superior mesenteric artery syndrome ( smas ) is a rare condition causing acute or chronic compression of the third part of the duodenum , due to a reduction in the aortomesenteric angle . laparoscopic duodenojejunostomy is a minimally invasive option that has been reported in up to 10 cases . we describe our operative technique in one case and review the literature on this condition . a previously well 66-year - old man presented with acute gastric dilatation . an abdominal computerized tomography ( ct ) scan and oral gastrografin meal revealed a dilated stomach and proximal duodenum due to compression of the third part of the duodenum between the superior mesenteric artery ( sma ) and aorta . gastrografin administration on the fifth day showed no leak , with free flow of contrast into the jejunum . it gives the same results as open surgery with all the advantages of minimally invasive surgery . superior mesenteric artery syndrome ( smas ) , also known as wilkie 's syndrome , is a very rare cause of proximal small - bowel obstruction that was first described by rokitansky in 1861 . although well documented in the english literature , some surgeons doubt the existence of smas as a real entity . smas is characterized by extrinsic compression of the third part of the duodenum between the aorta and the superior mesenteric artery ( sma ) , due to narrowing of the aortomesenteric angle , and results in acute or chronic intermittent duodenal obstruction . a 66-year - old man , with no previous medical history , presented with severe upper abdominal pain and distension that had been present for a few days . he had no history of nausea , vomiting , recent weight loss , altered bowel habits , or previous abdominal surgery . on examination , he was alert , afebrile , with a pulse rate of 107/min and blood pressure of 155/95 mm hg . an urgent computerized tomography ( ct ) scan revealed marked distension of the stomach and proximal duodenum with narrowing of the third part of the duodenum between the superior mesenteric artery ( sma ) and aorta ( figure 1 ) . the sagittal - ct showed a marked narrowing of the aortomesenteric angle ( white arrow ) to 8.6 degrees compatible with a diagnosis of superior mesenteric artery syndrome ( smas ) ( figure 2 ) . the patient 's symptoms improved with nasogastric decompression , and he got himself discharged against medical advice the next day . he presented again in the emergency department 2 days later with similar symptoms , bilious vomiting and severe dehydration . the first and second parts of the duodenum were dilated with a collapsed lumen in the third part . the scope , however , could pass through the third part . gastrografin administration showed hold up of contrast in the third part of the duodenum with proximal dilatation and slow passage into the distal small bowel ( figure 3 ) . conservative management with nasojejunal feeds was not successful because the patient was non - compliant and refused tube feeding . axial computed tomographic scan showing markedly dilated stomach and proximal duodenum with compression of the third part of the duodenum between the sma and aorta . preoperative gastrografin meal showing a dilated proximal duodenum with hold up of contrast in the third part and delayed passage distally . the patient , while under general anesthesia , was positioned supine with both legs abducted to allow the surgeon to stand in between . four ports were inserted - 1st port ( 10-mm camera ) : supraumbilical ; 2nd port ( 5 mm ) : left midclavicular line midway between the umbilicus and costal margin ; 3rd port ( 12 mm ) : right midclavicular line midway between the umbilicus and costal margin ; 4th port ( 5 mm ) : epigastrium ( figure 4 ) . the small bowel was traced from the duodenojejunal ( dj ) flexure to the cecum and found to be normal . the hepatic flexure , transverse mesocolon , and gastrocolic omentum were mobilized to visualize the duodenum and the head of the pancreas , which were elevated by the underlying aortic aneurysm . an on - table egd helped in visualization and kocherization of the dilated duodenum with harmonic shears . a proximal loop of jejunum about 25 cm from the dj - flexure was brought below the dilated duodenum and fixed with it by using interrupted seromuscular 2 0 vicryl sutures . the duodenum and jejunal lumen was then opened by using hook diathermy , and an endogia stapler ( ethicon endosurgery , somerville , nj ) was inserted and fired ( figure 5 ) . after confirming hemostasis of the staple line , the openings in the duodenum and jejunum were sutured together with continuous full - thickness 2 0 vicryl sutures . the anastomosis was tested for a leak , by instillation of methylene blue solution via the nasogastric tube . a tube drain was placed adjacent to the anastomosis , and the 10- and 12-mm port sites closed . a gastrografin meal study on the fifth postoperative day showed the anastomosis to be functioning well with no contrast leak ( figure 6 ) . the delay in discharge was due to social reasons and transfer to a step - down facility . the patient remained well and asymptomatic during follow - up at 1 and 3 months . position of trocar sites on the patient . stapled side - to - side laparoscopic duodenojejunostomy . postoperative day 5 gastrografin meal showing no leak with free flow into jejunum across the anastomosis . the patient , while under general anesthesia , was positioned supine with both legs abducted to allow the surgeon to stand in between . four ports were inserted - 1st port ( 10-mm camera ) : supraumbilical ; 2nd port ( 5 mm ) : left midclavicular line midway between the umbilicus and costal margin ; 3rd port ( 12 mm ) : right midclavicular line midway between the umbilicus and costal margin ; 4th port ( 5 mm ) : epigastrium ( figure 4 ) . the small bowel was traced from the duodenojejunal ( dj ) flexure to the cecum and found to be normal . the hepatic flexure , transverse mesocolon , and gastrocolic omentum were mobilized to visualize the duodenum and the head of the pancreas , which were elevated by the underlying aortic aneurysm . an on - table egd helped in visualization and kocherization of the dilated duodenum with harmonic shears . a proximal loop of jejunum about 25 cm from the dj - flexure was brought below the dilated duodenum and fixed with it by using interrupted seromuscular 2 0 vicryl sutures . the duodenum and jejunal lumen was then opened by using hook diathermy , and an endogia stapler ( ethicon endosurgery , somerville , nj ) was inserted and fired ( figure 5 ) . after confirming hemostasis of the staple line , the openings in the duodenum and jejunum were sutured together with continuous full - thickness 2 0 vicryl sutures . the anastomosis was tested for a leak , by instillation of methylene blue solution via the nasogastric tube . a tube drain was placed adjacent to the anastomosis , and the 10- and 12-mm port sites closed . a gastrografin meal study on the fifth postoperative day showed the anastomosis to be functioning well with no contrast leak ( figure 6 ) . the delay in discharge was due to social reasons and transfer to a step - down facility . the patient remained well and asymptomatic during follow - up at 1 and 3 months . position of trocar sites on the patient . stapled side - to - side laparoscopic duodenojejunostomy . postoperative day 5 gastrografin meal showing no leak with free flow into jejunum across the anastomosis . about 400 cases have been described in the english literature with a slight female preponderance . the availability of dynamic ct - scans has made the diagnosis of this rare and controversial condition much easier . normally , the sma leaves the aorta at an angle of 45 degrees , and it is through this aortomesenteric vascular angle that the third part of the duodenum passes through . a mass of fat and lymphatic tissue around the sma normally provides an adequate cushion to prevent extrinsic duodenal compression . any condition that narrows the aortomesenteric angle to approximately 6 degrees to 16 degrees can lead to smas . in our patient , he also had an accompanying 4-cm infrarenal aortic aneurysm that may have contributed to this narrowed angle . ahmed and taylor stressed the importance of differentiating smas from other conditions causing a similar clinical picture , such as scleroderma , systemic sclerosis , diabetes , myotonic dystrophy , and myxoedema . gondos suggested that the compression in these cases is brought on by dilatation and loss of muscle tone of the duodenum with secondary imprinting of the duodenum by the sma . , patients may present with features of acute gastric dilatation or proximal small bowel obstruction depending on whether the vomitus is bile - stained . the majority of cases are however chronic and present many times over several years for investigation of episodic upper abdominal pain with vomiting , anorexia , and early satiety . typically , the pain is relieved by postural changes that increase the angle between sma and the aorta . a high index of suspicion , in the presence of known risk factors , is the key to early diagnosis and avoiding complications like massive gastric dilatation , necrosis , or even perforation . investigations like abdominal x - rays usually reveal a dilated stomach and proximal duodenum but are nonspecific . endoscopy does not indicate the diagnosis but is important to rule out more common intraluminal causes of obstruction . barium or gastrografin contrast findings suggestive of smas are dilatation of the stomach , first and second parts of the duodenum , abrupt vertical or linear cutoff of contrast in the third part of the duodenum with normal mucosal folds , delay of 4 hours to 6 hours in gastroduodenal transit and reverse peristalsis in the proximal dilated duodenum . with the advent of modern ct scanners , the dynamic ct - scan is a safe , rapid , noninvasive diagnostic tool , which can clearly demonstrate the compression of the duodenum between the sma and aorta and the narrowed aortomesenteric angle . conservative treatment of smas involves nasogastric decompression , prokinetic agents to improve gastrointestinal transit , and reversing or removing the precipitating factor . nutrition may be either in the form of small , frequent feeds in the left lateral or knee - chest posture , or nasojejunal feeding , or total parenteral nutrition . the aim is to provide a high - calorie diet to increase mesenteric fat and expand the aortomesenteric angle . conservative management was attempted , but the patient was noncompliant and refused prolonged tube feeding . we , therefore , decided to perform a surgical bypass for a definitive cure . risk factors that predispose to superior mesenteric artery syndrome several surgical procedures have been described in the literature . strong 's technique of mobilizing the duodenum by dividing the ligament of treitz has the benefit of avoiding an anastomosis but an unacceptably high failure rate . gastrojejunostomy , due to inadequate decompression of the duodenum and the high risk of stomal ulceration , is controversial . duvie has described transposition of the third part of the duodenum anterior to the superior mesenteric vessels to permanently circumvent the obstruction . duodenojejunostomy , first described by staveley , remains the most frequently performed and favored operation over the years , with excellent results . subsequent successful results with acceptable operating time , faster recovery , and shorter hospitalization have been reported by other authors . in our case , laparoscopic duodenojejunostomy showed excellent results with rapid recovery and relief of symptoms until the final follow - up at 6 months . it gives the same results as open surgery with all the advantages of a minimally invasive procedure and should be the treatment of choice whenever surgical correction of smas is indicated .