Feasibility and Surgical Outcomes of Simultaneous Laparoscopic Management of Superior Mesenteric Artery Syndrome and Hiatus Hernia

Feasibility and Surgical Outcomes of Simultaneous Laparoscopic Management of Superior Mesenteric Artery Syndrome and Hiatus Hernia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Feasibility and Surgical Outcomes of Simultaneous Laparoscopic Management of Superior Mesenteric Artery Syndrome and Hiatus Hernia Tantawi Abdelnaem Mohamed, Ahmed Eid Zarif shehata This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7681741/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Superior mesenteric artery (SMA) syndrome, or Wilkie’s syndrome, is a rare cause of proximal intestinal obstruction resulting from compression of the third part of the duodenum between the SMA and the abdominal aorta. Its coexistence with hiatus hernia is extremely uncommon, complicating both diagnosis and management. Case Presentation: We report a 20-year-old female presenting with persistent vomiting, continuous regurgitation, chest discomfort, and significant weight loss. Her medical history included Helicobacter pylori infection, chronic gastritis, and gastroesophageal reflux disease, which were managed medically without long-term relief. Upper gastrointestinal endoscopy revealed diffuse gastritis and a Hill’s class II hiatus hernia, while contrast-enhanced CT scan demonstrated a reduced aortomesenteric angle (18°) and distance (6 mm) consistent with SMA syndrome. Management and Outcome: The patient underwent simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication. Postoperatively, she tolerated oral intake, experienced resolution of vomiting and reflux, and had an uneventful recovery. Follow-up confirmed sustained symptomatic relief and improved quality of life. Conclusion This case highlights the importance of considering SMA syndrome in patients with persistent vomiting and weight loss, and demonstrates the feasibility and efficacy of combined laparoscopic management for coexisting SMA syndrome and hiatus hernia. Surgery Pathology Internal Medicine Superior Mesenteric Artery Syndrome Hiatus Hernia GERD Laparoscopic Surgery Duodenojejunostomy Nissen Fundoplication Figures Figure 1 Figure 2 Figure 3 Introduction Superior mesenteric artery (SMA) syndrome, also known as Wilkie’s syndrome, is a rare cause of proximal intestinal obstruction resulting from compression of the third portion of the duodenum between the superior mesenteric artery and the aorta [ 1 , 2 ]. The key anatomical factor is a reduction in the aortomesenteric angle and distance, which normally measure 38°–65° and 10–28 mm, respectively[ 1 ].In SMA syndrome, these parameters decrease to 6°–25° and 2–8 mm, leading to partial or complete duodenal obstruction, most commonly associated with rapid weight loss or anatomical variations [ 2 ] Hiatus hernia, often associated with gastroesophageal reflux disease (GERD), involves herniation of the stomach through the esophageal hiatus of the diaphragm[ 3 ]. The coexistence of SMA syndrome and hiatus hernia is extremely uncommon, posing a diagnostic and therapeutic challenge. This case illustrates a 20-year-old female patient with persistent vomiting, continuous regurgitation, chest discomfort, and weight loss, ultimately diagnosed with both SMA syndrome and hiatus hernia, and successfully managed with simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication[ 4 ] Case Presentation A 20-year-old female initially presented with a history of Helicobacter pylori infection, which was successfully eradicated using first-line triple therapy consisting of omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily[ 5 ]. She also had a history of chronic gastritis and gastroesophageal reflux disease (GERD) for the past three years, for which she was maintained on omeprazole 20 mg once daily and a prokinetic agent, domperidone 10 mg three times daily[ 6 ]. During this period, she experienced Heartburn, persistent regurgitation, continuous vomiting, and unintentional weight loss, with her body weight decreasing to 50 kg. Following successful eradication therapy and management of GERD, her weight gradually increased to 60 kg. One year later, the patient reported a recurrence of GERD symptoms, now accompanied by persistent regurgitation, chest pain, and constipation. An upper gastrointestinal endoscopy was performed, revealing a normal oropharynx, an irregular Z-line with a mucosal break < 5 mm consistent with GERD Class B (Los Angeles classification), a hiatus hernia (Hill’s Class 2), and diffuse erythema of the stomach consistent with diffuse gastritis. The pyloric ring and duodenum