Understanding SMA Syndrome and Its Surgical Treatment
Superior Mesenteric Artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare gastrointestinal condition where the third part of the duodenum becomes compressed between the superior mesenteric artery (SMA) and the aorta. This compression is typically caused by a rapid and significant loss of the mesenteric fat pad, which reduces the angle between these two arteries, leading to a small bowel obstruction. Patients often experience symptoms like chronic abdominal pain, nausea, vomiting, and significant weight loss. When conservative measures, such as nutritional support and weight gain, fail to resolve the symptoms, surgical intervention is considered.
The Strong Procedure Explained
The Strong procedure was historically one of the surgical options for treating SMA syndrome. It is the least invasive surgical procedure mentioned in some literature as it doesn't involve creating a new connection between sections of the bowel (anastomosis).
The procedure involves the following steps:
- Lysis of the Ligament of Treitz: The surgeon divides the ligament of Treitz, a peritoneal fold that holds the duodenojejunal junction in place.
- Mobilization of the Duodenum: By releasing the ligament, the fourth portion of the duodenum is mobilized.
- Repositioning: The duodenum and jejunum are then repositioned to the right of the superior mesenteric artery.
The goal of this repositioning is to prevent the extrinsic compression on the duodenum and restore proper gastrointestinal flow. The procedure can be performed via open surgery or, more commonly today, a minimally invasive laparoscopic approach.
Why the Strong Procedure is No Longer the Gold Standard
Despite its less invasive nature, the Strong procedure has largely fallen out of favor with surgeons due to its high rate of failure. The reason for this high failure rate is attributed to anatomical limitations, such as short branches of the inferior pancreaticoduodenal artery, which can prevent the duodenum from being sufficiently mobilized and repositioned away from the compressing artery. This can lead to a recurrence of symptoms, and in some cases, the patient may require a more complex, revisional surgery.
Alternative and Preferred Surgical Treatments
Given the documented high failure rates of the Strong procedure, other surgical options have become the standard of care for SMA syndrome. The most common and successful procedure is the duodenojejunostomy.
Comparison of Surgical Procedures for SMA Syndrome
| Surgical Procedure | Mechanism | Success Rate | Invasiveness | Notes |
|---|---|---|---|---|
| Duodenojejunostomy | Creates a new bypass connection between the duodenum and the jejunum, rerouting the food away from the compressed area. | High (80-100%) | Minimally invasive (laparoscopic) | Considered the most effective long-term solution. Involves bowel anastomosis. |
| Strong Procedure | Divides the ligament of Treitz to mobilize and reposition the duodenum, relieving the compression. | High Failure Rate | Minimally invasive (laparoscopic) | Less invasive but often ineffective due to anatomical constraints, leading to recurrence. |
| Gastrojejunostomy | Bypasses the obstruction by creating a connection between the stomach and the jejunum. | High | Minimally invasive (laparoscopic) | Less preferred than duodenojejunostomy as it leaves the obstructed portion of the duodenum still in place, potentially causing complications like biliary stasis. |
The Laparoscopic Duodenojejunostomy: The Modern Approach
The laparoscopic duodenojejunostomy has become the optimal definitive surgical treatment when conservative measures fail. This minimally invasive technique offers several advantages, including reduced postoperative pain, shorter hospital stays, and a faster return to normal activities compared to older, open surgical methods. The high success rates reported for this procedure have solidified its position as the preferred surgical option for most cases of chronic or refractory SMA syndrome.
The Role of Nutritional Support
Before any surgical intervention, and sometimes as a primary form of management, nutritional support is a critical component of treatment. By restoring weight and increasing the mesenteric fat pad, conservative management may help resolve the duodenal compression. This can involve nasojejunal feeding tubes placed beyond the obstruction or, in more severe cases, total parenteral nutrition (TPN). Patients are typically evaluated for surgery only after conservative treatment has proven unsuccessful. A thorough re-evaluation of the patient's nutritional status is often performed prior to surgery to ensure the best possible outcome.
Conclusion: Choosing the Right Treatment Path
While the Strong procedure is a recognized surgical intervention for Superior Mesenteric Artery syndrome, its high failure rate has led most surgeons to favor more definitive solutions. For patients with SMA syndrome who do not respond to conservative nutritional therapy, the laparoscopic duodenojejunostomy is now considered the standard of care due to its high success rate and minimally invasive benefits. A detailed discussion with a qualified surgeon is essential to determine the most appropriate treatment plan based on the individual's specific condition and overall health. For more detailed medical information on this and other rare conditions, visit the National Institutes of Health website.
