superior mesenteric artery ( sma ) syndrome is a rare disorder , recognized as weight loss , nausea , vomiting , and post - prandial pain due to compression and partial obstruction of the third portion of the duodenum by the sma .
if conservative treatment fails , then laparotomy with duodenojejunostomy or lysis of the ligament of treitz is indicated .
we report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum .
a very thin woman with a diagnosis of sma syndrome was prepared for surgery after having failed medical therapy .
the patient was placed in a supine position , and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy .
it provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient .
vascular compression of the duodenum was first described by rokitansky in 1842 , with the first successful operative treatment , a duodenojejunostomy , performed by stavely in 1908 .
the site of obstruction typically occurs in the third portion of the duodenum as the organ is held between the superior mesenteric artery and lumbar spine .
symptoms are typically chronic and intermittent and include nausea , vomiting , distention , and post - prandial epigastric pain , with resultant weight loss .
the compression may occur in the setting of a narrowed aortomesenteric angle , abdominal compression by a cast or girdle , or it may be categorized as idiopathic .
some authors have suggested a genetic predisposition patients are usually young , and women are affected more often than men .
other technical approaches include lysis of the ligament of treitz or gastro - jejunostomy which may be less effective ; a duodenojejunostomy is required if these fail .
recently , advances in laparoscopic skills have enabled surgeons to forego the need for laparotomy when performing operations of increasing complexity . in this report
, we describe the first known case of laparoscopic duodenojejunostomy for superior mesenteric artery ( sma ) syndrome .
the patient is a thin 24-year - old female with past medical history of total abdominal colectomy and ileorectal anastomosis five years earlier .
she had previously done well ; however , she began to complain of nausea , bilious vomiting and a recent 20 pound weight loss .
an upper gastrointestinal series with small bowel follow through demonstrated a partial obstruction of the third portion of the duodenum with marked dilatation proximally . with these clinical and radiologic findings , the diagnosis of sma syndrome was made .
the patient did not improve with conservative management and subsequently surgical consultation and operation was requested .
after thorough evaluation , the patient was taken to the operating room for a laparoscopic duodenojejunostomy . due to the previous operation
, an open hasson technique was performed in the right paramedian position , lateral to the umbilicus . as the intra - abdominal adhesions were cleared , three additional trocars were placed , one each in the left lateral abdomen , xiphoid , and at the umbilicus ( figure 1 ) .
a kocher maneuver was performed revealing no masses in the duodenum or head of the pancreas .
the ligament of treitz was identified , and a portion of the proximal jejunum , approximately 30 cm distal to the ligament of treitz , was found to easily reach the duodenum .
a silk suture was placed between the duodenum and jejunum , holding these two portions of the bowel in apposition .
a duodenotomy was made in the lateral aspect of the second portion of the duodenum avoiding the ampulla .
after performance of an anti - mesenteric jejunotomy , a 35 mm gia ( united states surgical corporation , norwalk , ct ) was introduced into both lumens and a duodenojejunostomy was created ( figure 2 ) .
a second load of the 35 mm gia was used to extend the anastomosis in excess of 5 cm .
the anastomosis was reinforced with interrupted 3 - 0 silk lembert sutures and was noted to be airtight by insufflating the duodenum under a pool of saline .
no drains or nasogastric tube were required , and the trocar sites were closed in the standard fashion .
the right paramedian trocar was inserted first utilizing an open procedure , due to a previous midline incision .
creation of a laparoscopic duodenojejunostomy utilizing a 35 mm gia stapler ( united states surgical corporation , norwalk , ct ) .
a gastrograffin study obtained on postoperative day 2 demonstrated free flow of contrast through the duodenojejunostomy ( figure 3 ) .
she was discharged home on postoperative day 4 without complications , tolerating a regular diet .
upper gastrointestinal series demonstrating a patent duodenojejunostomy with flow of contrast past the stapled anastomosis .
sma syndrome is a rare condition whose incidence ranges from 0.0024 to 0.34% for the general population , with a slightly higher incidence in chronic care facilities . its actual incidence is largely unknown since its diagnosis is not frequently pursued in the chronically ill
patients typically assume the knee - chest position after eating , which widens the aortomesenteric angle , relieves their partial duodenal obstruction , and allows the passage of gastric contents through this area of duodenal narrowing .
the use of total parenteral nutrition or aggressive nutritional support may increase the bulk of the retroperitoneal fat pad and provide relief by widening the aortomesenteric angle .
this syndrome can be caused by body casts or girdles and removing these implements can aid by decreasing the extraluminal compressive forces inflicted upon the duodenum .
open surgical approaches have included amputation of the ligament of treitz with repositioning of the duodenum , gastro - jejunostomy , and duodenojejunostomy .
the most successful approach for treatment of the sma syndrome has been the performance of a duodenojejunostomy , and some authors have suggested that other operative interventions are ineffective .
our group opted to treat this syndrome laparoscopically by the same operation that we chose in open surgery , a duodenojejunostomy bypass .
this is the first case report , to our knowledge , of performance of a laparoscopic duodenojejunostomy for treatment of sma syndrome .
postoperative radiologic studies confirmed patency of the duodenojejunostomy , and there have been no further obstructive episodes .
in conclusion , sma syndrome can be added to the growing list of disorders that can be successfully treated laparoscopically .
laparoscopic treatment via duodenojejunostomy is safe and effective and may offer patients the benefit of decreased pain , hospital stay , and postoperative disability .
 background and objectives : superior mesenteric artery ( sma ) syndrome is a rare disorder , recognized as weight loss , nausea , vomiting , and post - prandial pain due to compression and partial obstruction of the third portion of the duodenum by the sma . 
 if conservative treatment fails , then laparotomy with duodenojejunostomy or lysis of the ligament of treitz is indicated . recently 
 , laparoscopic division of the retroperitoneal attachments of the duodenum has been described . 
 we report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum.methods:a very thin woman with a diagnosis of sma syndrome was prepared for surgery after having failed medical therapy . 
 the patient was placed in a supine position , and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy.results:the patient did well postoperatively . 
 a gastrograffin study revealed no leak with patency of the duodenojejunal anastomosis . 
 she was subsequently discharged home on a regular diet on postoperative day four.conclusion:laparoscopic duodenojejunostomy is a viable option to treat vascular compression of the duodenum . 
 it provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient . 