Minimally invasive surgical management of superior mesenteric artery syndrome (SMAS) in children

Minimally invasive surgical management of superior mesenteric artery syndrome (SMAS) in children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Minimally invasive surgical management of superior mesenteric artery syndrome (SMAS) in children Joel Cazares, Eduardo de la Rosa-Bustamante, Jorge Colin-Garnica, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4903565/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Superior mesenteric artery syndrome (SMAS) is a rare but potentially life-threatening disorder. It has a low incidence, and its clinical presentation can often mimic other disorders, making its diagnosis challenging. Methods Four patients treated from 2017–2023 presented with chronic abdominal pain, nausea, vomiting and severe weight loss, leading to malnutrition. Psychological evaluations were conducted to comprehensively assess their condition. Diagnostic tests included abdominal X-rays demonstrating gastric distension, upper gastrointestinal series revealing duodenal contrast retention, endoscopy indicating difficulty in advancing into the third portion of the duodenum and CT angiography demonstrating a decrease in the angle between the SMA and the abdominal aorta. Referral to pediatric surgery was necessary after conservative management yielded no improvement. Results In three patients, laparoscopic duodenojejunostomy was performed, whereas one patient underwent laparoscopic gastrojejunostomy. All patients were discharged with satisfactory recovery and no complications. Conclusions This study highlights the effectiveness and safety of laparoscopic surgical techniques in managing pediatric SMAS patients who are unresponsive to conservative measures. Laparoscopic duodenojejunostomy and gastrojejunostomy have demonstrated favorable outcomes in this context. Further research and data collection are warranted to continue evaluating the long-term success of these techniques in managing SMAS. Level of evidence IV, case series with no comparison group. Superior mesenteric artery syndrome Wilkie syndrome laparoscopic duodenojejunostomy laparoscopic gastrojejunostomy pediatric surgery minimally invasive surgery Figures Figure 1 Introduction Superior mesenteric artery syndrome (SMAS) is a rare condition that results from narrowing of the aortomesenteric angle and a reduced distance between the aorta and superior mesenteric artery (SMA), leading to mechanical obstruction of the third portion of the duodenum by mesenteric vessels [ 1 ]. This can result from various underlying causes, including weight loss, alterations in spine anatomy and other anatomical factors, such as high insertion of the Treitz ligament, peritoneal adhesions and different types of SMAs, which are more commonly associated with type I SMA, which is defined as the presence of all SMA branches [2,3]. This syndrome has an exceptionally low prevalence (0.13–0.3%), making it a challenging condition to diagnose and treat. It tends to be more prevalent among young adults and teenagers, with a higher proportion in females; however, it can still occur in pediatric patients, with only a few case reports published in newborn patients. Notably, there is no established genetic predisposition associated with the syndrome, despite a familiar occurrence reported by Ortiz et al. in 1990, involving five cases within an eight-member family [ 4 – 7 ]. The clinical presentation of this syndrome is characterized by several main symptoms, including recurrent postprandial discomfort (66.7%), abdominal pain (61.1%), early satiety (50%), anorexia (44.4%), nausea (33.3%), and vomiting (33.3%). These symptoms are often associated with gastric and duodenal ulcers, as well as gastroesophageal reflux disease. SMAS is associated with comorbid conditions such as weight loss (50%), gastritis or reflux (16.7%). SMAS can often be misdiagnosed as a psychiatric disorder such as anorexia nervosa or bulimia (5.6%) in young female patients because of the similarity of symptoms. It is also more common in patients with spine alterations or neurological disorders [ 8 – 10 ]. Diagnosing SMAS can be challenging because of its nonspecific symptoms and rarity [ 11 ]. However, a comprehensive clinical assessment with a high suspect index is needed. Imaging studies such as computed tomography (CT) or upper gastrointestinal series (UGIs) and consideration of the patient's medical history can aid in making the diagnosis. An aortomesenteric angle less than 22° and an aortomesenteric distance less than 8 mm have been proposed as diagnostic criteria for SMAS, but it is important to note that the severity of symptoms does not always correlate and that it is important to have both image criteria and a clinical correlation for an accurate diagnosis [ 12 ]. The management of SMAS in children involves a multidisciplinary approach, with initial conservative measures such as nutritional support, body positioning, placement of a nasojejunal tube or parenteral nutrition. If conservative measures are ineffective, surgical intervention may be necessary, with six weeks as the maximum duration for conservative management before surgery is considered [ 8 ]. Minimally invasive surgical techniques have emerged as promising approaches for the management of SMAS in children. Laparoscopic duodenojejunostomy is one such procedure that aims to create a bypass for the duodenum, relieving the obstruction without the need for extensive abdominal incisions. This approach not only reduces surgical trauma and recovery time but also offers favorable long-term outcomes and has better outcomes than other procedures like Strong procedure [ 13 – 15 ]. Our objective in this study is to publish the first case series of four patients in North Mexico with SMAS that failed conservative management via minimally invasive techniques with laparoscopic duodenojejunostomy and gastrojejunostomy for patients in which duodenojejunostomy could not be performed and to report the short- and midterm outcomes of these interventions in our population, highlighting the effectiveness and outcomes of laparoscopic duodenojejunostomy and gastrojejunostomy in patients with SMAS. Methods Patient selection Four pediatric patients who underwent surgery at our institution between 2017 and 2023 were diagnosed with SMAS, and the data extracted included patient characteristics, symptoms and comorbidities, diagnostic methods, UGI, endoscopy, abdominal CT, conservative management, surgical technique details, postoperative outcomes, and length of hospital stay ( Table 1 ). Table 1 Patients characteristics and demographics Total patients n = 4 Sex: Female n = 3 Male n = 1 Ethnicity: Hispanic n = 4 Age at surgery median, IQR 13 (12.5–13) BMI