Superior mesenteric artery (SMA) syndrome is a rare cause of proximal intestinal obstruction resulting from compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. The Strong procedure offers a physiological alternative to duodenojejunostomy by performing full duodenal mobilization, thereby omitting the need for an intestinal bypass (e.g., duodenojejunostomy). We present the case of a woman with chronic postprandial abdominal pain, nausea, and bloating, refractory to conservative management. When the patient positioned herself in a left lateral fetal position, the complaints resolved. Preoperative imaging demonstrated a reduced SMA-aorta distance (8.1 mm) with a normal aortomesenteric angle (52.1°), as well as signs of duodenal stasis, all potentially consistent with SMA syndrome. The patient underwent a Robot Strong procedure consisting of division of the ligament of Treitz and full duodenal mobilization, including Kocherization. The postoperative course was uneventful. At 6 weeks of follow-up, symptoms were resolved completely, with improved oral intake. At imaging follow-up, the duodenum was placed more caudally, fitting with the expected outcome. These findings confirm the feasibility and clinical effectiveness of the Robot Strong procedure in highly selected patients with SMA syndrome.

Amyand's hernia is defined by the presence of the vermiform appendix within an inguinal hernia sac and occurs in fewer than 1% of all inguinal hernias. When the appendix is inflamed or perforated, the incidence decreases to 0.1%, and when additional intra-abdominal organs are involved, the condition becomes exceptionally rare. We present the case of a 62-year-old man with a 10-year history of an untreated right-sided inguinoscrotal hernia who presented to the emergency department with a five-day history of progressive scrotal swelling, discoloration, pain, and inability to defecate or tolerate oral intake. Examination revealed a 17 × 10 cm inguinoscrotal mass with violaceous skin discoloration and visible necrosis at the scrotal base. Plain abdominal radiographs showed air-fluid levels consistent with small bowel obstruction. Emergency laparotomy confirmed a Losanoff-Basson type 4 Amyand's hernia with right-sided mixed hernial contents extending 370 cm from the angle of Treitz into the scrotum, including the cecum, appendix, and terminal ileum, with cecal perforation, appendiceal compromise, fecaloid spillage, and Fournier's gangrene of the scrotum , with approximately 30 cm of small bowel. Surgical management included resection of the small bowel at 340 cm from the angle of Treitz with a colonic pouch, terminal ileum ileostomy, right orchiectomy, scrotal debridement with repeated surgical washouts, and primary hernia defect repair without mesh. The patient underwent five additional surgical washouts during a 33-day hospitalization, followed by intestinal transit restoration during outpatient follow-up. To our knowledge, this case represents one of the most anatomically extensive right-sided Amyand's hernias with simultaneous cecal perforation and Fournier's gangrene reported in the indexed literature. Early surgical recognition and aggressive multivisceral management were the determining factors in the patient's survival.

Mesenteric cystic lymphangiomas are benign tumors, considered surgical rarities. They can develop from the duodenum to the rectum, on the entire mesentery surface. The preoperative diagnosis is difficult because they can mimic a wide range of tumors. The treatment of choice is surgery and diagnosis is confirmed by histopathological examination. A 57-year-old male patient was admitted to the 2nd Surgery Clinic from Târgu Mureş, after a control ultrasonography examination incidentally highlighted a tumor mass at the mesenteric level and the growth of the tumor volume was observed. The preoperative CT scan presented a cystic mass adjacent to the jejunal loops, at a distance of 65 mm from the Treitz angle, measuring 75 × 100 × 92 mm with a volume of 430.24 cm3. During surgery total enucleation of the mesenteric cyst was performed. The cystic wall presented yellowish color and the fluid content had a milky white appearance. Histopathological examination confirmed the diagnosis of cystic lymphangioma. The immunohistochemical profile presented positive reaction of endothelial cells with CD34, CD31, podoplanin, and negative reaction with CK AE1/AE3 and CK7. The patient was discharged after 7 days following the surgical intervention. No recurrence was highlighted during the 12 months of follow-up. In most cases, the diagnosis of mesenteric cystic lymphangioma is made incidentally. During imaging investigations, they can mimic multiple malignant lesions. The gold standard of treatment is radical resection which ensures also recurrence prevention and a good prognosis. Orv Hetil. 2026; 167(20): 798-804.

Lipomas of the small intestine are rare and generally asymptomatic. However, they can present with obstructive symptoms or gastrointestinal bleeding that is difficult to localize. A 63-year-old female patient was admitted to the emergency department with a complaint of melena for four days. Endoscopy and colonoscopy were performed without any abnormalities. The patient showed no further externalization of symptoms and had a suspicion of intussusception on a CT scan. A capsule endoscopy was performed, revealing an elevated and ulcerated lesion in the proximal jejunum near the Treitz angle. An attempt at enteroscopy was made, but it was suspended due to gastric stasis. The patient developed obstructive symptoms and underwent exploratory laparotomy, which required enterectomy. The histopathological examination confirmed that the lesion was an ulcerated lipoma. Lipomas of the small intestine are rare and challenging to diagnose. The use of capsule endoscopy and enteroscopy allows for the diagnosis of these lesions, greater accuracy in localization, and, in some cases, treatment.

Ulcerative jejunitis (UJ) or ulcerative enteritis (UE) is a rare complication of celiac disease (CeD). Guidelines regarding diagnosis and management are missing, and these cases have seldom been reported in the United States.

