(2003 May) At D M Hosp, Pune, India, a diagnosis of SMA syndrome was made on an oral-contrast CT (7th May 2003) and gastrograffin follow-through (8th May 2003)taking only duodenal films. She was investigated under care of a pediatrician by a gastro-enterologist and a radiologist and was later (13th May 2003) operated upon by a pediatric surgeon. It is sad to note that no one ever thought of having a clearly defined view of IC-JN. On the second day after CT abd, they did a Gastrograffin FT. That too fails to show SMA syndrome with reasonable degree of confidance. The D2 shows a gentle taper and not a sudden cut off. Oral dye has made it to ascending colon and is responsible for causing contrast artefacts (as reported by radiologist).Yet, the conclusion given by the radiologist is "appearances are highly suggestive of SMA syndrome".
Ba Meal FT and CT Abd that lead to diagnosis of SMA syndrome. Take a note of the fact that a plenty of Ba has reached distal jejunal loops or even the ascending colon, and that the Ba in D2 is no wider than the adjacent L2, L3 vertebrae.
It is important to note that no attempt was made to define IC junction and terminal ileal loops despite
(a) the history of previous surgery -Appendicectomy- close to IC-Junction,
(b) periumbilical abdominal pain related to mid-gut and
(c) duodenum to IC time of over 6 hours in earlier Ba follow-throughs.
On 9th May 2003 posted for Duodeno-Jejunostomy. But because of menses this was actually done very hastily on 13th May 2003 (without even looking intra-operatively at the easily accessible previously operated appendicectomy site). On questioning the Paed-surgeon and gastro-enterologist in Nov 2009, they declared that looking at IC-JN was un-necessary as the diagnosis of SMA syndrome was crystal clear. Please see the diagram-3 at the end to see how this D2-J was done!). In effect a technically wrong D-J was done (with a non-dependent anastomosis and possible sites of mesocolic window obstructions to afferent and/or efferent loops), in presence of an obstructing lesion downstream.
It is worthwhile to note that NO medical management in form of post-prandial knee-elbow position was tried for 3-4 months after diagnosing SMA syndrome; despite a paediatrician, a gastro-enterologist and a pediatric surgeon looking after her during this admission.
Post D2 - J, three weeks were full of vomiting and pain. But she had 3-4 months later on with few symptoms. After this, till 2009 her symptoms became much more severe with abdominal pain, vomiting and constipation. She had many a Ba meal-follow throughs done, but all were done when the pain was absent. All showed a prolonged D-J flexure to IC-Jn transit time of more than 6 hrs. All were reported to be NORMAL. She had 2 post-op endoscopies, which showed patent D2-J.
Therefore she was shunted from one physician to another, gastro-enterologists, to psychiatrists and para-normal healers. 2003 to 2009 is punctuated with 3 Electro-Convulsive Therapies, 3 attempted suicides and prolonged periods of horrendous abdominal pain, vomiting, constipation.
(19th Oct 2009) - I admitted V K to J Hosp with bad abdominal pain. A Ba meal-FT was done during the worse pain and hyper-peristalsis was noted. Even after passing through the D-J, the progression of barium was in a to-fro manner. Duodenum to IC-Jn time was 17 hours. After splaying the IC junction, a long stricture of IC Jn was noted with dilatation of proximal ileal loops. This was reported as terminal ileal stricture due to ?IC-Jn tuberculosis. Barium passed through the D2-J and afferent loop without any e/o hold-up. Also take a note of the fact that the whole C loop of duodenum is seen without any compression suggestive of SMA compression of the D3. Her PCR-TB was negative for tuberculosis.
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| Diagram 2: The 30 min film shows undilated D2-J with a normal afferent loop consisting of distal D2, D3, D4, DJ and 1st loop of jejunum. 17 Hrs film shows a long IC-JN stricture with proximal ileal loop dilatation. |
(a) how much pain originated from IC-Jn stricture and
(b) how much from D2 -J (which was undilated on Ba F-T). It was rather uncertain, if any pain came from D-J at all at that stage.
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| Many tell-tale vicryl suture marks are seen at terminal ileum; some of which are seen here in between the thumb and index finger (upper left corner). |
In the immediate post-op period, she had many bouts of abdominal pain with changed location to epigastrium. Despite the pain she began eating.
On 29th Nov 2009, I sat with V K to figure out the symptomatology. The symptoms seem to have worsened after D2-J. Also, she revealed to me about passage of gas P/V many times since her childhood. She also elaborated on the constipation. Every time after evacuation she used to have a varying period of abdominal pain to such an extent that she used to postpone evacuation to a time after getting back from school in the after-noon.
I have discussed post op period and the required remedial steps with my contacts in India as well in UK. No one seems to have come across such an anastomosis. In fact, there is no parallel case presented in world literature that I have looked so far.
Logically I feel that I must wait for 2 more months and if naturally she does not get relieved, do another Ba meal FT during another episode of pain and then depending on the findings,take down the D-J sacrificing 1-2 inches of the jejunum at anastomosis, and rejoin the jejunum in infra-colic area. We will have to treat this as ‘duodenal injury’ with closure of the defect and placement of three tubes as described in Maingot's abdominal surgery (see the dia).
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Schematic diagram to show the findings and what the teaching is for correcting SMA syndrome |
COMPILED IN DEC 2009
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