Favorable minimal invasive surgery in the treatment of superior mesenteric artery syndrome: Case report

IntroductionThe Superior Mesenteric Artery Syndrome (SMAS) is a rare form of intestinal obstruction. The diagnosis is based on findings from imaging studies, including vascular compression of the duodenum by the SMA and can be associated with duodenal dilatation.Presentation of caseWe report a case of a patient with SMAS and recurrent episodes of intestinal obstruction, which was successfully treated by laparoscopic duodenojejunostomy.DiscussionThe initial treatment is usually conservative for patient’s clinical improvement. Surgery is indicated when conservative treatment fails as well for patients with recurrent symptoms. Minimal invasive surgery might be a good approach, specially in patients who suffers from this disease and currently are in depleted health conditions.ConclusionThe procedure herein demonstrated may be considered safe and resolutive, with good visualization of structures, relative short surgical time and fast post-operative recovery.     

Post-reperfusion syndrome during isolated intestinal transplantation: outcome and predictors

Siniscalchi A, Cucchetti A, Miklosova Z, Lauro A, Zanoni A, Spedicato S, Bernardi E, Aurini L, Pinna AD, Faenza S. Post‐reperfusion syndrome during isolated intestinal transplantation: outcome and predictors.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01530.x
© 2011 John Wiley & Sons A/S. Abstract: Background: Post‐reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long‐term outcome. The primary aim of this study was to determine the independent clinical predictors of intra‐operative PRS, as well as to investigate the link between the severity of PRS and the intra‐operative profiles and to examine the post‐operative complications and their relationship with transplant outcome. Methods: This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre‐unclamping value and lasted for at least one min within 10 min after unclamping. Results and conclusions: The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre‐operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra‐operative PRS was associated with significantly more frequent post‐operative renal failure and early post‐operative death.     

Portal venous gas and thrombosis complicating superior mesenteric artery syndrome (Wilkie's syndrome) in a child

We report a case of a 10-year-old girl presenting with portal venous gas and thrombosis associated with superior mesenteric artery syndrome. To our knowledge, this is the first reported case of superior mesenteric artery syndrome complicated by gastric wall pneumatosis, portal venous gas, and thrombosis in childhood. Although these complications usually lead to bowel resection in adults and result in a high mortality rate, our pediatric patient was successfully treated nonoperatively with intensive care management and jejunal tube feedings. Presence of portal venous gas may occur in superior mesenteric artery syndrome in children and does not necessarily lead to bowel injury, allowing conservative medical management as a first-line treatment.     

Laparoscopic Duodenojejunostomy for Treatment of Superior Mesenteric Artery Syndrome

Background and Objectives:

Superior mesenteric artery (SMA) syndrome is a rare disorder, recognized as weight loss, nausea, vomiting, and post-prandial pain due to compression and partial obstruction of the third portion of the duodenum by the SMA. If conservative treatment fails, then laparotomy with duodenojejunostomy or lysis of the ligament of Treitz is indicated. Recently, laparoscopic division of the retroperitoneal attachments of the duodenum has been described. We report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum.

Methods:

A very thin woman with a diagnosis of SMA syndrome was prepared for surgery after having failed medical therapy. The patient was placed in a supine position, and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy.

Results:

The patient did well postoperatively. A gastrograffin study revealed no leak with patency of the duodenojejunal anastomosis. She was subsequently discharged home on a regular diet on postoperative day four.

Conclusion:

Laparoscopic duodenojejunostomy is a viable option to treat vascular compression of the duodenum. It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient.     

A case report of B-cell lymphoma masquerading as superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is a rare cause of intestinal obstruction, especially in children, whereas intussusception is far more common. We report the case of a child, who after an episode of acute weight loss presented with features suggestive of SMA syndrome. This child subsequently was shown at operation to have disseminated lymphoma causing a secondary high jejunal intussusception and tumor involvement of retroperitoneal lymph nodes causing compression of the third part of the duodenum. This case emphasizes that the SMA syndrome should be considered a sign rather than a diagnosis in itself. As such, an active search should be made to determine the cause of the condition. Routine preoperative imaging is recommended.     

