Laparoscopic Hand-Sewn Duodenojejunostomy for Superior Mesenteric Artery Syndrome Using 3D-4K Image - A Case Study

Background: Superior mesenteric artery (SMA) syndrome, also known as wilkie’s syndrome, is a rare condition characterized by vascular compression of third part of the duodenum that leads to duodenal obstruction. Traditionally, open or laparoscopic stapled duodenojejunostomy is recommended when conservative management failed. We report a 3D-4K image hand-sewn duodenojejunostomy (DJ) for the treatment of SMA syndrome. Materials and Methods: A 13 years old patient presented with anorexia, post prandial vomiting, dull abdominal pain & weight loss for 6 years. Upper GI endoscopy revealed duodenal stenosis and Barium follow through demonstrated obstruction to the third part of the duodenum. Ultrasound examination revealed gastric & duodenal dilatation. With these clinical and radiological findings, the diagnosis of SMA syndrome was suspected. He was identified as a candidate for a duodenojejunostomy. 3D-4K image system was used for superior image quality and binocular depth perception and a laparoscopic hand-sewn duodenojejunostomy performed on september 20, 2020 Results: Diagnostic laparoscopy detected SMA syndrome. Laparoscopic hand-sewn duodenojejunostomy took 120 minutes time. There were no intraoperative complications. The blood loss was minimum. The postoperative course was uneventful with resolution of duodenal obstruction. The patient discharged on 6th postoperative day. He gained 10 kg weight 6weeks after surgery. Conclusion: 3D-4K image laparoscopic hand-sewn duodenojejunostomy as a surgical option for the treatment of SMA syndrome is safe, cost effective, feasible, and valid alternative to open and laparoscopic stapled technique with added benefits of a minimally invasive approach. Additionally hand-sewn anastomosis ensures good tissue approximation. Of course it is time consuming and needs expertise in intracorporeal suturing. 3D-4K image technology makes this difficult procedure easier. J Bangladesh Coll Phys Surg 2022; 40: 68-71

TWMP-02. Supplementary motor area syndrome in glioma surgery - towards a classification system based on clinical and imaging data

OBJECTIVES Surgical resection of gliomas involving the supplementary motor area (SMA) frequently results in a symptom complex commonly described as „SMA syndrome“, which is characterized by transient contralateral akinesia and mutism. As factors potentially influencing the severity and duration of symptoms still remain elusive, we aim to further investigate potential predictors in a multicentric cohort of glioma patients. METHODS Fifty patients with gliomas located in the superior frontal gyrus from 3 centers were included in this retrospective study. Patients with injury of M1 and/or the corticospinal tract were excluded. Early postoperative motor outcome, the occurrence of mutism and duration of acute symptoms in days were assessed. The long-term outcome was assessed in follow-up examinations 3 months after surgery. Atlas-based lesion-symptom mapping was performed using postoperative MR imaging estimating surgical grey matter damage as well as white matter disconnection severity. Associations between functional outcome and imaging findings were analyzed using group tests and correlation analyses. RESULTS Median duration of symptoms in the cohort was 3 days (range: 1 – 42 days). Persistent deficits concerning fine motor movements and speech after initial recovery were found in 27 patients (54%). Disconnection of the central segment of the corpus callosum was associated with longer symptom duration (FDR corr. p < 0.05), while disconnection of the mid-posterior segment of the corpus callosum was associated with persistent deficits at follow-up (FDR corr. p < 0.05). CONCLUSIONS The present study shows a high variability regarding the recovery time of postoperative SMA syndrome and a high prevalence of persistent deficits in fine motor movements and speech after initial recovery of acute symptoms. The pivotal role of interhemispheric connectivity in the recovery process is reinforced. These findings will help neurosurgeons in patient consultation and provide a foundation for future studies aiming to establish prediction models of the SMA syndrome.

TWMP-01. RESECTION OF SUPPLEMENTARY MOTOR AREA GLIOMAS: REVISITING SUPPLEMENTARY MOTOR SYNDROME AND THE ROLE OF THE FRONTAL ASLANT TRACT