appeared normal. Following the patient’s clinical deterioration, characterized by persistent vomiting and weight loss down to 48 kg, a contrast-enhanced CT scan of the abdomen was performed to further evaluate the underlying cause. The study demonstrated a mildly distended stomach, with distension of the pyloric region and duodenum. Notably, the aorto-mesenteric angle was reduced to 18 degrees, and the aorto-mesenteric distance measured 6 mm, findings which are highly suggestive of Superior Mesenteric Artery (SMA) Syndrome Treatment: preoperative laboratory investigations to assess her hematologic status and overall fitness for surgery. The results revealed mild microcytic, hypochromic anemia, suggestive of chronic nutritional deficiency or ongoing gastrointestinal blood loss. Her hemoglobin level was 11.0 g/dL (normal range: 12–16 g/dL), and hematocrit was 33.6% (normal range: 36–46%), both indicating a mild reduction in red cell mass. The mean corpuscular volume (MCV) measured 71.0 fL (normal range: 80–100 fL) and the mean corpuscular hemoglobin (MCH) was 23.3 pg (normal range: 27–33 pg), confirming a microcytic and hypochromic pattern. Additionally, the red cell distribution width (RDW) was elevated at 15.2% (normal range: 11.5–14.5%), consistent with anisocytosis, reflecting variability in red blood cell size. These findings were carefully considered in the preoperative optimization and perioperative management to minimize surgical risk and support postoperative recovery. Surgical Procedures: Following preoperative optimization, the patient underwent simultaneous laparoscopic management of Superior Mesenteric Artery (SMA) Syndrome and hiatus hernia. Duodenojejunostomy for SMA Syndrome: Under general anesthesia, the patient was positioned supine. Laparoscopic ports were inserted, and the duodenum and proximal jejunum were carefully mobilized. The compressed segment of the third portion of the duodenum was identified beneath the superior mesenteric artery. A side-to-side duodenojejunostomy was performed distal to the obstruction, ensuring a tension-free, wide-caliber anastomosis to restore normal passage of gastrointestinal contents. Hemostasis was confirmed, and the operative field was irrigated prior to closure[ 7 ]. Laparoscopic Nissen Fundoplication: (Hiatus Hernia Repair) Attention was then directed to the esophageal hiatus. The hernial sac was reduced into the abdominal cavity, and the esophageal hiatus was narrowed using interrupted non-absorbable sutures to prevent recurrence. The gastric fundus was mobilized, and a 360-degree fundoplication was performed around the distal esophagus. The wrap was secured with interrupted sutures, and its integrity and position were verified laparoscopically. Hemostasis was ensured, and the laparoscopic ports removed with closure of incisions[ 7 , 8 , 10 ]. Postoperative course and outcome The patient’s postoperative recovery was uneventful. She was managed with intravenous fluids, antibiotics, proton pump inhibitors, and analgesics. Oral intake was resumed gradually, progressing from clear fluids to a soft diet, which she tolerated well without recurrence of vomiting or reflux. Abdominal pain and distension resolved, bowel function normalized, and surgical wounds healed without complications. Discussion Superior mesenteric artery (SMA) syndrome is a rare clinical entity caused by compression of the third part of the duodenum between the SMA and the aorta due to a reduced aorto-mesenteric angle and distance. It is often associated with significant weight loss and can mimic other gastrointestinal disorders, making the diagnosis challenging[ 1 ]. Computed tomography with contrast is considered the gold standard for confirming the diagnosis, as it allows direct visualization of the narrowed aorto-mesenteric angle and duodenal compression. Hiatus hernia, on the other hand, is a more common condition that frequently coexists with gastroesophageal reflux disease (GERD). The simultaneous presence of SMA syndrome and hiatus hernia in the same patient is extremely uncommon, with very few reports available in the literature. This overlap can complicate both diagnosis and management, as both conditions may present with overlapping symptoms such as vomiting, reflux, and weight loss [ 2 , 4 , 6 ] In our case, the patient presented with features of both SMA syndrome and GERD secondary to a hiatus hernia. The diagnosis was established using upper gastrointestinal endoscopy and contrast-enhanced CT scan. Initial medical therapy, including proton pump inhibitors and prokinetics, provided only temporary relief, and the persistence of symptoms along with significant