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Greaser J, Nasrullah A, Thornburgh C. I saw the "hook" sign of median arcuate ligament syndrome. Clin Imaging 2024; 113:110249. [PMID: 39106656 DOI: 10.1016/j.clinimag.2024.110249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/09/2024]
Abstract
The hook sign is a radiologic finding best appreciated on a sagittal view of the celiac artery with computed tomography (CT) that indicates compression of the celiac artery. It refers to the hooked-shape of the proximal celiac artery caused by extrinsic compression by the median arcuate ligament. When seen in a patient with concurrent abdominal symptoms, it suggests median arcuate ligament syndrome (MALS). We saw the sign in a 15-year-old male via duplex ultrasonography and abdominal CT. He underwent laparoscopic release of the median arcuate ligament and had full resolution of his symptoms at follow-up.
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Affiliation(s)
- Josh Greaser
- School of Medicine, University of Missouri, Columbia, MO, United States of America.
| | - Ayesha Nasrullah
- School of Medicine, University of Missouri, Columbia, MO, United States of America; Department of Radiology, University of Missouri Healthcare, Columbia, MO, United States of America
| | - Cody Thornburgh
- School of Medicine, University of Missouri, Columbia, MO, United States of America; Department of Radiology, University of Missouri Healthcare, Columbia, MO, United States of America
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DeCicco J, Raja F, Ganesan S, Kim C, El-Hayek K. Pediatric Outcomes After Robotic Median Arcuate Ligament Release, Celiac Ganglionectomy, and Lymphadenectomy. J Pediatr Surg 2024:161664. [PMID: 39209688 DOI: 10.1016/j.jpedsurg.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a neurovascular disorder characterized by gastrointestinal symptoms due to celiac artery and ganglion compression. Limited literature primarily focuses on adults. This study aims to characterize clinical and histopathologic findings in pediatric MALS. METHODS Patients <18 years undergoing robotic MAL release, celiac ganglionectomy, and lymphadenectomy from 2020 to 2024 were evaluated. Clinical and histopathologic outcomes were analyzed. RESULTS Twelve patients met inclusion criteria and were reviewed (15.7 ± 1.2 years, 75% female, BMI 20.9 [18.6-24.0] kg/m2). Comorbidities included depression/anxiety (83%), postural orthostatic tachycardia syndrome (POTS) (50%), gastroesophageal reflux disease (GERD) (50%), nutrition support (50%), mast cell activation syndrome (MCAS) (42%), hypermobile Ehlers-Danlos syndrome (hEDS) (42%), other vascular compression syndromes (33%). All patients who received preoperative celiac plexus block had temporary symptom relief (10/10). Mean operative time was 119.7 ± 22.4 min. No intraoperative complications, 30-day readmissions, reoperations, or complications occurred. Histopathologically, 92% had fibroadipose tissue, 100% had reactive lymph nodes, none had intraparenchymal nerves, and one had lipogranulomas. Median fibrosis scores were 1 [0.5-2] on H&E and 2 [1-2] on trichrome. Fibrosis score severity was not significantly associated with symptom improvement (χ2 = 3.67, p = 0.16). Median postoperative celiac artery velocity was 258.5 [192.5-350.5] cm/s with a median change of -80.5 [-106.1-+82.8] cm/s from preoperative 308.0 [229.3-344.0] cm/s (S = -5.0, p = 0.55). Those with lower preoperative velocities were more likely to have symptom improvement postoperatively (S = 19, p = 0.04). MALS symptoms improved in 83%; however, despite reporting "MALS pain" was improved, 64% (all female) had other comorbidities such as POTS, MCAS, hEDS, and colonic dysmotility contributing to other ongoing symptoms. CONCLUSION Robotic MALS surgery is safe and effective in pediatrics. Clinical improvement rates and fibrosis scoring are comparable to adults; however, findings reveal challenges with multiple comorbidities contributing to separate symptoms that may continue postoperatively, particularly in females. We recommend a multidisciplinary team approach in addressing comorbidities and optimizing medical and surgical care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jamie DeCicco
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, USA
| | - Fnu Raja
- Department of Pathology, The MetroHealth System, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Santhi Ganesan
- Department of Pathology, The MetroHealth System, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chong Kim
- Department of Physical Medicine and Rehabilitation, The MetroHealth System, Cleveland, OH, USA
| | - Kevin El-Hayek
- Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Almaguer J, Motamedi S, Murray D, Murray M, Murray R. Retrograde Arterial Flow Secondary to Median Arcuate Ligament Syndrome as a Contraindication to Gastroduodenal Artery Angioembolization. Cureus 2024; 16:e67130. [PMID: 39290939 PMCID: PMC11407704 DOI: 10.7759/cureus.67130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2024] [Indexed: 09/19/2024] Open
Abstract
Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) exerts external compression on the celiac trunk. Most cases are asymptomatic and diagnosed incidentally on radiographic imaging; however, some patients may experience gastrointestinal (GI) symptoms related to foregut ischemia and/or celiac neuropathy. In the following case, we present a patient with hemorrhagic peptic ulcer disease of the duodenum, which resulted in episodes of hemodynamic instability requiring multiple blood transfusions. Upon attempted transarterial angioembolization of the gastroduodenal artery (GDA), celiac stenosis and retrograde arterial flow from the superior mesenteric artery confirmed the presence of MALS. This rendered GDA angioembolization a contraindication, as the GDA became the dominant arterial supply for the distal celiac organs. The patient then received open surgical MAL release with concurrent surgical ligation of the hemorrhaging duodenal artery, which resolved his symptoms without the need for further intervention.
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Affiliation(s)
- Joey Almaguer
- Radiology, Texas Tech University Health Sciences Center, Amarillo, USA
| | - Sheedeh Motamedi
- Radiology, Texas Tech University Health Sciences Center, Lubbock, USA
| | | | | | - Richard Murray
- Diagnostic and Interventional Radiology, Northwest Texas Healthcare System, Amarillo, USA
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Gao Z, Vithran DTA, Hu X. Recurrent myocardial infarction in a patient with median arcuate ligament syndrome: a case report and literature review. J Int Med Res 2024; 52:3000605241271891. [PMID: 39192603 DOI: 10.1177/03000605241271891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024] Open
Abstract
Median arcuate ligament (MAL) syndrome, otherwise known as celiac artery compression syndrome, is rare and is characterized by celiac artery compression by the median arcuate ligament. We report a unique case of MAL syndrome with recurrent myocardial infarction as the primary manifestation, and offer new pathophysiological insights. A man in his early 50s experienced recurrent upper abdominal pain, electrocardiographic changes, and elevated troponin concentrations, which suggested myocardial infarction. Contrast-enhanced computed tomography showed considerable celiac artery stenosis due to MAL syndrome. The patient was diagnosed with MAL syndrome and acute myocardial infarction. He declined revascularization owing to economic constraints, and opted to have conservative treatment with Chinese herbal extracts and medications. He succumbed to sudden cardiac death during a subsequent abdominal pain episode. The findings from this case show that MAL syndrome can present with recurrent myocardial infarction rather than typical intestinal angina symptoms. The pathophysiological link may involve intestinal and cardiac ischemia. An accurate diagnosis and appropriate management of MAL syndrome require careful evaluation and investigation.
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Affiliation(s)
- Zhen Gao
- Cardiovascular Center, Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan, China
| | - Djandan Tadum Arthur Vithran
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoyong Hu
- The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Ward EP, Vincent-Sheldon S, Tolat P, Kulkarni N, Aldakkak M, Budithi R, Clarke CN, Tsai S, Evans DB, Christians KK. Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy. Surgery 2024; 175:1386-1393. [PMID: 38413302 DOI: 10.1016/j.surg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut. METHODS All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]). RESULTS Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction. CONCLUSION Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.
