The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes

Laparoscopic management of median arcuate ligament syndrome: a video vignette

Median arcuate ligament syndrome (MALS) is a rare condition and a diagnosis of exclusion. We present a 30-year-old man, who had postprandial upper abdominal pain and weight loss of 6 kg in 3 months. His gastroscopy and abdominal ultrasound results were both unremarkable. Computed tomographic angiography showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a 'J' shaped course of artery with poststenotic dilatation and dilated branches of the celiac artery. The patient underwent laparoscopic release of the median arcuate ligament. The intraoperative blood loss was 20 mL and duration of the procedure was 140 minutes. The patient had an uneventful recovery and was discharged on postoperative day 2. The symptoms subsided 2 months following surgery and he started gaining weight. Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method to decompress the celiac artery.

Laparoscopic Median Arcuate Ligament Release: Surgical Technique and Clinical Outcomes

BACKGROUND

Median arcuate ligament syndrome (MALS) is characterized by a constellation of symptoms related to the compression of the celiac artery trunk. Laparoscopic release of the ligament has demonstrated its effectiveness in alleviating these symptoms while showing lower postoperative complication rates, reduced hospital stays, and improved clinical outcomes. This study describes a single institution's experience with this procedure and reports on the preoperative assessment, surgical technique, and clinical outcomes of patients with MALS.

METHODS

We performed a retrospective chart review of all patients who underwent a primary laparoscopic MAL release (MALR) at a single high-volume academic institution from June 2021 to July 2023. Patient demographics, preoperative assessment, postoperative complications, and resolution of preoperative symptoms data were collected.

RESULTS

A total of 30 patients underwent laparoscopic MALR, with 76.7% being female and a mean age of 33.4±16.3 years. The most common presenting symptom was postprandial epigastric pain (100%), followed by abdominal pain and nausea (83.3%), among others. The preoperative evaluation for all patients included a duplex mesenteric doppler and CT angiogram during inspiration and expiration and 3D reconstruction. Successful laparoscopic decompression of the celiac artery was achieved in 96.6% of cases, with only one conversion to an open procedure. There was only one reported early (<30 d postoperatively) complication with no subsequent late complications or mortality. None of the patients required reintervention or reoperation. Only 1 patient required postoperative celiac plexus/splanchnic block injection to alleviate pain.

CONCLUSIONS

MALS can be effectively and safely managed using a laparoscopic approach when performed by an experienced minimally invasive surgeon. Further studies with longer follow-ups are needed to confirm the long-term effectiveness of this technique.

Surgical therapy of celiac axis and superior mesenteric artery syndrome

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.

Simultaneous laparoscopic treatment of median arcuate ligament syndrome and segmental adenomyomatosis of the gallbladder: A case report

INTRODUCTION

Median Arcuate Ligament Syndrome (MALS) is a condition in which the median arcuate ligament tightly compresses the celiac artery. A patient presented with MALS and segmental adenomyomatosis of the gallbladder, both treated simultaneously using a laparoscopic approach.

PRESENTATION OF CASE

A 48-year-old male with adenomyomatosis of the gallbladder presented with postprandial epigastric pain. Abdominal three-dimensional computed tomography scan showed compression of the celiac artery, and the patient was diagnosed with MALS. Laparoscopic dissection of the median arcuate ligament and cholecystectomy were performed to treat both conditions. By optimizing port positions, both conditions could be treated simultaneously. The patient was discharged on postoperative day 6 and has no recurrent symptoms 20 months postoperatively.

DISCUSSION

To the best of our knowledge, there are no previously reported cases of simultaneous laparoscopic division of the median arcuate ligament and cholecystectomy.

CONCLUSION

By optimizing the port positions, laparoscopic division of the median arcuate ligament and cholecystectomy were performed simultaneously, minimally invasively, safely and effectively.

Systematic Review of the Efficacy of Treatment for Median Arcuate Ligament Syndrome

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.

