Introduction

The aberrant right subclavian artery (ARSA) is the most frequent vascular aortic anomaly with an incidence of 0.4% - 2% in the general population. In 80% of the cases it has a retroesophageal location, also 30% of ARSA is found in patients with trisomy 21. Endoscopic ultrasound (EUS) enables the diagnosis of multiple pathologies and the assessment of vascular structures, in which anomalies such as ARSA can be detected. The main objective of our research is to evaluate the presence of the ARSA as an infrequent finding in upper EUS.

Aims & Methods

The main objective of our research is to evaluate the presence of the ARSA as an infrequent finding in upper EUS. The population of the study consists in all of the patients referred for upper EUS, for different reasons, excluding those with esophageal stenosis, those referred for linear endosonography and patients under 18y.o, at the Gastroenterology Division of both the Centro Medico Docente La Trinidad and the Clinica Atias, health centers located in Caracas, Venezuela. This is a retrospective, observational descriptive, cross-sectional study

Results

A total of 9,966 patients with upper EUS using a radial transducer were studied, six of them were diagnosed with ARSA, two males and four females, between the ages 39 to 72 (mean of age: 55 for males, 60 for females), all cases were confirmed with computed tomography angiography and none of them were previously diagnosed during their upper endoscopy or any other techniques before EUS. Furthermore, one of the patients with ARSA also had Kommerell's diverticulum. However, of the six patients only one reported intermittent dysphagia to solids.

Conclusion

Despite being the most common aortic vascular anomaly, ARSA is still a rare finding; it may go unnoticed during upper endoscopy and EUS. With the radial echoendoscope transducer an anechoic tubular structure can be seen emerging from the distal arch of the aorta crossing to the right between the vertebral column and the posterior wall of the esophagus. When comparing the incidence of ARSA with other reports, we had 0.06% versus 0.33% found in another study.

References

1. Tony E Yusuf,* Michael J Levy,* Maurits J Wiersema et al. Endoscopic ultrasound in the diagnosis of aberrant right subclavian artery
2. Maeder M, Binek J. Impact of endoscopic ultrasonography in the diagnosis of aberrant right subclavian artery: a case report. Ultraschall.Med 2004, 25:296–8
3. De Luca L, Bergman JJ, Tytgat GN, Fockens PE. US imaging of the arteria lusoria: case series and review.Gastrointest. Endosc.2000; 52:670–3
4. Stone WM, Brewster DC, Moncure AC et al. Aberrant right subclavian artery: varied presentations and management options. J Vasc Surg [Internet]. 1990; 11(6):812–7
5. Domínguez-Massa C, Berbel-Bonillo A, Pérez-Guillen M, Montero-Argudo JA. Dissected aberrant right subclavian artery with Kommerell diverticulum. Rev Port Cardiol (Engl Ed) [Internet]. 2019; 38(10):737.e1-737.e4
6. Mark NM, Madtes DK. Aberrant right subclavian artery on endobronchial ultrasound. Am J Respir Crit Care Med [Internet]. 2017; 196(6):e14.

Disclosure

NONE

Clinical Case Summary

A 71-year-old female presented to the gastroenterology clinic following a two year history of dysphagia and sensation of food sticking in the oesophagus. Her dysphagia was limited to solid foods, and symptoms were not exacerbated by positional change. Pain was mostly localised around the sternal notch where she would have the sensation of a food bolus. Over the preceding 2 years, she had experienced about 7.5kg of weight loss with no constitutional symptoms of fevers or fatigue. Her past medical history included hypertension, dyslipidaemia, lower back pain, cold agglutinin disease, monoclonal B lymphocytosis and peripheral arterial disease. On examination, there were no signs of malnourishment or palpable lymph nodes in the axilla, neck or supraclavicular region. Her abdomen was soft and non-tender. Given largely non-illuminating blood results, an oesophageal-gastroduedonoscopy was performed. However, no findings were noted, specifically no oesophageal webs, Zenker diverticulum, gastroparesis, trachealisation of the oesophagus or corrosive pathology. H. pylori was also not isolated on histopathology. A barium swallow was then performed which showed extensive external compression of the proximal third of the oesophagus at the level of the arch of the aorta, most indicative of dysphagia lusoria (Fig 1). Computed tomography angiography (CTA) showed retroesophageal aberrant right subclavian artery bifurcating from the ascending aorta independent of a brachiocephalic artery and causing external oesophageal compression (Fig 2 & 3). Given this definitive diagnosis, the patient was then seen in clinic where management of dysphagia lusoria was explained. Despite ongoing symptoms, the patient decided to continue with conservative management and lifestyle modifications, which included eating smaller bites and increase in fluid intake. Although an extensive compression typically requires surgical intervention, our patient was stable at two-year follow-up (Fig 4 A-B).