weight loss necessitated surgical intervention Laparoscopic duodenojejunostomy has become the procedure of choice for SMA syndrome, offering definitive bypass of the obstructed duodenal segment with excellent long-term results. Similarly, laparoscopic Nissen fundoplication is widely accepted as the gold standard for surgical management of GERD with associated hiatus hernia. Performing both procedures in the same setting is technically feasible and avoids the morbidity of two separate operations[ 7 ] Our patient tolerated the combined procedures well, with uneventful recovery, resolution of obstructive and reflux symptoms, and gradual weight gain during follow-up. This outcome is consistent with reports in the literature that highlight the safety and efficacy of minimally invasive approaches in managing complex and combined gastrointestinal pathologies. Conclusion This case underscores the clinical challenge of diagnosing SMA syndrome, especially when it coexists with hiatus hernia and GERD. It demonstrates that simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication is a safe and effective approach, resulting in symptom resolution, weight gain, and improved patient quality of life. Early recognition and combined surgical management are key to optimal outcomes. Declarations Consent Statement: The patient has provided informed consent to participate in this study and for the clinical case to be published The study was approved by the relevant Ethical Committee. The authors confirm that all research was performed in accordance with relevant guidelines and regulations, and consent was obtained from all participants and/or their legal guardians Funding Statement: The authors received no financial support for the research, authorship, and/or publication of this article Authors' Contributions: Tantawi Abdelnaem Mohamed: Conceptualization, Methodology, Software. Ahmed Eid Zarif Shehata: Data curation, Writing – Original Draft, Reviewing and Editing. References Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg. 2007;24(3):149–156. doi:10.1159/000103166 Al-Hayani R, Al-Mashdali AF, Al-Absi H. Superior Mesenteric Artery Syndrome: Case Report and Literature Review. Cureus. 2022;14(1):e21234. doi:10.7759/cureus.21234 Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601–616. doi:10.1016/j.bpg.2008.03.005 Watanabe T, Yamasaki M, Sato M, et al. Coexistence of superior mesenteric artery syndrome and hiatal hernia: a case report. Surg Case Rep. 2017;3:105. doi:10.1186/s40792-017-0392-1 Malfertheiner P, Megraud F, O’Morain CA, et al. Management of Helicobacter pylori infection—the Maastricht V/Florence Consensus Report. Gut. 2017;66:6–30. doi:10.1136/gutjnl-2016- Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease. Am J Gastroenterol. 2006;101:1900–1920. doi:10.1111/j.1572-0241.2006.00630.x Kumpf VJ, Resnick MB. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Surg Endosc. 2010;24:3159–3163. doi:10.1007/s00464-010-1151-5 Campos GM, et al. Laparoscopic Nissen fundoplication: indications and outcomes. World J Gastroenterol. 2014;20(32):11225–11233. doi:10.3748/wjg.v20.i32.11225 Unal B, Aktas A, Kemal G, et al. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol. 2005;11:90–95. Kocakusak A, et al. Simultaneous surgical management of SMA syndrome and hiatal hernia. Surg Laparosc Endosc Percutan Tech. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7681741","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":518883095,"identity":"eec37006-961e-46f8-9896-3572c8022036","order_by":0,"name":"Tantawi Abdelnaem Mohamed","email":"","orcid":"","institution":"Minia University- Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tantawi","middleName":"Abdelnaem","lastName":"Mohamed","suffix":""},{"id":518883594,"identity":"0a997eec-077a-4123-a17a-1bf11eaa8881","order_by":1,"name":"Ahmed Eid Zarif shehata","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0004-1295-5776","institution":"Bashkir state medical university","correspondingAuthor":true,"prefix":"","firstName":"Ahmed","middleName":"Eid Zarif","lastName":"shehata","suffix":""}],"badges":[],"createdAt":"2025-09-22 16:21:50","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7681741/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7681741/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92053357,"identity":"d884c8ac-7627-4a3e-8e59-2e5ee05e8d02","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":157033,"visible":true,"origin":"","legend":"","description":"","filename":"Document35.docx","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/bf6cc57e0d020975326e40c7.docx"},{"id":92053370,"identity":"21f5d838-45a6-4ca5-94ef-70a74aa77269","added_by":"auto","created_at":"2025-09-24 06:23:22","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7681741.json","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/ff6b4d0e106e6dd10be9ba79.json"},{"id":92053358,"identity":"1f3471ba-38f3-47aa-89af-4a6e07791319","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":29695,"visible":true,"origin":"","legend":"","description":"","filename":"rs76817410enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/fa4525a084cfa9581bb6da0a.xml"},{"id":92053376,"identity":"7bdd1530-4e75-4083-8dd4-cbb54fc5e893","added_by":"auto","created_at":"2025-09-24 06:23:22","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46720,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/b09de7da26d550aeb55aa3ae.png"},{"id":92053356,"identity":"67c2bf37-cb10-4036-97fe-1de6f9ca4708","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60664,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/2235ff09caa31da00caebf01.png"},{"id":92053362,"identity":"ca74f262-4c52-406d-a403-b0e997028341","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":328274,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/aef8578c17a0b03911e5b153.png"},{"id":92053354,"identity":"e08545e1-4233-4698-9954-6c4bcefdaef2","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28445,"visible":true,"origin":"","legend":"","description":"","filename":"rs76817410structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/21090b3306dc9bef36bdc8a1.xml"},{"id":92053371,"identity":"ef4e09a6-71a8-4e87-891d-f1e06a40d47a","added_by":"auto","created_at":"2025-09-24 06:23:22","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32796,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/56ded977d07b9da3805d184e.html"},{"id":92053347,"identity":"f75e77d8-f9d6-44c1-b0a8-f9d87d7a6932","added_by":"auto","created_at":"2025-09-24 06:23:21","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32673,"visible":true,"origin":"","legend":"\u003cp\u003eContrast-enhanced CT scan showing a reduced aorto-mesenteric angle (18°) and decreased distance (6 mm) between the aorta and the superior mesenteric artery, consistent with superior mesenteric artery syndrome.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/513d01207d79ef58b8a94e62.jpeg"},{"id":92054225,"identity":"ccb3ab24-1c6a-4b23-a48f-d60d73f7c223","added_by":"auto","created_at":"2025-09-24 06:31:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41469,"visible":true,"origin":"","legend":"\u003cp\u003eAxial contrast-enhanced CT scan showing gastric and proximal duodenal dilatation proximal to the compression site of the third part of the duodenum between the aorta and the superior mesenteric artery, confirming the diagnosis of superior mesenteric artery syndrome.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/e9e149ee2da05678cc7d34a8.jpeg"},{"id":92053378,"identity":"4da09b81-ea50-4f17-8880-0262d39bf8ff","added_by":"auto","created_at":"2025-09-24 06:23:22","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1012234,"visible":true,"origin":"","legend":"\u003cp\u003eLaparoscopic view showing side-to-side duodenojejunostomy\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/483e5a6807e6371090c32b12.jpeg"},{"id":92054226,"identity":"a7622ee1-e065-42b9-be08-5a4309fa8e31","added_by":"auto","created_at":"2025-09-24 06:31:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1439145,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7681741/v1/0910b238-cf2f-4388-a5e9-4b3407bbe91d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFeasibility and Surgical Outcomes of Simultaneous Laparoscopic Management of Superior Mesenteric Artery Syndrome and Hiatus Hernia\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuperior mesenteric artery (SMA) syndrome, also known as Wilkie\u0026rsquo;s syndrome, is a rare cause of proximal intestinal obstruction resulting from compression of the third portion of the duodenum between the superior mesenteric artery and the aorta [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The key anatomical factor is a reduction in the aortomesenteric angle and distance, which normally measure 38\u0026deg;\u0026ndash;65\u0026deg; and 10\u0026ndash;28 mm, respectively[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].In SMA syndrome, these parameters decrease to 6\u0026deg;\u0026ndash;25\u0026deg; and 2\u0026ndash;8 mm, leading to partial or complete duodenal obstruction, most commonly associated with rapid weight loss or anatomical variations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHiatus hernia, often associated with gastroesophageal reflux disease (GERD), involves herniation of the stomach through the esophageal hiatus of the diaphragm[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The coexistence of SMA syndrome and hiatus hernia is extremely uncommon, posing a diagnostic and therapeutic challenge.