Outcomes After Duodenoduodenostomy for Superior Mesenteric Artery Syndrome

BackgroundSuperior Mesenteric Artery Syndrome (SMAS) is a very rare disease that causes starvation and malnutrition secondary to a mechanical obstruction of the 3rd portion of the duodenum between the superior mesenteric artery and aorta. Long-term outcomes following surgery for SMAS by current methods have a high failure rate of 21%-67%. We report the 3-year outcomes of a novel operation for SMAS described as the duodenoduodenostomy (DD).MethodsThis is a longitudinal case series of 12 patients who underwent the DD operation for SMAS, comparing pre-surgery to post-surgery 3-year outcomes. Weight, Body Metabolic Index (BMI), iron levels, and subjective data were collected to assess restoration of nutrition, correction of malabsorption, and lifestyle. The Wilcoxon signed-rank test was applied to nonparametric matched or dependent samples, with statistical significance set at P < 0.05.ResultsAt the end of 3 years, there was a significant increase in median weight and BMI, at 108 lbs vs 123.1 lbs (P-value 0.0156) and a BMI of 18.57 vs 20.59 (P-value 0.0161). At 3 months, iron levels normalized after surgery and stayed normal at 45 mcg/dL vs 130 mcg/dL (P-value = 0.046). After 3 years, 75% of patients gained weight and BMI while 83% were able to maintain their BMI to a normal range.ConclusionOur study demonstrates that DD surgery leads to significant increases in weight and BMI, accompanied by improved iron levels. The DD procedure emerges as a promising surgical option in the definitive treatment for SMAS.

Duodenojejunostomy following failed gastrojejunostomy in superior mesenteric artery syndrome: A case report

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare duodenal-vascular anatomic disorder leading to external compression on the duodenum. The first step of treatment usually is conservative, and in the case of failure, surgical management is the treatment choice. Treatment success with duodenojejunostomy after failure in gastrojejunostomy can show the uniqueness of this article.

CASE PRESENTATION

A 14-year-old boy came to our hospital with a complaint of epigastric pain, nausea, bilious vomiting, and weight loss since 6 months ago. Conservation therapy and laparotomic Braun anastomosis and gastrojejunostomy was performed due to the SMA syndrome diagnosis 2.5 months before the admission. At our hospital, an alteration of gastrojejunostomy by duodenojejunostomy employing a diamond-shaped anastomosis between the third portion of the duodenum (D3) and a part of jejunum that was placed 15 cm away from the ligament Treitz was done. A significantly dilated stomach and the first three parts of the duodenum were observed during the procedure. After the second surgical intervention, the general condition of the patient dramatically improved.

CLINICAL DISCUSSION

Conservative treatment, including nasogastric tube decompression, postural changes, and nutritional support with hyperalimentation, has a variable success rate. However, in some cases, surgery may be necessary. Surgeons prefer laparoscopic duodenojejunostomy due to its outstanding success rate, ranging from 80 % to 100 %. But, in some case reports it is suggested that gastrojejunostomy could be done in cases with severe duodenal dilation instead of duodenojejunostomy. The initial gastrojejunostomy failed because of ongoing symptoms, which was finally revised with a duodenojejunostomy.

CONCLUSION

It is suggested to use duodenojejunostomy after failure of gastrojejunostomy or it can be employed as the first surgical option even in cases with severe dilation. Because it is a more efficient correction with fewer complications than gastrojejunostomy.

Laparoscopic lateral duodenojejunostomy for pediatric superior mesenteric artery compression syndrome: a cohort retrospective study

PURPOSE

There are only a few case reports of laparoscopic lateral duodenojejunostomy (LLDJ) in children with Wilkie's syndrome, also known as superior mesenteric artery compression syndrome (SMAS). We aimed to describe our laparoscopic technique and evaluate its outcomes for SMAS in children.

METHODS

From January 2013 to May 2021, SMAS children who received LLDJ were included. The procedure was carried out utilizing the four-trocar technique. The elevation of the transverse colon allows good exposure of the dilated and bulging second and third sections of the duodenum. Using a linear stapler, we established a lateral anastomosis connecting the proximal jejunum with the third part of the duodenum. Following that, a running suture was used to intracorporeally close the common enterotomy. Clinical data on patients was collected for analysis. The demographics, diagnostic findings, and postoperative outcomes were analyzed retrospectively.

