The Management of SMA Syndrome

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Presentation transcript:

The Management of SMA Syndrome Dr Chun-fai LAU United Christian Hospital Joint Hospital Surgical Grand Round 11 Feb 2012

Case presentation Mr. Leung M/63 Diagnosed to have localized CA sigmoid colon in Oct 2011 PMH Old CVA Ankylosing spondylitis

Case presentation Lap converted open sigmoidectomy on 13 Oct 2011 Post-op required ICU care with ventilatory support for aspiration pneumonia Unable to tolerate oral feeding with repeated vomiting

Case presentation Postop CT image Dilatation of duodenum down to D3

Case presentation Postop CT image

Case presentation Suggestive of SMA syndrome Decreased aortomesenteric distance 5.5mm Dilated duodenum down to D3 Suggestive of SMA syndrome

Case presentation Endoscopic and fluoroscopic guided feeding tube insertion on 8 Nov 2011 ( 3 week postop ) Failed conservative management Laparotomy with division of ligament of Treitz on 13 Dec 2011 ( 8 weeks postop ) Post-op Water soluble contrast study confirmed passage of contrast from duodenum to distal small bowel

Superior Mesenteric Artery (SMA) Syndrome

SMA Syndrome Duodenal obstruction due to compression of D3 between the aorta and the SMA Prevalence ~0.013-0.3% Female > Male Mostly 10-39 years old Other names: Aortomesenteric duodenal compression Duodenal vascular compression Wilkie’s syndrome Cast syndrome

History 1842: 1st described by the Austrian professor Carl von Rokitansky 1908: 1st operative treatment by Stavely (DJ) 1927: Wilkie published the largest SMA syndrome study based on 75 cases. He concluded that DJ was the treatment of choice 1995: 1st laparoscopic treatment performed by Massoud, by dividing the ligament of Treitz 1998: 1st laparoscopic DJ performed by Gersin and Heniford

Anatomy Aorta Ligament of Treitz SMA D3

Anatomy normal = 38-65º Normal = 10-28mm The SMA originates behind the neck of the pancreas at the level of L1 and leaves the aorta at an acute angle The left renal vein crossing the vertebral column, the uncinate process of the pancreas and lymphatics are embedded in retroperitoneal fat tissue sustaining the physiologic aortomesenteric angle normal = 38-65º Normal = 10-28mm

Predisposing factors 1. Rapid weight loss 2. Following surgery 3. Rarely anatomical variants -High ligament of Treitz -Low origin of the SMA 4. Compression from an AAA or SMA aneurysm

Predisposing factor: Rapid weight loss Reduction of the mesenteric fat around the SMA Causes: AIDS, malabsorption, cancer, cerebral palsy, and other conditions associated with cachexia Catabolic conditions e.g. burns Eating disorders e.g. anorexia nervosa and drug abuse Aorta

Predisposing factor: Following surgery Spine surgery Scoliosis correction, due to a relative lengthening of the spine post-op (prevalence 0.5-2.4%) Ileal pouch-anal anastomosis (IPAA) Stretch the SMA over duodenum as the ileal pouch reaches pelvis Surgery associated with rapid weight loss Bariatric surgery, esophagectomy, abdominal trauma

Predisposing factors: Anatomical variants Anatomic variants high ligament of Treitz low origin of the SMA

Symptoms VICIOUS CYCLE Nausea and vomiting Intermittent or post-prandial epigastric pain relieved by a prone or knee-chest (open up the aortomesenteric angle) Esophageal reflux Anorexia Weight loss VICIOUS CYCLE

Diagnosis High index of suspicion Symptoms Radiological evidence of D3 compression by SMA Aorto-mesenteric angle <22º (normal 38-65º) Aorto-mesenteric distance <8mm (normal 10-28mm) Proximal duodenal dilation with cut-off at D3

Radiological investigations Contrast X-ray studies Barium studies CT abdomen (with oral contrast) CT angiogram

Treatment Conservative management Surgical management In the absence of displacement by an abdominal mass, an aneurysm or another pathologic condition that requires immediate surgical exploration Surgical management If conservative management fails

Conservative Treatment Nil by mouth NG tube decompression Replacement of fluids and electrolytes Nutritional support with nasojejunal feeds when possible or TPN in selected patients Positioning the patient in a knee-to-chest position or prone after eating to improve symptoms

Surgical Treatment Strong’s procedure Bypass operation Mobilize the DJ flexure and divide the ligament of Treitz Move D3 away from the narrow aorto-mesenteric angle Advantage: No bowel anastomosis Maintains bowel integrity Earlier post-op recovery Bypass operation Gastrojejunostomy Duodenojejunostomy

Which is better ?

