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

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

3. 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

4. Case presentation
Postop CT image
Dilatation of duodenum down to D3

5. Case presentation
Postop CT image

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

7. 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

8. Superior Mesenteric Artery (SMA) Syndrome

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

10. 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

11. Anatomy
Aorta
Ligament of Treitz
SMA D3

12. 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

13. 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

14. 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

15. Predisposing factor: Following surgery
Spine surgery
Scoliosis correction, due to a relative lengthening of the spine post-op (prevalence %)
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

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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. Which is better ?

24. 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

25. 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

26. Duodenojejunostomy

27. Duodenojejunostomy – Reference (1)
Magee G. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Digestive Diseases & Sciences. 2011;56(9):
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

28. 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

29. 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

30. 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):

31. 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

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

33. 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

34. 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

35. Thank you

37. 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

38. 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

39. End of Reference