Duodenogastrojejunum Annular Internal Drainage for Superior Mesenteric Artery Syndrome: A Modified Staveley’s Surgery
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Abstract
INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is caused by acute or chronic compression of the third part of the duodenum in the aortomesenteric angle. Staveley’s duodenojejunostomy (DJ) is an option when conservative management fails. In current case study, we reported a modified technique in treating the young patients who presented with a long-term history of intractable SMAS.
METHODS: Twelve patients presented with history of supper abdominal pain, nausea, distension and postprandial vomiting as well as weight loss. The finding of a significant narrowing of aortomesenteric angle and substantial duodenal compression established by endoscopic ultrasound and contrast-enhanced spiral CT, was in good agreement with a diagnosis of SMAS. Conservative treatment including enteral feeding failed to relieve the symptoms. Five cases were performed by traditional DJ and the other seven patients were applied with a modified DJ by duodenum-gastro-jejunum annular internal drainage. The patient health-related quality of life was evaluated by EQ-5D and SF-12 in all the cases within 1-yr and 3-yr follow ups.
RESULTS: There was no marked intra-abdominal hemorrhage, anastomotic leakage, postoperative infection and stromal hemorrhage / ulcers in all cases. There was no difference with respect to the intraoperative blood loss and urine output, and postoperative emerging time of negative fluid balance between the DJ and modified DJ groups. Compared to the traditional DJ, the modified procedure had an increased operation time (2.67 ± 0.29 vs 1.83 ± 0.29, P=0.03) and surgical stress score (SSS) (0.19 ± 0.02 vs 0.14 ± 0.01, P=0.02). Within postoperative one-month, sixty percent (3 cases) of DJ group had recurrent vomiting and epigastric pain and one patient need reoperation. During the 1-year and 3-year follow-ups, the recurrence cases of intermittent abdominal pain, distension and nausea were two and one respectively in DJ group. The patients in both groups showed increased weight gains in the follow ups. The patients with the modified DJ surgery showed not reflux gastritis, anastomotic ulcer and stricture with a complete relief of symptoms and a relatively higher SF-12 (PCS) compared to the DJ surgery (1-yr: 30.5 ± 3.1 vs 36.9 ± 3.2, P=0.04; 3-yr: 32.1 ± 3.1 vs 38.9 ± 3.2, P=0.04).
CONCLUSION: The case study showed that the modified procedure with duodenum annular internal drainage is feasible in relieving the symptoms when conservative treatment fails in young adults with SMAS. The new procedure increases surgery time and SSS. However, it potentially reduces the recurrence rate and postoperative complications of duodenal obstruction and antiperistalsis and improves quality of life. Further study will be required for effectiveness and safety of the modified procedure in the people with SMAS with longstanding history.
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Superior Mesenteric Artery Syndrome, Duodenojejunostomy, Duodenum-gastro-jejunum Annular Internal Drainage
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