Superior mesenteric artery syndrome in a patient with Charcot Marie Tooth disease

The extrinsic compression of the third part of the duodenum as it passes through the aorto-mesenteric angle is known as the superior mesenteric artery syndrome(SMAS).This syndrome is a rare mechanical cause of upper intestinal obstruction,with a reported incidence of between 0.2% and 0.78%.Clinical manifestations of SMAS may be chronic or acute;chronic symptoms include intermittent gastric pain,fullness and occasional episodes of postprandial vomiting,while acute symptoms include incoercible vomiting,oral intolerance,mainly epigastric abdominal distension and abdominal pain.Surgery is recommended only when initial conservative treatment fails.Here,we report what appears to be the third published case of SMAS associated with hereditary motor and sensory neuropathy or Charcot Marie Tooth disease.     

Laparoscopic management of persistent mullerian duct syndrome

Persistent mullerian duct syndrome (PMDS), characterized by the presence of mullerian structures in a virilized male, frequently presents as undescended testis, either intraabdominal or within a hernial sac. We describe a 10-month-old infant with PMDS successfully managed by the laparoscopic approach. At the age of 1.5 months, the patient presented with a left inguinal hernia and bilateral nonpalpable gonads in another center and underwent left inguinal exploration. The uterus and a gonadlike structure along with the hernia sac were found in the inguinal canal. Left inguinal herniotomy was performed after reduction of the uterus and gonadlike structure. No gonadal biopsy was obtained. The patient was further investigated in the same center. His karyotype was 46,XY. Magnetic resonance imaging of the abdomen and pelvis revealed a uterinelike structure posterior to the urinary bladder, but neither testis nor ovaries were visualized. At 10 months of age, he was referred to our department for further management. A laparoscopic single-stage orchiopexy was performed. Both testes were identified and brought to the scrotum by splitting the uterus in the midline and then bringing the testes with the vas and attached uterine tissue into the scrotum. The aim of placement of well-vascularized testes in the scrotum was achieved as confirmed on follow-up color Doppler ultrasound study 6 months postoperatively, which showed normal vascularity. Laparoscopic surgical techniques for this condition are also discussed.     

Mesenteric thrombosis causing short bowel syndrome in nephrotic syndrome

Nephrotic patients are at risk of developing venous and arterial thrombotic complications. Pulmonary embolism due to affected deep leg veins is by far the most common event. Renal or cerebral vein thromboses have been described. Thrombosis of arterial vessels is less frequent. Mesenteric infarction is a rare but severe complication in patients with nephrotic syndrome (NS). We report a 7-year-old boy with a steroid-dependent (SD) NS and a homozygous mutation of methylenetetrahydrofolate reductase, increasing the risk of thromboembolic events. He developed a thrombosis of his superior mesenteric artery during his ninth relapse, which was responsible for a necrosis of 240 cm of his small bowel, necessitating resection of necrotic parts and double external ostomy diversion. Remission was achieved with pulse prednisolone therapy. Corticoids were reduced over 4 months progressively. Oral cyclosporin A (CyA) was initiated for long-term treatment. Due to a short bowel syndrome with severe malabsorption, even oral administration of 22.5 mg/kg per day CyA did not lead to sufficient plasma levels. Intravenous cyclophosphamide pulse therapy over 6 months led to a complete remission. No relapse occurred over a period of more than 5 months after the last cyclophosphamide pulse. Anticoagulation and screening for increased susceptibility for thrombotic events are necessary in every nephrotic patient. Intravenous cyclophosphamide pulse therapy is a useful alternative in SDNS with impaired intestinal absorption of applied immunosuppressive drugs.     

