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weekly question 23/6/2024

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A 15-year-old girl recently lost more than 15% of her body weight due to nausea and emesis associated with symptomatic cholelithiasis which was treated with laparoscopic cholecystectomy. Postoperatively her nausea and emesis persisted and an UGI showed evidence of SMA syndrome with failure of contrast to progress beyond the third portion of the duodenum due to extrinsic compression and a dilated proximal duodenum. She has gained her weight back with non-operative management but continues to have persistent nausea and vomiting. A repeat UGI shows continued delay of contrast across the midline. What is the least invasive appropriate surgical management for this patient?

A Ligament of Treitz release

B Duodenojejunostomy

C Gastrojejunostomy

D Ligament of Treitz release with duodenal derotation (Strong Procedure)

E Roux-en-Y duodenojejunostomy
 
Correct answer
A Ligament of Treitz release

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction seen commonly in females between the ages of 10-39 years. It is due to a compression of the third portion of the duodenum as it traverses between the SMA and the aorta. Management is typically nonoperative and can include nasojejunal or nasoduodenal feeds as well as TPN. It is believed that this results in increased fat deposition between the SMA and aorta increasing the SMA angle and allowing for improved transit of enteral contents through this area.

A subset of patients do fail medical management and require surgical therapy to alleviate their symptoms. Numerous surgical options exist for the management of SMA syndrome of varying complexity. No large scale studies exist to provide direct comparison of surgical options and most literature involves case reports or single institution case series. The duodenojejunostomy, performed either open or laparoscopically, has been shown to bypass the affected segment while providing symptomatic relief, however this procedure is associated with complications including bleeding, anastomotic leak, anastomotic stricture, reverse peristalsis, and blind loop syndrome. Because of these complications some authors recommend a less aggressive initial surgical approach

Dekonenko et al. (2020) published their series of individuals with SMA syndrome who underwent laparoscopic ligament of Treitz release. This is similar to other manuscripts that have described a modified Ladd’s procedure for the initial treatment of SMA syndrome. The procedure lowers the duodenum out of the SMA angle by releasing the retroperitoneal attachments of the third portion of the duodenum. In their series, 75% of patients had a resolution of symptoms following ligament of Treitz release. These results suggest that this procedure may be beneficial as a less aggressive surgical option in patients with SMA syndrome before proceeding on with more complex surgical therapies.

View attachment dekonenko2020.pdf
 
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