Superior mesenteric artery syndrome: a single centre experience of laparoscopic duodenojejunostomy as the operation of choice

Abstract

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.

Superior Mesenteric Artery Syndrome Improved by Enteral Nutritional Therapy: A Retrospective Case-Series Study in a Single Institution

“…Among surgical options to consider are lysis of the ligament of Treitz, gastrojejunostomy, and duodenojejunostomy. Recently, a laparoscopic approach has also been reported [1,2,[23][24][25]. In 1927, Wilkie concluded that duodenojejunostomy was the treatment of choice [26].…”

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

“…In addition, we agree with other surgeons that asking adolescent patients to have a nasojejunal tube for several weeks is very difficult . Several alternative surgical approaches have been described in the literature: duodenal derotation , laparoscopic duodenojejunostomy , robot‐assisted laparoscopic duodenojejunostomy , Strong's procedure , and laparoscopic Roux‐en‐Y duodenojejunostomy . According to the literature, laparoscopic duodenojejunostomy is the technique of choice for SMA syndrome .…”

“…Moreover, it is rapid, non‐invasive, and minimizes exposure to radiation. Therefore, we believe that ultrasound performed by an experienced pediatric radiologist should be the test of choice .…”

“…Several alternative surgical approaches have been described in the literature: duodenal derotation , laparoscopic duodenojejunostomy , robot‐assisted laparoscopic duodenojejunostomy , Strong's procedure , and laparoscopic Roux‐en‐Y duodenojejunostomy . According to the literature, laparoscopic duodenojejunostomy is the technique of choice for SMA syndrome . Here, we present the first case reports of laparoscopic duodenojejunostomy using a 3‐D imaging system.…”

Oclusión gastroduodenal crónica por síndrome de Wilkie: reporte de un caso

“…En este caso, la paciente presentó inicialmente un síndrome de estenosis gastroduodenal crónico asociado a pérdida de peso progresivo, con anorexia, vómitos biliosos y de alimentos no digeridos de los días previos y que además agregó por el mismo mecanismo fisiopatológico antes descrito, una injuria renal aguda multifactorial con elevación de azoemia y creatininemia, causada por la deshidratación y por compresión de la vena renal izquierda que fue confirmada con ecografía 10,18,21 El objetivo terapéutico en el síndrome de Wilkie es mejorar el estado nutricional, con NPT y dieta enteral por sonda nasoyeyunal (SNY) si es que se logra sortear el obstáculo; de esta manera se genera tejido graso retroperitoneal que ensancha el ángulo mesentérico y alivia la oclusión con muy buenos resultados, descritos en la literatura mayores al 85% 17,22,23 , también se añade la prevención de factores desencadenantes en el campo neuropsíquico. (5) En la paciente se realizó el mismo plan terapéutico a excepción de la colocación de la SNY debido a que la colocación de SNG y el decúbito lateral izquierdo fueron suficientes para aliviar la oclusión en el primer episodio 3,10,24,25 .…”