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Affiliation(s)
- Erin P Ward
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT.
| | | | | | | | | | | | | | - Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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Kakavand B, Burns RC, Centner A, Casas-Melley A. Median Arcuate Ligament Syndrome in Children: A Single-Center Experience. Cureus 2024; 16:e57184. [PMID: 38681309 PMCID: PMC11056100 DOI: 10.7759/cureus.57184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Data on median arcuate ligament syndrome (MALS) in children are scant. It is postulated that MALS can cause chronic abdominal pain. It is unclear what percentage of children with this condition are symptomatic and what comorbidities are associated with this syndrome. METHODS In this retrospective study, data on consecutive patients in a single center diagnosed coincidentally with MALS during routine echocardiogram were reviewed. Symptom burden, comorbidities, and the effect of anthropometric indices on MALS were investigated. Descriptive statistics and nonparametric tests were used to describe the findings and to compare variables with normal distribution. RESULTS Between 2013 and 2020, there were 82 children, 55 females (67%), mean age 13.9 ± 3.2 years, with MALS and complete record. Mean velocity across the stenotic area was 2.6 ± 0.4 m/s. Forty-six patients (57%) had abdominal pain. Age, gender, weight, body mass index (BMI), and Doppler velocity had no statistically significant influence on symptom occurrence. Conversely, patients with joint hypermobility and symptoms of orthostatic intolerance were more likely to have abdominal pain from MALS. Of 24 patients with joint hypermobility, 18 patients had abdominal pain (p=0.027). Thirty-eight patients with orthostatic intolerance (OI) with MALS complained of abdominal pain vs 13 patients with OI and no abdominal pain (p=<0.0001). CONCLUSION Nearly half of patients with MALS had abdominal pain. Age, gender, weight, and the degree of stenosis had no statistically significant influence on symptom occurrence. OI, specifically postural orthostatic tachycardia syndrome (POTS), and joint hypermobility on exam predicted a higher propensity for abdominal pain in patients with MALS.
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Affiliation(s)
| | | | - Aliya Centner
- Medicine, University of Central Florida College of Medicine, Orlando, USA
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Skelly CL, Stiles-Shields C, Goldenthal H, Bohr N, Feldman E, Mak GZ, Drossos T. Median arcuate ligament syndrome: a cost analysis to determine the economic burden of a rarely diagnosed disease. Front Psychol 2024; 14:1166744. [PMID: 38292522 PMCID: PMC10824967 DOI: 10.3389/fpsyg.2023.1166744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Background Chronic abdominal pain (CAP) is a medical condition resulting in enormous economic burden and healthcare utilization costs. One understudied source of CAP is the median arcuate ligament syndrome (MALS). MALS is often not diagnosed and treated for a variety of reasons, including the fact that MALS is highly comorbid with psychological symptoms and psychiatric disorders similar to CAP. To better inform future work on the study of MALS, we undertook a pilot study to estimate the economic impact and public health burden of this condition. We hypothesized that MALS imposes a significant public health burden. Methods Pediatric and adult patients enrolled in a prospective study undergoing multidisciplinary evaluation and treatment for MALS at a tertiary care facility were invited to participate in a brief self-report survey, the Direct and Indirect Medical Care Impact of MALS Form, to capture health care resources including procedures, surgeries, health care visits, and absenteeism (school and work). To estimate costs from the Direct and Indirect Medical Care Impact of MALS Form, the medical care usage data self-reported by patients were converted to dollar value utilizing FSC-93 billing data and corresponding current procedural terminology (CPT) codes for procedures and provider visits one year prior to surgery and then following surgery. Descriptive analyses were conducted to characterize the sample in terms of demographics and reported absences from school and work. Results One hundred and nineteen patients (mean age = 30.9 ± 13.0) completed the questionnaires, yielding a 57% response rate. 82.4% (n = 98) of the participants were female and 90.8% (n = 108) were non-Hispanic/Latine white. The mean and median surgical follow-up periods were 5.3 and 5.4 years, respectively. Overall, median cost of provider and ancillary healthcare provider visits for each patient was (US)$19,119 including the pre-operative and post-operative visits. The mean cost for providers alone was (US)$28,908. Wilcoxon signed-ranks tests indicated that the postoperative missed number of days of school were significantly lower than the pre-surgical number of missed school days (Z = -3.36, p = 0.001). Similarly, there were significantly less missed work-days following surgery than before for the entire sample (Z = -2.86, p = 0.004). Conclusion Median arcuate ligament syndrome imposes a large economic burden on patients and the healthcare system. The current findings, although reflective of a homogenous population, are adding to a growing body of literature suggesting that healthcare disparities play a role in the low rates of diagnosis and treatment of MALS.
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Affiliation(s)
- Christopher L. Skelly
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - Colleen Stiles-Shields
- Institute for Juvenile Research, Department of Psychiatry, The University of Illinois at Chicago, Chicago, IL, United States
| | - Hayley Goldenthal
- Department of Psychiatry and Behavioral Sciences, University of Chicago Medicine, Chicago, IL, United States
| | - Nicole Bohr
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago Medicine, Chicago, IL, United States
- Department of Nursing Research, University of Chicago Medicine, Chicago, IL, United States
| | - Estee Feldman
- Department of Psychiatry and Behavioral Sciences, University of Chicago Medicine, Chicago, IL, United States
| | - Grace Zee Mak
- Department of Surgery, Section of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - Tina Drossos
- Department of Psychiatry and Behavioral Sciences, University of Chicago Medicine, Chicago, IL, United States
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Qasim A, Peesapati VSR, Patel J, Davidson J. Enigma of Bowel Angina: Unraveling Celiac Trunk Stenosis. Cureus 2023; 15:e40258. [PMID: 37440806 PMCID: PMC10335776 DOI: 10.7759/cureus.40258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
The celiac axis is commonly involved in conditions that cause the narrowing or blockage of a celiac artery atherosclerosis and other vascular disease. Celiac artery compression syndrome is defined as chronic abdominal pain occurring because of compression of the celiac artery commonly in middle-aged (40 to 60 years) females. Various etiologies include atherosclerosis of mesenteries vessels, pancreatitis, median arcuate ligament syndrome, and tumor invasion. It is an uncommon condition, and symptoms include post-prandial abdominal pain mostly in the epigastrium, weight loss, nausea, diarrhea, anorexia, and bloating. Patients are asymptomatic for a prolonged duration due to collateral blood supply to the bowel from the patent superior mesenteric and inferior mesenteric arteries. We present a case of a 67-year-old female who initially presented with signs and symptoms suggestive of small bowel obstruction, however, due to persistent abdominal pain, she underwent a CT scan suggestive of severe celiac trunk stenosis causing abdominal angina. The patient was managed conservatively and responded well with close follow-up.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, New York, USA
| | | | - Jay Patel
- Internal Medicine, BronxCare Health System, New York, USA
| | - Joshua Davidson
- Pulmonary and Critical Care Medicine, BronxCare Health System, New York, USA
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9
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Skelly CL, Mak GZ. Median arcuate ligament syndrome: surgical approaches to a rarely diagnosed and undertreated disease. J Vasc Surg 2023; 77:578-579. [PMID: 36681484 DOI: 10.1016/j.jvs.2022.11.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Christopher L Skelly
- Section of Vascular and Endovascular Surgery, Department of Surgery, the University of Chicago Medicine, Chicago, IL
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, the University of Chicago Medicine, Chicago, IL
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10
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Cruz SM, Srinivas S, Wala SJ, Head WT, Michalsky MP, Aldrink JH, Diefenbach KA. Robotic-assisted minimally invasive surgery: Foregut procedures in pediatric patients. Semin Pediatr Surg 2023; 32:151256. [PMID: 36746111 DOI: 10.1016/j.sempedsurg.2023.151256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | | | | | - W Taylor Head
- Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State School of Medicine, Columbus, OH, USA
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Jonas JP, Rössler F, Ghafoor S, Kobe A, Pfammatter T, Schlag C, Gutschow CA, Petrowsky H, Müller PC, Oberkofler CE. Surgical therapy of celiac axis and superior mesenteric artery syndrome. Langenbecks Arch Surg 2023; 408:59. [PMID: 36690823 PMCID: PMC9870837 DOI: 10.1007/s00423-023-02803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Compression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome. METHODS A systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up. RESULTS Twenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0-217) and 31 ml (21-50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1-12) for CAS and 5 days (1-10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms. CONCLUSION Failure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.
