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Asian J Endosc Surg ISSN 1758-5902

C A S E R E P O RT

Superior mesenteric artery syndrome treated with single-incision laparoscopy-assisted duodenojejunostomy Seiichi Shinji,1 Satoshi Matsumoto,1 Hayato Kan,1 Itsuo Fujita,1 Yoshikazu Kanazawa,1 Takeshi Yamada,1 Nobutoshi Hagiwara,1 Michihiro Koizumi,1 Hiroyuki Onodera,1 Kazuhide Ko,1 Tadashi Machida2 & Eiji Uchida1 1 Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan 2 Departments of Radiology, Nippon Medical School, Tokyo, Japan

Keywords Duodenojejunostomy; single-incision laparoscopic surgery; superior mesenteric artery syndrome Correspondence Seiichi Shinji, Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan. Tel: +81 3 3822 2131 Fax: +81 3 5685 0989 Email: [email protected] Received 23 May 2014; revised 4 August 2014; accepted 17 August 2014 DOI:10.1111/ases.12140

Abstract Superior mesenteric artery (SMA) syndrome is an uncommon disease resulting from compression and partial obstruction of the third portion of the duodenum from the SMA. A 77-year-old man, who did not have a history of surgery, experienced repeated vomiting and developed abdominal distension. Abdominal CT showed a narrowed third portion of the duodenum, with a distended stomach and proximal duodenum. The patient was diagnosed as having SMA syndrome and was initially treated conservatively, but his condition did not improve. Single-incision laparoscopy-assisted duodenojejunostomy was performed. The patient recovered well and was discharged from hospital on postoperative day 8. Laparoscopic treatment is feasible for the treatment of SMA syndrome given its safety and minimal invasiveness. This is a report of the first case of single-incision laparoscopyassisted duodenojejunostomy. This procedure is safer and less invasive than a conventional laparoscopic approach in a patient with SMA syndrome.

Introduction

Case Presentation

Superior mesenteric artery (SMA) syndrome is caused by a low aortomesenteric angle resulting in vascular compression of the third part of the duodenum, which is relatively immobile and crossed by the mesenteric root (1). SMA syndrome is characterized by postprandial epigastric pain, nausea, vomiting, anorexia, and weight loss. The treatment of SMA syndrome usually begins with conservative approaches, including nasogastric tube placement, placing the patient in the prone or left lateral decubitus position, and providing nutritional support. When conservative treatment fails, surgery is proposed in symptomatic patients. Duodenojejunostomy is the most frequent surgical procedure, and it has a success rate of about 80% (2). 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 case of singleincision laparoscopy-assisted duodenojejunostomy for SMA syndrome.

A 77-year-old Japanese man became anorexic in January 2011 and gradually lost 5 kg of body weight during the year. He visited a clinic complaining of repeated vomiting and continuous abdominal distension in December 2011. He was diagnosed with infectious gastroenteritis and given medication. However, starting from January 2012, his symptoms were typically chronic and intermittent, and included nausea, vomiting, and abdominal distention. He visited our emergency room (Nippon Medical School Hospital) complaining of mild loss of consciousness. Our physical examination showed a distended abdomen with tenderness in the left upper abdominal region and severe dehydration. On admission, his body weight was 44.6 kg and his height was 156 cm. His blood pressure was 102/ 62 mmHg. His heart rate was 100 bpm and his respiratory rate was 34 breaths per minute. He was in a confused state, but he retained his sense of orientation. CT images showed distension of the stomach and second portion of the duodenum. The patient was then

Asian J Endosc Surg 8 (2015) 67–70 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

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SILS duodenojejunostomy for SMA syndrome

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Figure 1 (a) CT image showing distension of the stomach and second portion of duodenum, as well as an aortomesenteric distance of 5 mm (arrow). (b) The angle between the aorta and superior mesenteric artery was 11°. (c) Barium contrast radiography shows dilatation of the stomach and proximal duodenum, and occlusion of the third portion of the duodenum by the SMA (arrow). (d) An upper gastrointestinal series on postoperative day 5 showed a duodenojejunal anastomosis with good ﬂow without leakage (arrow). Ao, aorta; Du, duodenum; SMA, superior mesenteric artery.

admitted to the emergency department of our hospital with the diagnosis of SMA syndrome. Abdominal X-ray radiography showed the double-bubble sign. The aortomesenteric distance was 5 mm (Figure 1a). The angle between the aorta and the SMA was 11° (Figure 1b). Barium contrast radiography showed dilatation of the stomach and proximal duodenum, and occlusion of the third portion of the duodenum by the SMA (Figure 1c). A nasogastric tube was placed for drainage of the bilious gastric contents, and the patient was given an intravenous drip to correct dehydration. His conscious level returned to normal; however, the amount of nasogastric aspirates was about 1000 mL/day. We considered that his condition would not improve by conservative therapy, so we decided to perform surgery. Laparoscopic duodenojejunostomy with endotracheal intubation was performed with the patient under general anesthesia. The patient was placed in the supine position.

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A LAP PROTECTOR (Hakko, Tokyo, Japan) for wound protection was inserted and passed through the 3-cm umbilical incision by an open technique. An EZ Access (Hakko), with three 5-mm EZ Trocars (Hakko), that was inserted previously was mounted to the LAP PROTECTOR (Figure 2a,b). An 8-mmHg carbon dioxide pneumoperitoneum was established, and a 5-mm flexible laparoscope was inserted. The patient was tilted to the reverse Trendelenburg position. The transverse mesocolon was lifted upward, and the small bowel was cleared from the field. The second and third portions of the duodenum could easily be seen through the transverse mesocolon. An approximately a 7-cm long incision was made on the transverse mesocolon, and the second and third portions of the duodenum could be seen (Figure 2c,d). The ligament of Treitz was identified, and a portion of the proximal jejunum, approximately 30 cm distal to the ligament of Treitz, was easily found and reached the duodenum. Under direct open visualization



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Figure 2 (a,b) A LAP PROTECTOR (Hakko) for wound protection was inserted and passed through the 3-cm umbilical incision. An EZ Access (Hakko), with three 5-mm EZ Trocars, that was inserted previously was mounted to the LAP PROTECTOR. (c,d) An approximately 7-cm long incision was made on the transverse mesocolon, and the second and third portions of the duodenum could be seen. (e,f) An Echelon 60 stapler (Ethicon Endo-Surgery) was ﬁrst inserted into the 12-mm XCEL trocar (Ethicon Endo-Surgery), and then it was introduced into both lumens under direct open visualization. A side-to-side duodenojejunostomy was carried out on the affected surrounding tissue under laparoscopy. (g,h) The common enterotomy was closed using a hand-sewn double-layered technique under direct open visualization.

from the umbilicus, a stay suture was placed between the duodenum and the jejunum to hold these two portions of the bowel in apposition and antiperistalsis. Duodenotomy and jejunotomy were carried out. An Echelon 60 stapler (Ethicon Endo-Surgery, Somerville, USA) was first inserted into the 12-mm XCEL trocar (Ethicon Endo-Surgery), and then it was introduced into both lumens under direct open visualization. A side-toside duodenojejunostomy was performed under laparoscopy on the affected surrounding tissue (Figure 2e,f). The common enterotomy was closed using a hand-sewn double-layered technique under direct open visualization (Figure 2g,h). No draining of the nasogastric tube was required, and the port sites were closed by a standard

procedure. Operating time was 125 min, and blood loss was negligible. The patient did well postoperatively, a Gastrografin study obtained on postoperative day 5 demonstrated free flow of contrast through the site of duodenojejunostomy (Figure 1d). The patient was discharged from the hospital on postoperative day 8 without complications and returned to a normal diet. He is doing well 17 months later without evidence of reoccurrence.

Discussion In most cases of SMA syndrome, the treatment usually begins with conservative approaches. Surgical


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management should be considered when conservative treatment fails. In our case, the amount of nasogastric aspirates did not decrease, although the patient received parenteral nutrition. Several surgical procedures including gastrojejunostomy, duodenojejunostomy, and Strong’s operation (duodenal mobilization for lowering the duodenojejunal flexure) have been performed to resolve or bypass duodenal compression. Duodenojejunostomy has been found to provide the best results in severe cases and significantly better results than gastrojejunostomy and Strong’s procedure (3). With recent progress in medical techniques, approaches in various fields have evolved to the point where laparoscopy-assisted surgery is now practiced as an alternative to conventional laparotomy. In 1998, Gersin and Heniford reported the first case of laparoscopic duodenojejunostomy for SMA syndrome (4). SILS is an emerging surgical technique that has gained much interest in the field of appendectomy, cholecystectomy, and colorectal surgery (5–7). The procedure is performed through one incision, which would be otherwise required for specimen extraction. It is potentially associated with a decrease in port-site- and incision-related morbidity and improved cosmetic features. Singleincision laparoscopic techniques have recently been adopted as a laparoscopy-assisted surgical option. A search of PubMed (http://www.ncbi.nlm.nih.gov/ PubMed), from 1950 to May 2014, using a combination of MeSH terms, including “superior mesenteric artery syndrome,” “single incision,” “single port,” and “duodenojejunostomy,” revealed no results. In our present case, single-incision laparoscopyassisted umbilical mini-laparotomy was performed, allowing the abdominal cavity to be observed, the appropriate site of jejunal anastomosis to be determined, and ileus release to be performed via the smallest possible wound required for anastomosis. The essential points of this technique are as follows: (i) bowel compression should be performed preoperatively if possible; (ii) a wound retractor should be used at the port for singleincision laparoscopic access to prevent wound infection; and (iii) because of limited manipulability, the automated suturing device should be inserted under direct open visualization, the anastomosis should be established under laparoscopy, and the opening through which the suturing device is inserted should be closed under direct open visualization. Although some cases involving procedures performed entirely under laparoscopy have ever been reported, the insertion of automated suturing devices and the closing of the openings through which

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the devices were inserted would be relatively cumbersome via multiport laparoscopy (4,8–10). Our method enables these operations to be managed under direct open visualization via a single port and appears to be the least invasive yet safest technique in comparison with past procedures. In conclusion, SMA syndrome can be successfully treated with a single-incision laparoscopy-assisted duodenojejunostomy. This is a safe and feasible technique that offers the benefits of reduced hospital stay and postoperative disability.

Acknowledgment The authors have no conflicts of interest or financial ties to disclose.

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