Minimally Invasive Duodenojejunostomy for Superior Mesenteric Artery Syndrome

Zhuo Sun, MD, John Rodriguez, MD, John McMichael, R Matthew Walsh, MD, Sricharan Chalikonda, MD, Raul J Rosenthal, MD, Matthew D Kroh, MD, Kevin El-Hayek, MD. 1 Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2 Digestive Disease Institute, Cleveland Clinic, Weston, FL.

Introduction: Superior mesenteric artery syndrome (SMAS) is a disorder characterized by vascular compression of the duodenum leading to mechanical obstruction. Surgical intervention is indicated in patients who fail non-operative management, typically post-obstructive enteral feeding. Current surgical options include division of the ligament of Treitz, gastrojejunostomy, and duodenojejunostomy; with duodenojejunostomy favored based on previous small series. Given the rarity of the condition, knowledge of the optimal indications for surgery, risk of postoperative complications, and prognosis of SMAS after minimally invasive duodenojejunostomy is limited.

Methods: A retrospective chart review was performed for patients undergoing duodenojejunostomy for SMAS from March 2005 to December 2011 in the Cleveland Clinic Health System. We described patients’ initial evaluation, and the main outcomes examined are symptom improvement and postoperative complications.

Results: A series of 11 patients (9 female/ 2 male) with SMAS underwent minimally invasive duodenojejunostomy. All of these patients met clinical criteria of SMAS with radiological confirmation. Presentation typically involved persistent vomiting, esophageal reflux, and post-prandial epigastric pain. Average weight loss before surgery was 12.7±7.1 kg. Depression and eating disorders were comorbid in 4/11 patients (36%). The mean age was 37 years (19-74). All operations were performed with minimally invasive technique. Nine operations were completed laparoscopically and two were performed with robotic assistance. Operation duration was 125±67minutes and average length of hospital stay was 4.8 days (1-10). There were no immediate post operative complications. One patient developed a delayed anastomotic stricture that responded to a single endoscopic dilation. Initial symptom improvement occurred in 10 patients (91%). At a mean follow up of 11 months, two patients experienced complications (2/11), including one infection at a simultaneously placed J-tube site and one patient with dumping syndrome. Mean weight gain was 2.4 kg (0.25-5).

Conclusion: Superior mesenteric artery syndrome should be considered a potential diagnosis in patients who present with a history of persistent postprandial vomiting, epigastric pain, and weight loss and confirmatory radiographic findings. Minimally invasive duodenojejunostomy is a safe and effective treatment for SMAS with excellent short-term symptom results.

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