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Affiliation(s)
- J P Jonas
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - F Rössler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Ghafoor
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - A Kobe
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - T Pfammatter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - C Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - C A Gutschow
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - H Petrowsky
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - P C Müller
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C E Oberkofler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland.
- Vivévis AG-Visceral, Tumor, Robotic Surgery, Clinic Hirslanden, Zurich, Switzerland.
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Metz FM, Blauw JTM, Brusse-Keizer M, Kolkman JJ, Bruno MJ, Geelkerken RH. Systematic Review of the Efficacy of Treatment for Median Arcuate Ligament Syndrome. Eur J Vasc Endovasc Surg 2022; 64:720-732. [PMID: 36075541 DOI: 10.1016/j.ejvs.2022.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Since the first description of the median arcuate ligament syndrome (MALS), the existence for the syndrome and the efficacy of treatment for it have been questioned. METHODS A systematic review conforming to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted, with a broader view on treatment for MALS including any kind of coeliac artery release, coeliac plexus resection, and coeliac plexus blockage, irrespective of age. Online databases were used to identify papers published between 1963 and July 2021. The inclusion criteria were abdominal symptoms, proof of MALS on imaging, and articles reporting at least three patients. Primary outcomes were symptom relief and quality of life (QoL). RESULTS Thirty-eight studies describing 880 adult patients and six studies describing 195 paediatric patients were included. The majority of the adult studies reported symptom relief of more than 70% from three to 228 months after treatment. Two adult studies showed an improved QoL after treatment. Half of the paediatric studies reported symptom relief of more than 70% from six to 62 months after laparoscopic coeliac artery release, and four studies reported an improved QoL. Thirty-five (92%) adult studies and five (83%) paediatric studies scored a high or unclear risk of bias for the majority of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) items. The meaning of coeliac plexus resection or blockage could not be substantiated. CONCLUSION This systematic review suggests a sustainable symptom relief of more than 70% after treatment for MALS in the majority of adult and paediatric studies; however, owing to the heterogeneity of the inclusion criteria and outcome parameters, the risk of bias was high and a formal meta-analysis could not be performed. To improve care for patients with MALS the next steps would be to deal with reporting standards, outcome definitions, and consensus descriptions of the intervention(s), after which an appropriate randomised controlled trial should be performed.
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Affiliation(s)
- Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands.
| | - Juliëtte T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Marjolein Brusse-Keizer
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Jeroen J Kolkman
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Department of Gastroenterology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
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Vovchuk IM, Khromykh KV, Formanchuk TV, Chyhir IV. DUNBAR SYNDROME: CLINICAL MANIFESTATION IN ADULTS, DIAGNOSTIC PROBLEMS (CASE REPORT). WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1801-1804. [PMID: 35962702 DOI: 10.36740/wlek202207135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In this case we used CBC and biochemical tests, ECG, ultrasound of the abdominal cavity and heart, CT scan with and without IV contrast. Women with complains on recurrent severe abdominal pain in epigastric region and right part of the abdomen radiating to the back, nausea, vomiting. Making laboratory and instrumental tests for confirmation of the diagnosis. Surgical treatment of DS was performed and after one year of the follow up there were no complications. DS may mimic other medical conditions such as gallbladder diseases, gastritis/peptic ulcer, appendicitis, colorectal malignancy, hepatitis, atherosclerotic diseases etc. That is why DS is a diagnosis of exclusion. This case illustrates pathway to find correct diagnosis and improve management tactic.
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Affiliation(s)
- Igor M Vovchuk
- VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | | | | | - Iryna V Chyhir
- VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
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Cabral MD, Patel DR, Greydanus DE, Deleon J, Hudson E, Darweesh S. Medical perspectives on pediatric sports medicine–Selective topics. Dis Mon 2022; 68:101327. [DOI: 10.1016/j.disamonth.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Birkhold M, Khalifeh A, Nagarsheth K, Kavic SM. Median Arcuate Ligament Syndrome is Effectively Relieved with Minimally Invasive Surgery. JSLS 2022; 26:JSLS.2022.00067. [PMID: 36721735 PMCID: PMC9840215 DOI: 10.4293/jsls.2022.00067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Objective Median arcuate ligament (MAL) syndrome is a constellation of symptoms related to compression of the celiac artery trunk. Minimally invasive release of the ligament has been shown to improve these symptoms. This study describes one institution's experience with this procedure and reports on outcomes of minimally invasive release and patient quality of life. Methods We performed a retrospective chart review of all patients who underwent minimally invasive release of the MAL at our institution. Patients were mailed a survey consisting of the 36-Item Short Form and Visick questionnaires. If surveys were not returned after one month, patients were called and asked to complete them over the phone. Demographic and pre- and postoperative data were collected and analyzed. Results Eleven patients underwent a laparoscopic MAL release from January 1, 2015 to January 31, 2020. Most patients, 73%, reported epigastric pain as their primary symptom for a median of 18 months. All cases were successfully completed laparoscopically, with only one intraoperative complication. Mean hospital length of stay was 1.4 d. At the time of survey completion, the mean weight change was 2.3 kg. Additional interventions for resolution of symptoms and celiac artery stenosis were required for two patients. Surveys were completed by eight patients. A mean Visick score of 1.8 showed resolution or improved symptoms for all patients. SF-36 scores were highest for physical functioning, emotional well-being, and social functioning health areas. Conclusions Minimally invasive release of the MAL is a safe and effective surgery for patients suffering from MALS. Symptoms improved after adequate release of the ligament, with minimal morbidity and additional postoperative procedures needed.
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Affiliation(s)
- Megan Birkhold
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Ali Khalifeh
- Department of Surgery, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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16
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Abstract
Symptomatic celiac artery compression syndrome (CACS) or median arcuate ligament syndrome (MALS) is a controversial diagnosis that should be considered in patients with chronic abdominal pain of unknown etiology despite an extensive medical evaluation. Once suspected, patients should undergo mesenteric duplex ultrasound. Diagnosis is confirmed with elevated celiac artery velocities which normalize with deep inspiration followed by CT angiogram showing the typical "J-hook" conformation of the celiac artery. Patients should then undergo evaluation by a multi-disciplinary team to appropriately select and prepare patients for potential surgical treatment. Surgical options include release of the median arcuate ligament, with or without neurolysis of the celiac nerve plexus, and with or without concomitant revascularization procedures. Approaches can be open, laparoscopic, or robotic. Surgical treatment has an overall success rate of 70-80% with patients reporting improved abdominal pain and quality of life. Post-operatively, patients can have persistent or recurrent abdominal pain and should undergo re-evaluation for possible need for a revascularization procedure for stenosis of the celiac artery or celiac plexus block if the celiac artery flow is normalized. Additionally, some patients will have persistent pain consistent with functional gastrointestinal disorder (FGID) that will then require medical management. Psychiatric comorbidities have been identified as a predisposing factor that may predict poorer outcomes, and there are preliminary findings suggesting that patients with dysautonomia diagnoses may have worse outcomes as well.