\u003c/p\u003e\u003cp\u003eThis case illustrates a 20-year-old female patient with persistent vomiting, continuous regurgitation, chest discomfort, and weight loss, ultimately diagnosed with both SMA syndrome and hiatus hernia, and successfully managed with simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 20-year-old female initially presented with a history of Helicobacter pylori infection, which was successfully eradicated using first-line triple therapy consisting of omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. She also had a history of chronic gastritis and gastroesophageal reflux disease (GERD) for the past three years, for which she was maintained on omeprazole 20 mg once daily and a prokinetic agent, domperidone 10 mg three times daily[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. During this period, she experienced Heartburn, persistent regurgitation, continuous vomiting, and unintentional weight loss, with her body weight decreasing to 50 kg. Following successful eradication therapy and management of GERD, her weight gradually increased to 60 kg.\u003c/p\u003e\u003cp\u003eOne year later, the patient reported a recurrence of GERD symptoms, now accompanied by persistent regurgitation, chest pain, and constipation. An upper gastrointestinal endoscopy was performed, revealing a normal oropharynx, an irregular Z-line with a mucosal break\u0026thinsp;\u0026lt;\u0026thinsp;5 mm consistent with GERD Class B (Los Angeles classification), a hiatus hernia (Hill\u0026rsquo;s Class 2), and diffuse erythema of the stomach consistent with diffuse gastritis. The pyloric ring and duodenum appeared normal.\u003c/p\u003e\u003cp\u003eFollowing the patient\u0026rsquo;s clinical deterioration, characterized by persistent vomiting and weight loss down to 48 kg, a contrast-enhanced CT scan of the abdomen was performed to further evaluate the underlying cause. The study demonstrated a mildly distended stomach, with distension of the pyloric region and duodenum. Notably, the aorto-mesenteric angle was reduced to 18 degrees, and the aorto-mesenteric distance measured 6 mm, findings which are highly suggestive of Superior Mesenteric Artery (SMA) Syndrome\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTreatment:\u003c/h2\u003e\u003cp\u003epreoperative laboratory investigations to assess her hematologic status and overall fitness for surgery. The results revealed mild microcytic, hypochromic anemia, suggestive of chronic nutritional deficiency or ongoing gastrointestinal blood loss. Her hemoglobin level was 11.0 g/dL (normal range: 12\u0026ndash;16 g/dL), and hematocrit was 33.6% (normal range: 36\u0026ndash;46%), both indicating a mild reduction in red cell mass. The mean corpuscular volume (MCV) measured 71.0 fL (normal range: 80\u0026ndash;100 fL) and the mean corpuscular hemoglobin (MCH) was 23.3 pg (normal range: 27\u0026ndash;33 pg), confirming a microcytic and hypochromic pattern. Additionally, the red cell distribution width (RDW) was elevated at 15.2% (normal range: 11.5\u0026ndash;14.5%), consistent with anisocytosis, reflecting variability in red blood cell size. These findings were carefully considered in the preoperative optimization and perioperative management to minimize surgical risk and support postoperative recovery.\u003c/p\u003e\u003cp\u003eSurgical Procedures:\u003c/p\u003e\u003cp\u003eFollowing preoperative optimization, the patient underwent simultaneous laparoscopic management of Superior Mesenteric Artery (SMA) Syndrome and hiatus hernia.\u003c/p\u003e\u003cp\u003eDuodenojejunostomy for SMA Syndrome:\u003c/p\u003e\u003cp\u003eUnder general anesthesia, the patient was positioned supine. Laparoscopic ports were inserted, and the duodenum and proximal jejunum were carefully mobilized. The compressed segment of the third portion of the duodenum was identified beneath the superior mesenteric artery. A side-to-side duodenojejunostomy was performed distal to the obstruction, ensuring a tension-free, wide-caliber anastomosis to restore normal passage of gastrointestinal contents. Hemostasis was confirmed, and the operative field was irrigated prior to closure[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eLaparoscopic Nissen Fundoplication: (Hiatus Hernia Repair)\u003c/p\u003e\u003cp\u003eAttention was then directed to the esophageal hiatus. The hernial sac was reduced into the abdominal cavity, and the esophageal hiatus was narrowed