median, IQR * 13 (12.77–13.57) BMI SD median, IQR * -3.7 (-3.99 — -3.2) Malnutrition n = 4 Difference between preoperative body weight and ideal body weight (p50) median, IQR * 15.2 (13.77–16.75) Aortomesenteric distance (milimeters) median, IQR 5.4 (4.6–6.25) Aortomesenteric angle (degree) median, IQR 12.1 (10.74–13.81) Duration of symptoms (months) median, IQR 12 (10–12) Patients characteristics before surgery BMI: Body mass index SD: Standard deviation IQR: Interquartile range *Based on growth charts for children with Down syndrome in the United States and 2022 CDC growth charts [20–21]. The first three patients were female patients, all of whom were 13 years old and were diagnosed with SMAS in a tertiary care hospital in Mexico after a 10–12-month period with similar clinical presentations and unsuccessful attempts at conservative management. All of them were treated by psychiatrists and psychologists for the diagnosis of eating disorders without success. These patients presented with abdominal pain, postprandial vomiting, and significant weight loss with moderate to severe malnutrition. They were referred by gastroenterology for surgical evaluation after failing conservative management, which consisted of gastric decompression, nutritional support with small portions, a failed attempt to place a nasojejunal tube and parenteral nutrition for weeks without any significant improvement in symptoms or weight gain, whereas the fourth patient was an 11-year-old male with Down syndrome, a history of duodenal surgery at birth, a clinical course of twelve months of evolution with postprandial vomiting, abdominal discomfort and weight loss despite conservative management, including gastric decompression and nutritional support for six weeks, who was also treated with minimally invasive techniques. In this case, we chose a gastrojejunostomy because duodenojejunostomy was not possible due to previous duodenal surgery in the neonatal period ( Table 2 ) . Table 2 Clinical presentation and medical history Total patients n = 4 Postprandial abdominal discomfort (%) 100 (n = 4) Vomiting (%) 100 (n = 4) Weight loss (%) 100 (n = 4) Follow-up by psychiatrist (%) 75 (n = 3) Depression (%) 75 (n = 3) Anxiety (%) 75 (n = 3) Eating disorders (%) 75 (n = 3) Follow-up by gastroenterologist (%) 25 (n = 1) Annular pancreas (%) 25 (n = 1) Unsuccessful medical treatment (%) 100 (n = 4) Unsuccessful nasojejunal feeding (%) 75 (n = 3) Patients clinical presentation and comorbidities before surgery Diagnostic criteria Diagnostic tests included abdominal X-ray demonstrating gastric distension, UGI revealing duodenal contrast retention, endoscopy indicating difficulty in advancing into the third portion of the duodenum and abdominal CT with evidence of a narrowed angle between the superior mesenteric artery and the aorta, with an aortomesenteric angle less than 22° and an aortomesenteric distance less than 8 mm, as well as symptoms consistent with SMAS. The parents of the four patients signed informed consent forms. Patients undergo minimally invasive techniques, including laparoscopic duodenojejunostomy and gastrojejunostomy ( Fig. 1 ) [ 5 , 15 , 16 ]. (A) Upper gastrointestinal series showing a vertical linear band-like defect across the third portion of the duodenum. (B) CT angiography demonstrating a decrease in the angle between the SMA and the abdominal aorta. (C) Laparoscopic duodenojejunostomy. (D) Laparoscopic gastrojejunostomy. Duodenojejunostomy operative technique The patient is placed in the supine position under general anesthesia in the French position. An 11 mm trocar is placed in the umbilicus, and two additional 5 mm trocars are placed in the right and left quadrants of the abdomen. A 10 mm laparoscopic camera is inserted through the umbilical trocar, allowing visualization of the abdominal cavity. The transverse colon is mobilized to expose the third portion of the duodenum and the proximal jejunum. The dilated portion of the duodenum is identified next to the SMA, and a window is made in the peritoneum, exposing the duodenum and dissecting it free circumferentially from surrounding tissues to permit further exposure and mobilization. The Treitz angle is identified, and the proximal jejunum is brought up from a distance of usually 15–20 cm from the liberated portion of the duodenum. A side-to-side duodenojejunostomy is performed by creating an anastomosis between the duodenum and the jejunum using reference silk 2 − 0 sutures. Then, an enterotomy is performed with a harmonic scalpel. A 5-mm camera is inserted, allowing a stapler to enter the 11-mm port, and the anastomosis is created via a 45 mm linear stapler. The enterotomy is then closed with a 2 − 0 V-Loc™ (Medtronic, Minneapolis, MN, USA) barbed suture. Lembert sutures are placed between the proximal jejunum and transverse colon with silk 2 − 0 to prevent blind loop syndrome, and finally, a Jackson-Pratt™ (Cardinal Health, Dublin, OH, USA) drain is placed at the surgical site to facilitate drainage and monitoring [1,5,11,13,15,17–20]. Operative technique for gastrojejunostomy In this technique, we use the same port placements and patient position as described in the previous operative procedure. The transverse colon is mobilized downward to expose the greater curvature of the stomach and the mesocolon. A window is created with a harmonic scalpel to identify the posterior portion of the stomach where gastrojejunostomy will be performed. The proximal jejunum is brought approximately 15–20 cm from the Treitz angle to the posterior wall of the stomach, where a side-to-side gastrojejunal anastomosis is created via reference silk 2–0 sutures and a 45 mm linear stapler, and the enterotomy is closed with V-loc™ barbed suture. If the mesocolon window is too large, it is closed with a silk 2–0 suture to prevent internal hernias. A Jackson-Pratt™ drain is placed at the surgical site for monitoring and drainage. Postoperative care Patients initiated early ambulation, commencing as early as the day following surgery, followed by a clear liquid diet on the third postoperative day and gradually progressing to a bland diet before advancing to a normal diet as tolerated. The drain was also removed during this time and sent home afterwards. Nutritional counseling and support were provided to ensure that they had adequate caloric intake and optimal nutrition to aid in their recovery. For patients treated with gastrojejunostomy, proton pump inhibitors and prokinetic medications were prescribed to prevent gastric reflux and ulcers and promote gastric emptying. Outcomes During the initial phase, considerable progress in the patient's health occurred, leading to a decrease in postmeal vomiting and stomach discomfort. The patients showed an increase in weight during