Endoscopic Gastrojejunostomy for Superior Mesenteric Artery Syndrome Using Magnetic Compression Anastomosis

Superior mesenteric artery syndrome in a 16-year-old girl patient: A rare case report from Syria

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare condition with a significant decrease in the angle between the SMA and the abdominal aorta.

PRESENTATION OF CASE

A 16-year-old girl presented with abdominal pain, vomiting, weight loss, and loss of appetite. Family history included allergies to contrast media. Clinical examination revealed a distended abdomen with a severely dilated stomach. Imaging showed narrowing in the duodenum. Upper endoscopy confirmed the diagnosis, and gastrojejunostomy was performed successfully. Patient recovered well post-surgery and was discharged after two weeks with resolved symptoms.

DISCUSSION

SMA syndrome is a rare and serious condition, more common in women, young adults, and teenagers. Mental health support is crucial in managing SMA syndrome patients. Treatment involves CT scans for diagnosis, and options include conservative care or surgery, with success rates varying in studies.

CONCLUSION

Early diagnosis and intervention are crucial in managing superior mesenteric artery syndrome, as prompt treatment can significantly improve patient outcomes and prevent life-threatening complications. This case contributes to the literature by emphasizing the importance of considering SMA syndrome in differential diagnoses, particularly in young patients with non-specific gastrointestinal symptoms, thereby enhancing awareness and understanding of this rare condition.

Endoscopic application of magnetic compression anastomosis: a review

Magnetic compression anastomosis (MCA) is a new method that provides sutureless passage construction for tubular organs. Due to the high recurrence rate of conventional endoscopic treatment and the high morbidity and mortality of surgical procedures, the MCA technique shows promise. The aim of this review is to comprehensively examine the literature related to the use of MCA in different gastrointestinal diseases over the past few years, categorizing them according to the anastomotic site and describing in detail the various methods of magnet delivery and the clinical outcomes of MCA. MCA is an innovative technique, and its use represents an advancement in the field of minimally invasive interventions. Comparison studies have shown that the anastomosis formed by MCA is comparable to or better than surgical sutures in terms of general appearance and histology. Although most of the current research has involved animal studies or studies with small populations, the safety and feasibility of MCA have been preliminarily demonstrated. Large prospective studies involving populations are still needed to guarantee the security of MCA. For technologies that have been initially used in clinical settings, effective measures should also be implemented to identify, even prevent, complications. Furthermore, specific commercial magnets must be created and optimized in this emerging area.

Superior mesenteric artery syndrome: Diagnosis and management

Superior mesenteric artery (SMA) syndrome (also known as Wilkie's syndrome, cast syndrome, or aorto-mesenteric compass syndrome) is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta. The median age of patients is 23 years old (range 0-91 years old) and predominant in females over males with a ratio of 3:2. The symptoms are variable, consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss and can mimic anorexia nervosa or functional dyspepsia. Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis, early diagnosis is required. The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography, which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage. The initial treatment is usually conservative, including postural change, gastroduodenal decompression, and nutrient management (success rates: 70%-80%). If conservative therapy fails, surgical treatment (i.e., laparoscopic duodenojejunostomy) is recommended (success rates: 80%-100%).

Endoscopic ultrasonography for pre-operative local assessment and endoscopic ultrasonography-guided marking before gastrojejunostomy for duodenal obstruction using magnetic compression anastomosis

BACKGROUND AND AIM

A 93-year-old woman who was bedridden with severe dementia was referred to our department with a 3-day history of repeated vomiting after meals. Computed tomography revealed significant dilatation of the duodenum up to the level of the third portion, which was compressed by a large, low-density mass. Upper gastrointestinal endoscopy showed narrowing of the third portion of the duodenum with edematous mucosa covered with multiple white spots, where the endoscope was able to pass through with mild resistance. B-cell lymphoma was histopathologically suspected from biopsy specimens of the mucosa. We performed gastrojejunostomy through the magnetic compression anastomosis (MCA) technique. We prepared two neodymium magnets: Flat plate shaped (15 × 3 mm) with a small hole 3 mm in diameter; a nylon thread was passed through each hole. We then confirmed the absence of no non-target tissue, including large vessels and intestine adjacent to the anastomosis where the magnets were to be placed using endoscopic ultrasonography (EUS) from the stomach. EUS-guided marking using biopsy forceps by biting the mucosa and placing a hemoclip was performed at the anastomosis site in the stomach. The magnet was pushed and delivered to the duodeno-jejuno junction, and another magnet was delivered to the marking point in the stomach. The magnets were attracted toward each other transmurally. The magnets fell into the colon by 11 days after starting the compression, and the completion of gastrojejunostomy was confirmed.

