Can Duodenal Derotation With Duodenoduodenostomy Be Performed Safely Robotically, and Is It the Optimal Surgical Intervention for SMAS?

BackgroundSuperior mesenteric artery syndrome (SMAS) is a rare disorder with 33% mortality. The Cleveland Clinic reported one of the largest series including 18 patients treated with duodenojejunostomy (DDJ), with 33% showing improvement at 3 years. Alvear et al reported 94.7% improvement in 19 patients treated with duodenal derotation, though 7 later required duodenoduodenostomy (DDD). Ang et al reported 12 patients treated with duodenal derotation with DDD, and 84% experienced improvement and increased BMI at 3 years. While duodenal derotation with DDD shows promising results, case series are limited and surgical treatment with a robotic approach has not been described.MethodsThirty three patients who underwent duodenal derotation with DDD for SMAS by a single surgeon between June 2023 and July 2025 were retrospectively identified. Preoperative, intraoperative, and postoperative data were collected.ResultsMean operative time was 346.9 min. Average length of stay was 8.7 days. Nineteen patients underwent concurrent surgery for Median Arcuate Ligament Syndrome (MALS). There was one conversion to open surgery. There were no intraoperative complications and no mortalities. There were 6 postoperative complications. Follow-up ranged from 3.9 weeks to 2 years. One patient was lost to follow-up. Of the remaining patients, 90.6% experienced significant pain relief, 81.3% no longer required supplemental nutrition, and 84.4% experienced significant weight regain.DiscussionDespite the increased risk for postoperative complications due to severe malnutrition and deconditioning in this patient population, duodenal derotation can be performed safely robotically and offers improved results in carefully selected patients when compared to DDJ.