Superior mesenteric artery syndrome (Wilkie's syndrome) is rare. It represents a vascular compression of the third part of the duodenum in the aortomesenteric angle, causing non-specific symptoms (nausea, vomiting, post-prandial epigastric pain). Many conditions can cause this entity: bariatric surgery, malignancies, eating disorders... Surgeons must have a low threshold of suspicion in order to make a correct diagnosis, since superior mesenteric artery syndrome (SMA) is usually an exclusion diagnosis.
Surgeons from the Surgery C Department form Centro Hospitalar e Universitário de Coimbra - Hospital Geral (Covões), in Portugal, published in June 2017 a case report of a young female patient with anorexia nervosa who developed a SMA. Miguel Albano et al. enhance in this paper a shift towards medical treatment aimed at increase body weight. The young female was treated only with nasogastric tube decompression, intravenous fluids, hyper caloric liquids for three days leading to symptoms resolution. Oral feeding was then started and tolerated. She had a 5kg gain in one month, and was asymptomatic at three months of follow-up.
Image (CT or MRI) is crucial for making a correct diagnosis. An aortomesenteric angle <25º, mainly with an aortomesenteric distance <8mm, is all that is need to diagnose a Wilkie's syndrome. Miguel Albano and fellows discuss the surgical options when conservative treatment fails. Although gastrojejunostomy and Strong's procedure (Treitz mobilisation) are both valid options, duodenojejunostomy offers the best results.
There is a question that still needs an answer: when do we consider that the the medical treatment failed? It is easy to understand that answering this question is crucial to decide to operate. Nowadays there is no established time period for medical treatment before surgery. The authors state that clinical and radiological evaluation are keys factors to help surgeons in decision making.
In conclusion: first, in face with a rare entity like SMA, surgeons must have a low threshold of suspicion to make a correct and early diagnosis; secondly, clinical evaluation still plays a major role during patient evaluation and treatment; third, conservative treatment is the first option in the majority of cases; fourth, when medical treatment fails duodenojejunostomy is the best option.
Do not forget: clinical evaluation gives the answer to lot of difficult questions!
Link to PubMed:
Carlos Eduardo Costa Almeida
General Surgeon