RESULTS

We retrospectively analyzed 9 SMAS patients (6 females and 3 males) who underwent LLDJ, aged between 7 and 17 years old. The mean operative time was 118.4 ± 16.5 min and the mean estimated blood loss was 5.6 ± 1.4 ml. There were no conversion, intraoperative complications or immediate postoperative complications. The mean postoperative hospital stay was 6.8 ± 1.9 days and the mean follow-up time was 5.4 ± 3.0 years. During follow-up, seven patients (77.8%) experienced complete recovery of symptoms prior to surgery. One patient (11.1%) still had mild vomiting, which resolved with medication. Another patient (11.1%) developed psychological-induced nausea, which significantly improved after treatment with education, training and diet management.

CONCLUSIONS

LLDJ represents a feasible and safe treatment option for SMAS in well-selected children. Further evaluation with more cases and case-control studies is required for the real benefits.

Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies

BACKGROUND

Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed.

OBJECTIVE

The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center.

MATERIALS AND METHODS

All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all.

RESULTS

In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign.

CONCLUSION

Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, "to-and-fro" motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.

Robotic modified Strong procedure for superior mesenteric artery syndrome

Key Clinical Message

The robotic modified Strong procedure is a safe and effective approach for surgical management of superior mesenteric artery syndrome in properly selected patients.

Abstract

Superior mesenteric artery syndrome is a rare syndrome of small bowel obstruction resulting from vascular compression of the duodenum. Here we present our modification of a robotic Strong procedure for the surgical management of SMA syndrome. This procedure is a safe and effective approach for management in properly selected patients.

Vascular compression of Duodenum: A case report of superior mesenteric artery syndrome

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.

Superior mesenteric artery syndrome following esophageal cancer surgery: A report of two cases and a literature review

The present study describes two cases of superior mesenteric artery syndrome (SMAS) which occurred following esophageal cancer surgery. The first case was that of a 68-year-old woman who underwent left sided trans-thoracic esophagectomy for esophageal squamous cell carcinoma. Specific symptoms, including bloating and postprandial vomiting, firstly appeared repeatedly 1 week following surgery. She was diagnosed with SMAS using a barium swallow (upper gastrointestinal series), and the symptoms did not improve following nutritional support treatment. Finally, the symptoms were relieved following a duodenojejunostomy. The second case involved a 66-year-old woman who underwent radical esophageal cancer resection. At 4 years after the surgery, the patient developed abdominal distension and postprandial vomiting. She was diagnosed with SMAS, again using an upper gastrointestinal series. Her symptoms were relieved following parenteral nutrition support. SMAS is a rare disease characterized by abdominal distension and vomiting. It is similar to the gastrointestinal manifestations caused by anastomotic stenosis and gastrointestinal reconstruction following esophageal cancer surgery, and it may also prompt thoracic surgeons to ignore the diagnosis of SMAS. Therefore, the possibility of SMAS occurrence in patients who have undergone radical esophageal cancer surgery, should be taken into consideration if they experience gastrointestinal symptoms, including abdominal distension and vomiting, following a rapid weight loss.

Endoscopic features for early decision to evaluate superior mesenteric artery syndrome in children

Background

Diagnostic delay of superior mesenteric artery syndrome (SMAS) is common due to its rarity and lack of index of clinical suspicion. Early diagnosis under suspicion is pivotal for adequate treatment. Present study aims to explore the endoscopic features for early decision to evaluate SMAS in children.

Methods

In case controlled observation study, the recruitment was limited to patients who had endoscopic finding I or finding 1 plus more as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s (finding I), a marked dilation of the duodenal first and second part during air insufflation at the third part of the duodenum (finding II), a bile mixed fluid collection (bile lake) in the stomach (finding III). SMAS was confirmed with UGI series or hypotonic duodenography in enrolled patients. We analyzed positive endoscopic findings related with SMAS.

Results

The enrolled 29 patients consisted of 18 (62.1%) with SMAS and 11 (37.9%) without SMAS. The three most common presenting symptoms were abdominal pain, postprandial discomfort, and early satiety. The clinical impressions based on history and physical examination before endoscopy were functional dyspepsia (34.6%), gastritis or gastric ulcer (31.0%), and SMAS (17.3%). The constellation of three endoscopic findings (finding I + II + III, feature D) observed in 13 (72.2%) patients of SMAS group and 3 (27.3%) patients of non SMAS group (P = 0.027). Of 16 patients with features D, SMAS was diagnosed in 13 patients (81.2%) and not detected in 3 patients (18.8%) on UGI series or hypotonic duodenography.

