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Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

Katsura M, Mototake H, Takara H, Matsushima K - World J Emerg Surg (2011)

Bottom Line: The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA.All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Okinawa Prefectural Hokubu Hospital, 2-12-3 Onaka, Nago, Okinawa 905-8512, Japan. morihiro@bj8.so-net.ne.jp.

ABSTRACT

Background and method: The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.

Case presentation: We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.

Conclusion: Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

No MeSH data available.


Related in: MedlinePlus

Sakamoto's type IV dissection of the SMA. (a) preoperative abdominal enhanced CT scan show isolated dissection of the SMA in which the false lumen was thrombosed without ulcer like projection(ULP). (b) postoperative 1 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved with narrow true lumen.
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Figure 1: Sakamoto's type IV dissection of the SMA. (a) preoperative abdominal enhanced CT scan show isolated dissection of the SMA in which the false lumen was thrombosed without ulcer like projection(ULP). (b) postoperative 1 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved with narrow true lumen.

Mentions: A 50-year-old man with an 8-day history of epigastric pain of acute onset was admitted. No associated symptoms of fever, nausea, constipation or diarrhea were present. He was previously healthy and had no remarkable medical history and trauma except for hypertension and appendectomy. On physical examination, mild tenderness and rebound tenderness over the epigastrium was observed, and no bruit was audible. Laboratory tests showed slightly elevated serum amylase and bilirubin. Therefore, we initially presumed that the patient had acute pancreatitis, but contrast-enhanced CT revealed isolated dissection of the SMA, in which the false lumen was thrombosed (figure 1a), and the dissecting portion began 6 cm from the origin of the SMA and extended to the distal branch. Bowel ischemia was suspected because of long-term continuous abdominal pain for 8 days and rebound tenderness, even though imaging showed no signs of ischemia. Exploratory laparotomy was performed and revealed a pale and pulseless small bowel without necrosis. We proceeded with a bypass operation between the distal portion of the SMA and the right common iliac artery, using the saphenous vein as a free graft. The postoperative course was uneventful without anticoagulation therapy, and follow-up CT showed good general vascularization of the bowel and full patency of the graft. The patient was discharge on postoperative day 14 and was symptom free 4 years after surgery with no recurrent symptoms or disease progression. One year after surgery, a thrombosed false lumen completely resolved with narrow true lumen on follow up CT(figure 1b).


Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

Katsura M, Mototake H, Takara H, Matsushima K - World J Emerg Surg (2011)

Sakamoto's type IV dissection of the SMA. (a) preoperative abdominal enhanced CT scan show isolated dissection of the SMA in which the false lumen was thrombosed without ulcer like projection(ULP). (b) postoperative 1 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved with narrow true lumen.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3108290&req=5

Figure 1: Sakamoto's type IV dissection of the SMA. (a) preoperative abdominal enhanced CT scan show isolated dissection of the SMA in which the false lumen was thrombosed without ulcer like projection(ULP). (b) postoperative 1 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved with narrow true lumen.
Mentions: A 50-year-old man with an 8-day history of epigastric pain of acute onset was admitted. No associated symptoms of fever, nausea, constipation or diarrhea were present. He was previously healthy and had no remarkable medical history and trauma except for hypertension and appendectomy. On physical examination, mild tenderness and rebound tenderness over the epigastrium was observed, and no bruit was audible. Laboratory tests showed slightly elevated serum amylase and bilirubin. Therefore, we initially presumed that the patient had acute pancreatitis, but contrast-enhanced CT revealed isolated dissection of the SMA, in which the false lumen was thrombosed (figure 1a), and the dissecting portion began 6 cm from the origin of the SMA and extended to the distal branch. Bowel ischemia was suspected because of long-term continuous abdominal pain for 8 days and rebound tenderness, even though imaging showed no signs of ischemia. Exploratory laparotomy was performed and revealed a pale and pulseless small bowel without necrosis. We proceeded with a bypass operation between the distal portion of the SMA and the right common iliac artery, using the saphenous vein as a free graft. The postoperative course was uneventful without anticoagulation therapy, and follow-up CT showed good general vascularization of the bowel and full patency of the graft. The patient was discharge on postoperative day 14 and was symptom free 4 years after surgery with no recurrent symptoms or disease progression. One year after surgery, a thrombosed false lumen completely resolved with narrow true lumen on follow up CT(figure 1b).

Bottom Line: The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA.All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Okinawa Prefectural Hokubu Hospital, 2-12-3 Onaka, Nago, Okinawa 905-8512, Japan. morihiro@bj8.so-net.ne.jp.

ABSTRACT

Background and method: The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.

Case presentation: We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.

Conclusion: Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

No MeSH data available.


Related in: MedlinePlus