Videopaper

Laparoscopic Duodenojejunostomy
for the SMA Syndrome

Introduction Case report

Superior Mesenteric Artery Syndrome
(SMAS) affects mostly young healthy fe-
males and presents with postprandial nau-
sea, vomiting, and abdominal pain result-
ing in anorexia and weight loss [1]. This
rare condition was first described in an
A 17-year-old female presented to our
hospital with nausea, vomiting and severe
abdominal pain. At that time, the patientʼs
body mass index (BMI) was 19.4 kg/m2.
She denied rapid weight loss. Her medical
history was not significant for any other preoperative treatment (NG tube, transfu-

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autopsy study by Austrian pathologist Ro- pathology. As a result of an obscure clini- sions) a laparoscopic duodenojejunostomy
kitansky in 1842 [2]. SMAS is also known in cal presentation, further investigations was scheduled.
literature as Cast syndrome, Wilkieʼs syn- were indicated. The patient underwent a
drome, arteriomesenteric duodenal com- CT scan of the abdomen and dilation of Surgical technique
pression and chronic duodenal ileus [3]. the stomach resulting in the notation of a After placing the patient in an supine posi-
The contributive factor of SMAS is consid- proximal duodenum (▶ Fig. 1). The dis- tion and induction of general anesthesia,
ered to be decreased distance and angle tance between the superior mesenteric ar- an initial 5 mm incision was made in the
between SMA and the aorta which leads tery and the aorta was measured and right hemi-abdomen. A 0-degree scope
to compression of the third and fourth found to be 8 mm. Moreover, SMA-aortic was placed through an optically viewing
portions of the duodenum located be- angle was evaluated and was found to be 5 mm trocar and safely inserted into the
tween these two vascular structures [4]. 24 degrees on sagittal view. An upper en- abdominal cavity. Pneumoperitoneum
Mechanical vascular obstruction of the dis- doscopy was performed and unchanged was established and the abdomen was ex-
tal portion of the duodenum results in dis- mucosa was identified at the level of ob- plored. The duodenum and stomach were
tention of the proximal duodenum, stom- struction with external compression of easily identified due to the absence of a
ach and consequently results in the symp- the third part of the duodenum. Duplex ul- visceral fatty tissue. An additional right-
toms mentioned above [5]. Rapid weight trasonography study confirmed narrowed sided 5 mm trocar as well as left-sided 12
loss for different reasons in young females SMA-aortic angle with the patent mesen- and 5 mm trocars were placed, the colon
is one of the crucial causative factors in the teric vasculature. Based on the patientʼs was elevated and the ligament of Treitz
development of this interesting condition symptoms and objective findings, diagno- with the root of the mesentery were iden-
[6]. SMAS is frequently detected by such sis of SMAS was established. After a short tified. Prominent superior mesenteric ves-
imaging studies as CT, MRI and ultrasound
as well as upper GI studies [1]. The first line
treatment for duodenal vascular com-
pression is conservative, including high
caloric total parenteral nutrition and the
placement of a enteral feeding tube endo-
scopically [5]. However, this type of treat-
ment rarely achieves desired results [1]. In
case of conservative management failure,
surgical treatment is indicated. To date,
the standard surgical approach for SMAS
remains open duodenojejunostomy [7].
The role of minimally invasive surgery in
the treatment of duodenal vascular com-
pression remains subject to debates [7].
Herein, we present a case of an 17-year-
old female with SMAS undergoing laparo-
scopic duodenojejunostomy and experi-
encing complete resolution of her symp- ▶ Fig. 1 CT scan abdomen. Red arrow: Aorta; yellow arrow: Superior mesenteric artery; blue
toms and appropriate postoperative arrow: obstructed duodenum.
weight gain.