Conclusions

Endoscopic examination to the third part of the duodenum can provide a clue making a decision to evaluate SMAS, which consists of features of three endoscopic findings as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s, a marked dilation of the first and second part of the duodenum, and a bile lake in the stomach.

Subacute duodenal obstruction caused by Common Celiaco-Mesenteric Trunk anomaly-A case report

Introduction and importance

The origin of the mesenteric vasculature is highly variable. One such variation is the common celiaco-mesenteric trunk (CMT). To our knowledge, this is the first reported case of subacute duodenal obstruction caused by common CMT. The awareness of this anomaly helps keep a high index of suspicion for varied presentations, prompts appropriate investigations, timely intervention, and avoids iatrogenic injury.

Patient profile

A 15-year-old boy presented with a history of repeated attacks of colicky abdominal pain with bilious vomiting. Computed tomography of the abdomen with intravenous contrast revealed subacute duodenal obstruction caused by an acute angulation of common CMT with the abdominal aorta. To relieve the obstruction, the patient underwent a side-to-side duodenojejunostomy.

Discussion

A common CMT, where the coeliac artery (CA) and superior mesenteric artery (SMA) have a common origin from the aorta, accounts for less than 1% of all splanchnic artery anomalies. Most CMTs are incidental findings, but aneurysm or dissection of the common trunk commonly accompany this anatomical aberrancy. Intestinal obstruction due to CMT anomaly is a rare occurrence.

Conclusion

There should be a high index of suspicion concerning vascular anomalies in patients, especially children presenting with repeated episodes of subacute intestinal obstruction. This knowledge of vascular aberrations prevents disastrous iatrogenic complications.

•

Rarity of the occurrence of common celiacomesenteric trunk

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As per our knowledge this is the first reported case of CMT presenting with duodenal obstruction.

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Its similarity to Wilkie's syndrome in terms of patient and management

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Different presentations of CMT

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Knowledge of this variations important in other surgeries and endovascular procedures to avoid dreadful complications.

Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome

BACKGROUND

Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS.

MATERIALS AND METHODS

We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages.

RESULTS

Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery.

CONCLUSIONS

Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

SMA syndrome: management perspective with laparoscopic duodenojejunostomy and long-term results

BACKGROUND

Superior mesentery artery syndrome (SMAS) is a rare vasculo-anatomic occlusive pathologic entity for which a period of conservative medical management is advocated with surgery reserved for nonresponsive cases. We present our management plan that entails a single admission approach and complete rendering of medical and surgical treatment to the patient on a background of the socioeconomic and cultural trends prevalent in this geographic region.

METHODS

A retrospective analysis of 22 cases of SMAS admitted in our health care system who underwent a period of preoperative conditioning followed by laparoscopic duodenojejunostomy from September 2009 to June 2019 was performed. Patients were followed up at regular intervals.

RESULTS

The mean follow-up of the cohort was 41.2 months (2-108 months). The median length of stay was 6 days. The mean postoperative stay was 4.13 days. A subgroup of six patients who had severe physiological depletion required a period of preoperative optimisation. Five of the 22 (22.7%) patients suffered from postoperative complications in the form of delayed return of bowel functions. None of the patients had complications more than Clavien-Dindo grade 2 with no mortality. Long-term data are available for 19 patients (86.3%) which showed no symptom recurrence.

CONCLUSION

Management of SMAS that entails an antecedent medical therapy followed by surgery can be accomplished in a single admission with good to excellent results in the intermediate and long-term follow-up. Physiologically depleted patients do require a period of intensive preconditioning but on long-term follow-up, they have excellent results.

Laparascopic Ladd's procedure as treatment alternative, when parenteral or prolonged hospital nutrition is not an option for superior mesenteric artery syndrome

OBJECTIVES

Superior mesenteric artery syndrome (SMAS) is an uncommon cause of duodenal obstruction in pediatric patients. It is extremely rare in young infants. The classic treatment for SMAS has been an open or laparoscopic duodenojejunostomy when conservative medical therapy failed to resolve the obstruction. We herein reported 3 cases of SMAS in infants treated by laparoscopic Ladd's procedure. The advantages and feasibility of laparoscopic Ladd's procedure applied for SMAS in infants were discussed.

