Spontaneous Isolated Superior Mesenteric Artery Dissection – When to Operate?

An elderly man presented with complaints of postprandial abdominal pain of a month duration. His contrast-enhanced computed tomography (CT) of the abdomen showed spontaneous isolated superior mesenteric artery dissection (SISMAD). Initially, there was no indication for surgery; hence, the patient was managed conservatively and kept under close follow-up. About 3 weeks following diagnosis, the patient presented with recurrent abdominal pain, distension, vomiting, and food intolerance. A follow-up CT scan of the abdomen revealed an additional finding of dilated jejunal loops with reduced enhancement. In view of recurrent subacute intestinal obstruction (SAIO) that required repeated hospital admission, the patient was planned for diagnostic laparoscopy. Intraoperatively, a strictured segment of jejunum was resected, and a side-to-side bowel anastomosis was performed. In the absence of guidelines for the management of SISMAD, we found that recurrent SAIO was a symptom of bowel stricture that required surgical intervention.