Dr. Amr Ahmed Redha Said. MD; MRCS.

Abstract:

Compression of the duodenum by the superior mesenteric artery (SMA) is an uncommon cause of proximal intestinal obstruction. It has been referred to by a variety of names including SMA syndrome, Cast syndrome, Willkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus It is defined formally as trapping of the third portion of the duodenum between the SMA and aorta secondary to a narrowing of the angle between the two vessels, usually due to loss of the intervening mesenteric fat pad. Despite multiple case reports, there has been controversy surrounding the diagnosis (and even the existence) of SMA syndrome since symptoms do not always correlate well with radiologic findings, and may not always improve following surgical correction Furthermore, the diagnosis may be confused with other anatomic or motility-related causes of duodenal obstruction, Results: 10 articles were reviewed. Most studies have evaluated the laparoscopic management of superior mesenteric artery sundrome. In addition to the  outcome in comparison to open surgery. Conclusion: laparoscopy is an acceptable management in SMA syndrome in a well-trained hand

Key word:

Superior mesenteric artery syndrome, arteriomesentric duodenal compression,  high intestinal obstruction

Introduction:

To date, more than 400 cases of superior mesenteric artery (SMA) syndrome have been reported. It is possible that this is an underestimation of the condition, as many such cases are probably not reported. SMA syndrome is characterized by symptoms of upper gastrointestinal obstruction such as nausea and vomiting, post-prandial epigastric pain, anorexia, and weight loss. It is caused by compression of the third part of the duodenum, as it passes between the SMA and the aorta. A narrowed angle between these two arteries may be seen in various situations: in patients who experience rapid weight loss (leading to a reduction in the amount of mesenteric fat surrounding the SMA), external cast compression, anatomic variants (a short/high ligament of Treitz or an unusually low origin of the SMA), and spinal cord injury and/or spinal surgery.In particular, patients with traumatic spinal cord injuries are predisposed to this condition due to rapid weight loss, prolonged supine positioning, and the use of spinal orthoses

Materials and Methods:

A literature review was performed using Springer link, PubMed, search engines like Google, and Yahoo. The following search terms were used: Laparoscopy · superior mesenteric artery syndrome versus open surgery · Survival, Recurrence and 1400 citations were found. Selected papers were screened for further references. Publications that featured illustrations of laparoscopy , compared it with open, with statistical methods of analysis, were selected.

CLINICAL MANIFESTATIONS:

Patients may present acutely (such as following surgery for scoliosis) or more insidiously with gradual or progressive symptoms . In both cases, symptoms are consistent with proximal small bowel obstruction. Patients with mild obstruction may have only postprandial epigastric pain and early satiety, while those with more advanced obstruction may have severe nausea and bilious emesis. Symptoms may be relieved when patients are in the left lateral decubitus, prone, or knee-chest position .Findings on physical examination are nonspecific but can include abdominal distension, a succussion splash, and high-pitched bowel sounds. Laboratory examination can be normal or demonstrate electrolyte abnormalities in patients with severe vomiting or diarrhea.

Several complications have been reported including

1. Fatalities due to electrolyte abnormalities
2. Fatalities due to gastric perforation
3. Gastric pneumatosis and portal venous gas
4. Formation of an obstructing duodenal bezoar

DIAGNOSIS — A high index of suspicion is required since symptoms can be nonspecific. Patients should undergo judicious testing for other disorders that can cause similar symptoms (which has already been accomplished in most patients, since SMA syndrome is typically not suspected). As a general rule, the following criteria should be present on imaging Duodenal obstruction with an abrupt cutoff in the third portion and active peristalsis.

A narrow angle between the aorta and the SMA with high fixation of the duodenum by the ligament of Treitz and/or an anomalous SMA crossing directly over the aorta at its intersection with the duodenum.