Strong’s procedure Study yr N Successful operation % success Welsch T 2007 1 100 Massoud WZ 1995 4* 3 75 Ferrer V Smith JS Jr 1994 total 7 5 71 * laparoscopic Welsch T. Recalling superior mesenteric artery syndrome. Digestive Surgery. 2007;24(3):149-56 Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. International Surgery. 1995;80(4):322-7 Ferrer V. The diagnosis of aorticomesenteric duodenal compression by magnetic resonance angiography. Revista Espanola de Enfermedades Digestivas. 1995;87(5):389-92 Smith JS Jr. Superior mesenteric artery syndrome in a tube-fed patient. Nutrition in Clinical Practice. 1994;9(4):151-3

Gastrojejunostomy Study yr N Successful operation % success Clapp B 2010 3* Yang WL 2008 1 Pan CH 2007 100 Tatar G 1996 Octavio de Toledo JM 1993 Total 7 3 43 * Laparoscopic Roux-en-Y GJ Clapp B. Superior mesenteric artery syndrome after Roux-en-Y gastric bypass. Journal of the Society of Laparoendoscopic Surgeons. 2010;14(1):143-6 Yang WL. Assessment of duodenal circular drainage in treatment of superior mesenteric artery syndrome. World Journal of Gastroenterology. 2008;14(2):303-6 Pan CH. Superior mesenteric artery syndrome complicating staged corrective surgery for scoliosis. Journal of the Formosan Medical Association. 2007;106(2 Supp):S37-45 Tatar G. Superior mesenteric artery syndrome. A case report. Turkish Journal of Pediatrics. 1996;38(3):367-70 Octavio de Toledo JM. Vascular compression of the duodenum related to a plaster cast (the cast syndrome). Revista Espanola de Enfermedades Digestivas. 1993;83(1):38-41

Duodenojejunostomy

Duodenojejunostomy – Reference (1) Magee G. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Digestive Diseases & Sciences. 2011;56(9):2528-31 Kurbegov A. Superior mesenteric artery syndrome in a 16-year-old with bilious emesis. Current Opinion in Pediatrics. 2010;22(5):664-7 Shiu JR. Clinical and nutritional outcomes in children with idiopathic superior mesenteric artery syndrome. Journal of Pediatric Gastroenterology & Nutrition. 2010;51(2):177-82 Le Moigne F. Superior mesenteric artery syndrome: a rare etiology of upper intestinal obstruction in adults. Gastroenterologie Clinique et Biologique. 2010;34(6-7):403-6 Munene G. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. American Surgeon. 2010;76(3):321-4 Wyten R. Laparoscopic duodenojejunostomy for the treatment of superior mesenteric artery (SMA) syndrome: case series. Journal of Laparoscopic & Advanced Surgical Techniques. Part A. 2010;20(2):173-6

Duodenojejunostomy – Reference (2) Singaporewalla RM. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2009;13(3):450-4 Fraser JD. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2009;13(2):254-9 Merrett ND. Superior mesenteric artery syndrome: diagnosis and treatment strategies. Journal of Gastrointestinal Surgery. 2009;13(2):287-92 Bognar G. Wilkie’s syndrome. Magyar Sebeszet. 2008;61(5):273-7 Shukla RC. Superior mesenteric artery syndrome: case report. Nepal Medical College Journal: NMCJ. 2008;10(2):144-5 Jo JB. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome: report of a case. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2008;18(2):213-5