the first few weeks after the operation. Continued monitoring for six months revealed continued improvement in nutritional well-being and overall physical condition, with no recurrence of symptoms associated with SMAS. The patient who underwent gastrojejunostomy was followed up monthly by gastroenterology until six months after surgery and every six months thereafter to prevent further complications secondary to the procedure. This study was approved by the hospital bioethics committee. All information and calculations of medians and interquartile ranges were performed with Microsoft Office Excel 365. Results Patients with SMAS nonresponsive to treatment underwent surgical intervention with either duodenojejunostomy or gastrojejunostomy from 2017–2023. Three patients were female (75%; n = 3), and one patient was male (25%; n = 1). All our patients were Hispanic (100%, n = 4) and ranged in age from 11–13 years; the median age at surgery was 10.5 years. All our patients were underweight, with mild (SD <-1) to severe malnutrition (SD <-3).. The median BMI was 16.7 kg/m2. The median difference between the preoperative weight and ideal body weight was 5 kg. The median aortomesenteric distance and angle were 5.4 mm and 12.1°, respectively. The median duration of symptoms before laparoscopic treatment was 12 months. All our patients (100%, n = 4) experienced postprandial abdominal discomfort, vomiting, and significant weight loss, leading to malnutrition, which was treated by gastroenterology (100%, n = 4). Three of them had a diagnosis of depression, anxiety and eating disorders treated by psychiatry and psychology (75%, n = 3), and 1 had a history of Down syndrome and annular pancreas at birth (25%, n = 1). All of them underwent X-ray, UGI, and CT scans and upper gastrointestinal endoscopy for diagnosis. All of them were treated for 6 weeks with medical treatment without success (100%, n = 4), and 3 of them had a failed intent to place a nasojejunal tube for feeding during the endoscopy procedure (75%, n = 3). Three of our patients underwent duodenojejunostomy (75%, n = 3), one patient underwent gastrojejunostomy (25%, n = 1), and one had a history of duodenum surgical intervention (25%, n = 1). The median duration of the procedures was 117.5 min, and the median duration of hospitalization was 7 days. The median duration for starting the diet was 3 days. All of the patients were fed a liquid diet after performing an UGI with normal pass of the contrast material, the median duration for tolerating a normal diet was 14 days. The median weight gain from surgery to the 6-month follow-up was 10.45 kg, with a median BMI of 17.85 kg/m2 (SD -0.575). The median difference between weight at follow-up and ideal weight (p50) was 6.9 kg. All our patients experienced improvement in symptoms at the 6-month follow-up. One patient (25%, n = 1) was treated with proton pump inhibitors and prokinetics followed by gastroenterology after gastrojejunostomy. Our patients did not require further hospitalization or had any major complications related to the surgery ( Table 3 ). Table 3 Surgery characteristics and Follow-up Total patients n = 4 Laparoscopic duodenojejunostomy (%) 75 (n = 3) Laparoscopic gastrojejunostomy (%) 75 (n = 3) History of duodenal intervention (%) 25 (n = 1) Surgery duration (minutes) median, IQR 117.5 (107-129.5) Days to starting liquid diet after surgery median, IQR 3 (3-3.5) Days to resumption of normal diet median, IQR 14 (14-14.5) Weight gain from surgery to 6 months follow up, median, IQR 10.45 (9.4–11.4) BMI at 6 month follow up* 17.85 (16.95-18.975) BMI at 6 month follow up DE median, IQR* -0.575 (-0.96 — -0.175) Weight difference between 6 months follow up and ideal weight 1 Median, IQR* 6.9 (5.2–8.42) Treatment with PPI and prokinetics 1 (25%) Surgery characteristics and follow-up IQR: Interquartile range BMI: Body mass index SD: Standard Deviation PPI: Proton pump inhibitors 1 : Percentile 50 for age *Based on growth charts for children with Down syndrome in the United States and 2022 CDC growth charts [20–21]. Discussion Four cases of SMAS in Northeast Mexico were successfully treated via minimally invasive techniques with positive results. Our patients had a typical clinical course consistent with SMAS symptoms; three of them were diagnosed with eating disorders, a differential diagnosis that can also be a comorbidity in this entity. The last patient had a medical history of annular pancreas and Down syndrome, which could be related to this condition through factors such as malnutrition or anatomical alterations, and further research is needed. The median age at diagnosis was 13 years, and three of them were female, which is consistent with previous findings that SMAS commonly occurs in young female patients, with a median age of onset around adolescence. The aortomesenteric distance and angle were measured, confirming the diagnosis of SMAS in our patients, with medians of 5.4 mm and 12.1 degrees, respectively [ 8 , 10 , 12 ]. All our patients received medical treatment for 6 weeks, which seems to be the safe limit of time before considering surgical intervention reported in the literature in children [ 8 ]. The median duration of the surgical procedures in our study was 117.5 minutes, which is comparable to that reported in previous studies. The median duration of hospitalization in our study was 7 days, which aligns with previous studies that reported a range of 4–9 days for hospital stay after SMAS treatment. The median time for starting a liquid diet after surgery was 3 days, which is in line with other studies. The median time for starting a normal diet after surgery in our study was 14 days, which is longer than that reported in some previous studies [13,20]. Our study revealed a significant improvement in weight gain and BMI percentiles at the 6-month follow-up, parameters that have been used to assess response to medical treatment [ 8 ]. Compared with other reports, the gastrojejunostomy was associated with a satisfactory reaction to the preventive therapy prescribed to avoid inherent complications [ 11 ]. Conclusion The successful management of these cases via minimally invasive techniques highlights the potential of laparoscopic duodenojejunostomy and gastrojejunostomy as effective interventions for pediatric patients with SMAS whose conservative management has failed [ 15 ]. This collection of cases adds to the increasing evidence that favors the application of minimally invasive surgical techniques for addressing this condition in our population. This study also highlights the importance of early detection and prompt intervention in preventing complications linked to SMAS. All our patients could have avoided malnutrition with an early diagnosis [ 11 , 13 , 17 – 19 ]. Managing