Síndrome de la arteria mesentérica superior (Síndrome de Wilkie): A propósito de un caso en una adolescente / Superior mesenteric artery syndrome (Wilkie syndrome): A case report in an adolescent

Introducción. El síndrome de la arteria mesentérica superior, también conocido como síndrome de Wilkie, es una entidad infrecuente en la que una reducción del ángulo o espacio aorto-mesentérico determina una compresión extrínseca con obstrucción del tercio distal del duodeno, demostrando síntomas y signos característicos de obstrucción intestinal. El pilar del tratamiento es el manejo médico conservador con repleción nutricional, con el objetivo de aumentar el grosor de la grasa retroperitoneal y con esto resolver la compresión duodenal. Caso clínico. Paciente de 16 años, con un curso crónico marcado por dolor abdominal, estreñimiento, distensión, pirosis y pérdida de peso. Inicialmente se trató como una enfermedad ácido-péptica, con pobre mejoría, por lo que se realizaron estudios imagenológicos con lo que se documentó una disminución del ángulo aortomesentérico. Resultado. Se instauró un manejo médico con un protocolo de repleción nutricional por vía oral, para lograr ganancia de peso y evitar la cirugía. Conclusión. Con base a los síntomas y hallazgos en imágenes diagnósticas se hizo el diagnóstico de síndrome de la arteria mesentérica superior, que es una causa de obstrucción intestinal con muy baja incidencia. Su presentación clínica incluye gran variedad de síntomas, entre los que destaca el dolor abdominal y la pérdida de peso. Es frecuente la confusión con otras enfermedades más frecuentes, como enfermedad ácido-péptica, reflujo gastrointestinal y malabsorción. Su diagnóstico requiere un alto índice de sospecha, por lo que es importante conocer esta entidad y considerarla en el estudio de pacientes con los síntomas mencionados.

Introduction. Superior mesenteric artery syndrome, also known as Wilkie syndrome, is a rare entity in which a reduction in the aorto-mesenteric angle or space determines extrinsic compression with obstruction of the distal third of the duodenum, demonstrating characteristic symptoms and signs of intestinal obstruction. The mainstay of treatment is conservative medical management with nutritional repletion, with the aim of increasing the thickness of the retroperitoneal fat and thereby resolving duodenal compression. Clinical case. A 16-year-old patient, with a chronic course marked by abdominal pain, constipation, bloating, heartburn and weight loss. Initially was treated as an acid-peptic disease, with poor improvement. Imaging studies were performed, which documented a decrease in the aorto-mesenteric angle. Conclusion. Based on the symptoms and findings on diagnostic images, the diagnosis of superior mesenteric artery syndrome was made, which is a cause of intestinal obstruction with a very low incidence. Its clinical presentation includes a wide variety of symptoms, among which abdominal pain and weight loss stand out. Confusion with other more common diseases is common, such as acid-peptic disease, gastrointestinal reflux and malabsorption. Its diagnosis requires a high index of suspicion, so it is important to know this entity and consider it in the study of patients with the aforementioned symptoms.

Un caso complejo de isquemia mesentérica crónica: Reporte de caso y revisión de la literatura / A complex case of chronic mesenteric ischemia: Case report and literature review

Introducción. La isquemia mesentérica crónica es una entidad infrecuente, con una prevalencia de 0,03 %, donde más del 90 % son debidas a enfermedad arterioesclerótica que compromete principalmente la arteria mesentérica superior. Sus síntomas son dolor abdominal crónico y pérdida de peso, asociado a alteraciones imagenológicas que hacen el diagnóstico. El tratamiento depende de las condiciones clínicas del paciente y el número de vasos comprometidos. Es claro que la enfermedad multivaso sintomática requiere revascularización. Caso clínico. Mujer de 67 años, fumadora activa con antecedentes de hipertensión arterial y dislipidemia, con cuadro de crisis hipertensiva tipo urgencia que requirió manejo en Unidad de Cuidados Intensivos. Se hizo diagnóstico de aneurisma toracoabdominal Crawford IV, oclusión aorto-ilíaca (TASC D) y oclusión crónica del tronco celíaco y la arteria mesentérica superior. Por los síntomas de isquemia mesentérica crónica fue llevada a tratamiento quirúrgico con baipás aorto-bifemoral más baipás retrógrado a la arteria mesentérica superior por vía abierta. Resultado. La paciente tuvo mejoría de la sintomatología y aumentó 13 % del peso al seguimiento a los 3 meses. Conclusión. La isquemia mesentérica crónica es una condición subdiagnosticada, marcador de riesgo cardiovascular, con alta carga de morbilidad y mortalidad, en la cual, con una identificación temprana se puede ofrecer una terapia de revascularización, sea por vía endovascular o abierta, con el fin de mejorar la calidad de vida y la ganancia de peso, y evitar la necrosis intestinal.

