INTRODUCTION The superior mesenteric artery (SMA) syndrome, or Wilkie's syndrome, is a rare cause of postprandial epigastric pain, vomiting and weight loss caused by compression of the third part of the duodenum as it passes beneath the proximal superior mesenteric artery. The syndrome may be precipitated by sudden weight loss secondary to other pathologies, such as trauma, malignancy or eating disorders. Diagnosis is confirmed by angiography, which reveals a reduced aorto-SMA angle and distance, and contrast studies showing duodenal obstruction. Conservative management aims to increase intra-abdominal fat by dietary manipulation and thereby increase the angle between the SMA and aorta. Where surgery is indicated, division of the ligament of Treitz, anterior transposition of the third part of the duodenum and duodenojejunostomy have been described. METHODS We present four cases of SMA syndrome where the intention of treatment was laparoscopic duodenojejunostomy. The procedure was completed successfully in three patients, who recovered quickly with no short-term complications. A fourth patient underwent open gastrojejunostomy (complicated by an anastomotic bleed) when dense adhesions prevented duodenojejunostomy. CONCLUSIONS The superior mesenteric artery syndrome should be considered in patients with epigastric pain, prolonged vomiting and weight loss. Laparoscopic duodenojejunostomy is a safe and effective operation for management of the syndrome. A multi-speciality team approach including gastrointestinal, vascular and radiological specialists should be invoked in the management of these patients.

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IntroductionDefence Medical Services has a history of sharing clinical practice and innovation with the civilian sector. Changes to surgical training has meant acquiring and maintaining trauma surgical skills is becoming more difficult. Anatomically correct, bleeding junctional vascular trauma task trainers have been developed for the Military Operational Specialist Team Training (MOSTT) course. We investigated the benefit of these models on a civilian trauma course attended by non-vascular surgeons. The Mass Casualty Damage Control Surgery Ortho Trauma Surgery (DCS) Course is taught by a combined civilian and military faculty.MethodGroin, pelvic and shoulder haemorrhage surgical task trainers with pulsatile blood flow were used in the course to simulate junctional haemorrhage requiring surgical intervention.Participants completed modified pre and post course questionnaires to record changes in their self-reported confidence.ResultsTen participants completed simulation scenarios using the models and provided feedback. Approach to femoral artery, subclavian artery, gaining proximal and distal arterial control and temporary arterial shunting all had statistically significant improvements in participant confidence (p<0.0047, p<0.0017, p<0.0012 and p<0.0009).ConclusionThese findings mirror the experience on the MOSTT course where 63% of participants indicated that their confidence had improved. These results demonstrate the value for high fidelity surgical simulation in civilian practice to help maintain currency in less frequently encountered injury patterns. The training includes the whole team in high fidelity DCS simulation without the need for live tissue or cadaveric material and shows that surgical mannequins developed for the military environment have utility on civilian trauma courses. Research by the authors about the effects of this model on surgical ability and performance is ongoing.