Robot Assisted Laparoscopy for Median Arcuate Ligament Syndrome Relief

Objective

To evaluate the outcomes of robot assisted laparoscopic surgery for median arcuate ligament syndrome (MALS) relief.

Methods

This was a single centre and retrospective study, including all consecutive patients with symptomatic MALS treated with robot assisted laparoscopic surgery. Symptom relief and quality of life (QoL) were evaluated post-operatively. A comparison between the peak systolic velocity (PSV) of the coeliac artery (CA) measured pre-operatively and post-operatively was carried out.

Results

Nine interventions were performed. No conversion to laparotomy was required. There was post-operative abdominal pain relief in eight patients and QoL was improved in seven patients. Post-operatively, the CA PSV decreased (175 (IQR 160 - 195) cm/s vs. 365 (IQR 350 - 419) cm/s; p < .001).

Conclusion

MALS relief with robot assisted laparoscopy is safe and provides satisfactory outcomes in terms of symptom relief and CA compression release.

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Robot assisted laparoscopy for median arcuate ligament syndrome is safe.

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Coeliac artery release provides satisfactory outcomes in terms of symptoms relief.

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Post-operatively, the coeliac artery peak systolic velocity significantly decreased.

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Quality of life was improved in the majority of cases after surgery.

Aneurysmal celiac trunk dissection caused by median arcuate ligament syndrome successfully treated by endovascular technique: a case report

Median arcuate ligament syndrome (MALS) is a chronic pathogenic process, resulting from the compression of the celiac axis by fibrous attachments of the diaphragmatic crura which named median arcuate ligament. In clinical, isolated spontaneous superior mesenteric artery (SMA) is common. Whereas, isolated celiac trunk (CA) dissection is rare, it is usually associated with aortic dissection. In this case report, the CA is not only dissected, but also the aneurysm formed. Because the long-time compression of the MALS, relative narrowing of the celiac artery causes the high pressure at the beginning of the CA and that may contribute to the aneurysmal celiac trunk dissection (ACTD). This case described a male patient who underwent hypertension and abdominal pain as their main clinical manifestation. Contrast-enhanced computed tomography angiography (CTA) showed that a slightly stenosed root of the celiac artery during inhalation and severe stenosis of the root during expiration. Moreover, a small intimal tear at the site of celiac artery proximal end with nonruptured aneurysmal dilation located on the celiac trunk. After our carefully examinations, the patient was diagnosed as ACTD caused by MALS. And we applied endovascular technique-stenting in this case. It could not only cover the dissection, but also could obstruct the aneurysm. The patient was in a stable condition after management of ACTD by stenting. Stenting is a safe and effective treatment for ACTD caused by MALS.

Laparoscopic treatment of rare median arcuate ligament syndrome – medium-term follow-up

<b>Introduction:</b> Median arcuate ligament syndrome (MALS) is a rare cause of chronic epigastric pain. The presentation might be unclear and non-specific. Diagnosing the syndrome requires interdisciplinary methods and specialists. Treatments consist of celiac axis release performed laparoscopically or robotically, and intraluminal stenting. </br></br> <b>Aim:</b> The aim of the study was to report the medium-term postoperative follow-up results for four patients with MALS. </br></br> <b>Materials and methods:</b> We performed 5 laparoscopic celiac axis releases in patients with MALS in our department in 2018. The study included 4 patients who were admitted 16–23 months after surgery for computed tomography angiography.</br></br> <b> Results:</b> Patients constituted 4 women aged 28–63 with a mean body mass index of 22.4 kg/m2. The diagnosis of MALS was confirmed by computed tomography angiography, which showed severe (>70%) narrowing of the celiac axis. Patients underwent laparoscopic celiac axis release, and were all discharged on the first postoperative day with no postoperative complications. The patients’ quality of life improved and their symptoms subsided completely. Follow-up computed tomography angiography confirmed full decompression of the celiac axis in all 4 patients, with no stenosis caused by scarification of the celiac axis.</br></br> <b> Conclusion:</b> Laparoscopy is a valuable and safe method to treat patients with MALS.