RELEVANCE FOR PATIENTS

Endoscopic gastrojejunostomy using MCA is useful as a minimally invasive alternative treatment for duodenal obstruction. EUS for the pre-operative local assessment and EUS-guided marking can ensure the safety of the MCA procedure.

Sutureless Duodeno-Ileal Anastomosis with Self-Assembling Magnets: Safety and Feasibility of a Novel Metabolic Procedure

BACKGROUND

Less invasive and safer anastomotic techniques are desirable. We aimed to determine technical feasibility and safety of sutureless duodeno-ileal side-to-side anastomosis in obese patients using self-assembling magnets.

METHODS

This was an open-label, prospective, and single-arm study including obese patients (BMI 30-50 kg/m2) with type II diabetes. The ileal magnet was deployed laparoscopically, and the duodenal magnet was deployed endoscopically. Both magnets were coupled under laparoscopic and fluoroscopic guidance. The primary endpoints were technical feasibility and safety. The secondary endpoints were patency of the anastomosis, HbA1c reduction, and weight loss 12 months after the procedure.

RESULTS

A total of 8 patients were enrolled in the study; median age was 51.5 years (range: 34-65), and median BMI was 38.8 kg/m2 (range: 35-47.9). The mean procedural duration was 63.5 min (range: 41-95). No intraoperative complications were recorded, and no major postoperative morbidity related to the procedure occurred. Magnets were expelled at a median of 29.5 days after the procedure with no associated complications. Upper endoscopy at 12 months confirmed patent anastomoses with healthy-appearing mucosa in all patients. HbA1c reduced below 7.0% in 6 out of 8 (75%) patients, and greater than 5% of total body weight loss was observed in 7 out of 8 (87.5%) patients at 12 months.

CONCLUSIONS

Sutureless duodeno-ileal side-to-side anastomosis using self-assembling magnets is feasible and safe in obese patients, and a dual-path enteral diversion with large-caliber and durable anastomosis can be achieved.

New Technique for Magnetic Compression Anastomosis Without Incision for Gastrointestinal Obstruction

BACKGROUND

Magnetic compression anastomosis (MCA) is a novel technique of anastomosis similar to that with surgery, but in a minimally invasive manner. Few reports are available on the utility and feasibility of MCA for gastrointestinal anastomosis without requiring general anesthesia in humans, owing to the difficulty of delivering magnets. We evaluated the safety, efficacy, and feasibility of MCA in gastrointestinal obstruction without requiring general anesthesia.

STUDY DESIGN

In this retrospective single-center study, patients who underwent MCA from January 2013 to October 2019 were included. Adult patients with gastrointestinal obstruction or stenosis, irrespective of the underlying disease, with severe comorbidities, complicated abdominal surgical history, or postoperative complications, and who were unable to tolerate surgery, were eligible for inclusion. Two magnets were delivered by a combination of endoscopic and fluoroscopic procedures and placed in the lumen of the organ to be anastomosed. The main outcome was the technical success of MCA.

RESULTS

Fourteen patients underwent MCA, and the technical success of MCA was achieved in 100% of the cases. The mean procedural time, duration for anastomosis formation, and postoperative hospital stay were 44 minutes, 13 days, and 36 days, respectively. Two patients underwent anastomotic restenosis, and 1 patient had an anastomotic perforation due to balloon dilatation to prevent restenosis. The mean follow-up period was 34 months.

CONCLUSIONS

MCA without general anesthesia for gastrointestinal anastomosis is safe, useful, and feasible. MCA can be a valuable alternative to surgery in gastrointestinal obstruction.

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report

BACKGROUND

Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction.

CASE PRESENTATION

A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society.

CONCLUSIONS

Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.