Wilkie's syndrome, also known as Superior mesenteric artery (SMA) syndrome, is characterized by intestinal obstruction due to aortomesenteric duodenal compression caused by the reduction of the normal angle between (38-65º) to <25º or to a distance <8mm. The clinical presentation is usually non-specific (dyspepsia, postprandial abdominal pain) but sometimes presented as an acute intestinal obstruction syndrome (nausea, vomiting, gastric dilatation and abdominal distention). In this study, we report the case of a 22-year-old patient with a BMI of 16.5 who presented to the emergency room with acute intestinal obstruction caused by SAMS. He presented with massive gastric dilation that caused ischaemic necrosis of the gastric mucosa with subsequent perforation. It should be noted that only one case associated with Wilkie syndrome has been described in the literature. Therefore, given the rare incidence of complications associated with this syndrome and the favourable prognosis with conservative management, surgery is usually the last line of treatment. However, we must not forget that when necrosis appears, it is often extensive and requires urgent surgical treatment in most cases.

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient.

Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position.

The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Superior mesenteric artery syndrome (SMAS) is a rare but severe condition characterized by acute angulation of the aortomesenteric axis. It can result in compression and obstruction of the third part of the duodenum leading to life-threatening dilation and perforation of the proximal duodenum and stomach.

We report a rare case of a patient with postural abnormality secondary to multiple sclerosis and a borderline but normal aortomesenteric axis who developed SMAS following a paraesophageal hernia repair with Nissen fundoplication complicated by massive gastric dilation and perforation secondary due to a closed-loop-like foregut obstruction. The patient was managed with emergent damage control surgery and washout with delayed duodenojejunostomy for SMAS.

SMAS with partial obstruction can mimic common complications after Nissen fundoplication such as gas-bloat syndrome. SMAS with complete obstruction is a life-threatening surgical emergency. Postoperative weight loss, large hiatal hernia reduction, gas-bloat syndrome and postural changes in this patient may have contributed to an altered aortomesenteric axis and promoted the development of SMAS. Identifying possible predisposing factors should heighten vigilance and prompt radiological evaluation and surgical management to prevent life-threatening complications.

SMAS after Nissen fundoplication is a potentially life-threatening complication that presents with non-specific symptoms mimicking common complications like gas-bloat syndrome. A high index of suspicious should prompt early radiological evaluation in patients with predisposing factors.

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, resulting from the compression of the duodenum between superior mesenteric artery and aorta. This prospective registry aims to describe demographic, clinical, and outcome features of patients suffering from SMAS and to point out the indications for surgery.

Between 2008 and 2016, patients with chronic gastrointestinal symptoms and diagnosis of SMAS were included. Demographics, clinical presentation, diagnosis, and surgical outcome were recorded. Symptoms were investigated with a standardized questionnaire. The diagnosis was achieved through barium swallow, CT/MR angiography (aortomesenteric angle ≤ 22°, distance ≤ 8 mm), endoscopy. All patients underwent duodenojejunostomy ± distal duodenum resection. At follow-up, symptom score and barium swallow were re-evaluated.

Thirty-nine patients (11 M/28 F, median age 38 years, median BMI 17.8 kg/m²) were included. Barium swallow showed a gastroduodenal dilation in 57% of patients, and a delayed gastroduodenal emptying in 38%. Median aortomesenteric angle was 11° and distance was 5 mm. All patients underwent duodenojejunostomy, and in 32 patients, a distal duodenum resection was also performed. At a median follow-up of 47 months, the overall symptom score significantly dropped (10 vs. 32, p < 0.0001) and BMI increased (19.5 vs. 17.8, p < 0.0001). Barium swallow at 2 months postoperatively showed an improvement in terms of gastroduodenal dilation and emptying in 38% of patients with preoperative pathological findings.

SMAS is a rare condition that should be suspected in cases of chronic, refractory upper digestive symptoms, particularly in females with low BMIs. Surgical treatment may improve symptoms and quality of life, although it is not curative in all cases. ClinicalTrials.gov Identifier: NCT03416647.

Background Superior mesenteric artery syndrome (SMAS) results from the compression of the third part of the duodenum between the aorta and the proximal part of the superior mesenteric artery (SMA). Clinical presentation of SMAS is characterized by the dilatation of the proximal part of the third part of the duodenum. SMAS is a rare cause of the upper gastrointestinal system (UGS) obstruction. In this study, we aimed to present our clinical experience in the treatment of five patients with SMAS, which is a rare clinical condition requiring surgery. Patients and methods The retrospective study included five patients who were treated due to SMAS at our clinic between January 2010 and January 2014. Results All the patients were underweight, with a mean BMI of 15.73 (14-16). The clinical symptoms included epigastric pain after food intake, large volume bilious emesis, early satiety, failure to gain weight, indigestion, esophageal reflux, sense of fullness, and persistent weight loss. SMAS was diagnosed using barium meal studies, upper gastrointestinal endoscopy, abdominal ultrasonography, and CT angiography. Four patients underwent duodenojejunostomy and one patient was managed with gastrojejunostomy. No complication was observed during the postoperative period, and all the patients achieved significant improvement in symptoms. Conclusion SMAS is a rare cause of UGS obstruction, and the diagnosis of SMAS is often delayed. SMAS should be suspected in the differential diagnosis of the patients with unsubstantiated symptoms of persistent nausea, emesis, and significant weight loss.

Acute pancreatitis subsequent to Nissen fundoplication for gastroesophageal reflux disease (GERD) is an extremely rare adverse event. We describe a pediatric case of acute pancreatitis resulting from superior mesenteric artery syndrome (SMAS) and gas bloat after fundoplication. Gas bloat is one of the known postoperative complications after Nissen fundoplication. Poor nutrition status, which is often associated with severe pediatric GERD, is a risk factor for SMAS. In this case, development of gas bloat and SMAS led to the formation of a closed loop and increased intraluminal pressure of the duodenum and pancreatic duct. Many pediatric patients who need anti-reflux surgery face the risk of developing this entity. Preventive measures, such as treatment with prokinetics and frequent small-volume meals, should be considered until improvement of nutritional status after fundoplication.