Introduction. Chronic mesenteric ischemia is a rare entity, with a prevalence of 0.03%, where more than 90% are due to arteriosclerotic disease that mainly affects the superior mesenteric artery. Its symptoms are chronic abdominal pain and weight loss, associated with imaging alterations that make the diagnosis. Treatment depends on the patient's clinical conditions and the number of vessels involved. It is clear that symptomatic multivessel disease requires revascularization. Clinical case. A 67-year-old woman, an active smoker with a history of high blood pressure and dyslipidemia, presented with an emergency-type hypertensive crisis that required management in the Intensive Care Unit. A diagnosis of Crawford IV thoracoabdominal aneurysm, aorto-iliac occlusion (TASC D), and chronic occlusion of the celiac trunk and superior mesenteric artery was made. Due to the symptoms of chronic mesenteric ischemia, she underwent surgical treatment with aorto-bifemoral bypass plus retrograde bypass to the superior mesenteric artery via an open approach. Result. The patient had improvement in symptoms and gained 13% weight at 3-month follow-up. Conclusion. Chronic mesenteric ischemia is an underdiagnosed condition, a marker of cardiovascular risk, with a high burden of morbidity and mortality, in which, with early identification, revascularization therapy can be offered, either endovascularly or open, in order to improve quality of life and weight gain, and avoiding intestinal necrosis.

Actualización en el manejo de la isquemia mesentérica aguda

La isquemia mesentérica aguda (IMA) es una emergencia médico-quirúrgica poco frecuente con alta morbimortalidad. Corresponde a una interrupción brusca del aporte sanguíneo a un segmento del intestino, produciendo isquemia, daño celular, necrosis intestinal y eventualmente la muerte. La principal etiología de este cuadro es la oclusión arterial de tipo embólica, seguida por la trombótica, no oclusiva y trombótica venosa. Es una patología infrecuente con una incidencia baja, de 12 por 100.000 habitantes en series internacionales. Su principal síntoma es el dolor abdominal tipo cólico de comienzo brusco, vómitos y diarrea, esta última sucediendo posteriormente. En el examen físico se pueden constatar signos de shock y distensión abdominal. Ante la sospecha, los pacientes hemodinámicamente inestables deben ser llevados urgentemente a laparotomía exploradora, y en aquellos estables, se debe solicitar un Angio-TC para confirmar el diagnóstico y planificar el tratamiento. Existen dos métodos para tratar esta patología: la cirugía abierta y la cirugía endovascular o mínimamente invasiva. Finalmente, con el avance de estos nuevos métodos, la tasa de mortalidad ha disminuido, significativamente, en la última década.

Acute mesenteric ischemia (AMI) is a rare medical-surgical emergency that must be treated early due to its high morbidity and mortality. It corresponds to a sudden interruption of the blood supply to a segment of the intestine, producing ischemia, cell damage, intestinal necrosis and eventually death if it is not treated. The main etiology of this condition is embolic-type arterial occlusion, followed by thrombotic, nonocclusive, and venous thrombotic. It is an infrequent pathology with a low incidence of 12 per 100,000 inhabitants in international series. During the information collection, no data was found on the Chilean population since before 1983. Its main symptom is colicky abdominal pain with a sudden onset, vomiting and diarrhea that begins after the pain. On physical examination, signs of shock and abdominal distention may be noted. Hemodynamically unstable patients should be urgently taken to exploratory laparotomy as soon as the condition is suspected, and in stable patients, an angio-CT should be requested to confirm the diagnosis and plan treatment. There are two methods to treat this pathology, open surgery and endovascular or minimally invasive surgery. The form of therapy depends on the preoperative or intraoperative findings and the type of etiology. Finally, with the advancement of these new methods, the mortality rate has decreased in the last decade.

Síndrome de Wilkie como reto diagnóstico en obstrucción intestinal: reporte de caso / Wilkie syndrome as a diagnostic challenge in intestinal obstruction: case report

RESUMEN El síndrome de Wilkie es una patología poco frecuente que genera un cuadro de obstrucción intestinal, debido a la disminución del ángulo aortomesentérico comprometiendo la tercera porción del duodeno. Describimos el caso de una paciente de 18 años de edad, diagnosticada con síndrome de Wilkie, con cuadro clínico de obstrucción intestinal y pérdida de peso. El diagnóstico se realizó con tomografía abdominal. El síndrome de Wilkie es una patología rara, que se vuelve un reto diagnóstico, por presentar un cuadro similar a otras patologías más comunes. Recomendamos que se sospeche ante un cuadro de obstrucción duodenal.

