Presentation on theme: "SUPERIOR MESENTERIC ARTERY SYNDROME"— Presentation transcript:
1SUPERIOR MESENTERIC ARTERY SYNDROME Dr. ST HungPrincess Margaret Hospital
2History F/73 Past Health: Metastatic CA breast ( Lung, Mediastinal LN ), on Femara® (letrozole) since 6/2012 for palliative intentAdmit for repeated bilious vomiting for daysabdominal distensionBO once every 2-3 daysDecrease intake & weight loss
3Physical Examinations CachexicAfebrile, BP/ P stableAbdomen: grossly distended, succusion splash+, no mass or herniaPR: No mass, brownish stool
10IntroductionThe superior mesenteric artery syndrome is defined as vascular compression of the third part of the duodenum in the angle between the aorta and the superior mesenteric artery.First described by Austrian Professor Carl Freiherr von Rokitansky in 1842Wilkie published the first comprehensive series of 75 patients, after which the eponym “Wilkie’s Syndrome” emergedOther names: arteriomesenteric duodenal compression syndrome, chronic duodenal ileus and cast syndrome
11EpidemiologyUnknown incidence; roughly estimated to be around to 0.3% in general populationFemales are more commonly affected, in ratio of 3:2About two thirds of patients are in age group between 10-39Cases described in preterm male of 23 weeks & 86 years old manNo racial difference
13Related Anatomy & Pathogenesis Aorto-mesenteric angle ≈ 6° to 16° (Normal: 38-65°)Aorto-mesenteric distance ≈2mm to 8mm (Normal:10-28mm)
14Congenital Vs Acquired EtiologyCongenital Vs Acquired
15Etiology Congenital Causes Anatomical variants: Short or High insertion of Ligament of TreitzCongenital peritoneal adhesions and Ladd’s bandsCongenital low origin of the SMAShort Mesenteric RootDuodenal Malrotation
17Clinical FeaturesDepend on the cause and grade of duodenal compressionChronic abdominal complaints with intermittent exacerbationRarely, rapid evolving upper intestinal ileusIntermittent or postprandial abdominal pain (59-81%)* followed by bilious vomitingEpigastric pain is relieved by a prone, knee-chest, left lateral decubitus position or Hayes maneuver that all reduce small bowel mesenteric tension at aortomesenteric angleEarly satiety with a sensation of fullness, food intolerance, anorexia that trigger a vicious cycle resulting in weight loss*Ylinen P, Kinnunen J, Hockerstedt K: Superior mesenteric artery syndrome. A follow up study of 16 operated patients. J Clin Gastroenterol 1989; 11: 386–391.
18ComplicationsBecause of the frequent delay in the diagnosis of SMAS, it can result in life threatening complications*Pancreatitis secondary to abnormal pancreaticoduodenal reflux within the closed intestinal loopGastroparesis is frequently encountered after correction surgery for SMASEsophageal tearPeptic ulcer and perforation of stomachAspiration pneumonia, cardiovascular collapse, metabolic alkalosis, electrolyte imbalance*M. T. Mandarry, L. Zhao, C. Zhang, Z. Q. Wei. A comprehensive review of superior mesenteric artery syndrome. Eur Surg (2010) 42/5: 229–236
19Investigations and Diagnosis Diagnosis is difficult and is often delayed because of incomplete obstruction and non-specific symptomsDiagnosis by exclusion; thus requires high index of suspiciousRosa Jimenez et al. advocated that the diagnosis should be based on clinical symptoms and radiologic evidences of obstruction**U¨ nal B, Aktas A, Kemal G, et al. Superior Mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol 2005;11:90–5.
20Investigations and Diagnosis Radiographic criteriaDilatation of the 1st and 2nd part of the duodenum +/- gastric dilatationAbrupt vertical and oblique compression of the mucosal foldsAntiperistaltic flow of contrast medium (barium) proximal to obstruction, producing to and fro movementsDelay of 4 to 6 hours in gastroduodenojejunal transit timeRelief of the obstruction when the patient is placed in a prone, knee-chest or left lateral positionsDietz UA, Debus ES, Heuko-Valiati L, Valiati W, Friesen A, Fuchs KH, Malafaia O, Thiede A: Aorto-mesenteric artery compression syndrome. Chirurg 2000; 71: 1345–1351.Hines JR, Gore RM, Ballantyne GH: Superior mesenteric artery syndrome. Diagnostic criteria and therapeutic approaches. Am J Surg 1984; 148: 630–632.