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17
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Sultan SA, Acharya Y, Mustafa M, Hynes N. Two Decades of Experience With Chronic Mesenteric Ischaemia and Median Arcuate Ligament Syndrome in a Tertiary Referral Centre: A Parallel Longitudinal Comparative Study. Cureus 2021; 13:e20726. [PMID: 35047313 PMCID: PMC8759710 DOI: 10.7759/cureus.20726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background Chronic mesenteric ischaemia (CMI) and median arcuate ligament syndrome (MALS) have similar clinical presentations with surgical intervention as the mainstay of treatment. However, surgical response varies and is unpredictable. Therefore, we aim to evaluate the technical and clinical success rates of selective revascularisation in older patients with CMI and younger patients with MALS undergoing arcuate ligament decompression with celiac sympathectomy. Methods We conducted a retrospective single-centre longitudinal comparative study of all the patients who underwent surgery for symptoms of CMI and MALS from December 2002 to 2020 at our tertiary referral vascular centre. Our primary outcome was symptom-free survival post-intervention. The secondary outcomes were perioperative mortality, technical success, and all-cause mortality at 17 years. Results We operated on 28 patients; 17 patients with CMI (revascularisations with bypass) and 11 with MALS (decompression and celiac sympathectomy). All (100%) patients had technical success. There was no perioperative mortality. All the MALS patients had symptom-free survival following the procedure throughout follow-up. In contrast, three patients with CMI complained of recurring abdominal pain even after one year of the surgery. However, there was no further weight loss and none of them required any intervention. Conclusion Stratified management of CMI with revascularisation and open surgical decompression with celiac sympathectomy in MALS are effective treatments with favourable long-term outcomes.
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Affiliation(s)
- Sherif A Sultan
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL.,Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
| | - Yogesh Acharya
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL
| | | | - Niamh Hynes
- Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
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18
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Often Overlooked Diagnosis: Median Arcuate Ligament Syndrome as a Mimicker of Crohn's Disease. ACG Case Rep J 2021; 8:e00675. [PMID: 34722791 PMCID: PMC8549686 DOI: 10.14309/crj.0000000000000675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Median arcuate ligament syndrome occurs when the celiac artery and/or the celiac plexus nerves is compressed by the median arcuate ligament during expiration causing a variety of gastrointestinal symptoms. Here, we present a case of median arcuate ligament syndrome in a persistently symptomatic 35-year-old man that presented as a mimicker of Crohn's disease. Symptomatology, computed tomography angiography, and abdominal ultrasound Doppler were consistent with celiac artery compression syndrome. After surgical decompression of the ligament and removal of the celiac ganglion, he reported a definitive relief of abdominal pain and resolution of symptoms.
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19
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Stiles-Shields C, Osos S, Heilbrun A, Feldman ECH, Mak GZ, Skelly CL, Drossos T. Targeting Coping to Improve Surgical Outcomes in Pediatric Patients With Median Arcuate Ligament Syndrome: Feasibility Study. Front Psychol 2021; 12:695435. [PMID: 34744860 PMCID: PMC8569106 DOI: 10.3389/fpsyg.2021.695435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome leading to postprandial epigastric pain, nausea, and weight loss; it can be treated surgically. While most patients report improved quality of life following surgical intervention, 30% continue to experience chronic abdominal pain. Pre-surgical diagnoses of depression and/or anxiety have been found to significantly predict post-surgical: quality of life, highest experience of pain, anxiety, and parent- and self-reported coping strategies. As such, increasing the coping strategies of pediatric patients with MALS may impact their post-surgical outcomes. The purpose of the current study was to: (1) implement a pre-operative cognitive behavioral therapy protocol with a focus on psychoeducation and coping strategies; and (2) determine feasibility of a pre-surgical intervention for this population. Method: Children (<18 years of age) with a diagnosis of MALS who were eligible for surgical intervention were invited to participate in a 7-week in-person or video-based pre-surgical cognitive behavioral therapy intervention. Psychiatric comorbidities were assessed at baseline and post-surgery; patient-reported distress, pain interference and intensity, health-related quality of life, and health status were assessed at four time points (baseline, week 4, week 7, and post-surgery). Descriptive analyses were used to characterize the sample, assess feasibility outcomes (i.e., attrition rates), and explore symptom-based outcomes across time. Results: Twelve pediatric patients (M age = 15.2 ± 1.7; 91.7% female) and their parents (91.7% mothers) participated. Feasibility metrics based on protocol completion were exceeded for engagement at the stages of consent (68.4% vs. goal of ≥50%), treatment initiation (92.3% vs. 85%), and treatment completion (84.6% vs. 75%). Out of the 12 participants, nine (75%) met criteria for at least one comorbid psychiatric diagnosis at baseline and nine (75%) elected to undergo MALS surgery after completing the intervention. Conclusion: The intervention implementation was feasible, despite chronic pain symptoms experienced by the sample, a high prevalence of psychiatric diagnoses, and an international pandemic, suggesting that it would be beneficial to further evaluate the efficacy of the intervention. Future research should include stakeholder input in the design, deployment, and evaluation of a pilot efficacy trial of pre-surgical cognitive behavioral therapy for pediatric patients with MALS.
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Affiliation(s)
- Colleen Stiles-Shields
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Sylwia Osos
- Department of Psychiatry and Behavioral Sciences, The University of Chicago Medicine, Chicago, IL, United States
- College of Arts and Sciences, Roosevelt University, Chicago, IL, United States
| | | | - Estée C. H. Feldman
- Department of Psychiatry and Behavioral Sciences, The University of Chicago Medicine, Chicago, IL, United States
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Grace Zee Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, United States
| | - Christopher L. Skelly
- Section of Vascular Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, United States
| | - Tina Drossos
- Department of Psychiatry and Behavioral Sciences, The University of Chicago Medicine, Chicago, IL, United States
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20
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Moak JP, Ramwell C, Fabian R, Hanumanthaiah S, Darbari A, Kane TD. Median Arcuate Ligament Syndrome with Orthostatic Intolerance: Intermediate-Term Outcomes following Surgical Intervention. J Pediatr 2021; 231:141-147. [PMID: 33338494 DOI: 10.1016/j.jpeds.2020.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/06/2020] [Accepted: 12/11/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To report the intermediate-term outcome following surgical intervention for median arcuate ligament syndrome (MALS) in adolescents and young adults with orthostatic intolerance (OI) to assess clinical improvement in the gastrointestinal and 5 other functional domains and if relief of arterial obstruction is associated with resolution of clinical symptoms. STUDY DESIGN Thirty-one patients were given 2 dysautonomia-designed questionnaires to assess changes in symptoms following operative intervention in 6 functional domains and underwent postoperative repeat abdominal ultrasound examinations. RESULTS Average follow-up after surgery was 22.4 ± 14.8 months. Self-assessed quality of health on a Likert scale (1-10 with 10 being normal) improved from 4.5 ± 2.1 preoperatively to 5.3 ± 2.4 postoperatively (P = not significant). Gastrointestinal symptoms of abdominal pain, nausea, and vomiting improved in 63% (P = .007), 53% (P = .040), and 62% (P = .014) of patients, respectively. Cardiovascular symptoms of dizziness, syncope, chest pain, and palpitations improved in 45% (P = not significant), 50% (P = not significant), 54% (P = .043), and 54% (P = .037) of patients, respectively. Transabdominal ultrasound peak supine expiratory velocity decreased from 348 ± 105 cm/s preoperatively to 251 ± 109 cm/s at 6 months or more after a ligament release procedure. Decrease of the postoperative celiac artery Doppler velocity was not associated with an improvement in gastrointestinal symptoms (P = .075). CONCLUSIONS Adolescent and young adult patients with median arcuate ligament syndrome and OI have a good response to surgical intervention. About two-thirds of patients report significant improvement in symptoms of abdominal pain, nausea, and vomiting. Despite these encouraging data, many patients with MALS and OI continue to have an impaired quality of health.