ABSTRACT Wilkie syndrome is a rare pathology that generates intestinal obstruction due to a decrease of the aortomesenteric angle compromising the third portion of the duodenum. We describe a case of an 18-year-old female patient, diagnosed with Wilkie syndrome, with clinical symptoms of intestinal obstruction and weight loss. The diagnosis was made with abdominal CT. Wilkie syndrome is a rare pathology, which becomes a diagnostic challenge because it presents a similar picture to other more common pathologies. We recommend that it should be suspected in the presence of duodenal obstruction.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm / Revascularização aberta na isquemia mesentérica crônica durante a era endovascular: experiência de um centro quaternário e um algoritmo de tratamento

Abstract Background Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR). Objectives To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition. Methods Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature. Results All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years. Conclusions Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Resumo Contexto A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta. Objetivos Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição. Métodos Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C. Resultados Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos. Conclusões A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Síndrome de la arteria mesentérica superior o Síndrome de Wilkie. Presentación de tres casos clínicos y revisión de la literatura

Objetivo: Presentar una causa rara de obstrucción duodenal como es el sindrome de arteria mesentérica superior (SAMS). Material y Método: se presentan tres casos clínicos de sindrome de SAMS. Resultados: el tratamiento médico y nutricional fue exitoso en los primeros dos casos, mientras que en el último fue necesario realizar una derivación quirúrgica. Discusión: en este sindrome, el ángulo aortomesentérico normal se encuentra disminuído, causando la compresión de la tercera porción del duodeno entre la aorta y la arteria mesentérica superior. Esto determina una obstrucción duodenal que se ve más frecuentemente en pacientes con pérdida importante y rápida de peso. Esto determina alteraciones hidroelectrolíticas y desnutrición severas. El tratamiento médico consiste en soporte nutricional y corrección de anormalidades hidroelectrolíticas. Los procedimientos quirúrgicos se reservan frente a los casos de falla del tratamiento médico. Conclusión: el SAMS es una entidad poco frecuente y un reto diagnóstico. El cuadro clínico puede ser grave con desnutrición severa y trastornos hidroelectrolíticos que ponen en riesgo la vida del paciente. El soporte hidroelectrolítico y nutricional, junto a la duodenoyeyunostomía, son los tratamientos de elección.

Aim: To present a rare cause of duodenal obstruction known as the superior mesenteric artery syndrome (SMAS). Material and Method: we present three cases of SMAS. Results: medical and nutritional treatment were effective in the first two cases while in the last case, a derivative procedure was necessary. Discussion: in this syndrome, the normal aortomesenteric angle is narrowed, causing compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. This leads to duodenal obstruction more frequently observed in patients with severe and fast weight loss. Medical treatment consists in nutritional support and correction of hydro electrolyte imbalance. Surgical procedures are reserved for cases with failure of medical treatment. Conclusion: SMAS is a rare entity and a diagnosis challenge. Clinical setting may be severe with extreme malnutrition and life-threatening dehydration and electrolyte disorder. Nutritional support, hydro electrolyte correction, combined with duodenojejunostomy, if necessary, are the treatments of choice.

Aneurisma de arteria mesentérica superior: causa muy rara de epigastralgia

Se describe el primer caso de tratamiento quirúrgico exitoso de un aneurisma de arteria mesentérica superior en el Hospital Regional III Honorio Delgado de Arequipa. El paciente presentó dolor epigástrico de 18 meses de evolución que fue diagnosticado mediante tomografía y angiotomografía computarizada. Fue sometido a laparotomía para resección de aneurisma y se realizó un bypass de arteria mesentérica superior utilizando un injerto de politetrafluoroetileno. El paciente tuvo una recuperación rápida y sin complicaciones y ha evolucionado adecuadamente hasta la fecha. Este tipo de aneurisma es raro, no contamos con incidencias reportadas en Perú. El tratamiento quirúrgico requiere una planificación cuidadosa debido al alto riesgo de ruptura y mortalidad. El apoyo tecnológico es primordial en la aproximación quirúrgica de este tipo de pacientes, lo cual muchas veces es un reto en hospitales públicos no especializados.

The first successful case of surgical treatment of a superior mesenteric artery aneurysm is described at the Honorio Delgado Regional Hospital III in Arequipa. The case report involved a patient who had experienced 18 months of epigastric pain and was diagnosed with computed tomography and computed tomography. The patient underwent laparotomy for aneurysm resection and a bypass of the superior mesenteric artery was performed using a polytetrafluoroethylene graft. The patient had a rapid and uncomplicated recovery and has since progressed well. This type of aneurysm is rare, with no epidemiological data in Peru. Surgical treatment requires careful planning due to the high risk of rupture and mortality. Technological support is essential in the surgical approach of these patients, which is often a challenge in non-specialized public hospitals.

