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

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Presentation on theme: "The Management of SMA Syndrome Dr Chun-fai LAU United Christian Hospital Joint Hospital Surgical Grand Round 11 Feb 2012."— Presentation transcript:

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

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

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

5 Case presentation Postop CT image

6 Case presentation 5.5mm Decreased aortomesenteric distance 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 ) Endoscopic and fluoroscopic guided feeding tube insertion on 8 Nov 2011 ( 3 week postop ) Failed conservative management Failed conservative management Laparotomy with division of ligament of Treitz on 13 Dec 2011 ( 8 weeks postop ) 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 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 Duodenal obstruction due to compression of D3 between the aorta and the SMA Prevalence ~ % Prevalence ~ % Female > Male Female > Male Mostly years old Mostly years old Other names: Other names: Aortomesenteric duodenal compressionAortomesenteric duodenal compression Duodenal vascular compressionDuodenal vascular compression Wilkie ’ s syndromeWilkie ’ s syndrome Cast syndromeCast syndrome

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

11 Anatomy Aorta SMA D3 Ligament of Treitz

12 Anatomy normal = º 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 SMAReduction of the mesenteric fat around the SMA Causes:Causes: AIDS, malabsorption, cancer, cerebral palsy, and other conditions associated with cachexia AIDS, malabsorption, cancer, cerebral palsy, and other conditions associated with cachexia Catabolic conditions e.g. burns Catabolic conditions e.g. burns Eating disorders e.g. anorexia nervosa and drug abuse Eating disorders e.g. anorexia nervosa and drug abuse Aorta

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

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

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

18 Diagnosis High index of suspicion High index of suspicion Symptoms Symptoms Radiological evidence of D3 compression by SMA Radiological evidence of D3 compression by SMA Aorto-mesenteric angle <22 º (normal 38-65º)Aorto-mesenteric angle <22 º (normal 38-65º) Aorto-mesenteric distance <8mm (normal 10-28mm)Aorto-mesenteric distance <8mm (normal 10-28mm) Proximal duodenal dilation with cut-off at D3Proximal duodenal dilation with cut-off at D3

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

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

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

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

23 Which is better ?

24 Strong’s procedure StudyyrN Successful operation % success Welsch T Massoud WZ 19954*375 Ferrer V Smith JS Jr total7571 * laparoscopic Welsch T. Recalling superior mesenteric artery syndrome. Digestive Surgery. 2007;24(3): 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): Smith JS Jr. Superior mesenteric artery syndrome in a tube-fed patient. Nutrition in Clinical Practice. 1994;9(4):151-3

25 Gastrojejunostomy StudyyrN Successful operation % success Clapp B 20103*00 Yang WL Pan CH Tatar G Octavio de Toledo JM Total7343 * 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 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 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 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): Tatar G. Superior mesenteric artery syndrome. A case report. Turkish Journal of Pediatrics. 1996;38(3): 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 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): 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 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): Shiu JR. Clinical and nutritional outcomes in children with idiopathic superior mesenteric artery syndrome. Journal of Pediatric Gastroenterology & Nutrition. 2010;51(2): 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 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 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 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 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 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): Merrett ND. Superior mesenteric artery syndrome: diagnosis and treatment strategies. Journal of Gastrointestinal Surgery. 2009;13(2): Bognar G. Wilkie ’ s syndrome. Magyar Sebeszet. 2008;61(5):273-7 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 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 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 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 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 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 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 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 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): Kadji M. Superior mesenteric artery syndrome: a case report. Annales de Chirurgie. 2006;131(6-7): Sozubir S. Incomplete duodenal obstruction in a newborn. Indian Journal of Pediatrics. 2006;73(4):364-6 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): Li AC. The superior mesenteric artery syndrome: an unusual cause of vomiting. Hepato-Gastroenterology. 2005;52(62): Kingham TP. Laparoscopic treatment of superior mesenteric artery syndrome. Journal of the Society of Laparoendoscopic Surgeons. 2004;8(4):376-9 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 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): 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 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 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 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 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 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 Duodenojejunostomy has highest success rate % successful Strong71 Gastrojejunostomy43 Duodenojejunostomy86

33 Duodenojejunostomy Lee et al concluded that duodenojejunostomy was the best procedure for severe cases after reviewing 146 cases from the literature 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 SMA syndrome is a rare condition Diagnosis requires a high index of suspicion Diagnosis requires a high index of suspicion No large scale study comparing the treatment modalities No large scale study comparing the treatment modalities Duodenojejunostomy appears to be superior to gastrojejunostomy or Strong ’ s operation Duodenojejunostomy appears to be superior to gastrojejunostomy or Strong ’ s operation

35 Thank you

36

37 Strong’s procedure - Reference Welsch T. Recalling superior mesenteric artery syndrome. Digestive Surgery. 2007;24(3): Welsch T. Recalling superior mesenteric artery syndrome. Digestive Surgery. 2007;24(3): Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. International Surgery. 1995;80(4):322-7 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): Ferrer V. The diagnosis of aorticomesenteric duodenal compression by magnetic resonance angiography. Revista Espanola de Enfermedades Digestivas. 1995;87(5): Smith JS Jr. Superior mesenteric artery syndrome in a tube-fed patient. Nutrition in Clinical Practice. 1994;9(4):151-3 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 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 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 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): Tatar G. Superior mesenteric artery syndrome. A case report. Turkish Journal of Pediatrics. 1996;38(3): 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 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


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