SMAS in children in northern Mexico presents unique challenges due to limited access to specialized healthcare services and delays in diagnosis. However, with the adoption of minimally invasive surgical techniques, there is potential to improve outcomes for pediatric patients with SMAS in this region. As described by Barkhatov et al., laparoscopic duodenojejunostomy is linked to quicker postoperative recovery and leads to an enhancement in patients’ overall quality of life [ 19 ]. Further studies and collaborative efforts are needed to establish standardized protocols, increase the availability of advanced surgical interventions, and facilitate early diagnosis of SMAS in children. Abbreviations Superior mesenteric artery syndrome (SMAS) Superior mesenteric artery (SMA) Computed tomography (CT) Upper gastrointestinal series (UGI) Declarations Acknowledgments The authors would like to express their gratitude to Jose Mendoza-Siqueiros, Bachelor of Science and Engineering, for his assistance in statistical analysis alongside our team. Conflicts of interest The authors have no competing interests to declare. Funding There was no funding or support granted. Informed consent The ethics committee of the Hospital Regional de Alta Especialidad Materno Infantil approved this study. Informed consent to publish the case report was not obtained. This research does not contain any personal information that could lead to the identification of the patients. Authorship All the authors attest that they meet the current ICMJE criteria. Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References Wilkie DPD. Chronic duodenal ileus. BJS.1921;34,204 – 14., Balcerzak A, Tubbs RS, Waśniewska-Włodarczyk et al (2022) Classification of the superior mesenteric artery. Clin Anat. ; 35, 501–11. https://doi.org/10.1002/ca.23841 Puranik SR, Keiser RP, Gilbert MG et al (1972) Arteriomesenteric duodenal compression in children. J Pediatr Surg 3:334–339. https://doi.org/10.1016/0002-9610(72)90037-2 Ortiz C, Cleveland RH, Blickman JG et al (1990) Familiar superior mesenteric artery syndrome. Pediatr Radiol 20:588–589. 10.1007/BF02129061 Tang J, Zhang M, Zhou Y Laparoscopic lateral duodenojejunostomy for pediatric superior mesenteric artery compression syndrome: a cohort retrospective study. 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J Pediatr Surg Open. https://doi.org/10.1016/j.yjpso.2023.100065 . 4;10065 Cienfuegos JA, Hurtado-Pardo L, Valentí V et al (2020) Minimally Invasive Surgical Approach for the Treatment of Superior Mesenteric Artery Syndrome: Long-Term Outcomes. World J Surg 44:1798–1806. 10.1007/s00268-020-05413-5 Kirby GC, Faulconer ER, Robinson SJ, Perry A et al (2017) Superior mesenteric artery syndrome: a single centre experience of laparoscopic duodenojejunostomy as the operation of choice. Ann R Coll Surg Engl 99:472–475. 10.1308/rcsann.2017.0063 Cullis PS, Gallagher M, Sabharwal AJ et al (2016) Minimally invasive surgery for superior mesenteric artery syndrome: a case report and literature review. Scott Med J 61:42–47. 10.1177/0036933015615261 Barkhatov L, Tyukina N, Fretland ÅA Superior mesenteric artery syndrome: quality of life after laparoscopic duodenojejunostomy. Clin Case Rep. ;6:323 – 29. doi: 10.1002/ccr3.1242. Zemel BS, Pipan M, Stallings VA, Hall W, Schadt K et al (2017) Growth Charts for Children With Down Syndrome in the United States. Peds.2015;136:1204-11. 10.1542/peds.2015-1652 (2022) CDC growth charts, https://www.cdc.gov/growthcharts/percentile_data_files.html Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4903565","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":344306632,"identity":"8e288ab5-9744-447f-8852-8d733ed98b32","order_by":0,"name":"Joel Cazares","email":"","orcid":"","institution":"Hospital Regional de Alta Especialidad Materno Infantil","correspondingAuthor":false,"prefix":"","firstName":"Joel","middleName":"","lastName":"Cazares","suffix":""},{"id":344306633,"identity":"c5d3f762-7554-4b4c-9f9d-5f2d188e615e","order_by":1,"name":"Eduardo de la Rosa-Bustamante","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYFCC5AZmhgoJORDzwAPitCQCtZyxMAZrSSBaC2NbRWIDiE2UFn72xLbPhW0S6fPDDj8E2mInp9tAQItkz8Pm2TPOSeRuvJ1mANSSbGx2gIAWgxuJzcw8ZUAtsxNAWg4kbiOkxR6shU0i3XB2+gfitBhIgLS0SSTIS+cQaYvEmYfNzDPOSBhukM4pOJBgQIRf+NuTDzMXVNTJy89O3/zhQ4WdHEEtCBeCVRoQqxwE5BtIUT0KRsEoGAUjCgAAXzhFzeddUEgAAAAASUVORK5CYII=","orcid":"","institution":"University of Monterrey","correspondingAuthor":true,"prefix":"","firstName":"Eduardo","middleName":"de la","lastName":"Rosa-Bustamante","suffix":""},{"id":344306634,"identity":"40214c51-a617-401a-94a9-3fc156758fbc","order_by":2,"name":"Jorge Colin-Garnica","email":"","orcid":"","institution":"University of Monterrey","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Colin-Garnica","suffix":""},{"id":344306635,"identity":"2d3270a4-8f47-4e74-9efc-dad0881c2534","order_by":3,"name":"Arturo Guillen-Cardenas","email":"","orcid":"","institution":"University of Monterrey","correspondingAuthor":false,"prefix":"","firstName":"Arturo","middleName":"","lastName":"Guillen-Cardenas","suffix":""},{"id":344306636,"identity":"791bbfa7-e848-4e81-8664-c9075a94a3f7","order_by":4,"name":"Jorge Cantu-Reyes","email":"","orcid":"","institution":"Hospital Regional de Alta Especialidad Materno Infantil","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Cantu-Reyes","suffix":""}],"badges":[],"createdAt":"2024-08-13 02:42:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4903565/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4903565/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64167984,"identity":"39ff0d2f-f421-4307-a27b-322e9fdcb799","added_by":"auto","created_at":"2024-09-09 09:55:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11710588,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Upper gastrointestinal series showing a vertical linear band-like defect across the third portion of the duodenum. (B) CT angiography demonstrating a decrease in the angle between the SMA and the abdominal aorta. (C) Laparoscopic duodenojejunostomy. (D) Laparoscopic gastrojejunostomy.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4903565/v1/3af205660a1b328e9073c521.png"},{"id":64168790,"identity":"66d2ad91-48b9-4a4a-b24c-9ee4278f105a","added_by":"auto","created_at":"2024-09-09 10:11:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11226699,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4903565/v1/5a3e0121-5360-497f-9ae4-01f83e86bd50.