Duodenojejunostomy – Reference (3) Yang WL. Assessment of duodenal circular drainage in treatment of superior mesenteric artery syndrome. World Journal of Gastroenterology. 2008;14(2):303-6 Okugawa Y. Superior mesenteric artery syndrome in an infant: case report and literature review. Journal of Pediatric Surgery. 2007;42(10):E5-8 Neto NI. Superior mesenteric artery syndrome after laparoscopic sleeve gastrectomy. Obesity Surgery. 2007;17(6):825-7 Palanivelu C. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2006;10(4):531-4 Naiz Z. Superior mesenteric artery syndrome: an uncommon cause of upper intestinal obstruction. Journal of the College of Physicians & Surgeons – Pakistan. 2006;16(10):666-8 Agarwalla R. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 2006;16(4):372-3

Duodenojejunostomy – Reference (4) Kadji M. Superior mesenteric artery syndrome: a case report. Annales de Chirurgie. 2006;131(6-7):389-92 Sozubir S. Incomplete duodenal obstruction in a newborn. Indian Journal of Pediatrics. 2006;73(4):364-6 Li AC. The superior mesenteric artery syndrome: an unusual cause of vomiting. Hepato-Gastroenterology. 2005;52(62):469-70 Kingham TP. Laparoscopic treatment of superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2004;8(4):376-9 Ocal K. A case of superior mesenteric artery syndrome following head trauma. Ulusal Travma ve Acil Cerrahi Dergisi. 2004; 10(4):264-7 Goitein D. Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obesity Surgery. 2004;14(7):1008-11

Duodenojejunostomy – Reference (5) Bermas H. Laparoscopic management of superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2003;7(2):151-3 Kim IY. Laparoscopic duodenojejunostomy for management of superior mesenteric artery syndrome: two cases report and a review of the literature. Yonsei Medical Journal. 2003;44(3):526-9 Nana AM. Wilkie’s syndrome. Surgical Endoscopy. 2003;17(4):659 Gersin KS. Laparoscopic duodenojejunostomy for treatment of superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 1998;2(3):281-4 Raissi B. Recurrent superior mesenteric artery (Wilkie’s) syndrome: a case report. Canadian Journal of Surgery. 1996;39(5):410-6

Which is better? Duodenojejunostomy has highest success rate % successful Strong 71 Gastrojejunostomy 43 Duodenojejunostomy 86 Duodenojejunostomy has highest success rate

Duodenojejunostomy Lee et al concluded that duodenojejunostomy was the best procedure for severe cases after reviewing 146 cases from the literature Lee CS, Mangla JC. Superior mesenteric artery compression syndrome. Am J Gastroenterol 1978;70:141-50

Bring Home message SMA syndrome is a rare condition Diagnosis requires a high index of suspicion No large scale study comparing the treatment modalities Duodenojejunostomy appears to be superior to gastrojejunostomy or Strong’s operation

Thank you

Strong’s procedure - Reference Welsch T. Recalling superior mesenteric artery syndrome. Digestive Surgery. 2007;24(3):149-56 Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. International Surgery. 1995;80(4):322-7 Ferrer V. The diagnosis of aorticomesenteric duodenal compression by magnetic resonance angiography. Revista Espanola de Enfermedades Digestivas. 1995;87(5):389-92 Smith JS Jr. Superior mesenteric artery syndrome in a tube-fed patient. Nutrition in Clinical Practice. 1994;9(4):151-3

Gastrojejunostomy - Reference Clapp B. Superior mesenteric artery syndrome after Roux-en-Y gastric bypass. Journal of the Society of Laparoendoscopic Surgeons. 2010;14(1):143-6 Yang WL. Assessment of duodenal circular drainage in treatment of superior mesenteric artery syndrome. World Journal of Gastroenterology. 2008;14(2):303-6 Pan CH. Superior mesenteric artery syndrome complicating staged corrective surgery for scoliosis. Journal of the Formosan Medical Association. 2007;106(2 Supp):S37-45 Tatar G. Superior mesenteric artery syndrome. A case report. Turkish Journal of Pediatrics. 1996;38(3):367-70 Octavio de Toledo JM. Vascular compression of the duodenum related to a plaster cast (the cast syndrome). Revista Espanola de Enfermedades Digestivas. 1993;83(1):38-41

End of Reference