
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01067-8
10.1016/j.ijscr.2024.110286
110286
Case Report
Weight loss as a potential trigger for nutcracker syndrome after a complex surgery: About a case report
Neirouz Kammoun neirouzkammoun@gmail.com
a⁎
Mohamed Hajri a
Aziz Atallah a
Belleh Zaafouri Elmontassar a
Mestiri Hafedh a
Dhouha Bacha b
a Surgery Department, Mongi Slim Hospital, Tunisia
b Pathology Department, University Hospital Mongi Slim, La Marsa, Tunisia
⁎ Corresponding author. neirouzkammoun@gmail.com
11 9 2024
10 2024
11 9 2024
123 1102866 8 2024
5 9 2024
9 9 2024
© 2024 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Nutcracker syndrome results from the compression of the left renal vein between the aorta and the superior mesenteric artery. The Nutcracker syndrome is rare and occurs in specific contexts such in patients who have lost significant weight. Our case presents an infrequent instance of nutcracker syndrome following a complicated biliary surgery.

Case presentation

A 32-year-old patient presented with symptomatic cholelithiasis. Laparoscopic cholecystectomy was complicated by an injury in the right hepatic artery necessitating a biliary reconstruction. After three months, the BMI was 18 Kg/m2.The patient was operated on, he had a hepaticojejunal anastomosis on the left hepatic duct. Right hepatectomy was unnecessary due to complete atrophy of the right liver. Postoperatively, persistent low back pain prompted a CT scan. It revealed compression of the left renal vein in the aortomesenteric clamp indicating a nutcracker syndrome. The patient was put on anticoagulants with a good evolution.

Discussion

The Nutcracker syndrome is categorized into three types: the anterior form, the posterior form and the posterolateral form. The aortomesenteric angle could be subject to variation depending on the body mass index (BMI). Significant weight loss could induce nutcracker syndrome by decreasing the Aorto- superior mesenteric artery angle due to reduced retroperitoneal and perivascular fat (D'Souza et al., n.d.). In our case, the patient's BMI dropped from 25 to 18 kg/m2 contributing to the syndrome. Radiological examinations should assess not only the anatomy of the aorto-mesenteric angle but to identify an eventual associated thrombosis. Conservative treatment is sufficient in most cases with a resolution of symptoms in 60 to 80 % of cases.

Conclusion

We aimed to bring attention to Nutcracker syndrome, especially in patients who have experienced significant weight loss after a complicated surgery.

Highlights

• Nutcracker syndrome is rare.

• It occurs when the left renal vein is compressed between the aorta and the superior mesenteric artery in the anterior form.

• It may result from significant weight loss after surgery due to a reduction of the perivascular fat (such in our case).

Keywords

Nutcracker syndrome
Aorta
Mesenteric artery
Weight loss
Case report
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pmc1 Introduction

Nutcracker syndrome results from the compression of the left renal vein between the aorta and the superior mesenteric artery [2]. This compression increases the pressure in the left renal vein and its collaterals, particularly the left genital vein. The Nutcracker syndrome is rare and occurs in specific contexts such as pregnancy, postpartum follow-up, and in patients who have lost significant weight [3].

Our case presents an infrequent instance of nutcracker syndrome following a complicated biliary surgery, serving educational and informative purposes. Herein is the case:

2 Case report

A 32-year-old patient with a body mass index (BMI) of 25 kg/m2 presented with symptomatic cholelithiasis. Laparoscopic cholecystectomy was complicated by intraoperative hemorrhage due to an injury in the right hepatic artery. The postoperative course was marked by the appearance of a biliary fistula (900 cc/day) and perihepatic collections managed by iterative CT-guided punctures with a good follow-up. The hepatic artery injury was classified as type 4 of the Bismuth classification. Thereby the patient was planned to have a right hepatectomy with a hepatico-jejunal anastomosis on the left canal. In the third month postoperatively, the patient was readmitted to have the biliary reconstruction. The BMI was 18 Kg/m2. Albumin was 29 g/dl. CT revealed a necrosis of the right liver (Fig. 1). The patient was operated on, he had a hepaticojejunal anastomosis on the left hepatic duct. Right hepatectomy was unnecessary due to complete atrophy of the right liver. Postoperatively, persistent low back pain prompted a CT scan. It revealed compression of the left renal vein in the aortomesenteric clamp with dilation of this vein and the left genital vein downstream (Fig. 2, Fig. 3) indicating a nutcracker syndrome. Pelvic varices were also noted (Fig. 2).Fig. 1 Abdominal CT showing right liver necrosis.