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally invasive surgical management of superior mesenteric artery syndrome (SMAS) in children","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuperior mesenteric artery syndrome (SMAS) is a rare condition that results from narrowing of the aortomesenteric angle and a reduced distance between the aorta and superior mesenteric artery (SMA), leading to mechanical obstruction of the third portion of the duodenum by mesenteric vessels [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This can result from various underlying causes, including weight loss, alterations in spine anatomy and other anatomical factors, such as high insertion of the Treitz ligament, peritoneal adhesions and different types of SMAs, which are more commonly associated with type I SMA, which is defined as the presence of all SMA branches [2,3].\u003c/p\u003e \u003cp\u003eThis syndrome has an exceptionally low prevalence (0.13\u0026ndash;0.3%), making it a challenging condition to diagnose and treat. It tends to be more prevalent among young adults and teenagers, with a higher proportion in females; however, it can still occur in pediatric patients, with only a few case reports published in newborn patients. Notably, there is no established genetic predisposition associated with the syndrome, despite a familiar occurrence reported by Ortiz et al. in 1990, involving five cases within an eight-member family [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe clinical presentation of this syndrome is characterized by several main symptoms, including recurrent postprandial discomfort (66.7%), abdominal pain (61.1%), early satiety (50%), anorexia (44.4%), nausea (33.3%), and vomiting (33.3%). These symptoms are often associated with gastric and duodenal ulcers, as well as gastroesophageal reflux disease. SMAS is associated with comorbid conditions such as weight loss (50%), gastritis or reflux (16.7%). SMAS can often be misdiagnosed as a psychiatric disorder such as anorexia nervosa or bulimia (5.6%) in young female patients because of the similarity of symptoms. It is also more common in patients with spine alterations or neurological disorders [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Diagnosing SMAS can be challenging because of its nonspecific symptoms and rarity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, a comprehensive clinical assessment with a high suspect index is needed. Imaging studies such as computed tomography (CT) or upper gastrointestinal series (UGIs) and consideration of the patient's medical history can aid in making the diagnosis. An aortomesenteric angle less than 22\u0026deg; and an aortomesenteric distance less than 8 mm have been proposed as diagnostic criteria for SMAS, but it is important to note that the severity of symptoms does not always correlate and that it is important to have both image criteria and a clinical correlation for an accurate diagnosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The management of SMAS in children involves a multidisciplinary approach, with initial conservative measures such as nutritional support, body positioning, placement of a nasojejunal tube or parenteral nutrition. If conservative measures are ineffective, surgical intervention may be necessary, with six weeks as the maximum duration for conservative management before surgery is considered [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMinimally invasive surgical techniques have emerged as promising approaches for the management of SMAS in children. Laparoscopic duodenojejunostomy is one such procedure that aims to create a bypass for the duodenum, relieving the obstruction without the need for extensive abdominal incisions. This approach not only reduces surgical trauma and recovery time but also offers favorable long-term outcomes and has better outcomes than other procedures like Strong procedure [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur objective in this study is to publish the first case series of four patients in North Mexico with SMAS that failed conservative management via minimally invasive techniques with laparoscopic duodenojejunostomy and gastrojejunostomy for patients in which duodenojejunostomy could not be performed and to report the short- and midterm outcomes of these interventions in our population, highlighting the effectiveness and outcomes of laparoscopic duodenojejunostomy and gastrojejunostomy in patients with SMAS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePatient selection\u003c/p\u003e \u003cp\u003eFour pediatric patients who underwent surgery at our institution between 2017 and 2023 were diagnosed with SMAS, and the data extracted included patient characteristics, symptoms and comorbidities, diagnostic methods, UGI, endoscopy, abdominal CT, conservative management, surgical technique details, postoperative outcomes, and length of hospital stay \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients characteristics and demographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12.5\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI median, IQR *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12.77\u0026ndash;13.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI SD median, IQR *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.7 (-3.99 \u0026mdash; -3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalnutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference between preoperative body weight and ideal body weight (p50) median, IQR *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2 (13.77\u0026ndash;16.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortomesenteric distance (milimeters) median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4 (4.6\u0026ndash;6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortomesenteric angle (degree) median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.1 (10.74\u0026ndash;13.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms (months) median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (10\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePatients characteristics before surgery\u003c/p\u003e \u003cp\u003eBMI: Body mass index\u003c/p\u003e \u003cp\u003eSD: Standard deviation\u003c/p\u003e \u003cp\u003eIQR: Interquartile range\u003c/p\u003e \u003cp\u003e*Based on growth charts for children with Down syndrome in the United States and 2022 CDC growth charts [20\u0026ndash;21].