PMC6854068_01
Upper gastrosintestinal contrast series (A) prior to laparoscopic surgery showing a large axial hernia with gastro-esophageal reflux (arrow) and (B) four weeks after successful laparoscopic hernia reduction, hiatoplasty and anterior hemifundoplication, showing successful hernia reduction and antireflux therapy.
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Esophageal contrast intestinal series showed a large axial hernia with gastro-esophageal reflux (Fig. 1A), compatible with an anatomical cause of gastro-esophageal-reflux-disease, and a normal gastric emptying. The postoperative upper gastrointestinal contrast series were unsuspicious (Fig. 1B).
Abdominal MRI showing (A) a dilated stomach (arrows), (B) a dilated duodenum (arrow) with change in caliber from before (*) to after (**) under passing the mesenteric root. Further an duodenal obstruction (C) between the superior mesenteric artery (*) and the abdominal aorta (**) can be seen. This duodenal obstruction is caused by a aorto-mesenteric angle of 14 , which is compared to normal angle values of 40-55 . These findings are compatible with a Wilkie's syndrome (superior mesenteric artery syndrome) diagnosis.
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This revealed a dilated stomach and duodenum, with a duodenal change in caliber underrunning the mesenteric root, compatible with a duodenal obstruction between the superior mesenteric artery and the abdominal aorta caused by a smaller angle between the two vessels of 14  (normal angle values 40-60 ) (Fig. 2).
Endoscopy showing (A) significant gastric food leftovers despite oral food waiver for approximately 24 h, (B) exclusion of a tangible anatomical luminal duodenal stricture and (C) radiological and endoscopic proof of an inconspicuous complete intestinal into the proximal jejunal loops.
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An upper gastrointestinal tract endoscopic study revealed significant gastric food leftovers despite oral food waiver for approximately 24 h, excluded a tangible anatomical luminal duodenal obstruction and provided a radiological and endoscopic proof of an inconspicuous intestinal passage into the proximal jejunal loops (Fig. 3).
Intraoperative view showing (A) manually pulled out (large arrow) duodenum from under the mesenteric root presenting a change in caliber and a clear demarcation line towards the jejunum (small arrow); (B) graphic illustration of the bypass operation between duodenum an proximal jejunum to obviate the duodenal stenosis at the height of the mesenteric root; (C) side-to-side duodeno-jejunostomy with a continuous double-layer resorbable monofilament suture.
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The patient underwent laparotomy with confirmation of a functional duodenal obstruction and duodenal change in caliber underpassing the mesenterial root (Fig. 4). A standardized side-to-side duodeno-jejunostomy with a continuous double-layer resorbable monofilament suture (PDS 4-0, Ethicon, Norderstedt, Germany) was performed to bypass the duodenal obstruction (Fig. 4).
Graphic illustration of (A) the normal angle of 40-60  between the superior mesenteric artery (SMA) and the aorta allowing a regular luminal diameter of the duodenum (D), in contrast to (B) a pathological low angle of <25  in Wilkie's syndrome resulting in duodenal compression, and (C) an angle of 14  in the here present case, resulting in a clinical relevant duodenal compression (arrow).
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Further follow-ups for clinical investigations are planned (Fig. 5).