Laparoscopic Roux‐en‐Y Duodenojejunostomy for a Patient With Superior Mesenteric Artery Syndrome Admitted to the Emergency Department

ABSTRACT

SMA syndrome is rare and often misdiagnosed. We report a patient (38 kg; BMI = 13.6 kg/m²) previously treated unsuccessfully for recurrent gastritis, with CT‐confirmed SMA–aorta angle/distance of 9°/5 mm. After Roux‐en‐Y duodenojejunostomy, symptoms improved; he was discharged after 1 week and gained 12.6 kg at 3 months (BMI = 18.1 kg/m²).

Key Clinical Message

SMA syndrome should be considered in severely malnourished patients presenting with refractory upper gastrointestinal symptoms. Early CT imaging and laparoscopic Roux‐en‐Y duodenojejunostomy can facilitate prompt diagnosis, relieve obstruction, and promote weight gain.

Abbreviations

EGD

esophagogastroduodenoscopy

LDJ

laparoscopic duodenojejunostomy

SMA

superior mesenteric artery

1. Introduction

SMA or Wilkie syndrome was first described by Von Rokitansky in his textbook in 1842 [1]. It is a rare intestinal obstruction disease caused by the compression between the SMA and the aorta (SMA‐Ao). Normally, the SMA‐Ao angle is from 38° to 65° with a distance of 10 to 33 mm [1]. In SMA syndrome, the SMA‐Ao mesenteric fat tissue loss, while the angle narrows to 6°–25° and the aortomesenteric distance shrinks to 2–8 mm, pinching the duodenum. In the general population, SMA occurs with a rate of 0.013%–0.78% but is higher in some cases, such as post‐scoliosis surgery (0.5%–3.4%), burn injury (1.0%–1.12%), anorexia nervosa (2.73%), and functional dyspepsia (10.8%) [1]. Conversely, it is very rare in patients admitted to the emergency department (0.001%–0.0052%). The syndrome usually occurs in young people, with a median age of 23 years (16–39 years), and is more common in women than in men. Typically, SMA patients present with nausea, bloating, epigastric pain, abdominal pain, and vomiting of bile. Besides, significant weight loss is a common sign of SMA syndrome. Because of its low prevalence and nonspecific symptoms, it is difficult to identify SMA syndrome early, which may lead to a significant rate of comorbidity and treatment failure [2, 3]. In addition to clinical symptoms and medical history, esophagogastroduodenoscopy (EGD), CT scanner, plain film X‐ray, barium X‐ray, and abdominal ultrasound are imaging tools commonly used in the investigation and diagnosis of SMA syndrome. Regarding treatment, conservative therapies are usually the first choice [1]. In case of initial regimen failure, surgical therapy, such as laparoscopic duodenojejunostomy (LDJ), is an alternative treatment with success rates of 80%–100%, along with improvements in symptom score, weight, BMI, and proton pump inhibitor therapy [1, 3].

2. Case Presentation

A 27‐year‐old male patient was admitted to the emergency department of our hospital with symptoms of abdominal bloating, distension, mild epigastric pain, gurgling sounds, and bowel sounds. The patient was severely malnourished (height 167 cm, weight 38 kg, BMI = 13.6 kg/m²). In the last 2 years, the patient has repeatedly had tension and pain in the epigastric region, vomiting of old food, and difficulty defecating. In addition, he was constantly fatigued, felt hungry, ate many times a day, but did not digest well. During that time, the patient suffered from dementia, had not completed a university program, and his physical and sexual activities were affected. Six months before hospitalization, the patient experienced rapid weight loss, and his condition progressively worsened. The patient had visited several hospitals (8 visits) and had been diagnosed with gastritis, but the treatment did not improve. Our doctors suspected that the patient was suffering from a condition other than gastritis.

3. Investigation

The patient first underwent an EGD procedure, which revealed a large amount of residual food in the stomach. Subsequent contrast X‐ray imaging demonstrated loss of normal gastric structure, with downward sagging to the iliac crest, and gastric distention forming a J‐shape (Figure 1). The contrast medium was retained in the lower stomach, and peristaltic waves required to propel the contrast into the duodenum were absent. At this point, our doctors suspected the patient had SMA syndrome. Contrast‐enhanced abdominal CT scan was performed in arterial and portal venous phases with multiplanar reconstruction, including oblique sagittal reformations along the aorta‐superior mesenteric artery axis. Coronal images revealed marked fluid‐filled dilatation of the stomach and proximal duodenum extending to the second portion (D2). Axial images identified a transition point at the third part of the duodenum (D3), where compression occurred between the aorta posteriorly and the SMA anteriorly, consistent with the aortomesenteric clamp sign (Figure 2). On oblique sagittal reformations, the measured aortomesenteric angle was 9°, and the aortomesenteric distance was 5 mm (reference ranges: 38°–56° for angle, 10–34 mm for distance) [1]. These findings were highly consistent with SMA syndrome in the clinical context (Figure 3) [1]. The left renal vein narrowing at the aortomesenteric interval (nutcracker morphology) was also observed, although no urinary symptoms were present (Figure 4). The CT scanner findings excluded other causes of external compression, such as pancreatic head or retroperitoneal masses, lymphadenopathy, midgut volvulus, or distal mechanical obstruction.

