case_images: PMC6854068_01
case_images: 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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case_images: fig0005
case_images: 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).
case_images: 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.
case_images: gr2.jpg
case_images: PMC6854068_01_gr2.jpg
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case_images: 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).
case_images: 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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case_images: PMC6854068_01_gr3.jpg
case_images: fig0015
case_images: 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).
case_images: 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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case_images: PMC6854068_01_gr4.jpg
case_images: fig0020
case_images: 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).
case_images: 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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case_images: PMC6854068_01_gr5.jpg
case_images: fig0025
case_images: Further follow-ups for clinical investigations are planned (Fig. 5).