Superior Mesenteric Artery Syndrome, also known as Wilkie's syndrome, mesenteric duodenal compression syndrome, or cast syndrome, is a rare entity defined as a compression of the third portion of the duodenum between the superior mesenteric artery and abdominal aorta, due to narrowing of the space between them. This syndrome was first described by the Austrian professor Carl Freiherr von Rokitansky in 1861 as autopsy finding. SMAS is primarily attributed to loss of the intervening mesenteric fat pad, leading to partial or complete duodenal obstruction. Several factors are associated with SMAS, mainly marked weight loss as a consequence of other diseases (cancer, bariatric surgery, chronic infections, and severe burns) but may also be congenital in conditions such as short ligament of Treitz or abnormal origin of the SMA, or associated with surgical interventions that distorts the anatomy as scoliosis correction or esophagectomy. Its manifestations are complex and non-specific, including postprandial epigastric pain (59%), nausea (40%), vomiting (50%), early satiety (32%), weight loss and anorexia (32%). SMAS may present as an acute syndrome or it may have an insidious onset with chronic symptoms. SMAS has an estimated prevalence in the general population that varies between 0.013 and 0.3%, and it most commonly affects young females.

This single-center prospective cohort study analysed 37 patients with Wilkie's syndrome who underwent infrarenal transposition of the SMA between January 2012 and December 2021. The indications for the surgery were severe weight loss and other gastrointestinal symptoms that were severely debilitating the patients' daily lives, along with radiological findings such as aortomesenteric angle < 25°, aortomesenteric distance <8mm and distention of the stomach and proximal part of the duodenum.

Of the 37 patients who underwent transposition of the SMA, 28 were female (75.6%) and 9 male (24.4%), mean ages 34.5 (14-62) and 27 (19-29), respectively. 7 patients (18.9%) concurrently had Dunbar syndrome (median arcuate ligament syndrome) which was treated in the same surgery. One patient (2.7%) was after a laparoscopic duodenojejunostomy with symptoms that relapsed 3 months postoperatively. Technical success of SMA transposition was achieved in all patients. The average weight gain in the first 6-month period was about 5.5kg. 1 patient (2.7%), 4 days postoperatively, had a lymphocele formed in the retroperitoneum which was successfully drained by a CT-guided percutaneous pigtail catheter 1 patient (2.7%) needed a re-laparotomy for adhesiolysis and omentoplasty, 1 patient (2.7%), 2-years post-operatively, had a proximal SMA stenosis up to 60% where drug-eluting balloon percutaneous transluminal angioplasty (DEB PTA) was performed successfully. Total percentage of complications equaled 8.1%, with 91.2% of the surgeries being complication free.

In cases of failure of conservative therapy in Wilkie's syndrome, we believe that transposition of SMA to the infrarenal part of the aorta can be considered a safe and feasible surgical option with more physiologically favorable outcomes as compared to gastrointestinal bypasses and their postoperative consequences. To our best knowledge, we believe that have the highest number of SMA transposition surgeries performed in a single center for the treatment of Wilkie's syndrome.

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