Clinical Endoscopy

Reverse Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Superior Mesenteric Artery Syndrome: A New Concept: Ming-ming Xu, Enad Dawod, Monica Gaidhane, Amy Tyberg, Michel Kahaleh; Clin Endosc 2020;53(1):94-96. Published online December 3, 2019; DOI: https://doi.org/10.5946/ce.2018.196

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Superior mesenteric artery syndrome (SMAS) causes compression and partial or complete obstruction of the duodenum, resulting in abdominal pain, nausea, vomiting, and weight loss. If conservative therapy fails, the patient is typically referred for enteral feeding or laparoscopic gastrojejunostomy.
The last few years have seen increasing use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for gastric obstruction indications. EUS-GJ involves the creation of a gastric bypass via an echoendoscope in cases in which the small intestine can be punctured under ultrasonographic visualization, resulting in an incision-free, efficient, and safe procedure.
In this case report, we present the first case of SMAS treated using a reverse EUS-GJ, and describe the steps and advantages of the procedure in this particular case.

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Superior Mesenteric Artery Syndrome Diagnosed with Linear Endoscopic Ultrasound (with Video) in a Patient with Normal Body Mass Index: Jee Wan Wee, Tae Hee Lee, Joon Seong Lee, Wan Jung Kim; Clin Endosc 2013;46(4):410-413. Published online July 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.4.410

Abstract PDF PubReader ePub

Superior mesenteric artery (SMA) syndrome is an uncommon disease that results from SMA compression of the third portion of the duodenum. Patients with SMA syndrome present with upper gastrointestinal symptoms, such as nausea, vomiting, and abdominal pain. The diagnosis is usually made from an upper barium study or computed tomography. Typically, SMA syndrome is caused by a decreased aortomesenteric angle of 6° to 25°. An underweight body mass index (BMI) is a risk factor for development of SMA syndrome. There are few reports of the role of linear endoscopic ultrasound (EUS) in the diagnosis of SMA syndrome. We report a case of SMA syndrome, with normal BMI, that was diagnosed with the aid of linear EUS. Although SMA syndrome is not typically within the scope of practice of endosonographers, it is useful to get familiar with the findings.

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The Identification of Superior Mesenteric Artery Syndrome Established by Endoscopic Ultrasound in a Patient with Severe Gastroptosis: Sung Jun Kim, M.D., Woo Chul Chung, M.D., Sung Hoon Jung, M.D., Jae Wuk Kwak, M.D., Myung Hyun Lee, M.D., Chang Nyol Paik, M.D. and Kang-Moon Lee, M.D.; Korean J Gastrointest Endosc 2010;40(2):121-125. Published online February 27, 2010

Abstract PDF: Superior mesenteric artery (SMA) syndrome is caused by compression of the transverse part of the duodenum between the SMA and the aorta, where the distance between these vessels decreases with loss of mesenteric fat. It occurs most frequently in patients with rapid weight loss. Conventionally, the diagnosis is established by digital fluoroscopy and contrast-enhanced spiral computed tomography (CT). A 17-year old woman was admitted via the emergency department with postprandial fullness, nausea, and bile stained vomiting. The initial radiological examination revealed severe gastroptosis. Fluoroscopic evaluation after barium swallowing failed due to a markedly distended stomach. The diagnosis of SMA syndrome was made by endoscopic ultrasound (EUS) using a mini-probe. EUS findings were in good agreement with the CT angiogram. A conservative trial was attempted, but symptoms remained refractory. Surgery was an alternative option and we treated the patient successfully with laparoscopic duodeno-jejunostomy. (Korean J Gastrointest Endosc 2010;40:121-125)

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A Case of Superior Mesenteric Artery Syndrome Treated by Laparoscopic Surgery: Ji-Sung Chun, M.D., Woo-Chul Chung, M.D., Seong-Su Hwang, M.D.*, Hyun-Min Cho, M.D.^†, Kang-Moon Lee, M.D., Bo-In Lee, M.D., Su-Yeon Lee, M.D., Ji-Won An, M.D., U-Im Chang, M.D., Jin-Mo Yang, M.D., Kyu-Yong Choi, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;32(3):215-220. Published online March 30, 2006

Abstract PDF: Superior mesenteric artery (SMA) syndrome is a symptom complex resulting from compression of third portion of duodenum by the root of the small bowel mesentery at the level of the SMA. This syndrome can occur as an acute illness but more commonly it appears as chronic condition. Identification of this syndrome can be a diagnostic dilemma and it is frequently made by exclusion. In our patient, rapid weight loss, nausea and bile stained vomiting were present. Ultrasound and MR-angiography were performed for measuring the angle and the distance between the SMA and the aorta. We confirmed the diagnosis via the reduced aorto-mesenteric angle and distance and the patient was then treated by laparoscopic surgery. After lysis of the ligament of Treitz, the patient's symptom were improved. This syndrome must be considered as one of the causes of upper gastrointestinal obstruction. (Korean J Gastrointest Endosc 2006;32:215⁣220)

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상장간막 동맥증후군 2예 ( Two Cases of Superior Mesenteric Artery Syndrome ): Korean J Gastrointest Endosc 1999;19(5):823-828. Published online November 30, 1998

Abstract PDF: Superior mesenteric artery (SMA) syndrome results from compression of the third portion of the duodenum by the superior mesenteric artery or one of its branches where this vessel crosses over the duodenum as it descends from the aorta. Recently 2 cases of SMA syndrome were experienced. A 43-year-old female and a 41-year-old male were admitted due to complaints of frequent postprandial abdominal distension and vomiting for 4 months. An UGI series and abdominal CT scan revealed distension of stomach and duodenum with a cut-off in the duodenal third portion. Both patients underwent duodenojejunostomy with successful symptom relief. (Korean J Gastrointest Endosc 19: 823∼828, 1999)

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