Superior Mesenteric Artery Syndrome After Restorative Proctocolectomy With Ileal Pouch-Anal Anastomosis: A Case Report

摘要

Purpose: Superior mesenteric artery syndrome (SMAS) is a rare complication following restorative proctocolectomy with only eight previous reports. We report the case of a 16-year-old girl known to have familial adenomatous polyposis who underwent a restorative proctocolectomy with an ileal pouch-anal anastomosis. Methods: The features of the case were studied followed by a review of the current literature. Results: After an uneventful first postoperative week, the patient developed SMAS, characterised by voluminous bilious vomiting. Laparotomy revealed compression of the duodenum by the overlying mesenteric root containing the superior mesenteric artery. Unexpected dense peri-mesenteric and intraperitoneal fibrosis was also encountered. Conclusion: Previous reports suggested the aetiology is directly related to the accentuated angle between the superior mesenteric artery and the aorta, which is created at the time of surgery. Our case suggests that it may actually be events in the postoperative period such as fibrosis of the mesentery that are responsible. When surgical intervention is required, we advocate duodenojejunostomy as the preferred solution. Introduction Compression of the duodenum by the superior mesenteric artery is a rare complication following restorative proctocolectomy. We report an interesting case in point, consider the possible aetiological factors, and discuss the management of the condition. Case Report A 16-year-old girl known to have familial adenomatous polyposis underwent a restorative proctocolectomy with anastomosis of a J-shaped ileal pouch to the anal canal and fashioning of a covering loop ileostomy. The small bowel mesentery was mobilised close to its root and the ileocolic artery was divided, facilitating an anastomosis free from any tension. The initial post-operative course saw a timely reinstatement of her normal diet with a satisfactory stoma function. On the eighth day, she developed significant fresh rectal bleeding, which although required a blood transfusion, was self-limiting. The anastomosis felt intact on digital rectal examination.On the tenth day, she complained of significant pain in her left iliac fossa and had voluminous bilious vomiting. The ileostomy continued to function normally and there were no other signs suggestive of bowel obstruction. Plain abdominal radiography was normal. A computed tomography scan demonstrated a distended stomach and duodenum to its third part (see figure 1). Total parenteral nutrition was started and she was managed expectantly.