Causa rara de dolor abdominal recurrente; coexistencia del síndrome de Wilkie y el síndrome del cascanueces / A rare cause of recurrent abdominal pain; the coexistence of Wilkie's syndrome and nutcracker syndrome

El síndrome del cascanueces es un síndrome que presenta síntomas clínicos como hematuria, proteinuria ortostática, congestión pélvica, varicocele del lado izquierdo, hipertensión y dolor en fosa renal. Estos síntomas se producen por la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior. En el síndrome de Wilkie, la tercera porción del duodeno está comprimida entre la arteria mesentérica superior y la aorta abdominal, lo que provoca diversos síntomas gastrointestinales. La coexistencia de estos dos síndromes constituye una afección rara y se incluye como casos clínicos en la bibliografía. En este artículo, se presentan los resultados clínicos y radiológicos de un paciente de 17 años que presentaba dolor abdominal recurrente debido al síndrome de Wilkie, acompañado del síndrome del cascanueces que le provocaba proteinuria, por lo que el paciente fue derivado a los consultorios externos de reumatología pediátrica con un diagnóstico preliminar de fiebre mediterránea familiar.

Nutcracker syndrome is a syndrome that has clinical symptoms such as hematuria, orthostatic proteinuria, pelvic congestion, left-sided varicocele, hypertension, and flank pain. These symptoms occur because of the compression of the left renal vein between the aorta and the superior mesenteric artery. In Wilkie's syndrome, the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, causing various gastrointestinal symptoms. The coexistence of these two syndromes is a rare condition and is included as case reports in the literature. This article presents the clinical and radiological results of a 17-year-old male patient who had recurrent abdominal pain due to Wilkie's syndrome, which was accompanied by nutcracker syndrome that caused proteinuria, and for this reason, the patient was referred to the Pediatric Rheumatology outpatient clinic with a preliminary diagnosis of familial Mediterranean fever.

Wilkie's and Nutcracker's syndromes overlapping a case of functional dyspepsia

We present the case of a patient suffering from a mixed-type functional dyspepsia who markedly reduced his diet to improve his symptoms leading him to malnourishment and a subsequent Wilkie's and Nutcracker's syndromes which exacerbated his pain. Our aim by presenting this case is to raise awareness as to what extent a so-called functional dyspepsia can evolve and of the possible overlap with these two entities in case of severe malnutrition.

Presentamos el caso de un paciente diagnosticado de dispepsia funcional de tipo mixto, el cual redujo marcadamente su dieta para mejorar sus síntomas, llevándolo a una desnutrición y a un posterior síndrome de Wilkie y del Cascanueces que agudizó su dolor. Nuestro objetivo con la presentación de este caso es concienciar de hasta qué punto puede evolucionar una denominada dispepsia funcional y del posible solapamiento de estas dos entidades en caso de desnutrición severa.

Combined superior mesenteric artery syndrome and nutcraker syndrome presenting as acute pancreatitis: a case report / Síndrome da artéria mesentérica superior em combinação com síndrome de quebra-nozes manifestando-se como pancreatite aguda: relato de caso

Abstract Superior mesenteric artery syndrome designates compression of the third part of the duodenum between the superior mesenteric artery and the aorta. This condition has a low incidence, being more common in thin young women. Nutcracker syndrome is compression of the left renal vein between the superior mesenteric artery and the aorta. Both entities are rare, and their coexistence has been reported in a few cases. Conservative treatment targeting weight gain is sufficient in most cases. An association between the superior mesenteric artery syndrome and acute pancreatitis has rarely been reported. We intend to describe the case of an 18-year-old girl who was admitted to the emergency room with epigastric pain and emesis. Our investigation revealed acute acalculous pancreatitis. During work-up, we discovered superior mesenteric artery syndrome and a compressed left renal vein. The patient is on conservative treatment, and her symptoms have improved.

Resumo A síndrome da artéria mesentérica superior designa compressão da terceira parte do duodeno pela artéria mesentérica superior e a aorta. Essa condição tem uma baixa incidência, sendo mais comum em mulheres jovens magras. A síndrome de quebra-nozes resulta da compressão da veia renal esquerda pela artéria mesentérica superior e a aorta. Ambas as entidades são raras, e a sua coexistência foi descrita em poucos casos. Tratamento conservador com o objetivo de ganho ponderal é suficiente na maioria dos casos. A associação entre a síndrome da artéria mesentérica superior e a pancreatite aguda foi raramente relatada. Pretendemos descrever o caso de uma jovem de 18 anos que recorreu ao serviço de urgência com epigastralgia e vômitos. A investigação realizada revelou pancreatite aguda alitiásica. Durante o estudo complementar, foi identificada a síndrome da artéria mesentérica superior, bem como uma veia renal esquerda comprimida. A paciente encontra-se em tratamento conservador, apresentando melhora clínica.

