteric artery and celiac trunk were determined. In group 2, a retrospective analysis was carried out from the medical records of the neonates. RESULTS: Fifteen fetuses with echogenic bowel and severe IUGR were evaluated by Doppler studies, and 21 neonates with neonatal necrotizing enterocolitis were reviewed. In group 1, none of the IUGR fetuses developed neonatal necrotizing enterocolitis, whereas in group 2, only one neonate was defined as IUGR. The mean gestational age at delivery did not differ statistically between the two groups (28.8 +/- 2.3 weeks versus 30.1 +/- 3.3 weeks), whereas the mean birth weight was significantly lower in the first group (700 +/- 200 g versus 1431 +/- 466 g in the second group, P <.001). The mean pulsatility index +/- standard deviation in the superior mesenteric artery and celiac trunk of the IUGR fetuses were 1.5 +/- 0.14 and 1.2 +/- 0.17, respectively, both being found significantly lower than those of normal, appropriate controls (1.9 +/- 0.15 and 1.7 +/- 0.1, respectively, P <.005). CONCLUSION: Fetal echogenic bowel in IUGR fetuses is not associated with development of neonatal necrotizing enterocolitis. In these fetuses, vasodilatation in the superior mesenteric artery and celiac trunk have been demonstrated.     

Superior mesenteric artery blood flow velocity in small for gestational age infants of very low birth weight during the early neonatal period

In order to elucidate intestinal blood flow after birth in infants with intrauterine growth retardation, we measured superior mesenteric artery blood flow velocity in uncomplicated small for gestational age infants with a birth weight of < 1500 g by pulsed Doppler ultrasound in days 1 to 7 of life. Peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery significantly increased with time. The resistance index and relative vascular resistance in the superior mesenteric artery significantly decreased after birth. Compared with gestational age matched appropriate for gestational age infants and birth weight matched appropriate for gestational age ones, peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery were lower in the small for gestational age infants. The difference between the small for gestational age group and the gestational age matched appropriate for gestational age group was statistically significant. The resistance index and relative vascular resistance in the superior mesenteric artery tend to be higher in the small for gestational age group than in the appropriate for gestational age groups. In conclusion, although intestinal blood flow velocity in infants with intrauterine growth retardation increases after birth, it is lower than appropriate for gestational age infants during the early neonatal period.     

Improvement of mesenteric superior artery Doppler velocimetry by amnio-infusion in fetal gastroschisis.

This study aimed to analyse the influence of amnio-infusion on superior mesenteric Doppler velocimetry and to correlate Doppler data with outcome in fetuses presenting with gastroschisis. Umbilical and intra- and extra-abdominal superior mesenteric artery Doppler velocimetry was measured prospectively before and after amnio-infusion in fetuses with gastroschisis. Doppler index values and changes were correlated with the following outcome parameters: importance of fibrous coating, duration of hospitalization in the neonatal intensive care unit, total duration of hospitalization, duration of parenteral feeding, duration of ventilatory assistance, and the interval to initiation of oral feeding. A significant improvement of diastolic flow was observed in the extra-abdominal superior mesenteric artery with amnio-infusion. No similar change was seen in the intra-abdominal superior mesenteric or in the umbilical artery. Pre-amnioinfusion extra-abdominal mesenteric Doppler index was correlated with maximal diameter of exteriorized bowel and slightly with duration of hospitalization in the neonatal intensive care unit, but no other relation between Doppler index and outcome parameter could be ascertained. Amnio-infusion induces modifications in the vascularization of exteriorized bowel in gastroschisis. This could partly explain the beneficial effect of this procedure on fetal gut.     

Vomiting during pregnancy due to midgut volvulus with duodenal obstruction

An interesting case of severe vomiting with dehydration and weight loss due to midgut volvulus with duodenal obstruction during pregnancy is reported. The patient was an 18-year-old primipara in the third month of pregnancy. She had experienced symptoms which were similar, but much less severe, for many years. The obstruction occurred at the level of the third portion of the duodenum and was produced by the torsion and tightening of the overlying superior mesenteric vessels. These vessels were the only support for an other-wise unattached small intestine. Complete and continuing relief of the patient's symptoms was achieved by operative by-pass of the area of obstruction by means of a duodenojejunostomy. The episode of obstruction and its operative management did not influence the normal course and termination of the pregnancy. The importance of an awareness of the possible occurrence of intestinal volvulus during pregnancy is emphasized.     

Effect of partial constriction of the superior mesenteric artery upon absorption of d-xylose, labeled triolein and labeled albumin.

Intestinal adsorption of triolein, Risa and d-xylose was determined before and after reduction of blood flow in the superior mesenteric artery. Absorption of d-xylose did not change, but absorption of triolein and Risa appeared to be slightly improved after arterial constriction, even if the artery was completely thrombosed. Enhancement in absorption of Risa and triolein was probably the result of extensive collateral formation around the constricted superior mesenteric artery.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

Retropancreatic control of the suprarenal aorta

An alternative approach to occluding the suprarenal abdominal aorta involves a Kocher maneuver and isolation of the retropancreatic aorta between the origins of the celiac axis and the superior mesenteric artery. The use of this approach is supported by operative dissections upon cadavers, as well as upon two patients in whom it was used without difficulty.     