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe first three patients were female patients, all of whom were 13 years old and were diagnosed with SMAS in a tertiary care hospital in Mexico after a 10\u0026ndash;12-month period with similar clinical presentations and unsuccessful attempts at conservative management. All of them were treated by psychiatrists and psychologists for the diagnosis of eating disorders without success. These patients presented with abdominal pain, postprandial vomiting, and significant weight loss with moderate to severe malnutrition. They were referred by gastroenterology for surgical evaluation after failing conservative management, which consisted of gastric decompression, nutritional support with small portions, a failed attempt to place a nasojejunal tube and parenteral nutrition for weeks without any significant improvement in symptoms or weight gain, whereas the fourth patient was an 11-year-old male with Down syndrome, a history of duodenal surgery at birth, a clinical course of twelve months of evolution with postprandial vomiting, abdominal discomfort and weight loss despite conservative management, including gastric decompression and nutritional support for six weeks, who was also treated with minimally invasive techniques. In this case, we chose a gastrojejunostomy because duodenojejunostomy was not possible due to previous duodenal surgery in the neonatal period \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation and medical history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostprandial abdominal discomfort (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight loss (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up by psychiatrist (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEating disorders (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up by gastroenterologist (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnular pancreas (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnsuccessful medical treatment (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnsuccessful nasojejunal feeding (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePatients clinical presentation and comorbidities before surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDiagnostic criteria\u003c/p\u003e \u003cp\u003eDiagnostic tests included abdominal X-ray demonstrating gastric distension, UGI revealing duodenal contrast retention, endoscopy indicating difficulty in advancing into the third portion of the duodenum and abdominal CT with evidence of a narrowed angle between the superior mesenteric artery and the aorta, with an aortomesenteric angle less than 22\u0026deg; and an aortomesenteric distance less than 8 mm, as well as symptoms consistent with SMAS. The parents of the four patients signed informed consent forms. Patients undergo minimally invasive techniques, including laparoscopic duodenojejunostomy and gastrojejunostomy \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(A) Upper gastrointestinal series showing a vertical linear band-like defect across the third portion of the duodenum. (B) CT angiography demonstrating a decrease in the angle between the SMA and the abdominal aorta. (C) Laparoscopic duodenojejunostomy. (D) Laparoscopic gastrojejunostomy.\u003c/p\u003e \u003cp\u003eDuodenojejunostomy operative technique\u003c/p\u003e \u003cp\u003eThe patient is placed in the supine position under general anesthesia in the French position. An 11 mm trocar is placed in the umbilicus, and two additional 5 mm trocars are placed in the right and left quadrants of the abdomen. A 10 mm laparoscopic camera is inserted through the umbilical trocar, allowing visualization of the abdominal cavity. The transverse colon is mobilized to expose the third portion of the duodenum and the proximal jejunum. The dilated portion of the duodenum is identified next to the SMA, and a window is made in the peritoneum, exposing the duodenum and dissecting it free circumferentially from surrounding tissues to permit further exposure and mobilization. The Treitz angle is identified, and the proximal jejunum is brought up from a distance of usually 15\u0026ndash;20 cm from the liberated portion of the duodenum. A side-to-side duodenojejunostomy is performed by creating an anastomosis between the duodenum and the jejunum using reference silk 2\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures. Then, an enterotomy is performed with a harmonic scalpel. A 5-mm camera is inserted, allowing a stapler to enter the 11-mm port, and the anastomosis is created via a 45 mm linear stapler. The enterotomy is then closed with a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc\u0026trade; (Medtronic, Minneapolis, MN, USA) barbed suture. Lembert sutures are placed between the proximal jejunum and transverse colon with silk 2\u0026thinsp;\u0026minus;\u0026thinsp;0 to prevent blind loop syndrome, and finally, a Jackson-Pratt\u0026trade; (Cardinal Health, Dublin, OH, USA) drain is placed at the surgical site to facilitate drainage and monitoring [1,5,11,13,15,17\u0026ndash;20].\u003c/p\u003e \u003cp\u003eOperative technique for gastrojejunostomy\u003c/p\u003e \u003cp\u003eIn this technique, we use the same port placements and patient position as described in the previous operative procedure. The transverse colon is mobilized downward to expose the greater curvature of the stomach and the mesocolon. A window is created with a harmonic scalpel to identify the posterior portion of the stomach where gastrojejunostomy will be performed. The proximal jejunum is brought approximately 15\u0026ndash;20 cm from the Treitz angle to the posterior wall of the stomach, where a side-to-side gastrojejunal anastomosis is created via reference silk 2\u0026ndash;0 sutures and a 45 mm linear stapler, and the enterotomy is closed with V-loc\u0026trade; barbed suture. If the mesocolon window is too large, it is closed with a silk 2\u0026ndash;0 suture to prevent internal hernias. A Jackson-Pratt\u0026trade; drain is placed at the surgical site for monitoring and drainage.\u003c/p\u003e \u003cp\u003ePostoperative care\u003c/p\u003e \u003cp\u003ePatients initiated early ambulation, commencing as early as the day following surgery, followed by a clear liquid diet on the third postoperative day and gradually progressing to a bland diet before advancing to a normal diet as tolerated. The drain was also removed during this time and sent home afterwards. Nutritional counseling and support were provided to ensure that they had adequate caloric intake and optimal nutrition to aid in their recovery. For patients treated with gastrojejunostomy, proton pump inhibitors and prokinetic medications were prescribed to prevent gastric reflux and ulcers and promote gastric emptying.\u003c/p\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003cp\u003eDuring the initial phase, considerable progress in the patient's health occurred, leading to a decrease in postmeal vomiting and stomach discomfort. The patients showed an increase in weight during the first few weeks after the operation. Continued monitoring for six months revealed continued improvement in nutritional well-being and overall physical condition, with no recurrence of symptoms associated with SMAS. The patient who underwent gastrojejunostomy was followed up monthly by gastroenterology until six months after surgery and every six months thereafter to prevent further complications secondary to the procedure.