Diagnostic evaluation should begin with an abdominal radiograph. Although it frequently is nonspecific, it may reveal suggestive findings such as gastric distension, dilation of the proximal duodenum, and, occasionally, an abrupt vertical cutoff of air in the third portion of the duodenum. Most patients require further evaluation with an upper gastrointestinal series, which usually demonstrates marked delay in passage of the contrast from the duodenum into the more distal small bowel. Passage of contrast typically halts abruptly at the third portion of the duodenum. The proximal duodenum and stomach are dilated and show prolonged retention of. Similar findings can be seen with CT. The above studies can be diagnostic in patients in whom there is heightened suspicion based upon the clinical setting. Additional testing is required in those in whom the diagnosis remains unclear. This has traditionally involved superior mesenteric arteriography (performed simultaneously with barium contrast radiography), which can demonstrate the SMA superimposed upon the barium-filled duodenum  The lateral arteriogram can demonstrate narrowing of the angle between the aorta and the SMA.

However, CT and MR angiography have mostly replaced traditional angiography since they are noninvasive, yield similar results, and provide additional information such as the amount of intra-abdominal and retroperitoneal fat. Endoscopic ultrasound has also been used to demonstrate the vascular cause of duodenal obstruction

TREATMENT

There are three major goals in the initial treatment of SMA syndrome:

• Correction of fluid and electrolyte imbalances
• Decompression of the obstruction via a nasogastric tube
• Institution of nutrition and bypass the narrowing

Result:

This study compared this rare syndrome (SMA syndrome) with the laparoscopic management compared to the traditional open techniques. All the patients were managed initially conservativewas:.Fluid and electrolyte imbalances are corrected, the stomach is decompressed with a nasogastric tube, and nutritional supportis instituted with either nasojejunal feeds or total parenteralnutrition. Gastric promotility agents such as metoclopramide may also be helpful If placement of a feeding tube is not possible, or if thecondition persists, surgical relief of the obstruction may be required either via a bypass procedure (duodenojejunostomy or gastrojejunostomy) or by mobilization of the duodenum (division of the ligament of Trietz). The most successful approach for treatment of SMA syndrome is a duodenojejunostomy. 3Although there are only a handful of case reports on laparoscopic duodenojejunostomy, this is a relatively simple procedure for the experienced minimally invasive surgeon. Initial reports describing this technique began with a Kocher manoeuvre and side-to-side (sometimes retrocolic) duodenojejunostomy at the mid-section of the second part of the duodenum. Three more recent reports have excluded the need for a Kocher maneuver in order to create a more dependent stoma using the third part of the duodenum in the infracolic region.

The review of the aricles showed that the laparoscopic  approach ides not show any operative superiority over the open technique intraoperatively, with an increase in the operative time of 45%. On the other hand the all patients were treated with mobilization and division of the fourth part of the duodenum with the end portion of the jejunum then being placed through the avascular portion of the right mesocolon and a side to side anastomosis between the third part of the duodenum and jejunum. All patients had uneventful postoperative recoveries. All patients had oral nutrition reinstated after 4 days. There were no wound infections or anastomotic breakdowns and the average length of stay was 10 days (range 7–14 days). All patients had an excellent clinical outcome gaining between 5 and 15 kg at 6 months review. Postoperative imaging with Ba meal studies and endoscopy showed good emptying from the stomach and duodenum and no evidence of further obstruction. The patient’s weight gain stabilized at the 6-month period with no patient recording any major weight gain after this period. One patient developed an incisional hernia for which she has since had a laparoscopic repair. Three of the patients continued to require long-term psychological support for their underlying psychological disorders and one patient committed suicide at 9 months. All other patients remain well (follow-up range 5–68 months).

Conclusion:

Laparoscopic duodenojejunostomy can be recommended as a safe and appropriate management option for SMA syndrome that fails conservative therapy. There have been no major complications reported for the technique described above, and all cases (to our knowledge) have resulted in the successful resolution of symptoms. This procedure offers patients the benefits of a minimally invasive approach and reduces the risk of incisional hernia formation from an open approach.

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