Surg Endosc DOI 10.1007/s00464-014-3743-z

and Other Interventional Techniques

DYNAMIC MANUSCRIPT

Superior mesenteric artery syndrome following sleeve gastrectomy: case report, review of the literature, and video on technique for surgical correction Allison M. Barrett • David J. Harrison Edward H. Phillips • Seth I. Felder • Miguel A. Burch



Received: 18 March 2014 / Accepted: 7 July 2014 Ó Springer Science+Business Media New York 2014

Abstract Superior mesenteric artery (SMA) syndrome is a rare condition in which the duodenum is compressed between the SMA and aorta. This often occurs following extreme weight loss and has been reported in the bariatric population. We present the first reported case of SMA syndrome following sleeve gastrectomy. The patient underwent laparoscopic duodenojejunostomy and recovered uneventfully. The following is a review of the literature and detailed operative approach in the attached video.

possible diagnoses, including adhesive intestinal obstructions, internal hernia, motility disorders, ulceration, phytobezoar, incisional hernia, and intussusception. Patients often undergo multiple tests to rule out more common pathologies before being diagnosed. Once the diagnosis of SMA syndrome is entertained, specific radiographic imaging can be obtained for confirmation. Here we present the first reported case of SMA syndrome following sleeve gastrectomy, including video of our operative technique and a review of the literature.

Keywords Bariatric  Superior mesenteric artery syndrome  Laparoscopy  Sleeve gastrectomy Case report Superior mesenteric artery (SMA) syndrome is rare, occurring in 0.013–0.3 % of the general population, with only a few hundred cases reported in the literature [1]. Patients typically present with chronic emesis and epigastric pain secondary to duodenal compression between the aorta and SMA. This often occurs in patients who have undergone extreme weight loss. However, making the diagnosis is challenging as the symptoms are non-specific. In the bariatric population, there are roughly 20 reported cases of SMA syndrome following adjustable gastric banding (AGB) [2] or roux-en-y gastric bypass (RYGB) [3–6]. The diagnosis is especially challenging in this population given alterations in anatomy and the long list of

Electronic supplementary material The online version of this article (doi:10.1007/s00464-014-3743-z) contains supplementary material, which is available to authorized users. A. M. Barrett (&)  D. J. Harrison  E. H. Phillips  S. I. Felder  M. A. Burch Department of Surgery, Cedars-Sinai Medical Center, 8635 W 3rd Street 795 W, Los Angeles, CA 90048, USA e-mail: [email protected]

The patient is a healthy 39-year-old female with a history of laparoscopic AGB, with subsequent AGB removal four years later for esophageal dilation and reflux. Over the following three years, she gained weight to a BMI of 36 then underwent laparoscopic sleeve gastrectomy (LSG) at an outside institution. Over the subsequent 4 months, she lost approximately 70 lbs, to a BMI of 24. She then developed persistent nausea, emesis, and epigastric pain occurring within 30 min of eating. Symptoms were relieved by sitting forward or lying on her left side. Two endoscopies were normal with no evidence of stricture, and she continued to lose weight during ongoing outpatient investigation. She then presented to the emergency room with persistent emesis and significant hypokalemia. A CT scan was performed, which demonstrated a dilated second portion and narrowed third portion of the duodenum at the level of the SMA (Fig. 1). This was confirmed on upper gastrointestinal study. Mesenteric artery duplex demonstrated a reduced aorta-SMA angle of 18 degrees and a distance of 5.8 mm when supine (Figs. 2, 3), confirming the diagnosis of SMA syndrome.

123

Surg Endosc

Fig. 1 CT scan demonstrating narrowing of the duodenum (asterisk) between the aorta and SMA (arrow)

mesocolon, the duodenum was mobilized to expose the second and third portions (1:00). A loop of jejunum approximately 30 cm distal to the ligament of Treitz was identified for anastomosis (1:09). Stay sutures were placed for orientation (1:25). Using a linear stapler, side-to-side anastomosis was performed to the third portion of duodenum (1:43). The common enterotomy was closed in two layers of running vicryl suture (2:11). Endoscopy was repeated, showing a widely patent anastomosis, and leak test was negative (2:52). The patient recovered well following surgery and was discharged home on postoperative day four on a full liquid diet. At most recent follow-up 9 months later, she was tolerating a regular diet, her weight was stable, and her nausea improved.

Discussion

Fig. 2 Angle between the aorta and SMA was 18 degrees when supine, consistent with SMA syndrome

Fig. 3 Distance between the aorta and SMA was 5.8 mm when supine, consistent with SMA syndrome

Following a two-week period of nutritional optimization, the patient was taken to the operating room for laparoscopic duodenojejunostomy (Video 1). Endoscopy was performed to confirm the area of extrinsic compression of the duodenum by the SMA (0:42). Through the transverse

123

The diagnosis of SMA syndrome is a challenging one to make, not only because it is rare but also because it is often not considered in the differential. Patients often undergo a litany of testing to rule out other possibilities. CT scan, upper GI study, and mesenteric duplex sonography are most useful for confirming the diagnosis, which requires documentation of a narrowed angle and distance between the aorta and SMA (normal: 25–60 degrees, 10–28 mm) [7, 8]. SMA syndrome is likely even more rare in RYGB patients, since only biliary and gastric secretions are present in the duodenum to contribute to obstruction. With this in mind, sleeve gastrectomy patients may be at higher risk for SMA syndrome, as they will have enteric, biliary, and gastric contents in the duodenum, as well as rapid weight loss that causes decreased SMA-aorta angle. In the post-bariatric surgery patient, the differential diagnosis for nausea and epigastric pain is broad, including ulceration, stricture, internal hernia, motility disorders, and symptomatic cholelithiasis, among others. Initial workup often includes basic lab work and a CT scan or upper GI study. Upper GI study is helpful to asses for stricture or leak, but cross-sectional imaging is preferred to assess for incisional hernias, intussusception, or postoperative fluid collections. CT scan is an imperfect tool for diagnosis of internal hernia, so if this is considered likely, a diagnostic laparoscopy should be performed. If CT scan is normal, upper endoscopy should be considered to rule out ulceration or stricture. Symptoms more consistent with biliary tract disease should be investigated with right upper quadrant ultrasound and liver function tests. If these studies fail to confirm a diagnosis, then SMA syndrome should be considered. If a diagnosis of SMA syndrome is entertained, directed studies should be obtained. In RYGB patients, since the

