The term SMA syndrome denotes a mechanical obstruction of the duodenum between the SMA and aorta. This syndrome can result in symptoms such as epigastralgia, abdominal distension, and vomiting of bile as a result of compression of the third portion of the duodenum between the SMA and aorta [1,2,3]. Characteristic manifestations include rapid weight loss, kyphosis, and abdominal aortic aneurysms. These patients may be bedridden for long periods, necessitating surgery [4,5,6]. Radiologic studies such as upper gastrointestinal barium study and abdomen CT are useful for diagnosing SMA syndrome [7]. CT imaging shows a mechanical obstruction of the duodenum between the SMA and aorta. The angle between the aorta and SMA is less than 25° and aorto-mesenteric distance less than 8 mm [8, 9]. Our patient met these criteria.

The treatment of choice for SMA syndrome is conservative, with total parenteral or enteral nutrition. This approach can promote an increase in the amount of fat in the retroperitoneum and mesentery. However, surgical intervention is needed if the patient’s condition does not improve with, or SMA syndrome recurs after, conservative treatment. Duodenojejunostomy, gastrojejunostomy, duodenum mobilization, and anterior transposition of the duodenum are recognized operative treatments for SMA syndrome. Recently, laparoscopic gastrojejunostomy or duodenojejunostomy has been performed on patients with SMA syndrome. In 1998, Gersin and Heniford reported the first laparoscopic duodenojejunostomy for SMA syndrome [10]. Currently, the most commonly performed laparoscopic procedure for SMA syndrome is laparoscopic duodenojejunostomy [11], whereas laparoscopic gastrojejunostomy is performed on patients with advanced gastric cancer and pyloric stenosis [12]. Because we have considerable experience of laparoscopic gastrojejunostomy for unresectable advanced gastric cancer, we elected to perform a laparoscopic gastrojejunostomy in the present case. Reduced port or single-incision laparoscopic surgery (SILS) has been adopted for management of SMA syndrome [7, 13]. However, the indications for SILS are controversial. Some studies have failed to demonstrate that SILS is superior to a conventional laparoscopic approach [14, 15]. In contrast, there have been several reports of favorable outcomes with SILS [16,17,18,19]. In the present case, we performed conventional laparoscopic surgery with five ports because we needed to close the common point of entry of the gastrojejunostomy and Braun anastomosis with a hand-sewn continuous running suture.

Additionally, we performed laparoscopic-assisted percutaneous endoscopic gastrostomy after creating the gastrojejunostomy. Laparoscopic-assisted percutaneous endoscopic gastrostomy is useful in minimizing inadvertent puncture of other organs and dealing with internal and external bleeding from the stomach. Moreover, this approach results in less postoperative pain and wound infection than does open gastrostomy. It also provides a satisfactory visual field during the procedure. Carlos et al. reported performing laparoscopic–percutaneous combined gastrostomy on 17 patients [20]. They found that this procedure is fast, feasible, safe, and cost effective. A laparoscopic-assisted approach enables safe construction of a percutaneous endoscopic gastrostomy after gastrojejunostomy.