METHODS

Three cases of infants with SMAS subjected to laparoscopic Ladd's procedure in our hospital were collected from January 2014 to December 2015. The patients' age, operative time, postoperative hospital observation, resumption of full diet, and postoperative complications were analyzed.

RESULTS

The median age at operation was 8 months (range, 6-9 months). The mean body weight was 7.9 kg (range, 6.5-8.8 kg). The mean operative time was 66.7 min (range, 65-75 min). The mean postoperative hospital stay was 4.3 days (range, 4-5 days) and the follow-up was 20.7 months (range, 12-34 months) without any specific postoperative complications.

CONCLUSION

Based on our reports, laparoscopic Ladd's procedure is a reliable and practicable minimally invasive surgery for in infants with SMAS.

The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old

This review is directed at increasing awareness of two diverse rare upper gastrointestinal problems that occur at opposite ends of the age spectrum and are difficult to diagnose and treat. The Superior Mesenteric Artery Syndrome (SMAS) likely involves a young patient, especially female, and is especially associated with rapid weight loss, resulting in relative strangulation of the duodenum by a narrowing of the angle between the Superior Mesenteric Artery (SMA) and the aorta. On the other hand, atherosclerosis of the SMA is associated most likely with postprandial upper intestinal ischemia and abdominal pain occurs in the elderly at high risk for cardiovascular (CV) disease. Medical management of the SMAS in the young involves good alimentation and weight gain to overall increase the intestinal fat pad. Medical management of SMA atherosclerotic ischemia in the elderly is directed at marked lipid lowering with atherosclerotic plaque stabilization or even regression. If needed, surgery for SMAS can be attempted laparoscopically with duodenojejunoscopy which is the most popular procedure but there are also more conservative possibilities that avoid division of the duodenum. In addition, sometimes direct vision is needed to successfully operate on SMAS. If surgery is needed for SMA atherosclerotic ischemia, it is usually attempted endoscopically with angioplasty and stent placement. Most important, in the case of these two rare clinical entities, is that the clinician have a suspicion of their presence when indicated so that the young or old patient can be spared unnecessary suffering and return to good health in a timely fashion.

Superior Mesenteric Artery Syndrome: a Prospective Study in a Single Institution

BACKGROUND

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, resulting from the compression of the duodenum between superior mesenteric artery and aorta. This prospective registry aims to describe demographic, clinical, and outcome features of patients suffering from SMAS and to point out the indications for surgery.

METHODS

Between 2008 and 2016, patients with chronic gastrointestinal symptoms and diagnosis of SMAS were included. Demographics, clinical presentation, diagnosis, and surgical outcome were recorded. Symptoms were investigated with a standardized questionnaire. The diagnosis was achieved through barium swallow, CT/MR angiography (aortomesenteric angle ≤ 22°, distance ≤ 8 mm), endoscopy. All patients underwent duodenojejunostomy ± distal duodenum resection. At follow-up, symptom score and barium swallow were re-evaluated.

RESULTS

Thirty-nine patients (11 M/28 F, median age 38 years, median BMI 17.8 kg/m²) were included. Barium swallow showed a gastroduodenal dilation in 57% of patients, and a delayed gastroduodenal emptying in 38%. Median aortomesenteric angle was 11° and distance was 5 mm. All patients underwent duodenojejunostomy, and in 32 patients, a distal duodenum resection was also performed. At a median follow-up of 47 months, the overall symptom score significantly dropped (10 vs. 32, p < 0.0001) and BMI increased (19.5 vs. 17.8, p < 0.0001). Barium swallow at 2 months postoperatively showed an improvement in terms of gastroduodenal dilation and emptying in 38% of patients with preoperative pathological findings.

CONCLUSIONS

SMAS is a rare condition that should be suspected in cases of chronic, refractory upper digestive symptoms, particularly in females with low BMIs. Surgical treatment may improve symptoms and quality of life, although it is not curative in all cases. ClinicalTrials.gov Identifier: NCT03416647.

Wilkie's syndrome in monozygotic twins treated by 3-D laparoscopic duodenojejunostomy

Superior mesenteric artery syndrome, also known as Wilkie's syndrome, is a rare cause of proximal duodenum obstruction in children. Here, we describe the first pediatric case of superior mesenteric artery syndrome in monozygotic twin brothers. Both patients underwent 3-D laparoscopic duodenojejunostomy at the same age with an uneventful recovery.

