Minimally-invasive duodenojejunostomy for superior mesenteric artery syndrome: Intermediate follow up results of a rare operation

Julietta Chang, MD1, Mena Boules, MD1, John Rodriguez, MD1, R Matthew Walsh, MD1, Raul Rosenthal, MD2, Matthew Kroh, MD1. 1Cleveland Clinic Institution, 2Cleveland Clinic Florida

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is a rare condition caused by partial obstruction of the 3rd portion of the duodenum by the SMA anteriorly and aorta posteriorly resulting in abdominal pain, bilious emesis, and bloating symptoms. Contrast radiography, CT scan, and sometimes endoscopy confirm diagnosis. Laparoscopic duodenojejunostomy has been described as a safe and feasible surgical intervention with favorable short-term outcomes. However, descriptions of intermediate outcomes are lacking in the literature.

METHODS AND PROCEDURES: A retrospective chart review was performed on patients who underwent minimally-invasive duodenojejunostomy for SMAS from March 2005 to August 2015 at our healthcare system. We analyzed patients' presentations, work-up, surgical therapy, short-term and intermediate (6 month or greater) outcomes.

RESULTS: Of 26 patients who underwent minimally invasive duodenojejunostomy for SMAS at the Cleveland Clinic, 18 were 6 months or more out from the initial procedure. Mean age was 30.0 with 4 men and 14 women. Patients’ diagnosis was made by clinical presentation, elimination of other diagnoses, and radiographic confirmation. Mean weight loss preoperatively was 7.0kg. 14 of 18 patients had other comorbid conditions. 16 patients underwent laparoscopic duodenojejunostomy; 2 underwent robotic duodenojejunostomy. There were no intraoperative complications. Postoperatively, 2 patients developed prolonged ileus. 1 underwent exploratory laparotomy and washout for presumed leak but none was identified. 3 patients were readmitted within 30 days; 2 for intolerance to enteral intake with dehydration, and 1 for abdominal pain related to an anastomotic stricture which was successfully dilated endoscopically. The average and median length of follow up was 29.6 months and 22.5 months, respectively. Patients gained an average of 2.2kg with an increase in body mass index of from 19.6mkg2 to 20.3m/kg2. 9 of 18 patients reported an improvement in symptoms, while only 3 reported resolution. 5 continued to be severely symptomatic. 3 required long-term parenteral nutrition. 1 was diagnosed with intestinal dysmotility and underwent a feeding jejunostomy tube placement. Another was diagnosed with gastroparesis and underwent a laparoscopic gastric electric stimulator placement and pyloroplasty. None suffered from symptoms of blind loop syndrome like new-onset bloating, diarrhea, or greasy stools. There were no mortalities.

CONCLUSIONS: Duodenojejunostomy is the most common surgical intervention in management of SMAS.  Laparoscopic duodenojejunostomy is associated with less morbidity in the perioperative period. Our intermediate follow-up reveals moderate improvement and infrequent resolution of preoperative symptomatology.  Patients had a modest average weight gain postoperatively. This may suggest that different preoperative work-up and treatment is indicated.

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