Superior Mesenteric Artery Syndrome: a Prospective Study in a Single Institution

Background: Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, resulting from the compression of the duodenum between superior mesenteric artery and aorta. This prospective registry aims to describe demographic, clinical, and outcome features of patients suffering from SMAS and to point out the indications for surgery. Methods: Between 2008 and 2016, patients with chronic gastrointestinal symptoms and diagnosis of SMAS were included. Demographics, clinical presentation, diagnosis, and surgical outcome were recorded. Symptoms were investigated with a standardized questionnaire. The diagnosis was achieved through barium swallow, CT/MR angiography (aortomesenteric angle 64 22\ub0, distance 64 8 mm), endoscopy. All patients underwent duodenojejunostomy \ub1 distal duodenum resection. At follow-up, symptom score and barium swallow were re-evaluated. Results: Thirty-nine patients (11 M/28 F, median age 38 years, median BMI 17.8 kg/m 2 ) were included. Barium swallow showed a gastroduodenal dilation in 57% of patients, and a delayed gastroduodenal emptying in 38%. Median aortomesenteric angle was 11\ub0 and distance was 5 mm. All patients underwent duodenojejunostomy, and in 32 patients, a distal duodenum resection was also performed. At a median follow-up of 47 months, the overall symptom score significantly dropped (10 vs. 32, p < 0.0001) and BMI increased (19.5 vs. 17.8, p < 0.0001). Barium swallow at 2 months postoperatively showed an improvement in terms of gastroduodenal dilation and emptying in 38% of patients with preoperative pathological findings. Conclusions: SMAS is a rare condition that should be suspected in cases of chronic, refractory upper digestive symptoms, particularly in females with low BMIs. Surgical treatment may improve symptoms and quality of life, although it is not curative in all cases. ClinicalTrials.gov Identifier: NCT03416647. \ua9 2018, The Society for Surgery of the Alimentary Tract

Fifteen Cases of Superior Mesenteric Artery Syndrome: Diagnosis and Surgical Strategies

Introduction: Superior mesenteric artery syndrome (SMAS) is a condition caused by duodenal compression between aorta and superior mesenteric artery (SMA). SMAS's symptoms are nausea, vomiting, post-prandial epigastric pain and weight loss. Computed tomography (CT) angiography and magnetic resonance (MR) angiography are at present the most informative diagnostic technique. Diagnostic criteria are a narrowing in the aorto-mesenteric angle lesser than 22\ub0 (normal 28\ub0- 65\ub0) and a reduction of the aorto-mesenteric distance to 8 mm or less (normal 10-28 mm). Usually SMAS is not recognized and mistreated. Medical treatment includes pro-motility agents, but surgical approach is advocate in case of conservative treatment failure. Methods & aim: Fifteen consecutive patients (11F, 4 M, mean age 45 +/- 9 years) who underwent surgical correction of SMAS between 2008 and 2010 have been enrolled in this prospective study. Before operation all patients have been investigated with CT and/or MR angiography with multi- planar three-dimensional reconstructions, EGDS, barium contrast radiography. In patients previously operated for GERD, also pH-metry and esophageal manometry were performed. Postoperative outcome was evaluated considering the following clinical variables: weight, BMI, medical therapy, serum albumine, amylase and lipase. Aim of the study is to evaluate safety, efficacy and outcome of surgical correction ofSMAS. Results: All the patients enrolled were symptomatic for abdominal pain, nausea and anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreat- itis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18\ub0 +/-1.8 and distance 4.6 +/- 2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 +/- 6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improve- ment in patient weight (pre-operatory mean 50+/-1 kg, post-operatory mean 55+/-9 kg p= 0.003) and BMI (pre-operatory mean 18.1+/-3.4 kg, post-operatory mean 20.0+/-3.4 kg p= 0.004) and there is a significant decreased in need of PPI therapy (p=0.004). We didn't observed significant differences, in the outcome, between the two surgical procedures. Conclusions: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass

Cost analysis of incisional hernia repair with synthetic mesh and biological mesh: an Italian study

Repair of an incisional hernia (IH) generates costs on several levels and domains of society. The aim of this study was to make a complete cost analysis of incisional hernia repair (IHR) with synthetic and biological mesh and to compare it with financial reimbursement. Patients were grouped into three levels to determine the complexity of their care, and hence, the costs involved. Group 1 included patients without comorbidities, who underwent a "standard" incisional hernia repair (SIHR), with synthetic mesh. Group 2 included patients with comorbidities, who underwent the same surgical procedure. Group 3 included all patients who underwent a "complex" IHR (CIHR) with biological mesh. Total costs were divided into direct (including preoperative and operative phases) and indirect costs (medications and working days loss). Reimbursement was calculated according to Diagnosis-Related Group (DRG). From 2012 to 2014, 76 patients underwent prosthetic IHR: group 1 (35 pts); group 2 (30 pts); and group 3 (11 pts). The direct costs of preoperative and operative phases for groups 1 and 2 were (sic)5544.25 and (sic)5020.65, respectively, and (sic)16,397.17 in group 3. The total reimbursement in the three groups was (sic)68,292.37 for group 1, (sic)80,014.14 for group 2, and (sic)72,173.79 for group 3, with a total loss of (sic)124,658.43, (sic)69,675.36, and (sic)100,620.04, respectively. All DRGs underestimate the costs related to IHR and CIHR, thus resulting in an important economic loss for the hospital. The cost analysis shows that patient-related risk factors do not alter the overall costs. To provide a correct "cost-based" reimbursement, different DRGs should be created for different types of hernias and prostheses

Superior Mesenteric Artery Syndrome as Potential Cause of Antireflux Surgery Failure

BACKGROUND: Superior mesenteric artery syndrome (SMAS) is characterized by upper gastrointestinal symptoms, such as nausea, food regurgitation, vomiting, post prandial epigas- tric pain and weight loss. SMAS is commonly not recognized and many patients are considered as affected by gastro-esophageal reflux disease or specific gastrointestinal motility disorders. For this reason its diagnosis is frequently delayed, resulting in ineffective symptomatic therapies and inappropriate investigations. We aimed to investigate the occurrence of this misdiagnosis in a large group of patients who underwent surgical treatment for SMAS. Moreover, we assessed medical history and final outcome. METHODS AND PATIENTS: 27 consecutive SMAS patients who underwent surgical correction (duodenojejunostomy or duodenojejunostomy+duodenum resection) between 2008-2013 have been enrolled in this study. Six patients had a previous fundoplication which had been performed elsewhere. Two patients had more than one antireflux procedure. Demographic and clinical data (weight, BMI, medical therapy, symptom duration) were prospectively collected. Symptoms were scored by using a detailed lickert-scale based questionnaire for vomiting, nausea, epigastric pain, regurgitation and post-prandial bloating. Before the surgical treatment for SMAS, all patients have been investigated with CT and/or MR angiography with multi-planar three- dimensional reconstructions, endoscopy, barium swallow, esophageal manometry and 24 hour pH-monitoring. RESULTS: All six patients were PPI no-responders before the antireflux surgery and had persistent symptoms after the previous fundoplication. The median of symptom duration was 90 months. At SMAS preoperative evaluation, 5 patients had negative 24 hour pH-monitoring and normal LES resting pressure. Mean aorto-mesenteric angle was 21\ub0 +/-1.8 and distance 6 +/- 2.1 mm. In all patients a duodenojejunostomy was performed: in 5 patients a distal duodenum resection was added. The morbidity and mortality of SMAS surgery were nil. At a median follow-up of 48 months (IQR 37-55), the median of symptom score was significantly lower after surgery (28 vs 8; p<0.001). In all patients the symptoms score increased after SMAS surgery. There was a significant improvement in patients' weight (52+/-1 kg vs 57+/-9 kg p<0.01) and BMI (18.5+/-3.4 kg vs 20.6+/-3.4 kg; p<0.01) and there was a significant decrease of anti-reflux medications use (p<0.01). CONCLUSIONS: Patients with long lasting nausea, vomiting and gastroesophageal reflux who are not respond- ing to PPI therapy should be carefully considered for possible SMAS before performing an antireflux procedure. Moreover, patients who underwent a fundoplication and still remainedsymptomatic reporting gas-bloat syndrome or persistent reflux should be addressed to a study of the duodenum for a possible presence of SMAS

