Fifteen Cases of Superior Mesenteric Artery Syndrome: Diagnosis and Surgical Strategies

Introduction: Superior mesenteric artery syndrome (SMAS) is a condition caused by duodenal compression between aorta and superior mesenteric artery (SMA). SMAS's symptoms are nausea, vomiting, post-prandial epigastric pain and weight loss. Computed tomography (CT) angiography and magnetic resonance (MR) angiography are at present the most informative diagnostic technique. Diagnostic criteria are a narrowing in the aorto-mesenteric angle lesser than 22\ub0 (normal 28\ub0- 65\ub0) and a reduction of the aorto-mesenteric distance to 8 mm or less (normal 10-28 mm). Usually SMAS is not recognized and mistreated. Medical treatment includes pro-motility agents, but surgical approach is advocate in case of conservative treatment failure. Methods & aim: Fifteen consecutive patients (11F, 4 M, mean age 45 +/- 9 years) who underwent surgical correction of SMAS between 2008 and 2010 have been enrolled in this prospective study. Before operation all patients have been investigated with CT and/or MR angiography with multi- planar three-dimensional reconstructions, EGDS, barium contrast radiography. In patients previously operated for GERD, also pH-metry and esophageal manometry were performed. Postoperative outcome was evaluated considering the following clinical variables: weight, BMI, medical therapy, serum albumine, amylase and lipase. Aim of the study is to evaluate safety, efficacy and outcome of surgical correction ofSMAS. Results: All the patients enrolled were symptomatic for abdominal pain, nausea and anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreat- itis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18\ub0 +/-1.8 and distance 4.6 +/- 2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 +/- 6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improve- ment in patient weight (pre-operatory mean 50+/-1 kg, post-operatory mean 55+/-9 kg p= 0.003) and BMI (pre-operatory mean 18.1+/-3.4 kg, post-operatory mean 20.0+/-3.4 kg p= 0.004) and there is a significant decreased in need of PPI therapy (p=0.004). We didn't observed significant differences, in the outcome, between the two surgical procedures. Conclusions: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass