SMA syndrome is a rare condition where the third portion of the duodenum is compressed between the superior mesenteric artery (SMA) and the aorta, causing duodenal obstruction. Risk factors include rapid weight loss or spine surgery. Patients experience symptoms of bowel obstruction like early satiety and abdominal pain. Diagnosis involves imaging showing compression of the duodenum and an aortomesenteric angle of less than 22 degrees. Treatment options include conservative management with feeding tubes or surgical procedures like duodenojejunostomy to bypass the obstruction.
SMA syndrome is a rare condition where the third portion of the duodenum is compressed between the superior mesenteric artery (SMA) and the aorta, causing duodenal obstruction. Risk factors include rapid weight loss or spine surgery. Patients experience symptoms of bowel obstruction like early satiety and abdominal pain. Diagnosis involves imaging showing compression of the duodenum and an aortomesenteric angle of less than 22 degrees. Treatment options include conservative management with feeding tubes or surgical procedures like duodenojejunostomy to bypass the obstruction.
SMA syndrome is a rare condition where the third portion of the duodenum is compressed between the superior mesenteric artery (SMA) and the aorta, causing duodenal obstruction. Risk factors include rapid weight loss or spine surgery. Patients experience symptoms of bowel obstruction like early satiety and abdominal pain. Diagnosis involves imaging showing compression of the duodenum and an aortomesenteric angle of less than 22 degrees. Treatment options include conservative management with feeding tubes or surgical procedures like duodenojejunostomy to bypass the obstruction.
SMA syndrome is a rare condition where the third portion of the duodenum is compressed between the superior mesenteric artery (SMA) and the aorta, causing duodenal obstruction. Risk factors include rapid weight loss or spine surgery. Patients experience symptoms of bowel obstruction like early satiety and abdominal pain. Diagnosis involves imaging showing compression of the duodenum and an aortomesenteric angle of less than 22 degrees. Treatment options include conservative management with feeding tubes or surgical procedures like duodenojejunostomy to bypass the obstruction.
between the aorta and the SMA Prevalence 0.013 0.3% Female > Male Mostly 10 39 years old Other names : Aortomesentric duodenal compression Duodenal vascular compression Wilkies syndrome Cast syndrome History 1842 : 1st describe 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 laparoscopy treatment performed by Massoud, by dividing the lig of Treitz 1998 : 1st laparoscopy DJ performed by Gersin and Heniford Anatomy Third portion of duodenum passes between the aorta and SMA around L3. Suspended in position by the ligament of Treitz Typical angle created by these 2 vessels is 38 -65 degrees. This angle is maintained by the mesenteric fat pad In SMA Syndrome this angle can be reduced to < 10% 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 aneurysma Predisposing Factor : Rapid weight loss Redustion of the mesentric fat around the SMA Causes : Malignancy Malabsorptive syndromes Anorexia nervosa Trauma Wasting diseases HIV, CHF, burns 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 Strecth the SMA over duodenum as the ileal pouch reaches pelvis Surgery associated with rapid weight loss Bariatric suegery, esophagectomy, abdominal trauma Clinical Manifestations Symptoms are consistent with small bowel obstruction Early Satiety Postprandial epigastric pain Nausea and Vomiting Bilious emesis May have distension, high pitched bowel sounds Symptoms may be relieved by lying prone or on left side Diagnosis High index of suspicion Symptoms Radiological evidence of D3 compression by SMA Aorto-mesentric angle < 22 (normal 38-65) Aorto-mesentric distance < 8 mm (normal 10-28 mm) Proximal duodenal dilation with cut-off at D3. Radiological Investigations Contrast X-ray studies Abd X-ray Barium studies CT abdomen (with oral contrast) CT angiogram Abdominal X-ray showing a distended stomach with air fluid level in the stomach and duodenal bulb. The Double bubble sign was consistent with high small bowel obstruction. Upper gastrointestinal series showing an abrupt Cut off at the third portion of the duodenum. CT scan demonstrating compression of the duodenum between aorta (black arrow) and SMA (red arrow). CT scan showing distended stomach and 2nd portion of duodenum (A); The angle between aorta and superior mesenteric artery (SMA) was 16.6 (B). Complications Electrolyte disturbances Hypokalemia, metabolic alkalosis Gastric perforation Gastric pneumatosis and portal venous gas Obstructing duodenal bezoar Differential Post-op paralytic ileus Duodenal dysmotility syndromes Diabetes mellitus Collagen vascular disease Scleroderma Chronic ideopathic intestinal pseudo- obstruction Treatment Conservative management In the absence of displacement by an abdominal mass, an aneurysma or another pathologic condition that requires immediate surgical exploration Surgical management If conservative management fails Conservative Treatment Correction of fluid and electrolyte imbalance Decompression via NG tube Nutrition Orally NJ feeds TPN A knee-to-chest position or prone after eating Surgical Treatment Strongs procedure Mobilize the DJ flexura and divide the lig of Treitz Move D3 away from the narrow aorto-mesentric angle Advatage : No bowel anastomosis Maintains bowel integrity
the third part of the duodenum Duodenojejunal anastomosis Duodenojejunostomy Lee et al : conclude that duodenojejunostomy was the best procedure for severe cases after reviewing 146 cases from the literature
Lee CS, Mangla JC. Superior mesenteric artery copression
syndrome. Am J Gastroenterol 1978;70:141-50 Bring Home Message SMA syndrome is rare condition Diagnosis requires a high index of suspicion Symptoms do not always correlate with radiography No large scale study comparing the treatment modalities Duodenojejunostomy appears to be superior to gastrojejunostomy or Strongs operation THANK YOU