SMA SYNDROME as a surgical point of view.pptx

SMA SYNDROME.pptx

1. SUPERIOR MESENTRIC ARTERY SYNDROME SEWBESEW KEFALE(SR1)

2. OUTLINE Anatomy Risk factor Clinical manifestation Complication Diagnosis Treatment

3. Case: 23 years old female known MDD and anorexia nervosa patient on follow up presented with 6month history of non projectile ingested matter vomiting with significant weight loss(15kg) and easy satiety. CT demonstrates SMA obstruction of third portion of duodenum. despite nasojejunal tube feeding over 6wks with appropriate weight gain, symptoms continued. Modified Strong’s procedure with D-J side to side anastomosis was done and discharged with no post op complication

4. Also called… Cast syndrome Wilkie syndrome Arteriomesentric duodenal obstruction Chronic duodenal illeus

5. A natomy Third portion of duodenum passes between the aorta and SMA around ligament of Treitz . Suspended in position by ligament of Treitz . Typical angle created by this 2 vessels is 28 -65degrees . This angle is maintained by mesentric ‘’fat pad’’

6. Anatomy cont…

7. RISK FACTOR Significant weight loss hypercatabolic states Malabsorptive syndromes Anorexia nervosa Sudden gain in height prolonged bed rest Congenital causes

8. CLINICAL MANIFESTATIONS C onsistent with small bowel obstruction Early satiety Postprandial epigastric pain Nausea/vomiting May have distension, high pitch bowel sounds Relieved by lying prone or on left side

9. complication Electrolyte disturbances Gastric perforation Gastric pneumatosis and portal venous gas Obstructing duodenal bezoars

10. D iagnosis Diagnosis of exclusion Distended duodenum and aortomesenteric angle <20 Peristalsis should still be present

11. Cont … KUB :gastric distension, dilation of proximal duodenum UGI :dilated stomach and proximal duodenum with retention of contrast CT/MRI :aortomesentric angle b/n 6-22 degree and distance 2-8mm. ARTERIOGRAPHY:narrowing of angle b/n SMA and aorta

12. TREATMENT Correction of electrolyte imbalance NG tube decompression Nutrition Body positioning Surgical management

13. Gastro- jejunostomy

14. PRONS AND CONS STRONG’S PROCEDURE MAINTAINS INTEGRITY OF BOWEL. however, failure occur up to one fourth of patients. Gastrojejunostomy decompress the stomach but failure to relieve duodenal obstruction may result in recurrent symptoms and blind loop syndromes or peptic ulceration. Duodenojejunostomy has superior results and with division of fourth part of duodenum establish bowel continuety and minimize issues with blind loop.

15. Follow-up Contrast studies are performed at one to two weeks post operatively to demonstrate patency of repair and normal emptying of duodenum Patients are followed for resolution of their preoperative systems and weight gain.

16. References Uptodate 21-2-1.2 Medscape pubmed

17. Thank you