Lower digestive tract bleeding occurs distal to the angle of Treitz. While many cases remit spontaneously; some pose a diagnostic challenge for surgeons. We present the case of a 68-year-old man with unexplained digestive tract bleeding. Despite various diagnostic efforts, the source remained unknown. Faced with the challenge of persistent bleeding and hemodynamic instability, surgery became necessary. During the procedure, intraoperative angiography with indocyanine green was used to facilitate the identification of the bleeding site, revealing a gastrointestinal stromal tumor in the small bowel. Resection was performed with favorable outcomes. Indocyanine green staining has become popular for locating intestinal bleeding during emergency surgeries, aiding surgeons in making precise decisions.

Superior mesenteric artery (SMA) passes over the third part of duodenum and can cause its obstruction when the aorto-mesenteric angle is hyper acute. Although the condition is rare, the diagnosis can be made using radiography and the treatment consists of division of ligament of Treitz and duodenojejunostomy. We present a case of SMA syndrome in an elderly lady, who was managed successfully with surgery.

Introduction Superior mesenteric artery syndrome (SMAS), also called mesenteric duodenal compression syndrome, Wilkie's syndrome, chronic duodenal ileus or cast syndrome, is a rare clinical condition defined as a compression of the third portion of the duodenum in between the SMA and abdominal aorta (AA), due to narrowing of the space between them. SMAS is primarily attributed to loss of the intervening mesenteric fat pad, leading to partial or complete duodenal obstruction. Its manifestations are complex and non-specific, including postprandial epigastric pain, nausea, vomiting, early satiety, weight loss and anorexia. SMAS may present as an acute syndrome, or it may have an insidious onset with chronic symptoms. SMAS mainly affects females between 10 and 40 years of age. This study aims to discuss the safety and efficacy of vascular decompression of the duodenum by infrarenal transposition of SMA. Methods This single-centre prospective clinical study analysed 37 patients with Wilkie's syndrome who underwent infrarenal transposition of the SMA between January 2012 and December 2021. The indications for the surgery were severe weight loss, uncontrolled upper abdominal pain, vomiting and other gastrointestinal (GI) symptoms that were severely debilitating to patients' daily lives, along with radiological findings such as aortomesenteric angle < 25°, aortomesenteric distance <8 mm and distention of proximal part of the duodenum and the stomach. Ten patients (27%) concurrently had Nutcracker syndrome and seven patients (18.9%) had Dunbar syndrome (median arcuate ligament syndrome). Three female patients (8.1%) had all three above-mentioned vascular compression syndromes, which were treated in the same surgery. One male patient (2.7%) was after a laparoscopic duodenojejunostomy with symptoms that relapsed three months postoperatively, which was cured after the infrarenal transposition of SMA. Results Technical operative and clinical success were achieved in all patients. There were no cases of anastomotic failure, SMA thrombosis or intestinal ischemia. All of the patients are currently living symptom-free. One patient (2.7%), four days postoperatively, had a lymphocele formed in the retroperitoneum, which was successfully drained by a CT-guided percutaneous pigtail catheter. Another patient (2.7%) after three months of surgery needed a re-laparotomy for adhesive obstruction of the second part of the duodenum and was treated by adhesiolysis and omentoplasty. One patient (2.7%), 2-year postoperatively, had a proximal SMA stenosis up to 60% where drug-eluting balloon percutaneous transluminal angioplasty (DEB PTA) was performed successfully. Finally, the upper GI symptoms were resolved in all 37 patients (100%). Conclusion Wilkie's syndrome, although rare, is frequently late-diagnosed or underdiagnosed. In cases of failure of conservative therapy, infrarenal transposition of the SMA can be considered a safe and feasible surgical option with more physiologically favourable outcomes comparable to gastrointestinal bypasses, especially in patients concurrently suffering from Nutcracker syndrome. Simultaneously, it also restores physiologic duodenal passage of gastroduodenal content without the need of creating a digestive tract anastomosis. To our best knowledge, we have the highest number of SMA transposition surgeries performed in a single centre for the treatment of Wilkie's syndrome.

Mesenteric abscess caused by chryseobacterium meningosepticum is an extremely rare clinical entity, most often found in immunodeficient patients. Castleman disease can manifest as a mesenteric abscess. We here report the case of a 23-year-old patient admitted with generalized acute peritonitis evolving over the last 2 weeks. Abdominal ultrasound showed hypoechoic mass in the intestinal loops, without any further details. During laparotomy, pus was found in the large cavity, a mesenteric abscess was detected in the mesentery of the jejunum 35 cm from the angle of Treitz, without loop perforation and mesenteric adenopathy was found in corresponence with the abscess. Pyoculture isolated chryseobacterium meningosepticum. Histological analysis of mesenteric adenopathy biopsies showed structural anomalies, suggesting hyaline vascular type of Castleman disease. Treatment was based on incision and drainage of the abscess, with pyogenic membrane removal and abdominal cavity lavage with physiological saline solution. Chryseobacterium meningosepticum was only susceptible to Ciprofloxacin. The postoperative course was simple and the patient was discharged on postoperative day 10 after surgery. Clinical and paraclinical follow-up at 12 months did not show any other lymphadenopathy or recurrence. The purpose of this study is to show an extremely rare case of mesenteric abscess due to chryseobacterium meningosepticum associated with isolated mesenteric Castleman disease in an immunocompetent patient and management approaches.