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Affiliation(s)
- Jeffrey P Moak
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Carolyn Ramwell
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Robin Fabian
- Division of Cardiology, Children's National Hospital, Washington, DC
| | | | - Anil Darbari
- Division of Gastroenterology, Children's National Hospital, Washington, DC
| | - Timothy D Kane
- Department of Surgery, Children's National Hospital, Washington, DC
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21
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Janssen SL, Scholbach T, Jeno S, Laurie H, Meyer M, Combs C. Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective. Eur J Case Rep Intern Med 2020; 7:001605. [PMID: 32665927 PMCID: PMC7350969 DOI: 10.12890/2020_001605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 11/16/2022] Open
Abstract
We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.
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Affiliation(s)
- Sclinda Lea Janssen
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Susan Jeno
- Department of Physical Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Mandy Meyer
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA.,Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | - Colin Combs
- Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
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22
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Severe ME in Children. Healthcare (Basel) 2020; 8:healthcare8030211. [PMID: 32674263 PMCID: PMC7551866 DOI: 10.3390/healthcare8030211] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022] Open
Abstract
A current problem regarding Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is the large proportion of doctors that are either not trained or refuse to recognize ME/CFS as a genuine clinical entity, and as a result do not diagnose it. An additional problem is that most of the clinical and research studies currently available on ME are focused on patients who are ambulant and able to attend clinics and there is very limited data on patients who are very severe (housebound or bedbound), despite the fact that they constitute an estimated 25% of all ME/CFS cases. This author has personal experience of managing and advising on numerous cases of severe paediatric ME, and offers a series of case reports of individual cases as a means of illustrating various points regarding clinical presentation, together with general principles of appropriate management.
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23
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Goodall R, Langridge B, Onida S, Ellis M, Lane T, Davies AH. Median arcuate ligament syndrome. J Vasc Surg 2020; 71:2170-2176. [DOI: 10.1016/j.jvs.2019.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
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24
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Fox CJ, Morton A, Watters A, Mehler PS. Abdominal Pain Associated With Anorexia Nervosa and Median Arcuate Ligament Syndrome: A Rare Condition Shadowed by a Postoperative Conversion Disorder. Vasc Endovascular Surg 2020; 54:528-531. [PMID: 32441203 DOI: 10.1177/1538574420927533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Median arcuate ligament syndrome (MALS) is an often discounted and vexing condition that may go unnoticed in a population of patients with complex comorbid conditions or those with poor psychiatric health. We report a unique case of a patient with anorexia nervosa in whom the successful operation for MALS was briefly complicated by a postoperative conversion disorder.
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Affiliation(s)
- Charles J Fox
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado School of Medicine, Aurora, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, CO, USA
| | - Alex Morton
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, CO, USA.,Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Ashlie Watters
- ACUTE Center for Eating Disorders at Denver Health, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, USACorresponding Author
| | - Philip S Mehler
- ACUTE Center for Eating Disorders at Denver Health, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, USACorresponding Author
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25
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CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know. Insights Imaging 2020; 11:48. [PMID: 32185572 PMCID: PMC7078419 DOI: 10.1186/s13244-020-00852-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 12/11/2022] Open
Abstract
Abdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest with atypical abdominal symptoms and acute complications, which may lead to significant morbidity if unrecognized. Although computed tomography (CT) is an accurate noninvasive technique for their detection, the diagnosis remains challenging due to the uncommon clinical presentation and often overlooked imaging features. Dynamic imaging may be performed in order to evaluate patients with inconstant symptoms manifesting in a specific position. The purposes of this paper are to review the CT imaging findings of abdominopelvic vascular compression syndromes, correlating with anatomical variants and to provide key features for the noninvasive imaging diagnosis.
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26
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Khrucharoen U, Juo YY, Sanaiha Y, Finn JP, Jimenez JC, Dutson EP. Factors Associated with Symptomology of Celiac Artery Compression and Outcomes following Median Arcuate Ligament Release. Ann Vasc Surg 2020; 62:248-257. [DOI: 10.1016/j.avsg.2019.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
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27
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Roberts B, Pevsner R, Alkhoury F. Robotic Approach for Median Arcuate Ligament Release in Pediatrics. J Laparoendosc Adv Surg Tech A 2019; 30:92-96. [PMID: 31859596 DOI: 10.1089/lap.2019.0337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.
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Affiliation(s)
- Bailey Roberts
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| | - Rachel Pevsner
- Department of Pediatric Radiology, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| | - Fuad Alkhoury
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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28
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San Norberto EM, Romero A, Fidalgo-Domingos LA, García-Saiz I, Taylor J, Vaquero C. Laparoscopic treatment of median arcuate ligament syndrome: a systematic review. INT ANGIOL 2019; 38:474-483. [PMID: 31580040 DOI: 10.23736/s0392-9590.19.04161-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is an uncommon condition caused by the extrinsic compression of the celiac trunk (CT) and celiac ganglion, secondary to an anatomical abnormality of the median arcuate ligament fibers. It is characterized by postprandial epigastric pain, chronic abdominal pain, weight loss, nausea and vomiting. MALS is typically diagnosed after the exclusion of other, more common conditions; however, a variety of imaging and diagnostic modalities, including Duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry and angiography can suggest findings consistent with MALS. EVIDENCE ACQUISITION Laparoscopic approach has been proposed as the option of choice for the treatment of these patients. A systematic review of the international literature regarding this modality of treatment is presented here. EVIDENCE SYNTHESIS The review included 504 cases, and several principles are suggested to improve the management. The advantages of this minimally invasive technique include short operative time (136.0 minutes, range 70-242), shorter hospital stay (3.8 days, range 0.5-7) and low rate of conversion to open surgery (4.2%). CONCLUSIONS Various treatment modalities are available to decompress the celiac trunk. Although open surgery has been traditionally accepted as the gold standard, laparoscopic division of the MALS has proven equal results. Others have described different treatment modalities, including bypass surgery and endovascular procedures (angioplasty or stent placement). Laparoscopic approaches to correct MALS are feasible and safe. It may be the preferred modality of treatment in view of its lack of morbidity, shorter hospital stay and good results.