22Radiographic Diagnostic Tools Conventional barium studiesClassic diagnostic technique; cheap, easy but non-specificA dilated proximal duodenum with an abrupt linear cut off at the 3rd part of the duodenum and a collapsed small bowel distal to the crossing SMARetention of barium within the duodenumHypotonic duodenography barium studyDuodenal peristalsis was suppressed by anti-cholinergics like propantheline bromide
23Radiographic Diagnostic Tools Computed tomography (CT) scancan clearly demonstrate the aortomesenteric angle and distance accuratelythe gastric and proximal duodenal dilatation, the duodenal obstruction (site of vascular compression of the duodenum)local pathologies e.g. aneurysm or neoplasm, etc.Provide an overall assessment of the abdominal cavity as well as the amount of retroperitoneal fat
24Radiographic Diagnostic Tools 3-Dimensional CT & MR angiographyMost popular; rapid, non-invasive, eliminate erroneous diagnoses that originate from the angulations of SMACalculating the aortomesenteric angle and distance preciselyCan demonstrate the direct pressure of SMA on the entrapped duodenumConventional angiographyGold standard modality in the pastInvasive, time-consuming
25Radiographic Diagnostic Tools Ultrasound color dopplerAdvocate for detection of reduced aortomesenteric angleUpper gastrointestinal endoscopyTo rule out intraluminal obstruction and gastric or duodenal ulcer disease that might be secondary to reflux or as a primary pathology mimicking SMASFluid retention in stomach, a dilated proximal duodenum, a pulsatile mass in the third part of duodenum precluding the passage of the scopeNot indicate the diagnosis
26Differential Diagnosis Mechanical obstructione.g. Pancreatic cysts or neoplasms, paraaortic lymphadenopathy, duodenumal tumor, adhesion, malrotation and Crohn’s diseaseFamilial neuropathic diseasee.g. megaduodenumPostoperative paralytic ileuse.g. general anesthesia, analgesic, electrolyte imbalance or greater splanchnic nerve injury during anterior spinalRecurrent biliary pancreatitisGastroparesis in Type I DiabetesPsychogenic vomitingRare causes with decreased peristalsise.g. dermatomyositis, SLE, myxoedema, amyloidosis, myotonic dystrophy or chronic idiopathic intestinal pseudo-obstruction
27TreatmentMedical Treatment to Surgical Treatment
28Medical TreatmentIn absence of displacement by an abdominal mass, an aneurysm or another pathologic condition that requires immediate surgical exploration, the treatment of the SMAS usually begins with conservative approachesAim: Reversal of weight loss; promote the restoration of retroperitoneal fat tissue which consequently increases the aortomesenteric angle**Jawad NH, Al-Sanae A, Al-Qabandi W. Superior mesenteric artery syndrome: An uncommon cause of intestinal obstruction; report of two cases and review of literature. Kuwait Med J 2006; 38:241–4.
29Medical Treatment Nil by mouth Nasogastric tube with regular aspirationCorrection of fluid and electrolyte balanceEnteral jejunal tube feeding, parental nutritionPosturing maneuversProkinetic drugs like metoclopramide or cisapride may be used to enhance stomach emptying by improving motility
30Medical Treatment No clear time limit for medical treatment Relief of symptoms has been observed from 2 to 12 days; nevertheless, it has been also reported up to 169 days* and even up to 7 months in different cases*Lee CS, Mangla JC: Superior mesenteric artery compression syndrome. Am J Gastroenterol 1978; 70: 141–150.
31Surgical TreatmentIndications for surgical intervention (Berner and Sherman, 1963) are:Failed conservative treatmentLongstanding disease with progressive weight loss and duodenal dilatation with stasisComplicated peptic ulcer disease and pancreatitis secondary to biliary stasis and refluxLocal pathology requiring laparotomyPatients’ preference
32Surgical Procedures Duodenojejunostomy Gastrojejunostomy Strong’s operationLaparoscopic duodenojejunostomyRobotic assisted intestinal bypass surgeryAnterior transposition of the third part of duodenumTransposition of the SMA to the infrarenal aortaDuodenal circular drainage
33Surgical Procedure Strong’s procedure Mobilization of the duodenum by division of the ligament of Trietz, allowing the duodenum to fall away from the aortaAvoids anastomosis thus, is less invasive, quicker, safer procedure, and with early postoperative recoveryFailure rate of 25%* presumably due toShort branches of the inferior pancreaticoduodenal artery not permitting the duodenum to fall inferiorlyAdhesion resulting in difficult dissection*Lee CS, Mangla JC: Superior mesenteric artery compression syndrome. Am J Gastroenterol 1978; 70: 141–150.
34Surgical Procedure Gastrojejunostomy Adequate gastric decompression Fail to completely release duodenal obstruction leading to persistence of symptoms that necessitated duodenojejunostomy in some cases*Persisting obstruction may lead to blind loop syndrome, gastric bile reflux and ulceration***Lee CS, Mangla JC: Superior mesenteric artery compression syndrome. Am J Gastroenterol 1978; 70: 141–150.**Geer MA. Superior mesenteric artery syndrome. Mil Med 1990;155:321–323
35Surgical Procedure Duodenojejunostomy Was first performed by Stavely in 1910The most frequent surgical procedure with a success rate of about 90% *Lee and Mangla * concluded after reviewing 146 cases operated after 1963 that duodenojejunostomy revealed the best results in severe cases and was significantly better compared to gastrojejunostomy and Strong’s procedure*Lee CS, Mangla JC: Superior mesenteric artery compression syndrome. Am J Gastroenterol1978; 70: 141–150.
36Surgical Procedure Laparoscopic duodenojejunostomy Gersin and Heniford reported the first successful laparoscopic duodenojejunostomy case in 1998Small series have reported success rates of % with laparoscopic division of the ligament of Treitz or laparoscopic duodenojejunostomy using a retrocolic stapled anastomosis.
37Surgical Procedure Others World’s first robotically assisted intestinal bypass surgery for SMAS: was reported in July 2008 at London Health Services CentreAnterior transposition of the third part of duodenumBillroth II gastrectomyTransposition of the SMA to the infrarenal aortaDuodenal circular drainage
38ConclusionSMAS is a very rare entity which has been associated with a wide range of predisposing factors, presenting with features of upper GIT obstruction and a recent abrupt weight loss.An early recognition of the condition, institution of the appropriate conservative measures and proper timely selection of a definite surgical method are critical to prevent the development of severe complications.M. T. Mandarry et al. A comprehensive review of superior mesenteric artery syndrome. Eur Surg (2010) 42/5: 229–236