PMC9035956_01
CT images of SMA syndrome. a A small red line indicated the aortomesenteric distance. b The aortomesenteric angle was measured as 11  by 3-dimensional reconstructed vascular images (red triangle).
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F1
CT images revealed that the aortomesenteric angle was narrow at 11 , and the distance was 4.5 mm, which is short (Fig. 1a, b).
Preoperative duodenography. Dilatation of the proximal duodenum and stagnation of contrast at the third portion of the duodenum was observed.
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F2
In addition, duodenography also revealed dilatation of the proximal duodenum and stagnation of contrast at the third portion of the duodenum (Fig. 2).
Surgical procedure. a The second portion of the duodenum was mobilized to prepare for the transverse-mesocolon approach. b The gauze was confirmed via retracted transverse mesocolon. c Side-to-side duodenojejunostomy was performed (white arrow). d The entry hole was closed by intracorporeal sutures.
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F3
Therefore, the procedure has been called semi-Kocherization (Fig. 3a). We retracted the transverse mesocolon cephalad and confirmed the presence of the gauze at the lateral side of the duodenum (Fig. 3b). Next, we made entry holes, and side-to-side anastomosis was performed using Endo-GIATM 45 mm camel cartridge (Medtronic plc, Dublin, Ireland) (Fig. 3c). The combined entry hole was closed by Albert-Lembert running sutures using STRATAFIXTM Symmetric PDS plus (Johnson & Johnson, New Brunswick, NJ, USA) (Fig. 3d).
Postoperative scar. Intraumbilical incision was cosmetically good, and the operation scar of neurectomy was also shown.
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F4
Figure 4 shows the postoperative scar.
Postoperative duodenography. An upper gastrointestinal contrast examination showed good patency and passage of duodenojejunostomy.
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F5
The postoperative course was unremarkable, and an upper gastrointestinal contrast examination on postoperative day 2 showed good patency and passage of duodenojejunostomy (Fig. 5).