腕管综合征96例分析

自1993年1月-2000年12月,诊治腕管综合征96例,其中手术治疗31例,现将有关资料进行分析。1临床资料1.1一般资料本组96例,男25例,女71例;年龄为26～63岁,平均43岁。16例为双侧性,病程最短为1周,最长为10年。病因:腕部外伤史17例,手部关节酸痛史23例,18例女性患者认为发病与妊娠或     

Ehlers-danlos syndrome complicated by eventration of the diaphragm,colonic perforation and jejunal perforation —A case report—

A case of a 61 year old woman with Ehlers-Danlos syndrome who developed recurrent gastrointestinal complications is reported herein. She has been followed by Kyoundo Hospital since 1965, when she originally underwent treatment for eventration of the diaphragm and a volvulus of the stomach at the age of 41. During the past 22 years she has experienced perforation of the colon three times and jejunal perforation once. This case was considered to be type II Ehlers-Danlos syndrome. We have found 12 other cases of Ehlers-Danlos syndrome with gastrointestinal complications in the Japanese literature. More thorough examination of Ehlers-Danlos syndrome cases may reveal more subclinical gastrointestinal abnormalities. We concluded from our experience and from the literature that when colonic perforation occurs in this syndrome, total colectomy and ileo-rectal anastomosis is reasonably indicated.     

原发性十二指肠损伤的诊断与治疗

目的 对十二指肠损伤的临床特点,诊断及外科治疗结果进行分析。方法 回顾性总结１９８４～１９９９年经手术证实的十二指肠损伤患者１７例。结果 单纯十二指肠损伤３例,合并伤１４例,其中合并２个以上脏器损伤８例,占４７％。损伤部位以降部及降部与水平部交界处为多,有１３例,占７６％。１６例治愈,治愈率为９４％,有术后并发症者４例,发生率为２４％,死亡１例,病死率为５％。结论 掌握十二指肠损伤的临床特点,提高     

十二指肠环形引流术治疗肠系膜上动脉综合征的评价

目的 评价十二指肠环形引流术治疗肠系膜上动脉综合征(SMAS)的临床价值。方法 分析1959年至2001年采用十二指肠环形引流术治疗42例SMAS的临床资料。结果 本组患主要症状为餐后上腹胀痛和频繁呕吐。37例采用十二指肠环形引流术后，经1—15年随访，效果良好。另有5例曾分别行十二指肠血管前移位术(1例)、胃空肠吻合术(1例)、十二指肠空肠吻合术(2例)和胃部分切除胃空肠Billroth Ⅱ式吻合术(1例)，但术后呕吐症状未缓解，后改行十二指肠环形引流术，经9～1O年随访效果亦佳。结论 肠系膜上动脉综合征患若逆蠕动强烈并持久存在，临床上出现频繁呕吐，一旦成为习惯性，逆蠕动就难以消除，即使手术解除十二指肠梗阻，临床症状也不能改善，其治疗关键必须着眼于解决逆蠕动问题。采用十二指肠环形引流术能解决十二指肠内容物的引流方向。使呕吐等症状消除。     

微型钩刀治疗腕管综合征12例

我们自行设计了微型钩刀配合扩张导管在半直视下松解腕管的新方法,治疗腕管综合征12例,效果良好,现报道如下.……     

ACTH非依赖性库兴综合征(附89例报告)

目的　总结促肾上腺皮质激素 (ACTH)非依赖性库兴综合征的诊断和治疗方法。　方法　对 89例ACTH非依赖性库兴综合征患者的临床资料进行总结。男 11例 ,女 78例。年龄 13～5 6岁 ,平均 34岁。其中腺瘤型皮质醇症 85例、肾上腺皮质癌 2例、大结节样肾上腺皮质增生 2例。回顾性总结其临床、生化特征 ,影像学特点和治疗方法。　结果　 85例腺瘤型皮质醇症术后效果良好 ,库兴综合征症状消失 ;2例肾上腺皮质癌未能切除者术后分别存活 7和 9个月 ;大结节样肾上腺皮质增生 2例行双侧肾上腺切除后治愈。　结论　血浆ACTH水平、地塞米松抑制试验及B超、CT等影像学检查有利于ACTH非依赖性库兴综合征的诊断和鉴别诊断 ,手术治疗腺瘤型皮质醇症和大结节肾上腺增生可获得较理想的疗效 ,肾上腺皮质癌预后差。     

Successful orthotopic heart transplantation in a patient with Marfan syndrome

Cardiovascular diseases represent the leading cause of mortality in patients with Marfan syndrome. Many treatments have been developed for patients with end‐stage heart failure, among which orthotopic heart transplantation remains the gold standard. We report a successful orthotopic heart transplantation for a Marfan syndrome patient in end‐stage heart failure.     

