Superior mesenteric artery syndrome - case series with review of literature - "the truth in between and the two extremes".

<b>Introduction:</b> Superior Mesenteric Artery Syndrome (SMAS) is a rare cause of upper intestinal obstruction characterizedby varying degrees of luminal obstruction of the third duodenal part. It can present suddenly or gradually with progressivesymptoms. Diagnosis is often delayed in view of nonspecific symptoms and extensive differential diagnosis. Considerablediscrepancy exists between radiological, endoscopic, and clinical features of SMAS. Cross-sectional imaging modalitieslike contrast-enhanced computed tomography (CECT) and MRI can identify the anatomical aberrations pathognomonic ofthe syndrome, besides helping to rule out other differential diagnoses. Upper gastro-intestinal (UGI) endoscopy can aid indecision-making and can help triage patients who need an upfront surgical approach. Patients with mild symptoms and nofeatures of luminal compromise on UGI endoscopy can be offered non-surgical treatment and monitored for their response.Surgery is indicated in patients with either significant upfront luminal compromise on UGI endoscopy or in cases that fail torespond to conservative management. Multiple surgical options have been described.<b>Case report:</b> In our case series, we present our experience with multiple cases diagnosed with SMAS. The two operated patients had quite different clinical presentations. One of the patients presented through the emergency department with features of upper gastrointestinal obstruction, whereas the other patient had chronic refractory symptoms not responding to maximal medical therapy. Both patients underwent a laparoscopic duodenojejunostomy with uneventful recovery. Three patients were chosen for conservative management and they responded well with significant improvement of their symptoms.<b>Conclusions:</b> SMAS is a rare diagnosis. The clinical presentation is very variable, and the list of differential diagnoses is large,explaining in part the delay in appropriate treatment. A thorough evaluation is needed to rule out other conditions that canmimic SMAS. Whenever indicated, laparoscopic duodenojejunostomy offers substantial sustained relief of symptoms.