Background Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient’s condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy. Case presentation A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up. Conclusion Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.
Background Because of the coronavirus disease 2019 (COVID-19) pandemic, preoperative screenings for COVID-19 infection are often performed in many institutions. Some patients are diagnosed with COVID-19 infection by antigen tests or polymerase chain reaction (PCR) testing for COVID-19, even if they have no symptoms, such as fever or respiratory symptoms. We herein describe a patient with gastric cancer who underwent distal gastrectomy 6 weeks after recovering from COVID-19 infection diagnosed by preoperative PCR. Case presentation An 86-year-old man was transferred to our hospital because of hematemesis and melena. A hemorrhagic gastric ulcer was found in the lesser curvature of the antrum by emergency endoscopy. Endoscopic hemostasis was performed, and he was discharged after recovery. A tumor-like lesion in the lesser curvature of the antrum was found on repeat endoscopy and was diagnosed as well-differentiated adenocarcinoma by biopsy. There was no evidence of lymph node metastasis or distant metastasis; therefore, we planned radical surgery. However, he was diagnosed with COVID-19 infection by preoperative PCR screening. Although he had no symptoms, such as fever or respiratory symptoms, he was hospitalized because of his advanced age. He was discharged 10 days after admission, and repeat COVID-19 PCR was negative. We planned radical surgery for the stomach tumor 6 weeks after recovery from the COVID-19 infection. A PCR-negative COVID-19 status was confirmed again before hospitalization. Open distal gastrectomy with Billroth I reconstruction was performed. We avoided ultrasonic scalpels and used a Crystal Vision 450D surgical smoke evacuator (I.C. Medical, Inc., Phoenix, AZ, USA) to reduce intraoperative surgical smoke. The postoperative course was uneventful. Conclusion Because of the COVID-19 pandemic, some patients are diagnosed with COVID-19 infection by preoperative antigen tests or PCR, even if they have no symptoms. If possible, elective surgery should be performed 4 to 6 weeks after recovery from COVID-19 infection to maximize safety. Moreover, surgeons must consider intraoperative surgical smoke.
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