Median Arcuate Ligament Syndrome with Orthostatic Intolerance: Intermediate-Term Outcomes following Surgical Intervention

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.

Median arcuate ligament (Dunbar) syndrome: Laparoscopic management and clinical outcomes of a single centre

Background:

Median arcuate ligament syndrome (MALS) is a condition characterised by chronic abdominal symptoms associated with median arcuate ligament (MAL) compression of the coeliac artery.

Aim:

In this observational study, we aimed to evaluate the outcomes of laparoscopic treatment in patients with MALS.

Materials and Methods:

The data of ten patients with MALS who were subjected to laparoscopic sectioning of the MAL were retrospectively reviewed. The following data were evaluated: age, gender, clinical and diagnostic test findings, American Society of Anaesthesiologists score, operative findings and complications and mortality, hospital stay duration and hospital readmission. The diagnosis of MALS was established by computed tomography (CT) angiography.

Results:

Six (60%) of ten patients with MALS were female and four (40%) were male. The mean age was 42.4 ± 12.3. The main symptoms were epigastric pain (100%) and weight loss (60%). CT angiography showed high-grade stenosis of the anterior wall of the proximal coeliac trunk and post-stenotic dilation caused by extrinsic compression of the MAL. Surgical procedure was uneventful in all patients. Operating time was 155.5 min (120–200) and intra-operative blood loss was 150 ml (100–250). Length of stay was 3.1 day (2–9), with no mortality. The post-operative complications developed in two female patients. One of them developed ileus and the other patient developed pulmonary thromboembolism. At 6-month follow-up, all patients were asymptomatic.

Conclusion:

Laparoscopic decompression is an effective treatment for MALS and can provide symptomatic relief. This method may be the preferred modality of treatment in view of its lack of morbidity and good results.

Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS) is the compression of the celiac artery (CA) by the median arcuate ligament. MALS can cause pseudoaneurysm of the gastroduodenal artery, which can lead to fatal bleeding. A 40-year-old male with no prior medical history presented with symptoms of upper gastrointestinal hemorrhage (UGIH). Severe duodenal bleeding was confirmed although endoscopic hemostasis was impossible and final hemostasis was achieved following a subsequent open duodenotomy. A postoperative computed tomographic angiography (CTA) visualized a significant CA stenosis, post-stenotic dilatation and an aneurysm on a jejunal branch artery. The patient underwent coiling of the gastroduodenal artery, gastroepiploic artery and two pancreaticoduodenal arterial branches. The patient was diagnosed with MALS and 6 months later underwent open resection of the median arcuate ligament. MALS should be considered as a rare cause of upper gastrointestinal bleeding. The literature and proposed treatments are discussed.

Long-term symptom improvement and health-related quality of life after operative management of median arcuate ligament syndrome

OBJECTIVE

To investigate long-term symptom improvement and health-related quality of life (HRQOL) after operative intervention for median arcuate ligament syndrome (MALS).

METHODS

Clinical data of all consecutive patients treated by operative management of MALS from 1999 to 2018 were reviewed. A cross-sectional questionnaire using the Visick score, the Gastrointestinal Quality of Life Index, and Short Form (SF)-12v2 questionnaires was performed to assess long-term outcomes. The SF-12 HRQOL domains were compared between symptom-free and symptomatic patient groups and to averages for the US general population. Treatment failure was defined as no relief after surgery and Visick category 3 to 4 symptoms. Freedom from symptoms was estimated at 5 years.

