Procedure for Duodenal Stricture With Malrotation Masquerading as Superior Mesenteric Artery Syndrome in an Adult Patient

Naoki Takahashi, PhD, Kazuyuki Gyoten, PhD, Kiyoshi Narita, MD, Rie Sato, PhD, Hideo Suzuki, PhD, Hideki Machishi, PhD, Yoshikatsu Okada, PhD

Department of Surgery, Kuwana East Medical Center, Kuwana, Mie, Japan (all authors).

ABSTRACT

Introduction: Duodenal stricture with malrotation is rare in adults. Anatomical anomalies of malrotation include narrowing of the root of the mesentery associated with volvulus and the presence of Ladd’s band, which causes duodenal obstruction. Two case reports of duodenal stricture not associated with Ladd’s band have been published in the English literature.

Case Presentation: A 36-year-old thin man was admitted for vomiting after meals and was diagnosed with superior mesenteric artery (SMA) syndrome by endoscopy and computed tomography.

Management and Outcomes: He received conservative treatment but returned 3 more times with the same symptoms. He underwent laparoscopy during his fifth admission after he was diagnosed with duodenal stricture with malrotation based on preoperative examinations. A membrane-like adhesion affecting the retroperitoneum to the duodenum and several cordlike adhesions wrapping around the right dorsal side of the SMA to the anal side of the duodenum were dissected to divide the adhesions. Ladd’s band was not observed. No recurrence has been observed for 1 year and 7 months.

Discussion: The jejunum was located on the dorsal side of the SMA and the duodenum was pulled by the cordlike adhesions wrapping around the right dorsal side of the SMA, and a concomitant duodenal obstruction was identified; therefore, the jejunum appeared to be compressed between the SMA and the aorta. Consequently, this case masqueraded as SMA syndrome. We successfully performed laparoscopic surgery for an adult patient with malrotation, especially with regard to dissection of the cordlike adhesions originating from the root of the SMA. This minimally invasive procedure is feasible for duodenal strictures with malrotation.

Key Words: Duodenal stricture, Ladd’s band, Malrotation, Superior mesenteric artery syndrome.

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