Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Superior Mesenteric Artery Syndrome Treatment & Management

  • Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Jul 27, 2015
 

Medical Care

Reversing or removing the precipitating factor is usually successful in a patient with acute superior mesenteric artery (SMA) syndrome. Conservative initial treatment is recommended in all patients with superior mesenteric artery syndrome; this includes adequate nutrition, nasogastric decompression, and proper positioning of the patient after eating (ie, left lateral decubitus, prone, knee-to-chest position, or Goldthwaite maneuver) Enteral feeding using a double lumen nasojejunal tube passed distal to the obstruction under fluoroscopic assistance is an effective adjunct in treatment of patients with rapid severe weight loss and also eliminates the need for intravenous fluids and the risks associated with total parenteral nutrition.

In some instances, both enteral and parenteral nutritional support may be needed to provide optimal calories. The patient's weight should be monitored daily. Subsequently, the patient can be started on oral liquids followed by slow and gradual introduction of small and frequent soft meals as tolerated. Finally, regular solid foods are introduced. Metoclopramide treatment may be beneficial. Review of the orthopedic literature reveals that the success rate is 100% with medical management only in cases with an acute presentation of superior mesenteric artery syndrome.

Next

Surgical Care

Surgical intervention is indicated when conservative measures are ineffective, particularly in patients with a long history of progressive weight loss, pronounced duodenal dilatation with stasis, and complicating peptic ulcer disease. A trial of conservative treatment should be instituted for at least 4-6 weeks prior to surgical intervention.

Options for surgery include a duodenojejunostomy or gastrojejunostomy to bypass the obstruction or a duodenal derotation procedure (otherwise known as the Strong procedure) to alter the aortomesenteric angle and place the third and fourth portions of the duodenum to the right of the superior mesenteric artery.[11] This is called derotation because the final position of the midgut is in direction opposition to the normal embryonic rotation of the midgut. This may be best suited for pediatric patients in whom the superior mesenteric artery syndrome may be related to congenital anatomic conditions that predispose to their symptomatology.[11]

Surgical duodenal derotation for superior mesenteric artery syndrome usually requires a laparotomy, during which the duodenum is mobilized after division of the ligament of Treitz. Once the duodenojejunal junction has been fully mobilized, the jejunum is passed behind the superior mesenteric artery and is positioned to the right of the superior mesenteric artery so it does not lie in the acute angle between the aorta and the superior mesenteric artery.[11, 18] This procedure can also be done laparoscopically and can be converted to a gastrojejunostomy or duodenojejunostomy if it fails to improve the patient's symptoms.

Another surgical approach to treating superior mesenteric artery syndrome is a duodenojejunostomy, in which the compressed portion of the duodenum is released and an anastomosis is created between the duodenum and jejunum anterior to the superior mesenteric artery. This is the classic approach to superior mesenteric artery syndrome. Advantages include the ease of procedure. Complications include risk of bleeding, leakage or stricture at the anastomotic site, and a creation of a nonphysiologic bilious circulation loop of unknown consequence.[11]

Successful laparoscopic duodenojejunal bypass has been described. The operation consists of a loop of jejunum anastomosed to the dilated duodenal segment, which is seen below the transverse mesocolon. Although experience is limited to case reports and small studies, laparoscopic approaches are feasible and provide a less invasive surgical option.[19, 20, 21] A gastrojejunostomy may be another surgical option but is usually reserved for patients who have contraindication to a duodenojejunostomy, such as duodenal ulcer disease or if both the stomach and duodenum are severely dilated.[11] Care in pursuing surgical correction should be taken in patients with significant premorbid conditions and malnutrition, such as end-stage renal disease, because these have a high surgical mortality when performed for superior mesenteric artery syndrome.[22]

A retrospective study evaluated 12 patients with superior mesenteric artery syndrome who were treated with laparoscopic enteric bypass. The study concluded that laparoscopic duodenojejunostomy is safe and effective and should be considered the optimal treatment for patients presenting with duodenal obstruction from superior mesenteric artery syndrome. The study also concluded that advances in minimally invasive surgery have demonstrated the safety and low morbidity of laparoscopically created enteric anastomoses. The authors add that the shorter hospital stay, low morbidity, and that the high success of laparoscopic enteric bypass make this approach favorable to traditional open techniques.[23, 24]

Previous
Next

Consultations

The following consultations may be indicated:

  • Pediatric gastroenterologist
  • Nutritionist
  • Pediatric surgeon
Previous
Next

Diet

Medical therapy usually begins with the initiation of intravenous fluids and, once no significant emesis, with the frequent administration of small amounts of liquids. In some cases, nasojejunal or nasogastric tube feedings with a standard liquid diet may be indicated. If the patient is completely obstructed or unable to tolerate liquids, total parenteral nutrition is indicated.