INTRODUCTION The supplemental motor area (SMA) is an eloquent region that is frequently a site for gliomas or the region is included in the resection trajectory to deeper lesions. METHODS Patient, tumor and outcome data were collected retrospectively from the UCSF tumor registry for patients who underwent surgical resection for newly diagnosed supratentorial diffuse glioma (WHO Grade II - IV) between 2010 and 2019 in the SMA region and the extent of SMA resection was determined by volumetric assessment. Tumors were registered to a standard brain atlas to create a frequency heat map of tumor volumes and resection cavities. RESULTS Although the volume of tumor within the SMA region did not correlate with the development of SMA syndrome, patients with SMA syndrome had larger resection cavities in the SMA region (25.4% SMA resection vs. 14.2% SMA resection, p = 0.039). The size of the resection cavity in the SMA region did not correlate with the severity of the SMA syndrome. Patients who developed SMA syndrome had cavities that were located more posteriorly in the SMA region and in the cingulate. When the frontal aslant tract (FAT) was preserved, 50% of patients developed SMA syndrome post-operatively; whereas 100% of patients who had disruption of the FAT during surgery developed SMA syndrome (p = 0.06). There was no difference in the overall survival for newly diagnosed glioblastoma patients with SMA syndrome compared to those without SMA syndrome (1.6 years vs. 3.0 years, p = 0.33). CONCLUSION For patients with SMA gliomas, larger resections and resections involving the posterior SMA region and posterior cingulate gyrus increased the likelihood of a post-operative SMA syndrome. Although SMA syndrome occurred in all cases where the FAT was resected, FAT preservation does not reliably avoid SMA syndrome post-operatively.

A CASE REPORT : A CASE OF SUPERIOR MESENTERIC ARTERY SYNDROME

Superior mesenteric artery (SMA) syndrome is an uncommon but well recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum between the aorta and the superior mesenteric artery. This results in chronic, intermittent, or acute complete or partial duodenal obstruction. Superior mesenteric artery syndrome was rst described in 1861 by Von Rokitansky, who proposed that its cause was obstruction of the third part of the duodenum as a result of arterio-mesenteric compression. Some studies report the incidence of superior mesenteric artery syndrome to be 0.1- 0.3%.

Superior mesenteric artery syndrome causing gastric outlet obstruction: A myth in acute abdomen

Objective: We aim to report a case of gastric outlet obstruction in adolescence that was diagnosed as a superior mesenteric artery syndrome and treated successfully by gastrojejunostomy. Case report: A 17-year-old female presented to emergency department with acute abdomen. She was also complaint of significant weight loss past 2 months. On clinical examination she was underweight with fullness of upper abdomen down to umbilicus. Oesophagogastroduodenoscopy (OGDS) was performed showed grossly dilated stomach with unable to go beyond D3 region. Contrast Enhanced Computed Tomography (CECT) abdomen suggestive of Superior Mesentery Artery (SMA) syndrome. She was subjected to gastrojejunostomy and recovered well postoperatively. Conclusion: An acute onset of gastric outlet obstruction in adolescence can be a diagnostic and treatment challenging. Our case patient was diagnosed as a SMA syndrome based on the history taking and CT findings. We would like to advocate a high index of suspicious SMA syndrome should be included in an acute abdomen in adolescence besides volvulus and malrotation. The treatment options should be individualized. In this case we opted for a gastrojejunostomy compared to duodenojejunostomy. The decision was made based on the patient nutritional status as patient was low Body Mass Index (BMI) was 16 kg/m2 which carries a high risk of anastomotic leak. Keywords: superior mesenteric artery syndrome; cast syndrome; wilkie’s syndrome; arteriomesenteric duodenal compression; duodenal vascular compression.

Features of intraoperative neuromonitoring of the supplementary motor area of the brain. Literature review and case report

Introduction. Supplementary motor area (SMA) syndrome is a symptom complex resulting from damage to the premotor cortex and it’s subcortical projection. There is no generally accepted protocol for functional mapping of SMA during neurosurgical intervention in this area.The objective of the publication is to present a review of the literature and clinical cases from practice that describes the treatment of two patients with glioblastomas in the posterior regions of the superior frontal gyrus with IOM. Given the localization of the tumor in the dominant hemisphere, one operation was performed with awakening, the other according to the protocol of total intravenous anesthesia with mapping of only motor representative areas.Clinical cases. In both cases, during intraoperative direct electrical stimulation of the cortex subjected to resection, evoked motor responses were not recorded. The modalities used made it possible to continuously evaluate the viability of the cortico‑spinal tract. During the surgery with awakening, episodes of an instantaneous termination of the initia‑ tion of speech and counter directional movements in the arm were recorded – in the subcortical projection of the SMA at a current strength of 1–2 mA. Both patients in the early postoperative period showed the development of a gross transient neurological deficit in the form of hemiparesis and sensorimotor aphasia, which was a manifestation of pos‑ tresection SMA syndrome. During the follow‑up (control) examination 6–7 months after the operation, the following was observed in the clinical picture: mild hemiparesis up to 4–5 points, impaired bimanual coordination; difficulty the ini‑ tiation of speech spontaneous speech.Conclusion. When mapping the cortex and subcortical structures, the localization of SMA can be assumed in the event of a negative motor response of the cerebral cortex using the protocol of low‑frequency 1 Hz stimulation under EcoG control. Standardization of the SMA mapping protocol would be useful in clinical practice for determining the bounda