Ehlers TOO et al. Laparoscopic Duodenojejunostomy for … Zentralbl Chir 2018; 143: 461–463 461
 Videopaper

sels were noted. There were no obvious

masses or other inflammation or abnor-
malities in this area. A distended second
and the third portion of the duodenum
proximally from the Treitz ligament were
quite easily seen through the transverse
mesocolon, which confirmed diagnosis of
the vascular obstruction of the duode-
num. A window was made through the
transverse mesocolon and the second,
third and fourth portions of the duode-
num were mobilized out of the retroperi-
toneum up to the level of the mesenteric
vessels. At this point, a site on the proxi-
mal jejunum approximately 8–10 cm distal
from the ligament of Treitz was identified

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and sutured to the fourth portion of the
duodenum proximal to the SMA obstruc-
▶ Fig. 2 Enterotomies on the duodenum and jejunum were performed and wide 6 cm anas-
tion through the transverse mesocolon.
tomosis was created using a single fire of a linear 60 mm stapler.
Enterotomies on the duodenum and jeju-
num were performed and a wide 6 cm
anastomosis was created using a single fire
of a linear 60 mm stapler (▶ Fig. 2). The
common enterotomy was over sewn in
two layers with a running 3–0 Vicryl suture
and multiple interrupted 2–0 silk sutures.
An additional suture was used to relieve
the tension on the anastomosis. No com-
plications and no significant blood loss
occurred intraoperatively. The operative
time was 66 minutes. The post-operative
period was uneventful. Patientʼs pain was
well controlled and after tolerating a regu-
lar diet, the patient was discharged on
post-operative day 3. On 6 months follow
up, the patient demonstrated significant
weight gain with a BMI of 22.7 kg/m2 and
complete resolution of the symptoms.

Conclusion ▶ Fig. 3 Duodenojejunostomy.

SMAS is more commonly seen in females

and usually associated with extreme
weight loss [3]. However, some patients
with SMAS do not experience progressive
weight loss [3]. In our case, a preoperative
CT scan revealed dilatation of the the duo-
denum and the distance between the SMA
and aorta at a 8 mm level. The Aorto-SMA
angle was measured by a Duplex ultra-
sound study and was found to be 22–24
degrees. According to the literature, the
mean aorto-mesenteric distance is nor-
mally 10–28 mm and the aorto-mesenter-
ic angle varies between 25–60° [8]. The
oral contrast study usually demonstrates
stenosis of the third and fourth portion of
the duodenum at the level of superior
mesenteric artery. The first line treatment
for SMAS is conservative therapy which in-
cludes gastric and duodenal decompres-
sion with nasogastric tube placement,
changes in feeding position, correction of
electrolyte abnormalities and nutritional
support [9, 10]. If medical treatments fail,
in symptomatic patients, surgery is indi-
cated [10]. Surgical management includes
gastrojejunostomy or dissection of the
ligament of Treitz (Strongʼs operation)
and duodenojejunostomy [3]. A recent
study comprised from 12 consecutive pa-
tients demonstrated a 100 % success rate
using duodenojejunostomy for SMAS [3]
(▶ Fig. 3).
A laparoscopic approach has demon-
strated its advantage over open surgery
with a shorter hospital stay, lower post-
operative pain and decreased risk of post-
operative incisional hernias [3]. SMAS is
still a poorly recognized pathology. A high
index of suspicion should be given for pa-
tients with unclear causes of postprandial
nausea, vomiting and abdominal pain, es-

462 Ehlers TOO et al. Laparoscopic Duodenojejunostomy for … Zentralbl Chir 2018; 143: 461–463
pecially in young females. The laparoscop-
ic approach seems to be effective and safe
for patients with SMAS who have failed
medical management.
Conflict of Interest
The authors declare that they have no
conflict of interest.
Authors
Till-Oliver Ehlers 1, Levan Tsamalaidze 2,
Lucio Pereira 3, John Stauffer 3
1 Klinik für Allgemein-, Viszeral- und Onkologi-
sche Chirurgie, Evangelisches Krankenhaus
Düsseldorf, Germany
2 Department of General Surgery, Mayo Clinic,
Jacksonville, United States
3 Division of General Surgery, Mayo Clinic,
Jacksonville, United States
Ehlers TOO et al. Laparoscopic Duodenojejunostomy for …
Correspondence
Till-Oliver Ehlers
Evangelisches Krankenhaus Düsseldorf
Klinik für Allgemein-, Viszeral- und
Onkologische Chirurgie
Kirchfeldstraße 40
40217 Düsseldorf
Germany
Phone: + 49 (0) 2 11 91 90
tilloliverehlers@gmail.com
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▶ Video 1 https://eref.thieme.de/BGEE7
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Bibliography
DOI https://doi.org/10.1055/a-0668-1991
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Thieme Verlag KG Stuttgart · New York |
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