Síndrome de cascanueces acompañando un caso de síndrome de Wilkie: a propósito de un caso / Nutcracker Syndrome Combined with Wilkie Syndrome: Case Report

Resumen Objetivo: describir la presentación clínica, el diagnóstico y el tratamiento quirúrgico de un paciente con síndrome de la arteria mesentérica superior o síndrome de Wilkie combinado con síndrome de cascanueces o síndrome de compresión de la vena renal izquierda, en un centro de alta complejidad de un país latinoamericano. Descripción del caso: paciente masculino de 25 años, procedente de Estados Unidos, quien consultó por un año de pérdida de peso y episodios de obstrucción intestinal de etiología desconocida tras múltiples estudios de imagen. Se le realizaron estudios endoscópicos sin hallazgos; en la sala de recuperación desarrolló dolor abdominal que requirió ingreso al servicio de urgencias. La enterotomografía mostró dilatación de asas de colon e intestino delgado, con disminución del ángulo aortomesentérico y la serie gastrointestinal con paso filiforme del medio de contraste. Se intentó el manejo conservador como terapia inicial, con intolerancia al soporte nutricional entérico. Finalmente, se optó por el tratamiento quirúrgico, con un proceso de recuperación tórpido inicialmente, pero al final con resolución de los síntomas y aumento de peso. Conclusión: el síndrome de Wilkie es una enfermedad rara y un desafío diagnóstico en pacientes con pérdida de peso y dolor abdominal. Describimos un caso de compresión de la arteria mesentérica superior en el que se logró el diagnóstico con múltiples estrategias diagnósticas y resolución completa luego del tratamiento quirúrgico. La disminución del ángulo aortomesentérico puede comprimir la arteria mesentérica superior, así como la vena renal izquierda, que en ese caso resultó en un síndrome combinado de Wilkie y de cascanueces.

Abstract Objective: to describe the clinical presentation, diagnosis, and surgical treatment of a patient with superior mesenteric artery syndrome or Wilkie syndrome combined with the nutcracker syndrome or left renal vein compression syndrome in a tertiary referral center in a Latin American country. Case description: a 25-year-old male patient from the United States who attended for a year of weight loss and intestinal obstruction episodes of unknown etiology after multiple imaging studies. Endoscopic studies were performed without findings. While in the recovery room, he developed abdominal pain requiring admission to the emergency service. The CT enterography showed dilation of the colon loops and small intestine with a decrease of the aortomesenteric (AOM) angle and the gastrointestinal series with the filiform passage of the contrast medium. Conservative management was attempted as initial therapy with intolerance to enteric nutritional support. Finally, we initially opted for surgical treatment, with a slow recovery process, but in the end, with a resolution of symptoms and weight gain. Conclusion: Wilkie syndrome is a rare disease and a diagnostic challenge in patients with weight loss and abdominal pain. We described a superior mesenteric artery compression case in which diagnosis was achieved with multiple diagnostic strategies and complete resolution after surgical treatment. The decreased aortomesenteric angle may compress the superior mesenteric artery and the left renal vein. In this case, it resulted in a combined Wilkie and nutcracker syndrome.

Tratamento combinado na dissecção de artéria mesentérica superior: desafio terapêutico / Combination treatment for superior mesenteric artery dissection: therapeutic challenge

Resumo A dissecção da artéria mesentérica superior é uma causa rara de dor abdominal, com quadro clínico variável. Seu diagnóstico é difícil, e não existe consenso sobre suas opções terapêuticas; elas variam em torno de tratamento conservador, correção aberta, endovascular ou combinada. Descrevemos o caso de um homem de 45 anos com dissecção isolada da artéria mesentérica superior, com quadro de dor abdominal persistente após tentativa de tratamento conservador. Ele foi submetido à revascularização cirúrgica aberta devido à localização e complexidade da dissecção. O tratamento com endarterectomia, arterioplastia com remendo de pericárdio bovino e acesso retrógrado para abertura da mesentérica com stent foi realizado com sucesso. A angina abdominal foi totalmente resolvida após estabilização do quadro. A combinação de abordagem aberta e endovascular deve ser considerada como terapia para casos de dissecção complexa isolada da artéria mesentérica superior.