The role of second-look procedure in improving survival time for patients with mesenteric venous thrombosis

Since 1978, 21 patients (12 men and nine women) suffering from mesenteric venous thrombosis (MVT) were treated at the Hadassah University Medical Center. The cause of MVT was multifactorial, and in only six patients was the process defined as primary or idiopathic. A preoperative diagnosis of MVT was made in eight patients. Surgical management of the individual patient was based on the extent of the ischemic process, the viability of infarcted intestine and the general condition of the patient. Nineteen patients were operated upon. Exploratory laparotomy without any attempt of intestinal resection was performed upon two patients. Eleven patients underwent resection and primary anastomosis. Second-look procedures were done upon ten patients, and in six, intestinal resection was followed by creation of a double ostomy. The over-all survival rate was reported to be 60 per cent; it was 71 per cent among the patients who were operated upon. The role of second-look procedures in improving survival time is outlined.     

Occlusion digestive de diagnostic anténatal, association inhabituelle: atrésie duodénale, apple peel syndrome et agénésie de l’artère mésentérique supérieure

Duodenal atresia is believed to be the result of incomplete recanalisation of the embryonic foregut while apple-peel atresia is attributed to a vascular accident in the superior mesenteric artery. We report the case of a newborn with atresia of the distal part of the duodenum, a typical “apple peel” bowel atresia and agenesis of the superior mesenteric artery. This is the fourth case reported. We propose a literature review trying to identify pathogenesis, embryological and therapeutical characteristics of this uncommon association.     

Angiographic control of pelvic bleeding from treated carcinoma of the cervix

Unremitting hemorrhage in two patients who had been treated by radiation for carcinoma of the cervix was managed by angiographic methods. In one patient, bleeding was shown to be from branches of the hypogastric artery and in the second, from branches of the inferior mesenteric artery. Selective embolization of the bleeding arterial branches with surgical gelatin (gelfoam) was followed by control of the acute hemorrhage in both patients.     

Whole abdominal radiation as salvage therapy for epithelial ovarian cancer

Thirty patients found to have residual epithelial ovarian cancer at second-look laparotomy were treated with whole abdominal radiation as salvage therapy. Dosage fractions were 120 rad per day until 3000 rad were delivered, then the pelvis was boosted to 5000 rad at 180 rad per day. Fourteen patients (47%) completed therapy without interruption and seven (23%) completed therapy with interruptions due to myelosuppression ranging from one to four weeks. Therapy was not completed in nine patients (30%). Four of 16 patients (25%) with microscopic residual disease before radiation remain alive and free of disease at 22 to 41 months. Two of six (33%) patients with minimal (less than or equal to 5 mm) residual disease remain alive and free of disease 19 to 40 months after radiation treatment. Patients with residual nodules greater than 5 mm uniformly did poorly. Patients who progressed on primary chemotherapy had a median survival of seven months, compared with more than 38 months for chemotherapy responders. Chronic bowel morbidity was a significant problem, with 30% of patients surviving at least four months from completion of radiation requiring laparotomy for small bowel obstruction. These preliminary results suggest that whole abdominal radiation may be useful in the management of patients who have responded to primary chemotherapy, but the benefit is confined to those patients who have minimal or microscopic disease at second-look laparotomy.     

Aortic and renal atherosclerotic disease

From 1972 to 1985, 39 patients underwent simultaneous aortic and renal revascularization. Thirty-six patients were hypertensive, whereas three patients were normotensive and the lesion of the renal artery was treated prophylactically. The operative mortality rate was 10 per cent. At late follow-up study, 65.6 per cent of the patients with hypertension were "cured" or "improved." Improvement of renal function was obtained in nine of 13 survivors with reduced renal function preoperatively. In addition, 133 patients who underwent aortic reconstruction without repairing the lesion of the renal artery because it was clinically "silent" were reviewed. Five patients experienced renal failure in the early postoperative period. At late follow-up study (a mean of 30 months), three of the 126 survivors died of renal failure and only 18 were hypertensive. Respectable results can be achieved after simultaneous aortic and renal revascularization. However, the increased operative mortality and morbidity warrants a conservative approach in patients considered at high risk or in whom stenosis of the renal artery causes few or no clinical problems.     

Type II single umbilical artery (persistent vitelline artery) in an otherwise normal fetus

A single umbilical artery resulting from absence of the umbilical arteries and persistence of the vitelline artery that arises directly from the abdominal aorta has been described only in malformed fetuses with sirenomelia or caudal regression. Such an aberrant artery was suggested to be the etiology of sirenomelia caused by a 'steal' mechanism of blood flow from the caudal end of the embryo. We present a case in which prenatal ultrasound showed a similar aberrant single artery arising from the abdominal aorta in an otherwise normal fetus with a normal course of pregnancy. This vessel, a continuation of the superior mesenteric artery (SMA), corresponds to a persistent vitelline artery assuming the function of the umbilical arteries. The etiology of such a finding and its possible consequences are discussed.