A 57-year-old male had a 3-year history of heartburn and a 1-year history of cough. The patient began to suffer heartburn, regurgitation, nausea, bloating, and vomiting 3 years ago. Acid could reflux to his mouth sometimes. He had to pad the head in order to reduce the incidence of reflux while sleeping. The patient began to cough while symptoms of regurgitation and heartburn aggravated 1 year ago.
The endoscopy result was esophagitis LA-C and atrophic gastritis with erosion. The patient was diagnosed as having GERD in a local hospital and received treatment of life adjustment and medicine including PPI and gastrointestinal prokinetic drug. The symptoms of cough, heartburn, and vomiting were relieved after taking drugs such as PPI in the beginning. However, the patient felt that symptoms were aggravated in the past 2 months and reoccurred after he stopping using drugs. He had a 5-kg weight loss during a period of 2 years. The body mass index of the patient was calculated to be 19.3 after hospital admission in our center. Physical examination revealed only abdominal slight tenderness.
The DeMeester score was 1.56 and the result did not meet the standard of acid reflux disease.
The lower esophageal sphincter pressure was lower than normal, all swallowing is invalid peristalsis.
Because the patient's 24-hour pH monitoring did not meet the standard of acid reflux disease, the patient completed upper gastrointestinal radiography to exclude other causes.
The results of the upper gastrointestinal radiography revealed esophageal reflux disease and possible gastritis; hence, SMA oppression syndrome (descending part of duodenal dilation, the contrast agent blocked through the tract, formation characteristic of penholder oppression) was considered (Fig. 1). Abdominal CT scan revealed a 25  angle between the SMA and the aorta, a distance of 7.8 mm.
The patient was diagnosed as having SMA syndrome. We combined laparoscopic Toupet fundoplication with duodenojejunostomy to manage SMA syndrome complicating extraesophageal symptoms.