Abstract Dissection of the superior mesenteric artery is a rare cause of abdominal pain, with a variable clinical picture. It is difficult to diagnose and there is no consensus on treatment options, which range from conservative treatment to open, endovascular, or combination repair. We describe the case of a 45-year-old man with isolated dissection of the superior mesenteric artery and persistent abdominal pain after conservative treatment had been attempted. He underwent open surgical revascularization due to the location and complexity of the dissection. Treatment consisting of endarterectomy, arterioplasty with bovine pericardium patch, and retrograde access to open the mesenteric artery with a stent was successful. Abdominal angina was completely resolved after the condition had stabilized. A combination of open and endovascular approaches should be considered as treatment for cases of isolated complex dissection of the superior mesenteric artery.

Síndrome de Wilkie: caso clínico / Wilkie syndrome: case report

Resumen Introducción: El síndrome de Wilkie es una causa poco frecuente de obstrucción del tracto digestivo superior, se caracteriza por una disminución del ángulo aorto-mesentérico que resulta en compresión de la tercera porción del duodeno que produce síntomas obstructivos altos. Caso Clínico: Presentamos el caso de una mujer de 64 años, con historia de dolor abdominal, pirosis, saciedad precoz e intolerancia a la vía oral, en quien los estudios iniciales mostraron esofagitis, pero en quien los síntomas no mejoraron con el tratamiento clásico para enfermedad ácido péptica y en quien estudios imagenológicos adicionales sugerían el síndrome de Wilkie como causa de los síntomas. Discusión y Conclusión: Se trata de una patología que debe conocerse y considerar en paciente con historia de pérdida de peso, marcada intolerancia a la vía oral y falta de respuesta al manejo.

Introduction: Wilkie syndrome is a rare cause of upper gastrointestinal tract obstruction, it is characterized by a decrease in the aorto-mesenteric angle that results in a compression of the third portion of the duodenum causing high obstructive symptoms. Case Report: We present the case of a 64-year-old woman, with a history of abdominal pain, heartburn, early satiety, and intolerance to the oral route, in whom initial studies showed esophagitis, but in whom symptoms did not improve with the classic treatment for peptic acid disease, additional imaging studies suggested Wilkie syndrome. Discussion and Conclusión: It is a pathology that must be known and suspected in patients with a history of weight loss, marked intolerance to oral intake, and lack of treatment response.

Síndrome de Wilkie. Diagnóstico por imágenes / Wilkie syndrome. Imaging diagnosis

RESUMEN El síndrome de Wilkie representa una rara causa de obstrucción intestinal por compresión externa de la tercera porción duodenal por la arteria mesentérica superior. Se presenta una mujer de 68 años que fue a consulta por presentar vómitos biliosos frecuentes, con distensión abdominal, y marcada pérdida de peso. Mediante estudios radiográficos baritados con control fluoroscópico y tomografía axial computarizada con contraste vía oral y endovenosa, se evidenció compresión duodenal extrínseca en la tercera porción; se diagnosticó un síndrome de Wilkie y se instauró un tratamiento conservador, el cual cursó favorablemente. El síndrome de Wilkie, a pesar de su baja incidencia, debe considerarse como diagnóstico diferencial en cuadros de obstrucción intestinal alta.

ABSTRACT Wilkie syndrome represents a rare cause of intestinal obstruction due to external compression of the third duodenal portion by the superior mesenteric artery. We present a 68-year-old woman who came to the consultation for frequent bilious vomiting, abdominal distension and marked weight loss. Extrinsic duodenal compression was evidenced in its third portion by means of barium radiographic studies with fluoroscopic control and computerized axial tomography with oral and intravenous contrast; Wilkie syndrome was diagnosed and conservative treatment was instituted, which progressed favorably. Wilkie syndrome, despite its low incidence, should be considered as a differential diagnosis in cases of upper intestinal obstruction.

Superior Mesenteric Artery Syndrome - An Uncommon Complication After Surgical Corrections of Spinal Deformities / Síndrome da artéria mesentérica superior - Uma complicação incomum após correções cirúrgicas de deformidades da coluna

Abstract Vascular compression of the third part of the duodenum by the superior mesenteric artery results in an unusual occlusion of the duodenal transit known as superior mesenteric artery syndrome. This syndrome can occur after surgeries to correct spinal deformities in a rate ranging from 0.5% to 4.7%. It results from a positional alteration of the artery emergency point due to a change in trunk length after surgery. It is associated with risk factors such as low body mass index and weight loss. Patients usually present with intestinal occlusion, abdominal pain, nausea, bilious vomiting, and early satiety. Superior mesenteric artery syndrome must be recognized early to institute an adequate treatment, which can be clinical (with gastric tube for decompression and nutritional support) or require a surgical procedure. Secondary complications related to superior mesenteric artery syndrome include delayed surgical and nutritional recovery, healing problems, and prolonged hospitalization. The present study aims to report a case of superior mesenteric artery syndrome in a patient with neuromuscular scoliosis secondary to a transverse myelitis who underwent surgical treatment for spinal deformity correction.

