he defined it as  a syndrome characterized by intermittent emesis with copious bile - stained material in asthenic people resulting from compression of the duodenum between the aorta and the superior mesenteric artery .  for the next 100 years , it was a controversial and often confusing diagnosis . in the 1960s , modern radiologic techniques allowed criteria to be established for the diagnosis of smas . in 1908 , stavely performed the first open duodenojejunostomy . in 1997 , laparoscopic techniques were introduced as an option in the operative management of smas . predisposing factors include wasting syndromes ( cancer , burns ) , pancreatitis , diseases of the spine ( lordosis , scoliosis ) , immobilization in a body cast or girdle , and dietary disorders ( anorexia nervosa , malabsorption).clinically , patients present with weight loss , bilious emesis , and postprandial epigastric pain . the pain is usually relieved by assuming a knee - chest position or when lying prone . the workup is often extensive because it is important to exclude other more common causes of gi obstruction . most patients will have an upper gi study , endoscopy , abdominal ultrasound , a computed tomography ( ct ) scan , and an aortogram . radiologic criteria include dilatation of the first and second portions of the duodenum , abrupt vertical and oblique compression of the mucosal folds , antiperistaltic flow of barium proximal to the obstruction producing to and fro movements , and delay in transit of 4 to 6 hours through the gastroduodenal region . arteriographic criteria include a significantly decreased aorto - sma angle of 6 to 25 ( nl=45 ) and a shortened aortomesenteric distance of 2 to 8 mm ( nl=10 to 20 mm ) . a decreased angle between the aorta and the sma can cause the duodenum to be pinched . the pathologic angle can either be congenital or it may be the result of weight loss with subsequent thinning of retroperitoneal and mesenteric fat . another abnormality is a short ligament of treitz , which wedges the duodenum into the aorto - sma angle . in terms of management , patients are initially treated medically with total parenteral nutrition ( tpn ) , intravenous fluids , frequent small meals with the patient in the knee - chest position , and promotility agents . laparoscopic surgery has recently been successfully used in the management of smas . in 1995 , massoud described laparoscopic severing of the ligament of treitz . in 1998 , gersin performed the first laparoscopic duodenojejunostomy . the patient is a 34-year - old male who had no medical problems and a past surgical history significant for an appendectomy . the patient complained of a 12-year history of abdominal pain . within the last 2 to 3 years , he had been experiencing daily vomiting episodes , nausea , and persistent periumbilical abdominal pain relieved by the knee - chest position . a presumptive diagnosis of smas was made and additional studies were obtained . an upper gi study and esophagogastroduodenoscopy ( egd ) failed to confirm the diagnosis . an aortogram demonstrated an aorto - sma angle of 5 to 10 degrees and an aorto - mesenteric distance of 5 mm . after consultation between the surgeon and the gastroenterologist , the diagnosis of smas was made . an open hasson technique was used and 3 other ports were placed . a wide kocher maneuver was performed . a duodenojejunostomy was created and 2 firings of a 30-mm endo - gia stapler were used to create the anastomosis . a running suture was used to close the resulting defect , which was bolstered by lembert sutures . on postoperative day 2 , he had a gastrograffin upper gastrointestinal study and small bowel follow through ( ugisbft ) that confirmed no leak or obstruction of the duodenojejunostomy . the patient was advanced to a liquid diet and discharged home on postoperative day 3 . upon follow - up , the patient is a 22-year - old male with a past medical history significant for asthma and food allergies and no previous surgeries . he had a 10-year history of abdominal pain and over the last 2 to 3 years had postprandial nausea , vomiting , and a 30 lb weight loss . he had had multiple previous hospitalizations that included consultations with an internist , gastroenterologist , neurologist , and an allergy specialist . a ct scan , ugisbft , egd , abdominal ultrasound , hydroxy iminodiacetic acid ( hida ) scan , and gastric emptying study were all normal . ultimately , he underwent an aortogram , which demonstrated a very oblique takeoff of the sma almost parallel to the aorta , which equaled an angle of zero . he had a repeat ct scan that showed a narrowed duodenum as it crossed between the aorta and the sma . a repeat egd showed a dilated duodenum and confirmed the narrowed segment of duodenum . based on this constellation of findings , an extensive kocher maneuver was performed , and the anastomosis was completed in a retrocolic fashion . he was taken back to the operating room on postoperative day 2 for re - exploration . on postoperative day 4 , he had a gastrograffin ugisbft that showed no leak or obstruction . he was advanced to a liquid diet and discharged home . on follow - up , the patient was feeling well , had resolution of his symptoms , and had gained 20 lbs . because smas is a rare condition , no randomized , controlled trials have been conducted to compare operative procedures . that procedure has largely been abandoned due to associated complications including dumping syndromes , blind loop syndrome , and marginal ulceration . lysis of the ligament of treitz has been used successfully in many cases . in 1958 , strong first described the procedure . in 1961 , martorell demonstrated its success on a 35-year - old man with smas . a major advantage of the procedure is the avoidance of a gastrointestinal anastomosis . in terms of laparoscopic treatment , massoud described a series of 4 patients with smas who were treated with laparoscopic severing of the ligament of treitz . he described an extensive dissection including the retropancreatic space , the superior paraduodenal fossa , and the posterior surface of the superior mesenteric vessels . once those areas have been taken down , the duodenum is able to drop away from the aorto - sma junction . duodenojejunostomy is the third surgical option and can be used when either of the other operations fails . in 1908 , stavely performed the first successful duodenojejunostomy . in 1976 , appel et al reported an accumulated series of 36 patients with smas who were treated surgically . in their series , 100% of the patients treated with a duodenojejunostomy were cured , whereas only 79% of the patients treated with lysis of the ligament of treitz were cured . in 1998 ,
objectives : the differential diagnosis of intestinal obstruction includes mechanical obstruction , obstruction secondary to systemic disease , and idiopathic intestinal pseudo - obstruction . the causes of these are extensive ; however , the majority of cases involve a mechanical cause . 
 superior mesenteric artery syndrome ( smas ) is a rare and controversial form of mechanical obstruction with just over 300 well - defined cases described in the literature . 
 the diagnosis is often difficult to establish , even after surgery . in addition , this syndrome sometimes may be managed conservatively , leaving a definitive diagnosis unproven . 
 we describe herein 2 patients with smas successfully treated with laparoscopic duodenojejunostomy.methods:two cases of smas occurred in young men ages 23 and 34 . 
 the workup included a consultation with a gastroenterologist , an upper gastrointestinal ( gi ) endoscopy , upper gi series with small bowel follow - through , computed tomography scan , ultrasound of the abdomen , and abdominal aortogram . 
 this diagnosis was established after consultation with the surgeon and the gastroenterologist in each case.results:laparoscopic duodenojejunostomy was performed in each case , and both patients have had complete resolution of their preoperative symptoms.conclusions:a laparoscopic approach to the management of superior mesenteric artery syndrome is a reasonable and successful way of treating these patients .