References

Figure 1: Barium swallow examination showing extrinsic compression of the proximal third of the oesophagus at the level of the aortic arch (white arrow).
Figure 2: Axial view of computed tomography angiography (CTA) showing the posterior course of the retroesophageal aberrant right subclavian artery.
Figure 3: Axial view of computed tomography angiography (CTA) showing compression of oesophagus (white arrow) by the retroesophageal aberrant right subclavian artery (white arrowhead).
Figure 4: Computed tomography angiography (CTA) multi-planar reconstruction (MPR) showing the posterior course of the right subclavian artery (white arrow), crossing the mediastinum and compressing the oesophagus. A. coronal view B. Sagittal view

Disclosure

None.

Introduction

Superior Mesenteric Artery Syndrome (SMAS), also known as Wilkie’s syndrome, is a rare gastrointestinal condition characterized by compression of the distal duodenum between the abdominal aorta (AA) and the superior mesenteric artery (SMA). Evidence on Wilkie’s syndrome is limited, reviews are based on small cohorts and case studies^1-3. Patients with SMAS typically present with postprandial epigastric discomfort, nausea, vomiting, stomach distention, and reflux, leading to malnutrition and weight loss. As mesenteric fat decreases due to the weight loss, the duodenal obstruction worsens, increasing SMAS symptoms. SMAS mostly affects young females aged 20-30 years and is challenging to diagnose due its overlap with dyspepsia, anorexia nervosa and median arcuate ligament syndrome^1-3. SMAS can present acutely, after weight loss from bariatric surgery, malnutrition or (hyper)metabolic disorders. It also presents chronically, due to an anatomically high duodenal position or a low aortic SMA origin^1-3. Diagnostic imaging, including computed tomography (CT) typically reveals a reduced SMA-AA angle <25° and a characteristic vertical, abrupt duodenal obstruction on barium X-ray series^1,2. Conservative treatment focuses on improving gastrointestinal motility and increasing the SMA-AA angle by weight gain to regain mesenteric fat¹. If conservative treatment fails, surgical intervention is considered, with duodenojejunostomy being most commonly performed. Yet, this carries potential severe complications such as anastomotic leakage and non-physiological gastro-duodenal changes. Recent evidence suggests laparoscopic Treitz ligament release may offer a viable and low-risk alternative^3,4.

Aims & Methods

This study aims to introduce a standardized, low risk treatment protocol for SMAS. The protocol includes: 1) Jejunal tube feeding for six-eight weeks, 2) Laparoscopic release of the Treitz ligament, and 3) SMA reimplantation⁵. The protocol was implemented at three hospitals in the Netherlands, Medisch Spectrum Twente, Franciscus, and Erasmus MC.

Results

A total of 12 patients were treated according to this protocol from 2020 until 2024. The cohort consisted of 7 (58.3%) female patients, with a mean age of 29.2 years (SD 11.8). The average weight and body mass index were 60.33 kg (SD 6.5) and 20.01 (SD 3.4). The mean SMA-AA angle measured on CT scans was 22.55° (SD 13.1). All patients started treatment with jejunal feeding. Nine patients underwent laparoscopic Treitz ligament release, with 7 experiencing complete resolution of symptoms. One patient with co-existing Nutcracker syndrome received primary SMA infra-renal reimplantation, with complete symptom release after the surgery. In two patients, symptoms persisted following Treitz ligament release, resembling gastroparesis and irritable bowel syndrome. The 2 remaining patients are planned for laparoscopic Treitz ligament release.