FIGURE 1.

Contrast‐enhanced abdominal CT (portal venous phase), coronal image, showing marked fluid‐filled dilatation of the stomach and proximal duodenum (up to D2), consistent with proximal obstruction.

FIGURE 2.

Contrast‐enhanced abdominal CT (portal venous phase), axial image, showing a transition point at the third part of the duodenum (D3), compressed between the aorta posteriorly (*) and the SMA anteriorly (**), consistent with the aortomesenteric clamp sign (arrow).

FIGURE 3.

Contrast‐enhanced abdominal CT (arterial phase), oblique sagittal reconstruction aligned with the aorta–SMA axis, showing (A) a reduced aortomesenteric angle (9°) and (B) a reduced aortomesenteric distance (5 mm).

FIGURE 4.

Contrast‐enhanced abdominal CT (portal venous phase), axial image, showing narrowing of the left renal vein within the aortomesenteric interval, consistent with Nutcracker morphology (arrow).

4. Treatment and Outcome

The patient received intravenous fluids, orogastric tube decompression to relieve gastric pressure, and total parenteral nutrition. Given the severity of the condition, surgical intervention was chosen after multidisciplinary consultation to relieve the severe duodenal stenosis. Laparoscopic duodenojejunostomy was performed to optimize both therapeutic efficacy and cosmetic outcomes. The patient underwent general anesthesia with endotracheal intubation and was placed in the supine position. The procedure was performed entirely laparoscopically using three trocars: one at the umbilicus and two in the left abdomen. Exploratory laparoscopy revealed no free fluid in the abdominal cavity. The liver was soft with a smooth, pinkish surface; the peritoneum was smooth, the gallbladder was not distended, and the bile ducts were not dilated. Conversely, the stomach was markedly dilated beyond the umbilicus. The second and third portions of the duodenum (D2 and D3) were markedly dilated up to the level where they crossed the SMA. After exposing the inferior duodenal flexure at the D2–D3 junction, the jejunum was divided approximately 25 cm distal to the ligament of Treitz using a linear stapler. The distal jejunal limb was brought up to the inferior duodenal flexure and anastomosed to the duodenum at the D2 level. The proximal jejunal limb was then anastomosed side‐to‐side to the distal jejunum, creating a Roux‐en‐Y reconstruction (Figure 5). The enterotomy and duodenotomy sites were closed with V‐Loc sutures. Twenty‐four hours postoperatively, the patient's condition was stable, and physical therapy was initiated (Figure 6). Nutritional support was resumed on postoperative Day 3 with soft, easily digestible liquids, including 50–150 mL of water and milk three times daily. By postoperative Day 5, the patient tolerated a regular soft diet consisting of porridge, soup, and other soft‐cooked foods, with passage of flatus and bowel movements, and was subsequently discharged. At the 1‐week follow‐up, the patient had completely recovered from abdominal pain, bloating, and vomiting and reported normal bowel function. At the 1‐month postoperative telephone follow‐up, he had resumed normal daily activities and gained 10 kg. Two months later, his weight had increased to 50.6 kg (BMI = 18.1 kg/m²), representing a total gain of 12.6 kg from baseline.

FIGURE 5.

Roux‐en‐Y duodenojejunostomy surgical plan for the patient.

FIGURE 6.

Initiation of physical therapy 24 h postoperatively.