Previous
 
 
Contributor Information and Disclosures
Author

Frederick Merrill Karrer, MD, FACS Professor of Surgery and Pediatrics, Head, Division of Pediatric Surgery, University of Colorado School of Medicine; The Dr David R and Kiku Akers Chair in Pediatric Surgery, Surgical Director, Pediatric Transplantation, The Children’s Hospital

Frederick Merrill Karrer, MD, FACS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, Children's Oncology Group, International Liver Transplantation Society, Transplantation Society, International Society of Paediatric Surgical Oncology, Pacific Association of Pediatric Surgery, International Pediatric Transplant Association, Colorado Medical Society, Society of Critical Care Medicine, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, Western Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Stephanie A Jones, DO Resident Physician, Department of Pediatric Surgery, University of Colorado School of Medicine

Stephanie A Jones, DO is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Received salary from University of Colorado Denver for employment.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Avinash Shetty, MD, and Ivor D Hill, MB, ChB, DCH, FCP, MD, to the original writing and development of this article.

References
  1. Gerasimidis T, George F. Superior Mesenteric Artery Syndrome. Wilkie Syndrome. Dig Surg. 2009 May 20. 26(3):213-214. [Medline].

  2. Shiu JR, Chao HC, Luo CC, et al. Clinical and nutritional outcomes in children with idiopathic superior mesenteric artery syndrome. J Pediatr Gastroenterol Nutr. 2010 Aug. 51(2):177-82. [Medline].

  3. Baltazar U, Dunn J, Floresguerra C. Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction. South Med J. 2000 Jun. 93(6):606-8. [Medline].

  4. Unal B, Aktas A, Kemal G, Bilgili Y, Güliter S, Daphan C. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol. 2005 Jun. 11(2):90-5. [Medline].

  5. Merrett ND, Wilson RB, Cosman P, Biankin AV. Superior mesenteric artery syndrome: diagnosis and treatment strategies. J Gastrointest Surg. 2009 Feb. 13(2):287-92. [Medline].

  6. Kyslan K, Barla J, Kyslan K, Stanislayova M. [Superior mesenteric artery (SMAS/AMS) syndrome and its management]. Rozhl Chir. 2008 May. 87(5):255-8. [Medline].

  7. Lim JE, Duke GL, Eachempati SR. Superior mesenteric artery syndrome presenting with acute massive gastric dilatation, gastric wall pneumatosis, and portal venous gas. Surgery. 2003 Nov. 134(5):840-3. [Medline].

  8. Fuhrman MA, Felig DM, Tanchel ME. Superior mesenteric artery syndrome with obstructing duodenal bezoar. Gastrointest Endosc. 2003 Mar. 57(3):387. [Medline].

  9. Ko KH, Tsai SH, Yu CY, Huang GS, Liu CH, Chang WC. Unusual complication of superior mesenteric artery syndrome: spontaneous upper gastrointestinal bleeding with hypovolemic shock. J Chin Med Assoc. 2009 Jan. 72(1):45-7. [Medline].

  10. Smith BG, Hakim-Zargar M, Thomson JD. Low body mass index: a risk factor for superior mesenteric artery syndrome in adolescents undergoing spinal fusion for scoliosis. J Spinal Disord Tech. 2009 Apr. 22(2):144-8. [Medline].

  11. Ha CD, Alvear DT, Leber DC. Duodenal derotation as an effective treatment of superior mesenteric artery syndrome: a thirty-three year experience. Am Surg. 2008 Jul. 74(7):644-53. [Medline].

  12. Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg. 2007. 24(3):149-56. [Medline].

  13. Saraya T, Kurai D, Ariga M, Nakamoto K, Koide T, Tamura M. Superior mesenteric artery syndrome caused by huge mycotic abdominal aortic aneurysm. Intern Med. 2009. 48(12):1065-8. [Medline].

  14. Mosalli R, El-Bizre B, Farooqui M, Paes B. Superior mesenteric artery syndrome: a rare cause of complete intestinal obstruction in neonates. J Pediatr Surg. 2011 Dec. 46(12):e29-31. [Medline].

  15. Reynolds EW, Kinnard TB, Kriss VM, Perman JA. Superior mesenteric artery syndrome: an uncommon cause of feeding intolerance in infancy. J Pediatr Gastroenterol Nutr. 2008 Jan. 46(1):92-5. [Medline].

  16. Agrawal GA, Johnson PT, Fishman EK. Multidetector row CT of superior mesenteric artery syndrome. J Clin Gastroenterol. 2007 Jan. 41(1):62-5. [Medline].

  17. Sundaram P, Gupte GL, Millar AJ, McKiernan PJ. Endoscopic ultrasound is a useful diagnostic test for superior mesenteric artery syndrome in children. J Pediatr Gastroenterol Nutr. 2007 Oct. 45(4):474-6. [Medline].

  18. Wilson-Storey D, MacKinlay GA. The superior mesenteric artery syndrome. J R Coll Surg Edinb. 1986 Jun. 31(3):175-8. [Medline].

  19. Fraser JD, St Peter SD, Hughes JH, Swain JM. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. JSLS. 2009 Apr-Jun. 13(2):254-9. [Medline].