\u003c/p\u003e \u003cp\u003e This study was approved by the hospital bioethics committee. All information and calculations of medians and interquartile ranges were performed with Microsoft Office Excel 365.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatients with SMAS nonresponsive to treatment underwent surgical intervention with either duodenojejunostomy or gastrojejunostomy from 2017\u0026ndash;2023. Three patients were female (75%; n\u0026thinsp;=\u0026thinsp;3), and one patient was male (25%; n\u0026thinsp;=\u0026thinsp;1). All our patients were Hispanic (100%, n\u0026thinsp;=\u0026thinsp;4) and ranged in age from 11\u0026ndash;13 years; the median age at surgery was 10.5 years. All our patients were underweight, with mild (SD \u0026lt;-1) to severe malnutrition (SD \u0026lt;-3).. The median BMI was 16.7 kg/m2. The median difference between the preoperative weight and ideal body weight was 5 kg. The median aortomesenteric distance and angle were 5.4 mm and 12.1\u0026deg;, respectively.\u003c/p\u003e \u003cp\u003eThe median duration of symptoms before laparoscopic treatment was 12 months. All our patients (100%, n\u0026thinsp;=\u0026thinsp;4) experienced postprandial abdominal discomfort, vomiting, and significant weight loss, leading to malnutrition, which was treated by gastroenterology (100%, n\u0026thinsp;=\u0026thinsp;4). Three of them had a diagnosis of depression, anxiety and eating disorders treated by psychiatry and psychology (75%, n\u0026thinsp;=\u0026thinsp;3), and 1 had a history of Down syndrome and annular pancreas at birth (25%, n\u0026thinsp;=\u0026thinsp;1). All of them underwent X-ray, UGI, and CT scans and upper gastrointestinal endoscopy for diagnosis. All of them were treated for 6 weeks with medical treatment without success (100%, n\u0026thinsp;=\u0026thinsp;4), and 3 of them had a failed intent to place a nasojejunal tube for feeding during the endoscopy procedure (75%, n\u0026thinsp;=\u0026thinsp;3).\u003c/p\u003e \u003cp\u003eThree of our patients underwent duodenojejunostomy (75%, n\u0026thinsp;=\u0026thinsp;3), one patient underwent gastrojejunostomy (25%, n\u0026thinsp;=\u0026thinsp;1), and one had a history of duodenum surgical intervention (25%, n\u0026thinsp;=\u0026thinsp;1). The median duration of the procedures was 117.5 min, and the median duration of hospitalization was 7 days. The median duration for starting the diet was 3 days. All of the patients were fed a liquid diet after performing an UGI with normal pass of the contrast material, the median duration for tolerating a normal diet was 14 days. The median weight gain from surgery to the 6-month follow-up was 10.45 kg, with a median BMI of 17.85 kg/m2 (SD -0.575). The median difference between weight at follow-up and ideal weight (p50) was 6.9 kg. All our patients experienced improvement in symptoms at the 6-month follow-up. One patient (25%, n\u0026thinsp;=\u0026thinsp;1) was treated with proton pump inhibitors and prokinetics followed by gastroenterology after gastrojejunostomy. Our patients did not require further hospitalization or had any major complications related to the surgery \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgery characteristics and Follow-up\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic duodenojejunostomy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic gastrojejunostomy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of duodenal intervention (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery duration (minutes) median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117.5 (107-129.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays to starting liquid diet after surgery median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3-3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays to resumption of normal diet median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (14-14.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight gain from surgery to 6 months follow up, median, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.45 (9.4\u0026ndash;11.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI at 6 month follow up*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.85 (16.95-18.975)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI at 6 month follow up DE median, IQR*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.575 (-0.96 \u0026mdash; -0.175)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight difference between 6 months follow up and ideal weight\u003csup\u003e1\u003c/sup\u003e Median, IQR*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.9 (5.2\u0026ndash;8.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment with PPI and prokinetics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgery characteristics and follow-up\u003c/p\u003e \u003cp\u003eIQR: Interquartile range\u003c/p\u003e \u003cp\u003eBMI: Body mass index\u003c/p\u003e \u003cp\u003eSD: Standard Deviation\u003c/p\u003e \u003cp\u003ePPI: Proton pump inhibitors\u003c/p\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e: Percentile 50 for age\u003c/p\u003e \u003cp\u003e*Based on growth charts for children with Down syndrome in the United States and 2022 CDC growth charts [20\u0026ndash;21].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFour cases of SMAS in Northeast Mexico were successfully treated via minimally invasive techniques with positive results. Our patients had a typical clinical course consistent with SMAS symptoms; three of them were diagnosed with eating disorders, a differential diagnosis that can also be a comorbidity in this entity. The last patient had a medical history of annular pancreas and Down syndrome, which could be related to this condition through factors such as malnutrition or anatomical alterations, and further research is needed. The median age at diagnosis was 13 years, and three of them were female, which is consistent with previous findings that SMAS commonly occurs in young female patients, with a median age of onset around adolescence. The aortomesenteric distance and angle were measured, confirming the diagnosis of SMAS in our patients, with medians of 5.4 mm and 12.1 degrees, respectively [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. All our patients received medical treatment for 6 weeks, which seems to be the safe limit of time before considering surgical intervention reported in the literature in children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe median duration of the surgical procedures in our study was 117.5 minutes, which is comparable to that reported in previous studies. The median duration of hospitalization in our study was 7 days, which aligns with previous studies that reported a range of 4\u0026ndash;9 days for hospital stay after SMAS treatment. The median time for starting a liquid diet after surgery was 3 days, which is in line with other studies. The median time for starting a normal diet after surgery in our study was 14 days, which is longer than that reported in some previous studies [13,20].