A modification of Nissen fundoplication improves patients\ue2\u80\u99 outcome and may reduce procedure-related failure rate

BACKGROUND: Laparoscopic anti-reflux surgery has a failure rate of 10-20%. We aimed to investigate whether a modification of Nissen fundoplication (MNF) may improve patients' outcome and reduce failure rate. MATERIALS & METHODS: We prospectively compared 40 consecutive patients with gastroesophageal reflux disease who underwent anti-reflux surgery: 20 Nissen fundoplication (NF) and 20 the MNF approach. Eight cases in the MNF group needed redo surgery. The MNF consisted in suturing the esophagus to the diaphragmatic crura on each side by means of 4 non-absorbable stitches and in fixing the upper stitch of the valve to diaphragm. In case of clearly weak crura, a reinforcement with Ultrapro mesh was used. All patients were assessed before and after surgery using validated symptoms and quality of life (GERD-HRQL) questionnaires, manometry and 24-h impedance-pH monitoring, endoscopy and barium-swallow. RESULTS: Mortality and postoperative complications were nil. At a median follow-up of 36 months, no significant differences emerged between the MNF and NF group in terms of symptoms, GERD-HRQL scores, manometric findings, and impedance-pH features. Dysphagia was not reported by the MNF group, while it was quite common (20% vs.0%, p = ns) in the NF group. Anti-reflux surgery was successful in all patients in the MNF group, whereas two patients in the NF group presented a slipped wrap and one recurrent reflux; two of these cases required redo-surgery (10% vs. 0%, p = ns). CONCLUSIONS: Our preliminary data demonstrated that the MNF is a safe and effective procedure. Further, it seems to reduce the failure rate associated to the surgical procedure

A modified Nissen fundoplication: subjective and objective midterm results

Purpose: The failure rate of laparoscopic anti-reflux surgery is approximately 10\u201320%. The aim of our prospective study was to investigate whether a modified Nissen fundoplication (MNF) can improve reflux symptoms and prevent surgical treatment failure in the midterm. Methods: The MNF consisted of (1) suturing the esophagus to the diaphragmatic crura on each side using four non-absorbable stitches, (2) reinforcing clearly weak crura with a tailored Ultrapro mesh, and (3) fixing the upper stitch of the valve to the diaphragm. Forty-eight consecutive patients experiencing typical gastroesophageal reflux disease (GERD) symptoms at least three times per week for 6 months or longer were assessed before and after surgery using validated symptom and quality of life (GERD-HRQL) questionnaires, high-resolution manometry, 24-h impedance-pH monitoring, endoscopy, and barium swallow. Results: Mortality and perioperative complications were nil. At median follow-up of 46.7 months, the patients experienced significant improvements in symptom and GERD-HRQL scores. One patient presented with severe dyspepsia and another complained of dysphagia requiring a repeat surgery 12 months after the first operation. Esophageal acid exposure (8.8 vs 0.1; p < 0.0001), reflux number (62 vs 8.5; p < 0.0001), and symptom-reflux association (19 vs 0; p < 0.0001) significantly decreased postoperatively. The median esophagogastric junction contractile integral (EGJ-CI) from 31 cases (8.2 vs 21.2 mmHg cm; p = 0.0003) and the abdominal length of the lower esophageal sphincter (LES) (0 vs 16 mm; p = 0.01) increased postoperatively. Conclusions: Our data demonstrate that the MNF is a safe and effective procedure both in the short term and midterm. \ua9 2018, Springer-Verlag GmbH Germany, part of Springer Nature