  20. Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001 Apr. 181(4):377-8. [Medline].

  21. Bermas H, Fenoglio ME. Laparoscopic management of superior mesenteric artery syndrome. JSLS. 2003 Apr-Jun. 7(2):151-3. [Medline].

  22. Yap DY, Ma MK, Lai AS, et al. Superior mesenteric artery syndrome complicating dialysis patients with peritoneal failure--report of 3 cases. Clin Nephrol. 2011 Feb. 75 Suppl 1:37-41. [Medline].

  23. Pottorf BJ, Husain FA, Hollis HW Jr, Lin E. Laparoscopic management of duodenal obstruction resulting from superior mesenteric artery syndrome. JAMA Surg. 2014 Dec. 149 (12):1319-22. [Medline].

  24. Boggs W. Laparoscopic Management Effective for Duodenal Obstruction Resulting From Superior Mesenteric Artery Syndrome. Reuters Health Information. Available at http://www.medscape.com/viewarticle/834592. November 10, 2014; Accessed: July 28, 2015.

  25. Altiok H, Lubicky JP, DeWald CJ, Herman JE. The superior mesenteric artery syndrome in patients with spinal deformity. Spine. 2005 Oct 1. 30(19):2164-70. [Medline].

  26. Altman DH, Puranik SR. Superior mesenteric artery syndrome in children. Am J Roentgenol Radium Ther Nucl Med. 1973 May. 118(1):104-8. [Medline].

  27. Barnes JB, Lee M. Superior mesenteric artery syndrome in an intravenous drug abuser after rapid weight loss. South Med J. 1996 Mar. 89(3):331-4. [Medline].

  28. Crowther MAA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine. 2002. 27:E528-33.

  29. Hutchinson DT, Bassett GS. Superior mesenteric artery syndrome in pediatric orthopedic patients. Clin Orthop. 1990 Jan. (250):250-7. [Medline].

  30. Jo JB, Song KY, Park CH. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome: report of a case. Surg Laparosc Endosc Percutan Tech. 2008 Apr. 18(2):213-5. [Medline].

  31. Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. Int Surg. 1995 Oct-Dec. 80(4):322-7. [Medline].

  32. Morris TC, Devitt PG, Thompson SK. Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome-How I Do It. J Gastrointest Surg. 2009 Apr 9. [Medline].

  33. Munns SW, Morrissy RT, Golladay ES. Hyperalimentation for superior mesenteric-artery (cast) syndrome following correction of spinal deformity. J Bone Joint Surg Am. 1984 Oct. 66(8):1175-7. [Medline].

  34. Ortiz C, Cleveland RH, Blickman JG. Familial superior mesenteric artery syndrome. Pediatr Radiol. 1990. 20(8):588-9. [Medline].

  35. Raissi B, Taylor BM, Taves DH. Recurrent superior mesenteric artery (Wilkie's) syndrome: a case report. Can J Surg. 1996 Oct. 39(5):410-6. [Medline].

  36. Rokitansky C. Handbuch der Pathologischen Anotomie. Vienna: Branmiller and Siedel. 1842.

  37. Santer R, Young C, Rossi T. Computed tomography in superior mesenteric artery syndrome. Pediatr Radiol. 1991. 21(2):154-5. [Medline].

  38. Shah MA, Albright MB, Vogt MT, Moreland MS. Superior mesenteric artery syndrome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr Orthop. 2003 Sep-Oct. 23(5):665-8. [Medline].

  39. Shapiro G, Green DW, Fatica NS, Boachie-Adjei O. Medical complications in scoliosis surgery. Curr Opin Pediatr. 2001 Feb. 13(1):36-41. [Medline].

  40. Shetty AK, Schmidt-Sommerfeld E, Haymon ML. Radiological case of the month. Superior mesenteric artery syndrome. Arch Pediatr Adolesc Med. 1999 Mar. 153(3):303-4. [Medline].

  41. Vitale MG, Higgs GB, Liebling MS, et al. Superior mesenteric artery syndrome after segmental instrumentation: a biomechanical analysis. Am J Orthop. 1999 Aug. 28(8):461-7. [Medline].

  42. Wilkie DPD. Chronic duodenal ileus. Am J Med Sci. 1927. 173:643-9.

  43. Ylinen P, Kinnunen J, Hockerstedt K. Superior mesenteric artery syndrome. A follow-up study of 16 operated patients. J Clin Gastroenterol. 1989 Aug. 11(4):386-91. [Medline].

 
Previous
Next
 
Prompt gastric emptying of residual contrast is present within the stomach into the second portion of the duodenum. Additional contrast was hand injected through the transpyloric feeding tube to further distend the second portion of the duodenum. The second portion of the duodenum is dilated with very slow transit across the spine into the jejunum. This occurred despite difference in position of the patient. The high-grade partial obstruction at the distal second portion of the duodenum is due to superior mesenteric artery (SMA) syndrome.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.