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Affiliation(s)
| | - Alejandro Romero
- Department of General Surgery, Valladolid University Hospital, Valladolid, Spain
| | | | - Irene García-Saiz
- Department of Anesthesia and Critical Care, Rio Hortega University Hospital, Valladolid, Spain
| | - James Taylor
- Department of Cardiac Surgery, Valencia General University Hospital, Valencia, Spain
| | - Carlos Vaquero
- Department Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
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29
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Patel MV, Dalag L, Weiner A, Skelly C, Lorenz J. Inability of conventional imaging findings to predict response to laparoscopic release of the median arcuate ligament in patients with celiac artery compression. J Vasc Surg 2019; 69:462-469. [DOI: 10.1016/j.jvs.2018.04.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 04/27/2018] [Indexed: 12/19/2022]
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30
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van Urk PR, Littooij AS, van Gestel JPJ, Kruyt MC. Celiac Artery Syndrome After Correction of Kyphoscoliosis. Spine Deform 2019; 7:176-179. [PMID: 30587313 DOI: 10.1016/j.jspd.2018.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 04/29/2018] [Accepted: 05/05/2018] [Indexed: 12/16/2022]
Abstract
Compression of the celiac artery by a tight arcuate ligament of the diaphragm is a rare syndrome that can arise after correction of severe kyphosis. Symptoms include abdominal pain and ileus and liver dysfunctions. These symptoms can be easily attributed to more common causes like the superior mesenteric artery syndrome, and a delay in the diagnosis of celiac artery obstruction may result in severe ischemic disease of the gastrointestinal tract. We present a case of celiac artery syndrome after correction of a kyphoscoliosis with severe sequelae that has not been documented before.
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Affiliation(s)
- P R van Urk
- Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands.
| | - A S Littooij
- Department of Radiology, Wilhelmina Children's Hospital (WKZ), University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands
| | - J P J van Gestel
- Intensive Care Unit, Wilhelmina Children's Hospital (WKZ), University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands
| | - M C Kruyt
- Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands
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31
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Skelly CL, Stiles-Shields C, Mak GZ, Speaker CR, Lorenz J, Anitescu M, Dickerson DM, Boyd H, O'Brien S, Drossos T. The impact of psychiatric comorbidities on patient-reported surgical outcomes in adults treated for the median arcuate ligament syndrome. J Vasc Surg 2018; 68:1414-1421. [PMID: 30064840 DOI: 10.1016/j.jvs.2017.12.078] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/28/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Median arcuate ligament syndrome (MALS) is an often overlooked, surgically correctable condition that mimics functional chronic abdominal pain. Patient-reported surgical outcomes are unpredictable in MALS. The objective of this study was to define the psychiatric comorbidities in a cohort of adults undergoing surgery for MALS and to determine whether these comorbidities are predictive of patient-reported quality of life (QOL) outcomes. METHODS A prospective observational trial was conducted between April 1, 2010, and December 31, 2015, at a single tertiary care hospital. Adults with a diagnosis of chronic abdominal pain in the setting of celiac artery compression were enrolled in a prospective Institutional Review Board-approved observational trial. Patients completed psychological assessments before surgery for MALS and at 6 months after surgery. The primary outcome was patient-reported health-related QOL (young adult version of the Pediatric Quality of Life Inventory). RESULTS A total of 51 patients (80% female; n = 41) with a mean age of 30.5 (±12.4) years were enrolled. Surgery significantly improved celiac artery hemodynamics in the entire cohort (P < .0001) as well as overall QOL (67.8 ± 14.6 [before surgery] vs 80.3 ± 13.7 [after surgery]; P < .001). Psychiatric diagnoses were common in this cohort, with 14 of 51 (28%) patients meeting criteria for a psychiatric diagnosis. There were no differences in the number of patients with psychiatric diagnoses between presurgical and postsurgical evaluations (14 [28%] vs 13 [26%]; P = .8). Exploratory analyses suggest that having a psychiatric diagnosis at the presurgical evaluation may predict significantly lower postsurgical QOL (R2 = 0.009; P = .01). CONCLUSIONS Surgery improves patient-reported QOL in adults treated for MALS. Psychiatric diagnoses are common in adults with MALS and predict worse patient-reported QOL outcomes.
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Affiliation(s)
- Christopher L Skelly
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago Medicine, Chicago, Ill.
| | - Colleen Stiles-Shields
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill; Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Grace Z Mak
- Department of Surgery, Section of Pediatric Surgery, University of Chicago Medicine, Chicago, Ill
| | - Christopher R Speaker
- Department of Surgery, Section of Pediatric Surgery, University of Chicago Medicine, Chicago, Ill
| | - Jonathan Lorenz
- Department of Radiology, University of Chicago Medicine, Chicago, Ill
| | - Magdalena Anitescu
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Ill
| | - David M Dickerson
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Ill
| | - Hope Boyd
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
| | - Setareh O'Brien
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
| | - Tina Drossos
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
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Psychological Factors and Outcomes in the Surgical Treatment of Pediatric Patients With Median Arcuate Ligament Syndrome. J Pediatr Gastroenterol Nutr 2018; 66:866-871. [PMID: 29373439 DOI: 10.1097/mpg.0000000000001900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Median arcuate ligament syndrome (MALS) is a frequently overlooked cause of chronic abdominal pain (CAP), and results in many symptoms that mimic other gastrointestinal conditions that result in CAP. A small, but growing body of literature indicates that surgery improves quality of life (QOL) in patients with MALS. The purpose of the current study was to examine the psychological characteristics of pediatric patients with MALS to determine their prevalence and impact on surgical outcomes. METHODS Thirty-two pediatric patients completed psychological assessments before surgery, and 6 months postsurgical intervention. Descriptive analyses and t tests were conducted to characterize the sample and compare psychosocial and QOL items. To explore possible associations between coping and ultimate changes in QOL, exploratory multiple regressions were conducted. RESULTS Comorbid psychological conditions were common, occurring in about half the sample before and after surgery. Current pain significantly improved, as well as patient and parent-reported QOL constructs (Ps < 0.05). Parent-reported observations of patients using catastrophizing or helpless strategies to cope with pain before surgery was significantly associated with changes in patient and parent-reported QOL following surgery (Ps = 0.04). CONCLUSIONS Comorbid psychological conditions are common in pediatric patients with MALS, and are maintained following surgery. While surgery improved pain and QOL, the need for presurgical psychological interventions for MALS is implicated.
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De'Ath HD, Wong S, Szentpali K, Somers S, Peck T, Wakefield CH. The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:1359-1363. [PMID: 29781769 DOI: 10.1089/lap.2018.0204] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Case reports and small series of the surgical and radiological management of median arcuate ligament syndrome (MALS) have been described, however, long-term outcome data are lacking. The purpose of this study was to review our experience of the laparoscopic management of MALS, and describe the long-term outcomes after surgical intervention. METHODS Data were collected between 2005 and 2016 in a single U.K. institution. All patients with MALS who underwent laparoscopic decompression of the celiac artery were included. Surgical outcomes were recorded from a prospectively collected database. Long-term outcomes were determined by outpatient review and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS Six patients were included. Five were female with a median age of 30 years (22.3-48.3). All six presented with abdominal pain and a bruit. Length of symptoms on presentation was 41 months (19-69). Duplex ultrasonography indicated celiac trunk stenosis in each case, with an elevated peak velocity flow in the celiac trunk of 230 cm/s (210-287.5). All six underwent successful laparoscopic decompression of the celiac artery with no conversions to open. Operating time was 137.3 minutes (95.6-166.3) and intraoperative blood loss was 110 mL (65-225). Length of stay was one day (1-2.3), with no postoperative complications or mortality. Median follow-up was 109.5 months (78-113.5). At this point, all patients remained symptom free with an overall GIQLI score of 129/144 (123.8-134.5). CONCLUSIONS MALS is a rare condition. Laparoscopic decompression of the median arcuate ligament is safe and offers long-term resolution of symptoms, and improvement in patient quality of life.