using interrupted non-absorbable sutures to prevent recurrence. The gastric fundus was mobilized, and a 360-degree fundoplication was performed around the distal esophagus. The wrap was secured with interrupted sutures, and its integrity and position were verified laparoscopically. Hemostasis was ensured, and the laparoscopic ports removed with closure of incisions[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePostoperative course and outcome\u003c/h3\u003e\n\u003cp\u003eThe patient\u0026rsquo;s postoperative recovery was uneventful. She was managed with intravenous fluids, antibiotics, proton pump inhibitors, and analgesics. Oral intake was resumed gradually, progressing from clear fluids to a soft diet, which she tolerated well without recurrence of vomiting or reflux. Abdominal pain and distension resolved, bowel function normalized, and surgical wounds healed without complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSuperior mesenteric artery (SMA) syndrome is a rare clinical entity caused by compression of the third part of the duodenum between the SMA and the aorta due to a reduced aorto-mesenteric angle and distance. It is often associated with significant weight loss and can mimic other gastrointestinal disorders, making the diagnosis challenging[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Computed tomography with contrast is considered the gold standard for confirming the diagnosis, as it allows direct visualization of the narrowed aorto-mesenteric angle and duodenal compression.\u003c/p\u003e\u003cp\u003eHiatus hernia, on the other hand, is a more common condition that frequently coexists with gastroesophageal reflux disease (GERD). The simultaneous presence of SMA syndrome and hiatus hernia in the same patient is extremely uncommon, with very few reports available in the literature. This overlap can complicate both diagnosis and management, as both conditions may present with overlapping symptoms such as vomiting, reflux, and weight loss [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn our case, the patient presented with features of both SMA syndrome and GERD secondary to a hiatus hernia. The diagnosis was established using upper gastrointestinal endoscopy and contrast-enhanced CT scan. Initial medical therapy, including proton pump inhibitors and prokinetics, provided only temporary relief, and the persistence of symptoms along with significant weight loss necessitated surgical intervention\u003c/p\u003e\u003cp\u003eLaparoscopic duodenojejunostomy has become the procedure of choice for SMA syndrome, offering definitive bypass of the obstructed duodenal segment with excellent long-term results. Similarly, laparoscopic Nissen fundoplication is widely accepted as the gold standard for surgical management of GERD with associated hiatus hernia. Performing both procedures in the same setting is technically feasible and avoids the morbidity of two separate operations[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOur patient tolerated the combined procedures well, with uneventful recovery, resolution of obstructive and reflux symptoms, and gradual weight gain during follow-up. This outcome is consistent with reports in the literature that highlight the safety and efficacy of minimally invasive approaches in managing complex and combined gastrointestinal pathologies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the clinical challenge of diagnosing SMA syndrome, especially when it coexists with hiatus hernia and GERD. It demonstrates that simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication is a safe and effective approach, resulting in symptom resolution, weight gain, and improved patient quality of life. Early recognition and combined surgical management are key to optimal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConsent Statement: The patient has provided informed consent to participate in this study and for the clinical case to be published\u003c/p\u003e\u003cp\u003eThe study was approved by the relevant Ethical Committee. The authors confirm that all research was performed in accordance with relevant guidelines and regulations, and consent was obtained from all participants and/or their legal guardians\u003c/p\u003e\u003ch2\u003eFunding Statement:\u003c/h2\u003e\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article\u003c/p\u003e\u003ch2\u003eAuthors' Contributions:\u003c/h2\u003e\u003cp\u003eTantawi Abdelnaem Mohamed: Conceptualization, Methodology, Software.