Minimally Invasive Management of Superior Mesenteric Artery Syndrome with Concurrent Nutcracker Phenomenon: Case Report

Superior mesenteric artery (SMA) syndrome is a rare cause of high duodenal obstruction.

We report a case of an asthenic male (BMI 17.9 kg/m²) presenting with acute bowel obstruction.

Methods. Multiphase CT demonstrated marked pre-stenotic dilation of the D2 of the duodenum (max 8.8 cm) and compression of the D3 between the aorta and SMA, with an aortomesenteric angle of 11–12° and distance of 7 mm. A morphological, asymptomatic nutcracker phenomenon was present without hematuria. CT-suggested colitis was ruled out endoscopically and histologically. After consultation with vascular surgeon and shared decision-making, the patient opted for enteral bypass. The patient’s preoperative anaesthesiology assessment revealed no contraindications to general anaesthesia for the planned laparoscopic procedure. A laparoscopic laterolateral, anisoperistaltic duodenojejunostomy was performed using a linear stapler (minimal blood loss; operative time 76 minutes) with a perianastomotic drain.

Results. Postoperatively, the nasogastric tube was removed on POD2, oral intake resumed from POD3, and the drain removed on POD4. Transient rise in CRP/leukocytosis on POD2 (negative presepsin) was managed empirically with ampicillin/sulbactam (Clavien–Dindo II). Patient was discharged on POD6 (7-day stay). At three months follow-up he remained symptom-free with objective nutritional gain (BMI + 2.3 kg/m²).

Conclusion. This case supports laparoscopic duodenojejunostomy as a safe and effective definitive option in hemodynamically stable patients with CT-quantified SMA obstruction. A concomitant asymptomatic nutcracker phenomenon does not require vascular intervention nor alter operative strategy.

1. Van Horne N., Jackson J.P. Superior mesenteric artery syndrome. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.

2. Welsch T., Büchler M.W., Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg. 2007; 24 (3): 149–156. DOI: 10.1159/000102097. PMID: 17476104.

3. Kurklinsky A.K., Rooke T.W. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. 2010; 85 (6): 552–559. DOI: 10.4065/mcp.2009.0586. PMID: 20511485.

4. Yoon T., Kim S.H., Kang E., Kim S. Nutcracker phenomenon and syndrome may be more prevalent than previously thought. Korean J Radiol. 2022; 23 (11): 1112–1114. DOI: 10.3348/kjr.2022.0617. PMID: 36305049.

5. Farina R., Iannace F.A., Foti P.V., Conti A., Ini F., Libra F., Fanzone L., et al. A case of nutcracker syndrome combined with Wilkie syndrome with unusual clinical presentation. Am J Case Rep. 2020; 21: e922715. DOI: 10.12659/AJCR.922715. PMID: 32317620.

6. Shi Y., Shi G., Li Z., Chen Y., Tang S., Huang W. Superior mesenteric artery syndrome coexists with Nutcracker syndrome in a female: a case report. BMC Gastroenterol. 2019; 19 (1): 15. DOI: 10.1186/s12876-019-0932-1. PMID: 30674275.

7. Khan H., Al-Jabbari E., Shroff N., Barghash M., Shestopalov A., Bhargava P. Coexistence of superior mesenteric artery syndrome and nutcracker phenomenon. Radiol Case Rep. 2022; 17(6): 1927–1930. DOI: 10.1016/j.radcr.2022.03.063. PMID: 35401899.

8. Agha R.A., Franchi T., Sohrabi C., Mathew G., Kerwan A..; SCARE Group. The SCARE 2020 guideline: updating Consensus Surgical Case Report (SCARE) guidelines. Int J Surg. 2020; 84: 226–230. DOI: 10.1016/j.ijsu.2020.10.034. PMID: 33181358.

9. World Health Organization. Body mass index (BMI). https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/body-mass-index?ysclid=mpmidu791c13.

10. Weimann A., Braga M., Carli F., Higashiguchi T., Hübner M., Klek S., Laviano A., et al. ESPEN guideline: clinical nutrition in surgery. Clin Nutr. 2017; 36 (3): 623–650. DOI: 10.1016/j.clnu.2017.02.013. PMID: 28385477.

11. England R.J., Li N. Superior mesenteric artery syndrome: a review of the literature. J Am Coll Emerg Physician Open. 2021; 2 (3): e12454. DOI: 10.1002/emp2.12454. PMID: 34179879.

12. Oka A., Awoniyi M., Hasegawa N., Yoshida Y., Tobita H., Ishimura N., Ishihara S. Superior mesenteric artery syndrome: diagnosis and management. World J Clin Cases. 2023; 11 (15): 3691–3384. DOI: 10.12998/wjcc.v11.i15.3369. PMID: 37383896.

13. Lee T.H., Lee J.S., Jo Y., Park K.S., Cheon J.H., Kim Y.S. Jang J.Y., et al. Superior mesenteric artery syndrome: where do we stand today? J Gastrointest Surg. 2012; 16 (12): 2203–2211. DOI: 10.1007/s11605-012-2049-5. PMID: 23076975.

14. Avgerinos E.D., Saadeddin Z., Humar R., Salem K., Singh M., Hager E., Makaroun M., et al. Outcomes of left renal vein stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2019; 7 (6): 853–859. DOI: 10.1016/j.jvsv.2019.06.016. PMID: 31471277.

15. Weimann A., Braga M., Carli F., Higashiguchi T., Hübner M., Klek S., Laviano A. et al. ESPEN practical guideline: clinical nutrition in surgery. Clin Nutr. 2021; 40 (7): 4745–4761. DOI: 10.1016/j.clnu.2021.03.031. PMID: 34242915.

16. da Silva J.S.V., Seres D.S., Sabino K., Adams S.C., Berdahl G.J., Citty S.W., Cober M.P., et al. ASPEN Consensus recommendations for refeeding syndrome. Nutr Clin Pract. 2020; 35 (2): 178–195. DOI: 10.1002/ncp.10474. PMID: 32115791.

17. Wills M.V., Barajas-Gamboa J.S., Mocanu V., Conner A., Brown J., Restrepo-Rodas G., Lee S., et al. Long-term outcomes of laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Surg Endosc. 2025; 39 (8): 5235–5243. DOI: 10.1007/s00464-025-11774-6. PMID: 40576774.

18. Reed N.R., Kalra M., Bower T.C., Vrtiska T.J., Ricotta 2 nd J.J., Gloviczki P. Left renal vein transposition for nutcracker syndrome. J Vasc Surg. 2009; 49 (2): 386–393. DOI: 10.1016/j.jvs.2008.09.051. PMID: 19216958.