\u003c/p\u003e \u003cp\u003eOur study revealed a significant improvement in weight gain and BMI percentiles at the 6-month follow-up, parameters that have been used to assess response to medical treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Compared with other reports, the gastrojejunostomy was associated with a satisfactory reaction to the preventive therapy prescribed to avoid inherent complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe successful management of these cases via minimally invasive techniques highlights the potential of laparoscopic duodenojejunostomy and gastrojejunostomy as effective interventions for pediatric patients with SMAS whose conservative management has failed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This collection of cases adds to the increasing evidence that favors the application of minimally invasive surgical techniques for addressing this condition in our population. This study also highlights the importance of early detection and prompt intervention in preventing complications linked to SMAS. All our patients could have avoided malnutrition with an early diagnosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eManaging SMAS in children in northern Mexico presents unique challenges due to limited access to specialized healthcare services and delays in diagnosis. However, with the adoption of minimally invasive surgical techniques, there is potential to improve outcomes for pediatric patients with SMAS in this region. As described by Barkhatov et al., laparoscopic duodenojejunostomy is linked to quicker postoperative recovery and leads to an enhancement in patients\u0026rsquo; overall quality of life [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Further studies and collaborative efforts are needed to establish standardized protocols, increase the availability of advanced surgical interventions, and facilitate early diagnosis of SMAS in children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSuperior mesenteric artery syndrome (SMAS)\u003c/p\u003e\n\u003cp\u003eSuperior mesenteric artery (SMA)\u003c/p\u003e\n\u003cp\u003eComputed tomography (CT)\u003c/p\u003e\n\u003cp\u003eUpper gastrointestinal series (UGI)\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors would like to express their gratitude to Jose Mendoza-Siqueiros, Bachelor of Science and Engineering, for his assistance in statistical analysis alongside our team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding or support granted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethics committee of the Hospital Regional de Alta Especialidad Materno Infantil approved this study. Informed consent to publish the case report was not obtained. This research does not contain any personal information that could lead to the identification of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors attest that they meet the current ICMJE criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWilkie DPD. Chronic duodenal ileus. BJS.1921;34,204\u0026thinsp;\u0026ndash;\u0026thinsp;14., Balcerzak A, Tubbs RS, Waśniewska-Włodarczyk et al (2022) Classification of the superior mesenteric artery. 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Peds.2015;136:1204-11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2015-1652\u003c/span\u003e\u003cspan address=\"10.1542/peds.2015-1652\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(2022) CDC growth charts,\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/growthcharts/percentile_data_files.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/growthcharts/percentile_data_files.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Superior mesenteric artery syndrome, Wilkie syndrome, laparoscopic duodenojejunostomy, laparoscopic gastrojejunostomy, pediatric surgery, minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-4903565/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4903565/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSuperior mesenteric artery syndrome (SMAS) is a rare but potentially life-threatening disorder. It has a low incidence, and its clinical presentation can often mimic other disorders, making its diagnosis challenging.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFour patients treated from 2017\u0026ndash;2023 presented with chronic abdominal pain, nausea, vomiting and severe weight loss, leading to malnutrition. Psychological evaluations were conducted to comprehensively assess their condition. Diagnostic tests included abdominal X-rays demonstrating gastric distension, upper gastrointestinal series revealing duodenal contrast retention, endoscopy indicating difficulty in advancing into the third portion of the duodenum and CT angiography demonstrating a decrease in the angle between the SMA and the abdominal aorta. Referral to pediatric surgery was necessary after conservative management yielded no improvement.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn three patients, laparoscopic duodenojejunostomy was performed, whereas one patient underwent laparoscopic gastrojejunostomy. All patients were discharged with satisfactory recovery and no complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study highlights the effectiveness and safety of laparoscopic surgical techniques in managing pediatric SMAS patients who are unresponsive to conservative measures. Laparoscopic duodenojejunostomy and gastrojejunostomy have demonstrated favorable outcomes in this context. Further research and data collection are warranted to continue evaluating the long-term success of these techniques in managing SMAS.\u003c/p\u003e\u003ch2\u003eLevel of evidence\u003c/h2\u003e \u003cp\u003eIV, case series with no comparison group.\u003c/p\u003e","manuscriptTitle":"Minimally invasive surgical management of superior mesenteric artery syndrome (SMAS) in children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-09 09:55:23","doi":"10.21203/rs.3.rs-4903565/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c7821b6-7dc3-48ed-b3c4-e6a2be90dd7d","owner":[],"postedDate":"September 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T09:55:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-09 09:55:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4903565","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4903565","identity":"rs-4903565","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}