Resection of supplementary motor area gliomas: revisiting supplementary motor syndrome and the role of the frontal aslant tract

OBJECTIVE The supplementary motor area (SMA) is an eloquent region that is frequently a site for glioma, or the region is included in the resection trajectory to deeper lesions. Although the clinical relevance of SMA syndrome has been well described, it is still difficult to predict who will become symptomatic. The object of this study was to define which patients with SMA gliomas would go on to develop a postoperative SMA syndrome. METHODS The University of California, San Francisco, tumor registry was searched for patients who, between 2010 and 2019, had undergone resection for newly diagnosed supratentorial diffuse glioma (WHO grades II–IV) performed by the senior author and who had at least 3 months of follow-up. Pre- and postoperative MRI studies were reviewed to confirm the tumor was located in the SMA region, and the extent of SMA resection was determined by volumetric assessment. Patient, tumor, and outcome data were collected retrospectively from documents available in the electronic medical record. Tumors were registered to a standard brain atlas to create a frequency heatmap of tumor volumes and resection cavities. RESULTS During the study period, 56 patients (64.3% male, 35.7% female) underwent resection of a newly diagnosed glioma in the SMA region. Postoperatively, 60.7% developed an SMA syndrome. Although the volume of tumor within the SMA region did not correlate with the development of SMA syndrome, patients with the syndrome had larger resection cavities in the SMA region (25.4% vs 14.2% SMA resection, p = 0.039). The size of the resection cavity in the SMA region did not correlate with the severity of the SMA syndrome. Patients who developed the syndrome had cavities that were located more posteriorly in the SMA region and in the cingulate gyrus. When the frontal aslant tract (FAT) was preserved, 50% of patients developed the SMA syndrome postoperatively, whereas 100% of the patients with disruption of the FAT during surgery developed the SMA syndrome (p = 0.06). Patients with SMA syndrome had longer lengths of stay (5.6 vs 4.1 days, p = 0.027) and were more likely to be discharged to a rehabilitation facility (41.9% vs 0%, p < 0.001). There was no difference in overall survival for newly diagnosed glioblastoma patients with SMA syndrome compared to those without SMA syndrome (1.6 vs 3.0 years, p = 0.33). CONCLUSIONS For patients with SMA glioma, more extensive resections and resections involving the posterior SMA region and posterior cingulate gyrus increased the likelihood of a postoperative SMA syndrome. Although SMA syndrome occurred in all cases in which the FAT was resected, FAT preservation does not reliably avoid SMA syndrome postoperatively.

TP7.2.15 Superior Mesenteric Artery Syndrome Managed with Laparoscopic Duodenojejunostomy: Case Series and Review of the Literature

Aims Superior Mesenteric Artery (SMA) Syndrome is a rare disorder which may be managed surgically when conservative management fails. We present a case series of six patients who underwent laparoscopic duodenojejunostomy in our tertiary centre for treatment of SMA Syndrome. The aim of our case series is to assess and present our outcomes in comparison to the limited available literature on the topic. Methods Retrospectively, we identified all patients who underwent laparoscopic duodenojejunostomy for SMA Syndrome in our tertiary university centre’s surgical database between December 2016 and July 2019. Data collected included demographics, presenting symptoms, co-morbidities, pre and post-operative Body Mass Index (BMI), operative approach, operative blood loss, operative duration, length of hospital stay, clinical and radiological results, in hospital/30 day complications, mortality and post operative follow up outcomes. Results We identified six patients, 1:5 male to female ratio, with a median age 18 years of age (range 17-31 years). All patients had refractory symptoms after a minimum of two months (range 2-5 months) of conservative management and subsequently underwent laparoscopic duodenojejunostomy. Median hospital stay was 7 days and no in hospital/30 day post operative mortality or complications were identified. Follow up data showed no recurrence of symptoms and a BMI median increase of 10.2 (range 8-13.6) at a median follow-up of 18 months (range 12-30 months) Conclusions Laparoscopic duodenojejunostomy is a safe treatment option for SMA syndrome and should be considered when patients do not respond to conservative management.