Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome

Abstract

An 81-year-old woman with a previous history of chronic mesenteric ischemia presented with recurrent post-prandial abdominal pain, early satiety, diarrhea, and weight loss. Her past history was significant for documented mesenteric ischemia, requiring multiple attempts of superior mesenteric artery (SMA) angioplasty and stenting 6 years prior to presentation. These procedures provided only short-term relief, and she subsequently underwent definitive supraceliac aorta-to-SMA bypass with a Dacron graft that alleviated her symptoms for several years. Over the past several months, she had experienced recurrent moderate abdominal pain after meals, early satiety, frequent and copious bowel movements, and significant weight loss from 120 to 85 lb. She denied nausea, vomiting, or fear of eating. Her past medical history was significant for atrial fibrillation and renovascular hypertension that was treated with bilateral renal artery stenting. Her surgical history was significant for an open cholecystectomy, appendectomy, hysterectomy, and supraceliac aorta-to-SMA bypass. Physical examination was unremarkable except for a scaphoid abdomen. No abdominal bruits were detected. Laboratory studies showed that her electrolytes were within normal limits and albumin borderline low at 3.4 g/dl. Fecal fat testing, stool cultures, and colonoscopy were negative. An upper gastrointestinal (GI) barium study with small bowel follow through revealed marked dilation of the third portion of the duodenum with a sharp vertical filling defect projected over the expected location of the SMA (Fig. 1). A computed tomography (CT) angiogram of the abdomen confirmed patency of the aorto-SMA graft (Fig. 2). The study similarly revealed marked dilation of the proximal duodenum with narrowing as it passed anterior to the spine and posterior to the chronically occluded SMA and the patent aorto-SMA bypass graft (Fig. 3). Based on these radiographic findings, the patient was diagnosed with SMA syndrome, with the cause likely being a fibrotic reaction from the stented and occluded native SMA and/or the adjacent parallel bypass graft. She was thus offered a surgical bypass via a laparoscopic duodenojejunostomy. Intra-operatively, the third portion of the duodenum was markedly dilated. A side-to-side anastomosis was created between the third portion of the duodenum and a loop of proximal jejunum at an infracolic location with an EndoGIA stapler (Fig. 4). The anastomosis was completed and reinforced with intracorporeal absorbable sutures. Her postoperative course was unremarkable. An upper GI study on post-operative day 4 showed good patency of the anastomosis, decompression of the duodenum and no evidence of extravasation (Fig. 5). She was discharged home on postoperative day 5 tolerating a regular diet. At her 2-week follow up visit, she had a very good appetite and no postprandial epigastric pain, but still had loose bowel movements. This was empirically treated with rifaximin for small presumed bowel bacterial overgrowth without improvement, and eventually was controlled with loperamide. At her 3-month follow up visit, she remains asymptomatic and was starting to gain weight.