Resumo A compressão vascular da terceira parte do duodeno pela artéria mesentérica superior resulta no desenvolvimento de uma condição incomum de oclusão do trânsito duodenal conhecida como síndrome da artéria mesentérica superior. Este fenômeno pode acontecer após cirurgias de correção de deformidades da coluna, e sua taxa de ocorrência é de 0,5 a 4,7% dos casos. Isso ocorre em virtude da alteração do posicionamento do ponto de emergência da artéria, decorrente da mudança do comprimento do tronco após a cirurgia, e está associado a fatores de risco, como baixo índice de massa corpórea e perda ponderal. Os pacientes costumam se apresentar com um quadro de oclusão intestinal, com dor abdominal, náusea, vômito bilioso e saciedade precoce. O reconhecimento desta condição é importante para instituir o tratamento adequado, que varia do tratamento clínico, com sondagem e descompressão gástrica associados a suporte nutricional; à necessidade de abordagem cirúrgica. Complicações secundárias relacionadas à síndrome da artéria mesentérica superior incluem: recuperação cirúrgica e nutricional retardadas, problemas com a cicatrização e hospitalização prolongada. O objetivo do presente estudo é relatar um caso de síndrome da artéria mesentérica superior, ocorrido em um paciente com escoliose neuromuscular secundária a sequela de mielite transversa, submetido ao tratamento cirúrgico da deformidade da coluna.

Damage control in abdominal vascular trauma

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

Duodenoyeyunostomía laparoscópica en el Síndrome de la Arteria Mesentérica Superior / Laparoscopic duodenojejunostomy for Superior Mesenteric Artery Syndrome

Introducción: El Síndrome de la Arteria Mesentérica Superior es causa poco frecuente de obstrucción duodenal. Los síntomas varían desde una obstrucción leve hasta emergencias agudas. El examen físico no siempre ayuda al diagnóstico, que se basa en los hallazgos imagenológicos. Objetivo: preconizar, recomendar el uso de las técnicas mínimamente invasivas en el manejo quirúrgico del Síndrome de la Arteria Mesentérica Superior. Presentación del caso: Mujer de 49 años de edad, antecedentes de pérdida de peso después de quimioterapia con náuseas, vómitos y dolor abdominal posprandial de dos años de evolución. Tratada exitosamente con duodenoyeyunostomía laparoscópica. El tratamiento inicial suele ser conservador. Publicaciones recientes respaldan que la duodenoyeyunostomía laparoscópica es un método seguro y efectivo para su tratamiento. Conclusiones: El tratamiento quirúrgico es cada vez más exitoso, la mayoría de los pacientes no presenta síntomas después de la cirugía(AU)

Introduction: Superior Mesenteric Artery Syndrome is an uncommon cause of duodenal obstruction. Symptoms may vary from mild obstruction to acute life-threatening emergencies. Physical examination does not always help in establishing the diagnosis which is based on findings from imaging studies. Objective: To recommend the laparoscopic approach for the surgical treatment of this entity. Case presentation: A 49-year old female patient with prior history of weight loss after chemotherapy and a two-year history of postprandial nausea, vomiting, and abdominal pain who was successfully treated by laparoscopic duodenojejunostomy is presented. Discussion: Initial treatment is usually conservative. Recently published studies support that laparoscopic duodenojejunostomy is a safe and effective method of treatment. Conclusions: Surgical treatment is becoming more successful and the majority of patients are symptom-free after surgery(AU)

Síndrome de la arteria mesentérica superior en una adolescente con anorexia nerviosa durante la pandemia del COVID - 19. Reporte de un caso clínico / Superior mesenteric artery syndrome in an adolescent with anorexia nervosa during the COVID-19 pandemic. A clinical case report

RESUMEN Se describe el caso de una paciente adolescente con diagnóstico de Síndrome de Arteria Mesentérica Superior causado por emaciación resultante de un Trastorno de Conducta Alimentaria (Anorexia Nerviosa, AN) cuya evolución fue severamente acentuada por la pandemia de COVID-19. El Síndrome se debe a la compresión de la tercera porción del duodeno entre la arteria mesentérica superior y la aorta. Se describen las características clínicas, etiopatogénicas y diagnósticas más saltantes de la AN, cuyo diagnóstico precoz es fundamental para mejorar un pronóstico complicado por las consecuencias de baja de peso y desnutrición. La comorbilidad ansiosa y depresiva asociada al estrés causado por el confinamiento y los rasgos de personalidad obsesiva de la paciente requirieron de un tratamiento conjunto de los servicios de Pediatría y de Psiquiatría del Niño y Adolescente, este último con intervenciones psicoterapéuticas individual y familiar.

