Superior Mesenteric Artery (SMA) Syndrome

Victor Roman Steele, MD
The Operative Review of Surgery. 2023; 1:291-295.

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Table of Contents

Pathophysiology and Presentation
Diagnosis and Treatment

References

Pathophysiology and Presentation

Also Known As

  • Wilkie Syndrome 1,2
  • Arteriomesenteric Duodenal Obstruction 3
  • Chronic Duodenal Ileus/Stasis 1,4
  • Megaduodenum 4
  • Cast Syndrome – Specifically if Occurs After Corrective Surgery for Scoliosis 5

Pathophysiology

  • Extrinsic Obstruction of the Third Portion of the Duodenum Between the SMA and Aorta
  • Anatomic Features:
    • Aortomesenteric Angle (AMA): Angle Between the SMA and Aorta (Normal: 38-65 Degrees) 6,7
    • Aortomesenteric Distance (AMD): Distance Between the SMA and Aorta (Normal: 10-28 mm) 7,8
  • A Sharp AMA and Decreased AMD Primarily Occurs from Loss of the Mesenteric Root Fat Pad – May Be Worsened in the Supine Position

Etiology

  • Profound Weight Loss – Most Common Cause
    • Severe Illness (Cancer, AIDS, Burns, or Trauma) 8-10
    • Bariatric Surgery 11-13
    • Paraplegia 14
    • Drug Abuse 15
    • Anorexia 16,17
  • Pediatric Patients with Insufficient Weight Gain Relative to Height Growth 18
  • Corrective Surgery for Scoliosis – Lengthens Spine and Displaces SMA 5,19,20
  • Other Surgeries Causing Weight Loss or Anatomic Changes (Esophagectomy, Colectomy, Appendectomy) 21-23
  • Abdominal Aortic Aneurysm (AAA) 24
  • Congenitally Short Ligament of Treitz (Rare) 25,26

Presentation

  • Nonspecific Signs of Proximal Small Bowel Obstruction 27,28
    • Nausea and Vomiting (Bilious)
    • Esophageal Reflux
    • Postprandial Epigastric Abdominal Pain
    • Early Satiety
    • Weight Loss
    • Electrolyte Abnormalities
  • Symptoms May be Relieved by Positioning to Decrease Compression 1
    • Positions: Prone, Left Lateral Decubitus, or Knees-to-Chest

SMA Syndrome 29

Diagnosis and Treatment

Diagnosis

  • Generally a Diagnosis of Exclusion
  • Radiographic Imaging: 27
    • Upper GI Contrast Series (UGI)
    • Ultrasound (US)
    • CTA or MRA
  • Imaging Findings:
    • Duodenum Dilation/Obstruction
    • Decreased Aortomesenteric Angle or Aortomesenteric Distance (AMA ≤ 25 Degrees is the Most Sensitive Measure for Diagnosis, Particularly if AMD is Also ≤ 8 mm) 30,31

Medical Management

  • Primary Treatment: Nutritional Support and High Calorie Diet 27,32
    • May Require Nasojejunal (NJ) Tube Placed Beyond the Obstruction for Tube Feeding if Unable to Tolerate Oral Feeding
    • Enteral Nutrition is Preferred but TPN May Be Required
  • Other Potential Treatment Requirements:
    • Correction of Electrolyte Abnormalities
    • Nasogastric (NG) Tube Decompression for Significant Obstruction
    • Psychologic Counseling – Many Are Associated with Underlying Psychologic Comorbidities (Drug Use, Anorexia, and Other Eating Disorders)
  • Surgical Intervention Considered if Medical Management Fails

Surgical Options

  • Gastrojejunostomy 33
    • Creates a Bypass Around the Obstruction
    • Does Not Relieve the Physical Obstruction – May Require a Second Procedure if Symptoms Persist
    • Risk for Bile Reflux Gastritis and Blind Loop Syndrome
  • Duodenojejunostomy 34
    • Generally Accepted as Having Superior Results to Other Surgical Options 32
    • Can Be Done with or without Division of the Fourth Portion of the Duodenum
    • More Physiologic Than Gastrojejunostomy
    • More Technically Challenging
    • Risk for Blind Loop Syndrome if the Fourth Portion of the Duodenum is Not Divided
  • Strong’s Procedure 35
    • Procedure: Division of the Ligament of Treitz
    • Allows Mobilization of the Duodenum to Lay to the Right Side Away from the Aorta
    • Does Not Compromise Bowel Integrity or Require Any Anastomoses
  • *Approaches Can Be Done Open or Minimally Invasive

SMA Syndrome on CT 36

SMA Syndrome on UGI – Obstruction at the Third Portion of the Duodenum 29

Strong’s Procedure 29

References

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