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Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome.

Singaporewalla RM, Lomato D, Ti TK - JSLS (2009 Jul-Sep)

Bottom Line: An abdominal computerized tomography (CT) scan and oral Gastrografin meal revealed a dilated stomach and proximal duodenum due to compression of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta.The patient resumed a normal diet and remained asymptomatic at 6-month follow-up.It gives the same results as open surgery with all the advantages of minimally invasive surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, National University Hospital, Singapore. reyam@yahoo.com

ABSTRACT

Background: Superior mesenteric artery syndrome (SMAS) is a rare condition causing acute or chronic compression of the third part of the duodenum, due to a reduction in the aortomesenteric angle. Traditionally, an open duodenojejunostomy is recommended when conservative management fails. Laparoscopic duodenojejunostomy is a minimally invasive option that has been reported in up to 10 cases. We describe our operative technique in one case and review the literature on this condition.

Methods: A previously well 66-year-old man presented with acute gastric dilatation. An abdominal computerized tomography (CT) scan and oral Gastrografin meal revealed a dilated stomach and proximal duodenum due to compression of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta.

Results: Esophagogastroduodenoscopy (EGD) ruled out intraluminal causes. A laparoscopic duodenojejunostomy was performed when conservative management failed. Postoperative recovery was quick and uneventful. Gastrografin administration on the fifth day showed no leak, with free flow of contrast into the jejunum. The patient resumed a normal diet and remained asymptomatic at 6-month follow-up.

Conclusion: Laparoscopic duodenojejunostomy is feasible, safe, and effective. It gives the same results as open surgery with all the advantages of minimally invasive surgery.

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Related in: MedlinePlus

Preoperative Gastrografin meal showing a dilated proximal duodenum with hold up of contrast in the third part and delayed passage distally.
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Figure 3: Preoperative Gastrografin meal showing a dilated proximal duodenum with hold up of contrast in the third part and delayed passage distally.

Mentions: A 66-year-old man, with no previous medical history, presented with severe upper abdominal pain and distension that had been present for a few days. He had no history of nausea, vomiting, recent weight loss, altered bowel habits, or previous abdominal surgery. On examination, he was alert, afebrile, with a pulse rate of 107/min and blood pressure of 155/95 mm Hg. The abdomen was distended, tympanic, with positive succussion splash and epigastric tenderness. A bedside ultrasound showed an incidental 4-cm abdominal aortic aneurysm. The initial blood investigations were normal. An urgent computerized tomography (CT) scan revealed marked distension of the stomach and proximal duodenum with narrowing of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta (Figure 1). The sagittal-CT showed a marked narrowing of the aortomesenteric angle (white arrow) to 8.6 degrees compatible with a diagnosis of superior mesenteric artery syndrome (SMAS) (Figure 2). The incidental 4cm infra-renal aortic aneurysm showed no leak or rupture. The patient's symptoms improved with nasogastric decompression, and he got himself discharged against medical advice the next day. He presented again in the emergency department 2 days later with similar symptoms, bilious vomiting and severe dehydration. After fluid resuscitation and nasogastric decompression, an esophagogastroduodenoscopy (EGD) was performed. It showed a dilated stomach with no outlet obstruction. The first and second parts of the duodenum were dilated with a collapsed lumen in the third part. The scope, however, could pass through the third part. Gastrografin administration showed hold up of contrast in the third part of the duodenum with proximal dilatation and slow passage into the distal small bowel (Figure 3). Conservative management with nasojejunal feeds was not successful because the patient was non-compliant and refused tube feeding. He required a surgical bypass for long-term relief. A laparoscopic duodenojejunostomy was successfully performed.


Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome.

Singaporewalla RM, Lomato D, Ti TK - JSLS (2009 Jul-Sep)

Preoperative Gastrografin meal showing a dilated proximal duodenum with hold up of contrast in the third part and delayed passage distally.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3015984&req=5

Figure 3: Preoperative Gastrografin meal showing a dilated proximal duodenum with hold up of contrast in the third part and delayed passage distally.
Mentions: A 66-year-old man, with no previous medical history, presented with severe upper abdominal pain and distension that had been present for a few days. He had no history of nausea, vomiting, recent weight loss, altered bowel habits, or previous abdominal surgery. On examination, he was alert, afebrile, with a pulse rate of 107/min and blood pressure of 155/95 mm Hg. The abdomen was distended, tympanic, with positive succussion splash and epigastric tenderness. A bedside ultrasound showed an incidental 4-cm abdominal aortic aneurysm. The initial blood investigations were normal. An urgent computerized tomography (CT) scan revealed marked distension of the stomach and proximal duodenum with narrowing of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta (Figure 1). The sagittal-CT showed a marked narrowing of the aortomesenteric angle (white arrow) to 8.6 degrees compatible with a diagnosis of superior mesenteric artery syndrome (SMAS) (Figure 2). The incidental 4cm infra-renal aortic aneurysm showed no leak or rupture. The patient's symptoms improved with nasogastric decompression, and he got himself discharged against medical advice the next day. He presented again in the emergency department 2 days later with similar symptoms, bilious vomiting and severe dehydration. After fluid resuscitation and nasogastric decompression, an esophagogastroduodenoscopy (EGD) was performed. It showed a dilated stomach with no outlet obstruction. The first and second parts of the duodenum were dilated with a collapsed lumen in the third part. The scope, however, could pass through the third part. Gastrografin administration showed hold up of contrast in the third part of the duodenum with proximal dilatation and slow passage into the distal small bowel (Figure 3). Conservative management with nasojejunal feeds was not successful because the patient was non-compliant and refused tube feeding. He required a surgical bypass for long-term relief. A laparoscopic duodenojejunostomy was successfully performed.

Bottom Line: An abdominal computerized tomography (CT) scan and oral Gastrografin meal revealed a dilated stomach and proximal duodenum due to compression of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta.The patient resumed a normal diet and remained asymptomatic at 6-month follow-up.It gives the same results as open surgery with all the advantages of minimally invasive surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, National University Hospital, Singapore. reyam@yahoo.com

ABSTRACT

Background: Superior mesenteric artery syndrome (SMAS) is a rare condition causing acute or chronic compression of the third part of the duodenum, due to a reduction in the aortomesenteric angle. Traditionally, an open duodenojejunostomy is recommended when conservative management fails. Laparoscopic duodenojejunostomy is a minimally invasive option that has been reported in up to 10 cases. We describe our operative technique in one case and review the literature on this condition.

Methods: A previously well 66-year-old man presented with acute gastric dilatation. An abdominal computerized tomography (CT) scan and oral Gastrografin meal revealed a dilated stomach and proximal duodenum due to compression of the third part of the duodenum between the superior mesenteric artery (SMA) and aorta.

Results: Esophagogastroduodenoscopy (EGD) ruled out intraluminal causes. A laparoscopic duodenojejunostomy was performed when conservative management failed. Postoperative recovery was quick and uneventful. Gastrografin administration on the fifth day showed no leak, with free flow of contrast into the jejunum. The patient resumed a normal diet and remained asymptomatic at 6-month follow-up.

Conclusion: Laparoscopic duodenojejunostomy is feasible, safe, and effective. It gives the same results as open surgery with all the advantages of minimally invasive surgery.

Show MeSH
Related in: MedlinePlus