Robotic Strong's procedure for the treatment of superior mesenteric artery syndrome. Description of surgical technique on occasion of the first reported case in the literature

BACKROUND

Superior Mesenteric Artery Syndrome (SMAS) is a rare disorder caused by compression of the third portion of the duodenum by the SMA. Once a conservative approach fails, usual surgical strategies include Duodenojejunostomy and Strong's procedure. The latter avoids potential anastomotic risks and complications. Robotic Strong's procedure (RSP) combines both the benefits of a minimal invasive approach and also enchased robotic accuracy and efficacy.

METHODS

For a young girl who was unsuccessfully treated conservatively, the paper describes the RSP surgical technique. To the authors' knowledge, this is the first report in the literature.

RESULTS

Minimal blood loss, short operative time, short hospital stay and early recovery were the short-term benefits. Significant weight gain was achieved three months after the surgery.

CONCLUSION

Based on primary experience, it is suggested that RSP is a very effective alternative in treating SMAS.

Superior Mesenteric Artery Syndrome: A Case Report of Two Surgical Options, Duodenal Derotation and Duodenojejunostomy

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction and its management is usually conservative with nasojejunal feeding. The pathophysiology entails the loss of the fat pad between the superior mesenteric artery and the abdominal aorta. This reduces the angle between the two vessels to less than 20 degrees with the resultant compression of the third part of the duodenum. The surgical management is usually a laparoscopic duodenojejunostomy. The two cases in our series had two different surgical procedures with good outcomes in both patients. The surgical management of each patient should be determined on its own merits irrespective of the standard of care.

Superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is an uncommon and potentially fatal cause of small bowel obstruction where the third portion of the duodenum is compressed between the abdominal aorta and the superior mesenteric artery. This is most frequently seen after sudden and significant weight loss, but other etiologies can also cause this duodenal compression. This syndrome can lead to food aversion, poor intake, and weight loss that exacerbate symptoms in a vicious cycle. SMA syndrome is often a diagnosis of exclusion due to nonspecific symptoms, including abdominal pain and distention, feelings of fullness after meals, and bilious emesis. Diagnosis may be assisted with radiography, tomography, endoscopy, and ultrasound imaging. Once SMA syndrome is identified, treatment is directed toward symptom management and nutritional support. If conservative measures fail, symptoms are severe, or the duodenum is compromised, several effective surgical procedures are routinely considered. This article provides an overview of SMA syndrome including history, pathophysiology, signs and symptoms, diagnostic testing, medical and surgical treatment, and implications for nursing staff.

Laparoscopic Toupet fundoplication with duodenojejunostomy for the management of superior mesenteric artery syndrome with reflux symptoms

RATIONALE

The patient had symptoms of GERD and the reflux even caused the symptom of cough. Gaining weight is a risk factor for the treatment of reflux as it could exacerbated symptoms of reflux and the drug treatment is not effective. Surgical intervention becomes necessary when there is failure following conservative medical therapy or the patient.

PATIENT CONCERNS

The patient was not satisfied with the drug treatment.

DIAGNOSES

Superior mesenteric artery syndrome, gastroesophageal reflux disease.

INTERVENTIONS

Laparoscopic Toupet fundoplication with duodenojejunostomy.

OUTCOMES

The patient discharged from hospital 10 days after surgery without any postoperative complication. The patient achieved complete relief of symptoms and discontinuation of drug.

LESSONS SUBSECTIONS

Superior mesenteric artery (SMA) syndrome may manifest the symptoms of GERD such as heartburn, acid reflux and cough. It is necessary to complete examination to exclude superior mesenteric artery syndrome for these patients. Laparoscopic fundoplication with duodenojejunostomy provided an effective treatment for patients who failed drug treatment.

Minimally invasive surgery for superior mesenteric artery syndrome: a case report and literature review

Introduction

Superior mesenteric artery syndrome is a rare condition characterised by nausea, vomiting, postprandial pain, anorexia and early satiety. Conservative management is tried initially, but if this fails, surgery is indicated. There are few reports in the literature concerning superior mesenteric artery syndrome in children, and fewer still managed surgically by minimally invasive means.

