2020. 2. 11. 04:05ㆍ카테고리 없음
Author Affiliation Disclosures Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. Abstract Superior mesenteric artery (SMA) syndrome is a rare and potentially life-threatening complication of scoliosis surgery.
The anatomical relationship of the duodenum and the superior mesenteric artery, the correction of angular deformity of the spine, and the normal adolescent growth spurt all contribute to the condition. We report the case of a 14-year-old boy who had a history of idiopathic scoliosis and presented with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation. After an unremarkable immediate postoperative course, on postoperative day 19 the patient presented to the emergency department with abdominal pain, nausea, and vomiting. Unrelenting brown vomitus, abdominal pain, and a 20-lb weight loss were noted. A series of upper gastrointestinal radiographs confirmed a diagnosis of SMA syndrome.
Evidence that (if true) proves an alleged fact, such as an eyewitness account of a crime.
A nasojejunal tube was placed, and nutritional rehabilitation was optimized. We highlight this case for its rarity and emphasize the importance of maintaining a high index of suspicion when evaluating a child who has had spinal deformity correction and presents with postoperative gastrointestinal complaints.
- Evidence, whether broken by a bullet or other means, may link a suspect or piece of evidence to a crime scene, and be used to deduce cause of breakage or direction of penetration.
- Satisfaction with the bank service provided in terms of physical evidence and employee interaction. Further analysis confirms that there is a difference in service as being provided and the layout of physical evidence between earlier established banks (EEB) and newly established banks (NEB) in creating customer satisfaction.
Early recognition of the nonspecific symptoms of abdominal pain, abdominal distension, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia plays a key role in post-scoliosis surgery and is crucial in preventing the severe morbidity and mortality associated with SMA syndrome. Take-Home Points.
Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery. Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death. Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752. 1 Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus. 2 We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite.
Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery. We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report. Case Report A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.
Physical Evidence Vocab On Flowvellane
Preoperative radiographs revealed a 55° right Lenke V C curve ( Figures 1, 2). Before the procedure, the patient weighed 111.6 lb and was 175 cm tall.
The surgery was uneventful, with a curve correction to about 7° ( Figures 3A, 3B). No abnormalities were noted during intraoperative neurologic monitoring. After an unremarkable postoperative course, on postoperative day 19 the patient presented to the emergency department (ED) with abdominal pain, nausea, and vomiting of 3 days’ duration. Right lower quadrant ultrasound revealed nonspecific fluid-filled bowel loops, and the patient was discharged with antiemetics and instructions for hydration. Two days later, he returned to the ED with unrelenting brown vomitus and abdominal pain and noted a 20-lb weight loss over 2 weeks.
He was admitted to the postanesthesia care unit for dehydration and for QT prolongation secondary to electrolyte abnormalities. On admission, he weighed 88.2 lb.
An upper gastrointestinal (GI) contrast radiograph confirmed a diagnosis of SMA syndrome, and a nasojejunal tube was placed. The patient gained no weight over 10 days; a gastrojejunal tube was placed until he was able to tolerate oral nutritional intake, 5 weeks later. He was followed by the nutrition and general surgery teams to ensure clinical improvement. The SMA, an anterior branch of the aorta at the L1 vertebral level, is encased in fat and lymphatic tissue. Its acute caudal descent is sometimes referred to as a nutcracker configuration. 2 Normal SMA angles are highly variable.
One study described 75 aortas with angles ranging from 20° to 70°. 3 SMA angle reduction results in extrinsic compression of the duodenum by the SMA. A common influence is the loss of protective peripancreatic and periduodenal fat below the SMA origin secondary to significant weight loss of any kind, such as from anorexia nervosa, malabsorption, and malignancy.
Correcting a scoliotic curve through spinal manipulation essentially results in a lengthening of the vertebral column, which displaces the SMA origin more superiorly and creates a more acute aortomesenteric artery angle. Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle. 3 Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.
2 This finding, dating to the 19th century, was reported by Willet 4 when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting. 5 Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS). Of note, about 50% of patients with SMA syndrome present in the first week after spine surgery, 35% in the second week, and 15% more than 2 weeks after surgery. A patient presenting with abdominal pain/distension, nausea, and vomiting after scoliosis surgery should be initially evaluated for signs of intestinal obstruction. 6 An abdominal radiograph can be used to assess for distended bowel gas or air-fluid levels, though this imaging study has also been found to be within normal range in an eventual SMA syndrome diagnosis.
SMA syndrome can often be differentiated from postoperative ileus by fever/tachycardia and peritoneal signs. In the presence of positive findings for intestinal obstruction, initial management should begin with nasogastric decompression, electrolyte correction, and intravenous hydration.
Otherwise, management should be to observe, treat with antiemetics, and reassess periodically. 6 The first step is to start auxiliary enteral nutritional support through a nasojejunal feeding tube—or total parenteral nutrition if enteral feeding is unacceptable. Often, SMA syndrome is definitively diagnosed with an upper GI barium study with simultaneous angiography.
If the diagnosis of SMA syndrome is made and symptoms improve, conservative management should be continued and diet slowly advanced. If symptoms worsen or significant weight loss occurs, surgical management should be considered.
Surgical management is performed through laparoscopic or open duodenojejunostomy, division of the ligament of Treitz, or a modified Ladd procedure. 7-10 Removal of spinal implants and cast is unnecessary, except when lumbar spine hyperextension is the cause, in which case cast and metal implants must be removed to relieve the duodenum from the SMA. 7The incidence of SMA syndrome after scoliosis surgery is 1% to 4.7%.
3,6,7 Our literature review of SMA syndrome after scoliosis surgery for AIS revealed 19 case reports over 45 years ( Table 2). Studies reported that the incidence of SMA syndrome was higher in certain groups based on the extent of spinal deformity and the Lenke classification system for scoliosis. 11,12 Specifically, groups with body mass index under the 25th percentile, Lenke B or C (laterally displaced, curved) scoliosis, and stiffer thoracic curves (.