胰十二指肠切除术后胃瘫的治疗体会

目的探讨胰十二指肠切除术(pancreaticoduodenectomy,PD)后胃瘫(postoperative gastroparesis syn-drome,PGS)的病因、发生机制及治疗方法。方法回顾性分析7例胰十二指肠切除术后PGS的临床资料及诊疗过程。结果PGS多发生于胰十二指肠切除术后7～14 d,经分阶段营养支持、改善胃肠动力等保守治疗,PGS均在术后4周内消除。结论胰十二指肠切除术后PGS的病因复杂,采取保守支持治疗是治疗胰十二指肠切除术后PGS的有效手段,分阶段营养支持是治疗的重要措施,不宜采用手术治疗。     

Anesthetic management of a patient with Freeman-Sheldon syndrome

The Freeman-Sheldon syndrome (FSS) is rare congenital myopathy and dysplasia. The musculoskeletal and soft-tissue manifestations of FSS often require orthopedic and plastic reconstructive surgery. We report a case of 19-month-old girl with FSS.     

胆囊切除术后综合征116例ERCP分析

目的探讨胆囊切除术后综合征的病因。方法回顾性总结分析2000年1月至2004年12月间临床诊断为胆囊切除术后综合征的116例ERCP资料。结果本组116例胆管显影率100％,胰管显影97例（83．62％）。原因为胆总管结石56例（48．28％）,十二指肠憩室、憩室内乳头19例（16．34％）,胆囊管残留过长、胆囊管结石15例（12．93％）,胆总管末端良性狭窄13例（11．20）,Oddis括约肌运动功能障碍4例（3．45％）,十二指肠乳头肿瘤3例（2．59％）,胆管损伤狭窄2例（1．73％）,硬化性胆管炎1例（0．86％）,胆管癌1例（0．86％）,残留胆囊伴结石1例（0．86％）,慢性胰腺炎伴胰管结石1例（0．86％）。结论胆囊切除术后综合征的原因以胆总管结石、十二指肠憩室、憩室内乳头、胆囊管残留过长、胆囊管结石、胆总管末端良性狭窄、Oddis括约肌运动功能障碍多见。胆囊切除术后术前症状不缓解或术后又复出现症状,不能拘于胆囊切除术后综合征的诊断,而是应积极寻找病因,以求得到合理治疗。     

复发的腕管综合征的显微外科治疗

目的 探讨复发的腕管综合征(CTS)的显微外科治疗效果. 方法 2001年6月至2009年12月采用显微神经松解联合带血管蒂小鱼际皮下脂肪瓣(HTFPF)治疗21例复发的CTS患者,男5例,女16例;年龄35～78岁,平均52.2岁.17例采用腕管切开松解减压术后复发,4例采用内镜下腕管松解术后复发.术后复发时间5 ～35个月,平均19.6个月.按照CTS分型:中度8例,重度13例.所有患者桡侧3～4个手指麻木、疼痛,有麻刺感;Tinel征均阳性;食指指腹两点分辨觉5～14mm,平均9.3mm;握力6～18 kg,平均11.7 kg.所有患者复发后采取保守治疗3周均无效.结果 21例患者术后获18 ～48个月(平均24.4个月)随访.正中神经卡压症状明显改善时间2～14d,平均7.2d;两点辨别觉提高至2～8mm,平均4.0 mm;握力18～37 kg,平均23.5 kg.所有患者手指活动、感觉正常,麻木、针刺感消失,无明显的腕部疼痛,拇指对掌功能正常,肌电图检查均阴性,Tinel征、Phalen征、Reverse Phalen征均阴性.术后18个月,按CTS功能评定标准:优16例,良4例,可1例,优良率为95.2％,腕部主观疼痛减轻率达100％.所有患者均恢复正常工作和生活.全部患者术后未出现支柱疼痛、小鱼际疼痛、反射性交感神经营养不良、正中神经及其返支、掌浅弓损伤等并发症. 结论 显微外科治疗是治疗复发的CTS的有效方法,显微神经松解联合HTFPF可以恢复正中神经的滑动,并提供良好的软组织营养基床,显著改善复发的CTS患者的症状.