SUMMARY The case of an adolescent patient diagnosed with Superior Mesenteric Artery Syndrome caused by emaciation resulting from an eating disorder (Anorexia Nervosa, AN) es described. Its clinical course was severely accentuated by the COVID-19 pandemic. The Syndrome is due to the compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. The main clinical, etiopathogenic and diagnostic characteristics of AN are described; its early diagnosis is essential to improve a prognosis complicated by the consequences of weight loss and malnutrition. Anxious and depressive comorbidities associated with the stress caused by the confinement, and the patient's obsessive personality traits required a joint treatment by the Pediatry and Child and Adolescent Psychiatry Services, the latter with individual and family psychotherapy interventions.

Distensión gástrica aguda causada por síndrome de arteria mesentérica superior en una paciente bulímica

La dilatación gástrica aguda se fundamenta por dos teorías, la mecánica que es explicada por el síndrome de arteria mesentérica superior, y la atónica que es producto de una condición médica en la que el estómago progresivamente se vuelve hipotónico y se sobredistiende aún en ausencia de una causa mecánica obstructiva; con mayor frecuencia la dilatación gástrica aguda se presenta en pacientes con trastornos de la alimentación y puede conllevar a una complicación rara pero letal como la perforación gástrica. Presentamos el caso de una paciente de 18 años, quien acude al servicio de emergencia con dolor abdominal agudo, es intervenida quirúrgicamente, donde se encontró perforación de la pared gástrica anterior. Se le realizó una gastrectomía parcial proximal, y se envió el espécimen para estudio patológico. La histopatología mostró necrosis transmural predominantemente en fondo gástrico.

Acute gastric dilation is based on two theories, the mechanical one that is explained by the superior mesenteric artery syndrome and the atonic one, the latter is the product of a medical condition in which the stomach progressively becomes hypotonic and over-distended even in the absence of an obstructive mechanical cause; it most often occurs in patients with eating disorders; which can lead to a rare but fatal complication such as gastric perforation. We present the case of an 18 year old patient who comes to the emergency service of our hospital with acute abdominal pain, undergoes surgery, where there is perforation of the anterior gastric wall, and a proximal. Partial gastrectomy is performed, and a sends the specimen for pathology study. Histopathology shows transmural necrosis predominantly in the gastric fundus.

Pseudoaneurisma roto de artéria ileocólica: relato de caso / Ruptured ileocolic artery pseudoaneurysm: case report

Resumo Os aneurismas de artérias viscerais (AAVs) e pseudoaneurismas de artérias viscerais (PAAVs) são condições raras e potencialmente letais quando rotos. Em geral, são encontrados incidentalmente na tomografia computadorizada de pacientes assintomáticos. Embora a cirurgia aberta convencional seja considerada atualmente o tratamento padrão ouro, a abordagem endovascular vem ganhando relevo por ser considerada um procedimento minimamente invasivo e com riscos cirúrgicos menores. Destaca-se, nessa abordagem, o uso de embolização por molas (coils) em AAVs e PAAVs saculares e implante de stent modulador de fluxo como alternativa de tratamento para aneurismas fusiformes. Apresentamos o caso de uma paciente de 51 anos com queixa de dor abdominal aguda, taquicardia e hipotensão, com evidência de sangramento abdominal em angiotomografia e diagnóstico de pseudoaneurisma de artéria ileocólica (AIC) roto. Ela foi submetida a tratamento endovascular precoce de embolização da AIC com sucesso, e houve melhora do quadro clínico.

Abstract Visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) are rare conditions and are potentially lethal when they rupture. They are usually found as incidental findings on computed tomography (CT) scans of asymptomatic patients. Although conventional open surgery is currently considered the gold standard treatment, the endovascular approach has gained prominence as a minimally invasive procedure with lower surgical risk. In this approach, use of coil embolization in saccular VAAs and VAPAs and implantation of flow-modulating stents constitute alternative treatments for fusiform aneurysms. We present the case of a 51-year-old female patient complaining of acute abdominal pain, tachycardia, and hypotension, with evidence of abdominal bleeding on CT angiography, who was diagnosed with a ruptured ileocolic artery (ICA) pseudoaneurysm. She underwent early endovascular treatment for ICA embolization, which was successful and achieved clinical improvement.