Laparoscopic duodenojejunostomy for recurrent acute pancreatitis associated with superior mesenteric artery syndrome in a medically complex patient: A case report and literature review.

RATIONALE: Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, and acute pancreatitis associated with SMAS is extremely uncommon. The causal relationship is usually inferred from persistent duodenal obstruction, exclusion of other etiologies, and resolution after decompression.

PATIENT CONCERNS: A 19-year-old male with a history of esophageal atresia repair, previous upper abdominal surgery, refractory epilepsy, severe developmental delay, and a bedridden status presented with recurrent vomiting and acute pancreatitis. Pancreatitis recurred over a period of 4 years despite repeated conservative management and eventually increased to approximately once per month.

DIAGNOSES: Contrast-enhanced computed tomography revealed marked gastric and duodenal dilation, compression of the third portion of the duodenum between the aorta and the superior mesenteric artery, and a narrowed aortomesenteric angle of 18°. Other causes of pancreatitis, including gallstones, pancreaticobiliary maljunction, and infection, were excluded. Recurrent acute pancreatitis associated with SMAS-related duodenal obstruction was diagnosed.

INTERVENTIONS: Conservative treatment included bowel rest, nasogastric decompression, intravenous fluid and electrolyte correction, and prokinetic medication. Because recurrent pancreatitis persisted, laparoscopic duodenojejunostomy with omega-loop reconstruction was performed at age 23. Dense intra-abdominal adhesions precluded safe intracorporeal anastomosis; therefore, extracorporeal side-to-side duodenojejunostomy was completed.

OUTCOMES: Postoperative contrast studies confirmed unobstructed passage through the anastomosis, with no leakage or residual obstruction. During 3 years of follow-up, no pancreatitis recurrence, bile reflux, or readmission occurred, and the patient's weight increased.

LESSONS: Although causality cannot be definitively established from a single case, surgical duodenal decompression may be considered in selected patients with recurrent pancreatitis associated with persistent SMAS-related duodenal obstruction after the exclusion of alternative causes and failure of conservative management. Continued long-term surveillance is required after omega-loop reconstruction.