Case presentation

A 12-year-old girl presented with weight loss, early satiety and vomiting after corrective scoliosis surgery. After upper gastrointestinal endoscopy, contrast study and computed tomography imaging, a diagnosis of superior mesenteric artery syndrome was made. Conservative management by nasojejunal feeding failed; therefore, a laparoscopic duodeno-jejunostomy was undertaken. At follow-up, her symptoms had improved.

Conclusion

This report describes the youngest child to undergo laparoscopic duodeno-jejunostomy for superior mesenteric artery syndrome. Laparoscopic duodeno-jejunostomy appears to be the most widely employed and reliable minimally invasive approach to superior mesenteric artery syndrome with a high success rate and acceptably low complication rate.

Laparoscopic Ladd's procedure for superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is an uncommon condition where the third portion of the duodenum is compressed and obstructed between the SMA and the aorta. An otherwise healthy 17-year-old female presented with a 2-month history of postprandial abdominal pain and weight loss. Upper gastrointestinal (UGI) series demonstrated SMA obstruction of the third portion of the duodenum. Despite nasojejunal tube feedings over 4months with appropriate weight gain, symptoms continued and repeat UGI demonstrated persistent SMA syndrome. A laparoscopic Ladd's procedure served as definitive treatment. The steps of the procedure include mobilization of the Ligament of Treitz, mobilization of the right colon, complete derotation of the duodenum, delivery of the small bowel to the right upper quadrant, and appendectomy. Following the procedure, a postoperative UGI showed complete resolution of SMA compression of the duodenum. The patient had an uneventful postoperative course with immediate resolution of symptoms. She was discharged home tolerating a regular diet.

Optimal duration of medical treatment in superior mesenteric artery syndrome in children

The aim of this study was to investigate the outcome, and optimal duration of medical treatment in children with superior mesenteric artery syndrome (SMAS). Eighteen children with SMAS were retrospectively studied. The data reviewed included demographics, presenting symptoms, co-morbid conditions, clinical courses, nutritional status, treatments, and outcomes. The three most common symptoms were postprandial discomfort (67.7%), abdominal pain (61.1%), and early satiety (50%). The median duration of symptoms before diagnosis was 68 days. The most common co-morbid condition was weight loss (50%), followed by growth spurt (22.2%) and bile reflux gastropathy (16.7%). Body mass index (BMI) was normal in 72.2% of the patients. Medical management was successful in 13 patients (72.2%). The median duration of treatment was 45 days. Nine patients (50%) had good outcomes without recurrence, 5 patients (27.8%) had moderate outcomes, and 4 patients (22.2%) had poor outcomes. A time limit of >6 weeks for the duration of medical management tended to be associated with worse outcomes (P=0.018). SMAS often developed in patients with normal BMI or no weight loss. Medical treatment has a high success rate, and children with SMAS should be treated medically for at least 6 weeks before surgical treatment is considered.

Superior mesenteric artery syndrome in intellectually disabled children

OBJECTIVES

Superior mesenteric artery syndrome (SMAS) is a rare cause of small intestinal obstruction in pediatric patients. Children with intellectual disabilities are a challenging patient population in which to make this diagnosis. The goal of this study was to determine the frequency, presenting symptoms, and outcomes of SMAS in intellectually disabled and non-intellectually disabled children.

METHODS

Retrospective chart review of pediatric patients with SMAS admitted to Penn State Hershey Children's Hospital between January 1999 and July 2010.

RESULTS

Sixteen children with SMAS were identified. The majority were male (n = 9) and more than two thirds had an intellectual disability (n = 11). Presenting symptoms were similar between groups, but 78% (7/9) of intellectually disabled patients who had a gastrostomy tube presented with feeding intolerance. Although intellectually disabled patients had a higher number of comorbidities and the number of health care visits before diagnosis was higher, this did not reach statistical significance. There were also no significant differences in length of symptoms before diagnosis and amount of weight loss. However, the weight-for-age percentiles in intellectual disabled children were significantly lower in those without an intellectual disability (9.09 [20.31] vs 48 [20.19], respectively, P ≤ 0.001). Seventy-five percent of patients responded favorably to conservative treatment, but 36% (4/11) of intellectually disabled patients required multiple treatments before there was an improvement in their condition.

CONCLUSIONS

Superior mesenteric artery syndrome was found more often in children with an intellectual disability. These data highlight the need to consider SMAS if there is difficulty tolerating gastrostomy tube feedings in patients with weight-for-age percentiles less than 5%.