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Affiliation(s)
- Henry D De'Ath
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Simon Wong
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Karoly Szentpali
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Shaw Somers
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Tom Peck
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Christian H Wakefield
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
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Ohlsson B, Gustafsson R, Swahn F, Toth E, Veress B, Thorlacius H. Endoscopic full-thickness biopsy, a novel method in the work up of complicated abdominal symptoms. Therap Adv Gastroenterol 2017; 11:1756283X17730747. [PMID: 29383022 PMCID: PMC5784575 DOI: 10.1177/1756283x17730747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Gastrointestinal complaints without obvious organic causes confirmed by clinical laboratory analyses, endoscopy or radiology are often referred to functional entities. Irritable bowel syndrome (IBS) is the most common functional disorder in the gut. Careful examination of these patients may reveal other diagnoses of defined etiologies, e.g., enteric neuropathy, microscopic colitis, and primary Sjögre's syndrome. The present case describes a young patient with incapacitating gastrointestinal symptoms presumed to be IBS, who underwent endoscopic full-thickness biopsy in sigmoid colon. Histopathological examination revealed degenerative enteric neuropathy, possibly secondary to chronic ischemia.
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Affiliation(s)
- Bodil Ohlsson
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Jan Waldenström Street 15, S-205 02 Malmö, Sweden
| | - Rita Gustafsson
- Department of Gastroenterology, Skane University Hospital, Malmö, Sweden
| | - Fredrik Swahn
- Department of Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Ervin Toth
- Department of Gastroenterology, Skane University Hospital, Malmö, Sweden
| | - Béla Veress
- Department of Cellular Pathology, Unilabs AB, Skövde, Sweden
| | - Henrik Thorlacius
- Department of Surgery, Lund University, Skane University Hospital, Malmö, Sweden
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Duran M, Simon F, Ertas N, Schelzig H, Floros N. Open vascular treatment of median arcuate ligament syndrome. BMC Surg 2017; 17:95. [PMID: 28851450 PMCID: PMC5575896 DOI: 10.1186/s12893-017-0289-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 08/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Median arcuate ligament syndrome is a rare condition with abdominal symptoms. Accepted treatment options are open release of median arcuate ligament, laparoscopic release of edian arcuate ligament, robot-assisted release of median arcuate ligament and open vascular treatment. Here we aimed to evaluate the central priority of open vascular therapy in the treatment of median arcuate ligament syndrome. Methods We conducted a monocentric retrospective study between January 1996 and June 2016. Thirty-one patients with median arcuate ligament syndrome underwent open vascular surgery, including division of median arcuate ligament in 17 cases, and vascular reconstruction of the celiac artery in 14 cases. Results In a 20-year period, 31 patients (n = 26 women, n = 5 men) were treated with division of median arcuate ligament (n = 17) or vascular reconstruction in combination with division of median arcuate ligament (n = 14). The mean age of patients was 44.8 ± 15.13 years. The complication rate was 16.1% (n = 5). Revisions were performed in 4 cases. The 30-day mortality rate was 0%. The mean in-hospital stay was 10.7 days. Follow-up data were obtained for 30 patients. The mean follow-up period was 52.2 months (range 2–149 months). Patients were grouped into a decompression group (n = 17) and revascularisation group (n = 13). The estimated Freedom From Symptoms rates were 93.3, 77.8, and 69.1% for the decompression group and 100, 83.3, and 83.3% for the revascularisation group after 12, 24 and 60 months respectively. We found no significant difference in the Freedom From Re-Intervention CA rates of the decompression (100% at 12, 24 and 60 months post-surgery) and revascularisation (100% at 12 months, and 91.7% at 24 and 60 months post-surgery) groups during follow-up (p = 0.26). Conclusions Open vascular treatment of median arcuate ligament syndrome is a safe, low mortality-risk procedure, with low morbidity rate. Treatment choice depends on the clinical and morphological situation of each patient.
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Affiliation(s)
- Mansur Duran
- Department of Vascular and Endovascular Surgery, Heinrich-Heine University Medical Center, Düsseldorf, Germany. .,Klinik für Gefäß- und Endovaskularchirurgie, Universitätsklinikum der Heinrich-Heine Universität, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Florian Simon
- Department of Vascular and Endovascular Surgery, Heinrich-Heine University Medical Center, Düsseldorf, Germany
| | - Neslihan Ertas
- Department of Vascular and Endovascular Surgery, Heinrich-Heine University Medical Center, Düsseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, Heinrich-Heine University Medical Center, Düsseldorf, Germany
| | - Nikolaos Floros
- Department of Vascular and Endovascular Surgery, Heinrich-Heine University Medical Center, Düsseldorf, Germany
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Divarci E, Celtik U, Dokumcu Z, Celik A, Ergun O. Laparoscopic Treatment of Median Arcuate Ligament Syndrome: A Rare Cause of Chronic Severe Abdominal Pain. J Indian Assoc Pediatr Surg 2017; 22:48-50. [PMID: 28082779 PMCID: PMC5217142 DOI: 10.4103/0971-9261.194624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Median arcuate ligament syndrome is a rare disorder characterized by chronic postprandial abdominal pain and weight loss caused by compression on celiac artery. A 17-year-old girl with chronic severe abdominal pain and weight loss was referred to our clinic. Other causes of chronic abdominal pain were investigated and excluded. The compression on celiac artery was detected on Doppler ultrasound and diagnosis was confirmed by computed tomography angiography. The patient underwent laparoscopic release of median arcuate ligament. There were no intraoperative complications; however, partial pain response was observed postoperatively that necessitated para-spinal ganglion blockage. The patient is symptom-free in 1-year follow-up period.
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Affiliation(s)
- Emre Divarci
- Department of Pediatric Surgery, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Ulgen Celtik
- Department of Pediatric Surgery, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Zafer Dokumcu
- Department of Pediatric Surgery, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Ahmet Celik
- Department of Pediatric Surgery, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Orkan Ergun
- Department of Pediatric Surgery, Faculty of Medicine, Ege University, İzmir, Turkey
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O'Brien K, Ferral H. Lessons learned from a case of multivessel median arcuate ligament syndrome in the setting of an Arc of Buhler. Radiol Case Rep 2016; 11:182-5. [PMID: 27594946 PMCID: PMC4996896 DOI: 10.1016/j.radcr.2016.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022] Open
Abstract
The median arcuate ligament (MAL) can rarely compress both the celiac axis and superior mesenteric artery. We present a case of a 70-year male who presented with isolated episodes of upper abdominal pain and diarrhea associated with sweats and nausea. Angiography images demonstrated complete occlusion of the celiac axis and compression of the superior mesenteric artery during the expiration phases. The celiac axis was reconstituted distal to its origin by a patent Arc of Buhler. Other reported cases of multivessel MALs have produced severe symptoms in young adults requiring surgical and/or endovascular intervention. In this case, our patient's Arc of Buhler was protective against more severe chronic mesenteric ischemia. We suggest that a patent Arc of Buhler is protective against symptoms in a single vessel MALs patient. A significant percentage of patients receiving surgical intervention for MALs do not have relief of symptoms. There should be a search for an Arc of Buhler before surgical management of patients suspected to have single vessel MALs.
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Affiliation(s)
- Kevin O'Brien
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL 60637, USA
- Corresponding author.
| | - Hector Ferral
- Department of Radiology, Northshore University Healthsystem, Evanston, IL, USA
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Mak GZ, Lucchetti AR, Drossos T, Fitzsimmons-Craft EE, Accurso EC, Stiles-Shields C, Newman EA, Skelly CL. Pediatric Chronic Abdominal Pain and Median Arcuate Ligament Syndrome: A Review and Psychosocial Comparison. Pediatr Ann 2016; 45:e257-64. [PMID: 27403674 DOI: 10.3928/00904481-20160613-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic abdominal pain (CAP) occurs in children and adolescents with a reported prevalence of 4% to 41% with significant direct and indirect costs to the child, family, and society. Median arcuate ligament syndrome (MALS) is a vascular compression syndrome of the celiac artery that may cause symptoms of epigastric pain and weight loss and is a frequently overlooked cause of CAP in the pediatric population. We have observed that the psychosocial presentation of patients with MALS is notable for various psychiatric comorbidities. In this article, we review MALS as well as our study results of the psychosocial profile of 30 MALS patients. Our data suggest that children and adolescents with MALS have similar psychosocial profiles to children with other gastrointestinal disorders resulting in CAP. The overlap of physical and psychosocial symptoms of patients who have MALS with other CAP disorders leads us to recommend that patients with CAP should be evaluated for MALS. [Pediatr Ann. 2016;45(7):e257-e264.].