5. Discussion

SMA syndrome is a rare disorder characterized by nonspecific symptoms, often resulting in a delayed diagnosis, advanced disease progression, and limited effectiveness of conservative management [2, 3]. Consequently, clinicians must remain informed and vigilant to facilitate early identification and appropriate intervention. In the present case, an emergency physician evaluated a patient with ambiguous symptoms, including abdominal distention, weight loss, indigestion, and multiple prior diagnoses of gastritis without therapeutic success. Following expert consultation and imaging studies, the diagnosis of SMA syndrome was established, revealing a markedly reduced aortomesenteric angle and distance (9° and 5 mm). These measurements are lower than those reported in the Ganss series of 39 cases, in which the median angle and distance were 11° and 5 mm, respectively [3]. This case represents the youngest patient with SMA syndrome and the most severe degree of stenosis documented in Vietnam to date. According to Unal B, an aortomesenteric angle cutoff of 22° distinguishes SMA syndrome from non‐SMA cases with a sensitivity of 42.8% and specificity of 100% [4]. When using a cutoff of 8 mm for aortomesenteric distance, both sensitivity and specificity of SMA diagnosis reach 100% [4]. These findings underscore the diagnostic value of computed tomography, which can identify three key features: (1) abnormal SMA‐aorta angle, (2) narrowing of the third portion of the duodenum due to compression between the SMA and aorta, and (3) dilatation of the proximal stomach and second portion of the duodenum.

Previous studies have demonstrated that conservative treatment for SMA syndrome can achieve relatively high efficacy rates (> 71%), and surgical intervention should be reserved for cases in which conservative management fails [2]. Various surgical approaches have been explored for SMA, including duodenojejunostomy, gastroduodenostomy, and gastrojejunostomy [1]. Rational open bypass surgery was the standard of care until the first successful laparoscopic duodenojejunostomy (LDJ) was reported in 1998 [5]. Since then, LDJ has become the preferred technique because it is more effective than open surgery (> 92%) and is now widely adopted [2]. In our patient, given the severe mesenteric artery stenosis (5 mm) and the prolonged disease course (2 years) culminating in an emergency presentation, we selected the LDJ (Roux‐en‐Y, Figure 5) procedure to restore physiological digestive function, reduce the risk of digestive fluid retention in the intestinal loops, optimize cosmetic outcomes, minimize pain, and shorten postoperative hospitalization. As anticipated, the patient resumed normal oral intake within 5 days, experienced significant symptom resolution, and was eligible for discharge, consistent with previous LDJ reports [6, 7, 8]. Chang monitored 18 SMA cases and observed no anatomic leakage postoperatively; 14 of 18 patients experienced symptom improvement, with an average weight gain of 2.2 kg and an increase in BMI from 19.6 to 20.4 kg/m² [6]. A long‐term evaluation of 25 cases by Wills MV demonstrated sustained benefits of laparoscopic surgery for SMA, including increased BMI (from 19.2 to 21.6 kg/m²), reduced reliance on supplemental nutrition, and decreased pain and nausea [7]. Only a minority of cases with gastrointestinal motility complications required additional surgical intervention, emphasizing the need for thorough preoperative assessment and extended follow‐up [7]. Lu's 10‐year report on 66 cases confirmed the safety and efficacy of laparoscopic surgery, with all patients undergoing successful procedures, a reduction in total symptom scores from 32 to 8, and an increase in BMI from 17.2 to 21.8 kg/m² [8]. Alamayreh utilized the SF‐36 scale and identified BMI as a significant factor associated with the patient's quality of life, underscoring the importance of comprehensive nutritional management in SMA treatment strategies [9]. In our case, the patient gained 12.6 kg over 3 months post‐op, corresponding to a BMI increase from 13.6 to 18.1 kg/m². We will continue to monitor and assess long‐term outcomes, including nutritional status and the patient's quality of life (physical and mental health).

6. Conclusion

In summary, SMA syndrome is an uncommon condition, especially within the acute general hospital setting. Due to its frequent onset at a young age and presentation with nonspecific symptoms, SMA syndrome is often overlooked or misdiagnosed, which may result in life‐threatening complications. Clinicians should maintain a high index of suspicion in clinical practice. Computed tomography and contrast X‐ray imaging are effective modalities for screening and diagnosis of SMA. Treatment decisions, including the choice between conservative management first and immediate surgical intervention, should be guided by the patient's status to ensure optimal outcomes.

Author Contributions

Toan The Nguyen: conceptualization, data curation, formal analysis, methodology, validation, supervision, writing – review and editing, funding acquisition, resources. Dang Hai Nguyen: formal analysis, data curation, methodology, validation, writing – original draft. Kieu‐Tram Tran Nguyen: data curation, formal analysis, writing – original draft. Thang Thanh Phan: conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review and editing, investigation. Loc Duc Nguyen: conceptualization, methodology, formal analysis, validation, supervision, writing – review and editing, funding acquisition, project administration.

Funding

The authors have nothing to report.

Ethics Statement

The study was approved by the Ethics Committee of Gia An 115 Hospital.

Consent

The patient was advised and signed a consent form for publication.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.