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 :
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

Earlier post-op recovery

Surgical Treatment
Bypass operation
Gastrojejunostomy
Duodenojejunostomy

Operative findings of the SMA obstructing

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
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