Fig. 1

Fig. 2 a: Abdominal CT revealing left renal vein compression between the aorta and the superior mesenteric artery. b: pelvic section showing multiple pelvic varices.

Fig. 2

Fig. 3 Angio-CT showing an aortomesenteric angle <50° with a left renal vein compressed within the aortomesenteric clamp.

Fig. 3

The patient was put on anticoagulants with a good evolution. We have a two-year follow-up, and the patient regained weight with a current BMI is 22 kg/m2. He is currently completely asymptomatic.

3 Discussion

The Nutcracker syndrome is categorized into three types: the anterior type occurs when the left renal vein is compressed between the aorta and the superior mesenteric artery. It is due to a low or deviated mesenterico-aortic angle <45°, a stretching of the left renal vein over the aorta due to a left renal ptosis or an abnormally high course of the left renal vein [2,4]. Excessive fibrous tissue at the origin of the superior mesenteric artery could also contribute to the left renal vein compression [5]. Elsewhere, it may be caused by a compression of the left renal vein between the aorta and the spine (posterior form) or between the left renal artery and the aorta (posterolateral form) [5].

The aortomesenteric angle could be subject to variation depending on the body mass index (BMI). Normally, a 4-5 mm space between the vessels is maintained by the retroperitoneal fat and the duodenum. Significant weight loss could induce nutcracker syndrome by decreasing the Aorta- superior mesenteric artery angle due to reduced retroperitoneal and perivascular fat [5]. In our case, the patient's BMI dropped from 25 to 18 kg/m2 contributing to the syndrome. This weight loss is explained by the hypercatabolism caused by the first intervention.

Typically, nutcracker syndrome presents with a triad of symptoms: hematuria, pain (low back pain, pelvic pain, dyspareunia), and varicocele (pelvic varices in women), however, this triad is not always found [3]. Imaging especially the CT, helps diagnose the syndrome by revealing a short superior mesenteric artery and an aorto-mesenteric angle <45° [3]. Magnetic resonance imaging is also effective but more expensive [5]. Doppler ultrasound can show a dilation of the left renal vein, measure the inner diameter ratio between the renal hilum and the stenotic segment, and assess the flow velocity in the veins (A five times increase in flow velocity in the left renal vein as it passes the mesenteric artery, is specific to nutcracker syndrome) [6]. Moreover, a renocaval pressure exceeding 3 mmHg stands for a reference point to define the nutcracker syndrome [5]. Phlebography can detect reflux in the gonadal, adrenal, and lumbar veins as well as varicose peripyelic veins [6]. Radiological examinations should assess not only the anatomy of the aorto-mesenteric angle but to identify an eventual thrombosis of the left renal vein and the left gonadal vein caused by the compression [8].

Conservative treatment is sufficient in most cases of nutcracker syndrome. Antiagregants should be continued for a year due to the risk of thrombosis and pulmonary embolism. This conservative treatment is recommended for cases with few symptoms [8]. Surgery, in other cases, may involve the left kidney by nephropexy, renal transposition, or nephrectomy, the left renal vein by a bypass, or the superior mesenteric artery (intra or extravascular bypass) [7]. Endovascular treatment includes placing a stent in the left renal vein or embolizing the left genital vein [6].

The resolution of symptoms is obtained in 60 to 80 % of cases.

4 Conclusion

By presenting a detailed case study, we aimed to bring attention to Nutcracker syndrome, especially in patients who have experienced significant weight loss after a complicated surgery. The purpose is to explain the anatomical anomalies, diagnostic techniques, and treatment strategies for this condition. We demonstrated the importance of accurate diagnosis and personalized treatment plans.

Ethical approval

Our institutions “Mongi Slim Hospital” and “School of Medicine of Tunis” require no ethical approval for case reports. It is required for studies on human participants. This is just a case report with written patient approval.

Funding

None.

Author contribution

Kammoun Neirouz: conceptualization, data curation, redaction.

Hajri Mohamed: conceptualization, data curation, redaction.

Atallah Aziz: conceptualization, redaction.

Zaafouri Elmontassar belleh: resources, visualization.

Mestiri Hafedh: resources, validation, visualization.

Bacha Dhouha: supervision, visualization.

Guarantor

Kammoun Neirouz.

Research registration number

Not applicable.

Conflict of interest statement

All authors declare that there is no conflict of interest.

Acknowledgment

None.

We had the consent of the patient to publish the work.

The case report is reported in line with the SCARE criteria [1].
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