History
SMAS was first described in 1861 by a pathologist named Carl Freiherr von Rokitansky. Sadly it remained an undefined pathology until 1927 when Wilkie published the first comprehensive series of patients who suffered from it. The Duodenojejunostomy was the first treatment to be suggested for SMAS. This was suggested by a doctor of the name of Bloodgood. This surgery was first performed by Dr Stavely in 1908. Since then it is still a common procedure done on SMAS patients. The very first laparoscopic duodenojejunostomy was done in 1997.
What is SMAS?
SMAS or Superior Mesenteric Artery Syndrome is the obstruction of the 3rd portion of the duodenum due to compression by the Superior Mesenteric Artery (SMA ) towards the Abdominal Aorta ( AA ) reducing the angle between these two structures to 6 – 22° ( normal 28 – 65° ) hence decreasing the aortomesenteric distance to 2 – 8 mm ( normal 10 – 34mm ). The obstruction can be intermittent, partial or complete. You can read Dr. Domingo Alvear's explanation and find our informational flyer here.
Symptoms
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Feeling full quickly when eating
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Bloating after meals
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Burping (belching)
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Nausea
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Vomiting of Partially Digested Food (regurgitation)
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Vomiting Bile-like Liquid
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Small bowel obstruction
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Weight loss
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Mid-abdominal pain
What causes SMAS?
SMAS is typically caused by the loss of the mesenteric fat pad. The fat pad is fatty tissue that surrounds the mesenteric artery. The SMA forms an angle with the abdominal aorta due in part to the fat pad and part of the duodenum sits within this angled space. Anything that severely narrows this angle between the aorta and the SMA can cause compression of the duodenum. This is what results in SMAS.
There are also some reports of familial cases of SMAS. One of those reports is a case study of affected identical twins. This suggests that there may be a genetic predisposition to SMAS in some people.
What causes loss of the mesenteric fat pad?
The most common cause of loss of the mesenteric fat pad is significant weight loss caused by medical disorders, psychological disorders or surgery. Comorbidities can also contribute to the loss of the fat pad which then causes SMAS.
Clinical Presentation & Diagnostic Workup
SMAS is often considered a diagnosis of exclusion. This means that after going through a full GI workup you may find your doctor giving you this diagnosis. Tests that may be needed to evaluate a person with symptoms of SMAS include. X-rays, Upper GI series, Ultrasound, Arteriography and CT scan. Finding out if you have SMAS is often a long process which can lead to a delayed diagnosis. This can result in significant complications for some patients.
Management
Meal Replacement Shakes
High Calorie Diets
Proper Positioning After Eating
Standing
Sitting in the knee to chest position
Lying down on your left side
Nasogastric Decompression (NG Tube)
IV Nutritional Support
Jejunostomy feeding tube (J Tube)
Metoclopramide Treatment
Surgery
Surgical Options
There are 3 common surgical options for SMAS, Strong’s Procedure, Gastrojejunostomy and Duodenojejunostomy.
Strong’s procedure: Where the duodenum is re-positioned to the right of the superior mesenteric artery
Gastrojejunostomy: Where the jejune (the part of the intestines that continues with the duodenum) is joined directly to the stomach
Duodenojejunostomy with or without division or resection of the fourth part of the duodenum.
Complications
Accumulation of gas in the portal vein
Gastric Pneumatosis
Formation of an obstructing duodenal bezoar
Electrolyte Abnormalities
Gastric Perforation
Consequential Cascade of the Disease Process
Superior Mesenteric Artery Syndrome (SMAS) is a rare condition that involves the small intestines. This condition occurs when the duodenum is compressed between two arteries. One being the Aorta and other being a branch of the Aorta called the superior mesenteric artery (SMA).
We've created a page on our website that can help you find research articles and helpful websites to learn more about Superior Mesenteric Artery Syndrome (SMAS).
HISTORY OF SMAS
1861
1908
1927
1997
2015
2017
First description of SMAS by Carl Freiherr von Rokitansky
First duodenojejunostomy by Dr. Stavely
Wilkie publishes first comprehensive series of SMAS patients
First laparoscopic duodenojejunostomy
Formation of SMAS Nonprofit Organization
First grant by SMAS Nonprofit