Surg Endosc

duodenum is excluded, swallowed contrast studies are obsolete. Addressing such challenges, Abou-Nukta et al. reported on six post-RYGB patients who were diagnosed with SMA syndrome by contrast study through a gastrostomy tube placed in the remnant or by HIDA scan [3]. As mentioned earlier, duplex sonography is also very useful to assess the angle and distance between the aorta and SMA. Initial management of patients with SMA syndrome includes gastric decompression and nutritional optimization, either by parenteral nutrition or enteral feedings distal to the ligament of Treitz. In patients with RYGB anatomy, gastrojejunostomy tube placement may be indicated and can accomplish both goals. In most patients, weight regain results in symptom resolution, but surgical intervention is needed in roughly one-third of patients [1]. Surgical correction has historically consisted of two techniques: division of the ligament of Treitz (Strong’s procedure) or duodenojejunostomy. Dr. Edward Strong first described his technique in 1958, involving division of the ligament of Treitz and mobilization of the third and fourth portions of duodenum off the pancreas to a more caudal position [9]. While advantageous in that there is no anastomosis, accessing the retroperitoneum can be challenging, and sufficient mobilization may not be achieved due to vascular attachments [1]. Duodenojejunostomy has been utilized more frequently than Strong’s procedure. Munene et al [10]. reviewed 13 reported cases of laparoscopic duodenojejunostomy with average operative time of 121 min and length of stay 4.5 days. One patient developed trochar site bleeding, and there were no other complications. Success rate is 80 % or more with duodenojejunostomy [1]. Roux-en-Y duodenojejunostomy has also been described in one case report [11]. In the patient presented here, with SMA syndrome status-post sleeve gastrectomy, the diagnosis was confirmed by CT scan, upper GI study, and mesenteric duplex sonography. Multiple surgical options were considered. Duodenojejunostomy was chosen due to its history of symptomatic improvement and low morbidity. To our knowledge, this is the first case report of a patient undergoing laparoscopic duodenojejunostomy for SMA syndrome following sleeve gastrectomy. The procedure included the use of endoscopy, which was very beneficial in identifying landmarks, confirming a patent anastomosis, and performing a leak test. The patient recovered uneventfully following surgery.

Conclusion SMA syndrome is a rare diagnosis in both the general and bariatric surgery populations. Detailed and directed workup is required to confirm the diagnosis. Laparoscopic duodenojejunostomy is a technically feasible and successful option for the management of SMA syndrome following bariatric surgery. Disclosures Allison M. Barrett, David J. Harrison, Edward H. Phillips, Seth I. Felder, and Miguel A. Burch have no conflicts of interest or financial ties to disclose.

References 1. Welsch T, Buchler MW, Kienle P (2007) Recalling superior mesenteric artery syndrome. Dig Surg 24(3):149–156 2. Cao MM, Dalton D (2012) Superior mesenteric artery syndrome following laparoscopic gastric banding. ANZ J Surg 82:655 3. Abou-Nukta F, Valin E, Rao S, Kim D, Contessa J, Reinhold R (2005) Superior mesenteric artery syndrome in patients undergoing gastric bypass surgery. Surg Obes Rel Dis 1:95–98 4. Clapp B, Applebaum B (2010) Superior mesenteric artery syndrome after roux-en-y gastric bypass. J Soc Laparosc Surg 14:143–146 5. Goitein D, Gagne DJ, Papasavas PK, Dallal R, Quebbemann B, Eichinger JK, Johnston D, Caushaj PF (2004) Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 14:1008–1011 6. Schroeppel TJ, Chilcote WS, Lara MD, Kothari SN (2005) Superior mesenteric artery syndrome after laparoscopic Roux-enY gastric bypass. Surgery 137:383–385 7. Agrawal GA, Johnson PT, Fishman EK (2007) Multidetector row CT of superior mesentery artery syndrome. J Clinic Gastroent 41(1):62–65 8. Konen E, Amitai M, Apter S, Garniek A, Gayer G, Nass S, Itzchak Y (1998) CT angiography of superior mesenteric artery syndrome. Am J Roentgen 171(5):1279–1281 9. Strong EK (1958) Mechanics of arteriomesenteric duodenal obstruction and direct surgical attack upon etiology. Ann Surg 148(5):725–730 10. Munene G, Knab M, Parag B (2010) Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Am Surg 76:321–324 11. Li J, Chousleb C, Hidalgo J, Patel S, Szomstein S, Rosenthal RJ (2011) Laparoscopic Roux-en-Y duodenojejunal bypass for superior mesenteric artery syndrome: case reports and review of the literature. Surg Laparosc Endosc Percutan Tech. 21(6):e344– e347

123

Superior mesenteric artery syndrome following sleeve gastrectomy: case report, review of the literature, and video on technique for surgical correction.

Superior mesenteric artery (SMA) syndrome is a rare condition in which the duodenum is compressed between the SMA and aorta. This often occurs followi...
431KB Sizes 0 Downloads 8 Views