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Contemporary management of median arcuate ligament syndrome provides early symptom improvement. J Vasc Surg 2015; 62:151-6. [PMID: 25758451 DOI: 10.1016/j.jvs.2015.01.050] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/21/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Optimal diagnosis and management of median arcuate ligament (MAL) syndrome (MALS) remains unclear in contemporary practice. The advent and evolution of laparoscopic and endovascular techniques has redirected management toward a less invasive therapeutic algorithm. This study examined our contemporary outcomes of patients treated for MALS. METHODS All patients treated for MALS at Dartmouth-Hitchcock Medical Center from 2000 to 2013 were retrospectively reviewed. Demographics and comorbidities were recorded. Freedom from symptoms and freedom from reintervention were the primary end points. Return to work or school was assessed. Follow-up by clinic visits and telephone allowed quantitative comparisons among the patients. RESULTS During the study interval, 21 patients (24% male), with a median age of 42 years, were treated for MALS. All patients complained of abdominal pain in the presence of a celiac stenosis, 16 (76%) also reported weight loss at the time of presentation, and 57% had a concomitant psychiatric history. Diagnostic imaging most commonly used included duplex ultrasound (81%), computed tomography angiography (66%), angiography (57%), and magnetic resonance angiography (5%). Fourteen patients (67%) underwent multiple diagnostic studies. All patients underwent initial laparoscopic MAL release. Seven patients (33%) underwent subsequent celiac stent placement in the setting of recurrent or unresolved symptoms with persistent celiac stenosis at a mean interval of 49 days. Two patients required surgical bypass after an endovascular intervention failed. The 6-month freedom from symptoms was 75% and freedom from reintervention was 64%. Eighteen patients (81%) reported early symptom improvement and weight gain, and 66% were able to return to work. CONCLUSIONS A multidisciplinary treatment approach using initial laparoscopic release and subsequent stent placement and bypass surgery provides symptom improvement in most patients treated for MALS. The potential placebo effect, however, remains uncertain. A significant minority of patients will require reintervention, justifying longitudinal surveillance and prudent patient selection. Patients can anticipate functional recovery, weight gain, and return to work with treatment.
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Uchida H, Sakamoto S, Matsunami M, Sasaki K, Shigeta T, Kanazawa H, Fukuda A, Nakazawa A, Miyazaki O, Nosaka S, Kasahara M. Hepatic artery reconstruction preserving the pancreaticoduodenal arcade in pediatric liver transplantation with celiac axis compression syndrome: report of a case. Pediatr Transplant 2014; 18:E232-5. [PMID: 25092155 DOI: 10.1111/petr.12329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2014] [Indexed: 12/16/2022]
Abstract
CACS is rare, although it has been reported to be a potential risk factor for hepatic artery thrombosis following LT. We herein present the case of a 14-yr-old male with stenosis of the origin of the celiac trunk. Preoperative CT and color ultrasonography showed narrowing of the proximal celiac artery. The patient underwent DDLT with standard arterial reconstruction without dividing the gastroduodenal artery. His postoperative course was uneventful, with an excellent hepatic artery flow on Doppler ultrasonography. Applying a meticulous preoperative evaluation and the appropriate surgical technique is crucial in patients with CACS.
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Affiliation(s)
- Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Abstract
OBJECTIVE The objective of this study was to report on the measurement properties of the Pediatric Quality of Life Inventory (PedsQL) Gastrointestinal Symptoms Module for patients with functional gastrointestinal (GI) disorders (FGIDs) and organic GI diseases, hereafter referred to as "GI disorders," for patient self-report ages between 5 and 18 and parent proxy-report for ages between 2 and 18 years. METHODS The 74-item PedsQL GI Module and 23-item PedsQL Generic Core Scales were completed in a 9-site study by 584 patients and 682 parents. Patients had physician-diagnosed GI disorders (such as chronic constipation, functional abdominal pain, irritable bowel syndrome, functional dyspepsia, Crohn disease, ulcerative colitis, gastroesophageal reflux disease). RESULTS Fourteen unidimensional scales were derived measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood, diarrhea, worry, medicines, and communication. The PedsQL GI Module Scales evidenced excellent feasibility, excellent reliability for the Total Scale Scores (patient self-report α = 0.97, parent proxy-report α = 0.97), and good-to-excellent reliability for the 14 individual scales (patient self-report α = 0.67-0.94, parent proxy-report α = 0.77-0.95). Intercorrelations with the Generic Core Scales supported construct validity. Individual Symptoms Scales known-groups validity across 7 GI disorders was generally supported. Factor analysis supported the unidimensionality of the individual scales. CONCLUSIONS The PedsQL GI Module Scales demonstrated acceptable-to-excellent measurement properties and may be used as common metrics to compare GI-specific symptoms in clinical research and practice both within and across patient groups for FGIDs and organic GI diseases.
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PedsQL™ Gastrointestinal Symptoms Scales and Gastrointestinal Worry Scales in pediatric patients with functional and organic gastrointestinal diseases in comparison to healthy controls. Qual Life Res 2014; 24:363-78. [PMID: 25148757 DOI: 10.1007/s11136-014-0781-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The primary objective was to compare the gastrointestinal (GI) symptoms and worry of pediatric patients with functional GI disorders (FGIDs) and organic GI diseases to healthy controls utilizing the Pediatric Quality of Life Inventory™ (PedsQL™) Gastrointestinal Symptoms and Worry Scales for patient self-reports ages 5-18 years and parent proxy-reports for ages 2-18 years. The secondary objective was to compare FGIDs and organic GI diseases to each other. METHODS The PedsQL™ Gastrointestinal Symptoms and Worry Scales were completed in a 9-site study by 587 pediatric patients with GI disorders and 685 parents of patients. Patients had physician-diagnosed GI disorders (chronic constipation, functional abdominal pain, irritable bowel syndrome, functional dyspepsia, Crohn's disease, ulcerative colitis, and gastroesophageal reflux disease). Ten Gastrointestinal Symptoms Scales measuring Stomach Pain, Stomach Discomfort When Eating, Food and Drink Limits, Trouble Swallowing, Heartburn and Reflux, Nausea and Vomiting, Gas and Bloating, Constipation, Blood, and Diarrhea were administered along with two Gastrointestinal Worry Scales. Five hundred and thirteen healthy children and 337 parents of healthy children completed the PedsQL™ Gastrointestinal Scales in an Internet panel survey. RESULTS The PedsQL™ Gastrointestinal Symptoms and Worry Scales distinguished between pediatric patients with FGIDs and organic GI diseases in comparison with healthy controls, supporting known-groups validity. Patients with FGIDs reported more GI symptoms and worry than patients with organic GI diseases. CONCLUSIONS The PedsQL™ Gastrointestinal Symptoms and Worry Scales may be utilized as common metrics across pediatric patient groups with FGIDs and organic GI diseases and healthy samples to measure GI-specific symptoms in clinical research and practice.
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