RESULTS

A total of 100 patients were treated for MALS (mean age, 38 ± 18 years; 75% female). Open surgical release was performed in 81 and laparoscopic release in 19 patients. The most common presenting symptom was abdominal pain in 99 patients with postprandial exacerbation in 85. There was no mortality. Major adverse events at 30 days had occurred in 21 patients (open 19, laparoscopic 2) including myocardial infarction (n = 1), pancreatitis (n = 2), respiratory failure (n = 4), estimated blood loss of more than 1 L (n = 8), and postoperative ileus (n = 8). One patient treated by laparoscopic release required conversion for an aortic injury, which was treated by primary repair and splenectomy. Forty-six patients responded to the questionnaire with a mean follow-up of 8 ± 4 years. Initial symptom resolution or improvement was reported by 38 patients (83%), whereas 8 patients (17%) reported treatment failure. Seven of the 38 patients (18%) with initial treatment success reported symptom recurrence. The estimated 5-year freedom from symptoms was 67 ± 7%. All SF-12 HRQOL domains were significantly lower and below the average population range in symptomatic patients compared with those who were symptom free, in which all domains were within the average population range. The Gastrointestinal Quality of Life Index scores were also significantly lower in symptomatic patients. Forty respondents (87%) reported that they would still undergo operative management if given the choice, including all respondents who reported symptom recurrence.

CONCLUSIONS

The operative management of MALS can be performed with a low rate of complications. Approximately two-thirds of respondents were free of symptoms 5 years after the procedure. Treatment success in symptom-free patients was associated with an improved HRQOL on par with the population average compared with symptomatic patients. The vast majority of respondents would opt to have the operation again if given a choice. However, patients should be well-informed about the possibility of failure to relieve symptoms and symptom recurrence.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Treatment of median arcuate ligament syndrome: outcome of laparoscopic approach

Background:

Median arcuate ligament syndrome(MALS) is a rare condition thatmay cause significant clinical manifestations, including abdominal pain and weight loss. Its diagnosis may be difficult and very often delayed. The laparoscopic approach became the standard treatment of MALS.

Aim:

To assess the outcome of laparoscopic treatment in patients with MALS.

Method:

The data of sixpatients with MALS who were subjected to laparoscopic sectioning of the median arcuate ligament were retrospectively reviewed.The following data were evaluated: age, gender, clinical and diagnostic tests findings, ASA score, operative findings and complications, postoperative complications and mortality, hospital stay duration, and hospital readmission.The diagnosis of MALS was established by CT angiography and/or MR angiography.

Results:

There were four (66.7%) women and two (33.3%) men aged from 32 to 60 years. The main symptoms were epigastric pain (100%) and weight loss (66.7%). The findings of high-grade stenosis of the proximal celiac axis and poststenotic dilation confirmed on angiography confirmed the diagnosis in all patients. Surgical procedure was uneventful in all patients. The only postoperative complication was urinary retention that occurred in a male. At three-month follow-up, all patients were asymptomatic.

Conclusion:

Laparoscopic treatment of MALS is safe and effective in relieving the clinical manifestations of patients.

Laparoscopic treatment of median arcuate ligament syndrome in a 16-year-old male

INTRODUCTION

MALS(Median Arcuate Ligament Syndrome) is rare disease. We experienced the case of MALS and successfully treated by laparoscopic approach.

PRESENTATION OF CASE

A 16-year-old male was admitted to our hospital with postprandial epigastric pain that had been present for 3 years. Abdominal three-dimensional computed tomographic angiography showed stenosis of the celiac trunk, and abdominal Doppler ultrasonography showed that the blood flow in the celiac trunk varied between inspiration and expiration. Hence, the patient was diagnosed with median arcuate ligament syndrome. Laparoscopic decompression of the celiac trunk was performed by division of the ligament and partial excision of the celiac plexus. Intraoperative Doppler ultrasonography showed markedly improved flow in the celiac artery. The patient was discharged from hospital on postoperative day 7, and has no recurrent symptoms at 12 months postoperatively.

DISCUSSION

This case was most youngest male MALS treated by laparoscopic approach.

CONCLUSION

Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method for decompression of the celiac artery.