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAhmed Eid Zarif Shehata: Data curation, Writing \u0026ndash; Original Draft, Reviewing and Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWelsch T, B\u0026uuml;chler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg. 2007;24(3):149\u0026ndash;156. doi:10.1159/000103166\u003c/li\u003e\n\u003cli\u003eAl-Hayani R, Al-Mashdali AF, Al-Absi H. Superior Mesenteric Artery Syndrome: Case Report and Literature Review. Cureus. 2022;14(1):e21234. doi:10.7759/cureus.21234\u003c/li\u003e\n\u003cli\u003eKahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601\u0026ndash;616. doi:10.1016/j.bpg.2008.03.005\u003c/li\u003e\n\u003cli\u003eWatanabe T, Yamasaki M, Sato M, et al. Coexistence of superior mesenteric artery syndrome and hiatal hernia: a case report. Surg Case Rep. 2017;3:105. doi:10.1186/s40792-017-0392-1\u003c/li\u003e\n\u003cli\u003eMalfertheiner P, Megraud F, O\u0026rsquo;Morain CA, et al. Management of Helicobacter pylori infection\u0026mdash;the Maastricht V/Florence Consensus Report. Gut. 2017;66:6\u0026ndash;30. doi:10.1136/gutjnl-2016-\u003c/li\u003e\n\u003cli\u003eVakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease. Am J Gastroenterol. 2006;101:1900\u0026ndash;1920. doi:10.1111/j.1572-0241.2006.00630.x\u003c/li\u003e\n\u003cli\u003eKumpf VJ, Resnick MB. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. Surg Endosc. 2010;24:3159\u0026ndash;3163. doi:10.1007/s00464-010-1151-5\u003c/li\u003e\n\u003cli\u003eCampos GM, et al. Laparoscopic Nissen fundoplication: indications and outcomes. World J Gastroenterol. 2014;20(32):11225\u0026ndash;11233. doi:10.3748/wjg.v20.i32.11225\u003c/li\u003e\n\u003cli\u003eUnal B, Aktas A, Kemal G, et al. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol. 2005;11:90\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eKocakusak A, et al. Simultaneous surgical management of SMA syndrome and hiatal hernia. Surg Laparosc Endosc Percutan Tech. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Minia University- Faculty of Medicine ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Superior Mesenteric Artery Syndrome, Hiatus Hernia, GERD, Laparoscopic Surgery, Duodenojejunostomy, Nissen Fundoplication","lastPublishedDoi":"10.21203/rs.3.rs-7681741/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7681741/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSuperior mesenteric artery (SMA) syndrome, or Wilkie\u0026rsquo;s syndrome, is a rare cause of proximal intestinal obstruction resulting from compression of the third part of the duodenum between the SMA and the abdominal aorta. Its coexistence with hiatus hernia is extremely uncommon, complicating both diagnosis and management.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eWe report a 20-year-old female presenting with persistent vomiting, continuous regurgitation, chest discomfort, and significant weight loss. Her medical history included Helicobacter pylori infection, chronic gastritis, and gastroesophageal reflux disease, which were managed medically without long-term relief. Upper gastrointestinal endoscopy revealed diffuse gastritis and a Hill\u0026rsquo;s class II hiatus hernia, while contrast-enhanced CT scan demonstrated a reduced aortomesenteric angle (18\u0026deg;) and distance (6 mm) consistent with SMA syndrome.\u003c/p\u003e\u003ch2\u003eManagement and Outcome:\u003c/h2\u003e\u003cp\u003eThe patient underwent simultaneous laparoscopic duodenojejunostomy and Nissen fundoplication. Postoperatively, she tolerated oral intake, experienced resolution of vomiting and reflux, and had an uneventful recovery. Follow-up confirmed sustained symptomatic relief and improved quality of life.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis case highlights the importance of considering SMA syndrome in patients with persistent vomiting and weight loss, and demonstrates the feasibility and efficacy of combined laparoscopic management for coexisting SMA syndrome and hiatus hernia.\u003c/p\u003e","manuscriptTitle":"Feasibility and Surgical Outcomes of Simultaneous Laparoscopic Management of Superior Mesenteric Artery Syndrome and Hiatus Hernia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 06:23:16","doi":"10.21203/rs.3.rs-7681741/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa0f962f-d295-4414-ace4-6f5102293235","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55138944,"name":"Surgery"},{"id":55138945,"name":"Pathology"},{"id":55138946,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2025-09-24T06:23:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 06:23:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7681741","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7681741","identity":"rs-7681741","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}