Conclusion

The combination of jejunal feeding followed by laparoscopic Treitz ligament release, represents a safe and effective treatment approach for SMAS; 7/9 patients who underwent the Treitz ligament release experienced resolution of all symptoms, demonstrating the efficacy of protocol. This approach offers an alternative to traditional surgical procedures, such as duodenojejunostomy, and reduces the risks of substantial short- and long-term complications. Further research with larger sample sizes is required to confirm the long-term outcomes and advantages of this protocol compared to other treatment strategies for SMAS.

References

1. 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 May 26;11(15):3369-3384. doi: 10.12998/wjcc.v11.i15.3369. PMID: 37383896;
2. Navandhar PS, Shinde RK, Gharde P, Nagtode T, Badwaik N. Understanding Superior Mesenteric Artery Syndrome: Etiology, Symptoms, Diagnosis, and Management. Cureus. 2024 Jun 2;16(6):e61532. doi: 10.7759/cureus.61532. PMID: 38957238; PMCID: PMC11218894
3. Beita AKV, Whayne TF. The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old. Cardiovasc Hematol Agents Med Chem. 2019;17(2):74-81. doi: 10.2174/1871525717666190920100518. PMID: 31538906.
4. Fang JF, Wei B, Zheng ZH, Lei PR, Chen TF, Wei HB. Laparoscopic lysis of the ligament of treitz for superior mesenteric artery syndrome. Dig Surg. 2014;31(4-5):291-6. doi: 10.1159/000367670. Epub 2014 Oct 17. PMID: 25342434.
5. Ali T, Tomka J, Bakirli I, Bakirov I. Surgical Treatment of Wilkie's Syndrome by Vascular Transposition. Cureus. 2022 Apr 18;14(4):e24251. doi: 10.7759/cureus.24251. PMID: 35475250; PMCID: PMC9018456.
6. Pourhassan S, Grotemeyer D, Fürst G, Rudolph J, Sandmann W. Infrarenal transposition of the superior mesenteric artery: a new approach in the surgical therapy for Wilkie syndrome. J Vasc Surg. 2008 Jan;47(1):201-4. doi: 10.1016/j.jvs.2007.07.037. Epub 2007 Oct 18. PMID: 17949939

Clinical Case Summary

Introduction: Superior mesenteric artery (SMA) syndrome, is a rare condition caused by compression of the third portion of the duodenum between the abdominal aorta and the SMA. This leads to functional duodenal obstruction, typically presenting with postprandial vomiting, weight loss, and abdominal pain. The condition is most often seen in patients with rapid weight loss or anatomical predispositions, and diagnosis is confirmed through contrast-enhanced CT imaging showing a reduced aorto-mesenteric angle and duodenal dilation.
Clinical case: A 16-year-old patient with no medical history presented with persistent postprandial vomiting for four months and weight loss of 8 kg. On examination, BMI was 18 with epigastric tenderness. Lab tests revealed hypokalemia and hypochloremic metabolic acidosis. Abdominal CT showed compression of the third part of the duodenum between the aorta and SMA, with an aorto-mesenteric angle of 12°, confirming the diagnosis of PAM. Initial management with hydration and electrolyte correction failed to improve symptoms. The patient underwent successful laparoscopic gastrojejunostomy with good clinical recovery. PAM remains a rare and often underdiagnosed cause of chronic gastrointestinal symptoms in adolescents and young adults. It is typically related to loss of mesenteric fat, a short Treitz ligament, or anatomical variation. Imaging remains crucial for diagnosis, with angles below 20° being highly suggestive. Medical management is first-line but is often insufficient. In our case, the severity and chronicity of symptoms led to early surgical intervention, with excellent short-term outcome and symptom resolution.
Figure 1&2 : CT image
Conclusion: This case highlights the importance of considering PAM in adolescents with unexplained postprandial vomiting and weight loss. Early CT imaging allows timely diagnosis. While medical therapy is first-line, surgery—particularly gastrojejunostomy—offers rapid and sustained relief in refractory cases.

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.