First description of a histopathologic grading system and relationship to outcomes after robotic median arcuate ligament release with celiac ganglionectomy and lymphadenectomy

BACKGROUND

Two dominating theories regarding median arcuate ligament syndrome include vascular and neurogenic etiologies from celiac artery and ganglion compression, respectively. Celiac ganglionectomy is not routine during surgery, and specimens are rarely excised; therefore, the extent of nerve involvement and histopathology are unknown. Our study aims to characterize histopathologic findings in median arcuate ligament syndrome, establish a histopathologic grading system, and correlate with clinical outcomes.

METHODS

Robotic median arcuate ligament release, celiac ganglionectomy, and lymphadenectomy were performed with specimens excised and stained using hematoxylin & eosin, trichrome, and S100. Neurofibrosis, adiposity, and reactive changes were described, a grading scale was developed, and results were analyzed with clinical outcomes.

RESULTS

Fifty-four patients were evaluated, of whom 36 met inclusion criteria (81% female, 34.9 [25.9-47.5] years, body mass index 23.5 [19.6-28.1] kg/m2). Histopathologic evaluation revealed fibrosis (hematoxylin & eosin and trichrome median score 1.5 [0-2.5]), reactive lymphadenopathy (89%), intraparenchymal nerves (31%), and lipogranulomas (31%). Greater fibrosis was associated with a lack of preoperative celiac plexus block relief (100% vs. 30%, P = .044) and lower postoperative celiac artery velocities (198 vs 323 cm/s, P = .02). Intraparenchymal nerves were associated with greater decreases in pre to postoperative velocities (161 vs 84 cm/s, P = .037). Symptoms improved in 28 patients (78%).

CONCLUSION

We developed the first histopathologic grading system and identified unique findings of intraparenchymal nerves and lipogranulomas. Histopathologic abnormalities were associated with objective improvement and symptomatic relief postoperatively. These findings support nerve compression and inflammation as predominant contributors to median arcuate ligament syndrome pain, celiac ganglia resection to treat symptoms, and continued histopathologic analysis to better elucidate median arcuate ligament syndrome etiology.

Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk

Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report

BACKGROUND

Ectopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions.

CASE PRESENTATION

We report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient's condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic.

CONCLUSION

We present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review

Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.

Gabapentin as a Symptomatic Modifier in Median Arcuate Ligament Syndrome: A Case Report and Assessment of Treatment Modalities

Median arcuate ligament syndrome (MALS) is a rare constellation of neurogenic gastrointestinal (GI) symptoms resulting from compression of the celiac trunk and celiac plexus by the median arcuate ligament. MALS is characterized by nonspecific symptoms including nausea, vomiting, diarrhea, bloating, unintentional weight loss due to food aversion, and postprandial epigastric abdominal pain. We present a case of atypical, chronic MALS that confounded clinicians for over a decade and led to various misdiagnoses, including early-onset Parkinson’s disease. Of the constellation of symptoms that MALS may present with, postprandial epigastric pain is a classic symptom and increases the index of suspicion for the diagnosis; however, the absence of the classic symptom of postprandial epigastric pain and the predomination of nonspecific GI symptoms and syncope in our patient further clouded clinicians’ ability to diagnose MALS. Upon further investigation, we elucidated a link between gabapentin, which our patient was chronically prescribed, and its efficacy in decreasing neurogenic hypersensitivity in the GI tract. Our case and the implications of gabapentin use to decrease neurogenic pain from MALS represents a novel addition to the literature on MALS treatment modalities and elucidates new avenues for continued research in the use of gabapentin as a symptom-modifying agent in the nonoperative and preoperative treatment of MALS.

Median arcuate ligament syndrome (Dunbar syndrome)

Median arcuate ligament syndrome (MALS) is a rare condition which is due to the compression of celiac trunk by low riding of fibrous attachments of median arcuate ligament and diaphragmatic crura. Technically, MALS is a diagnosis of exclusion, consisting of vague symptoms comprising of postprandial epigastric pain, nausea, vomiting and unexplained weight loss. Different imaging modalities like Doppler ultrasound, computed tomography, magnetic resonance imaging and mesenteric angiogram are helpful to demonstrate celiac axis compression. The goal of treatment is decompression of celiac trunk either by open, laparoscopic or robotic method along with adjuvant interventional procedures like percutaneous transluminal angioplasty (PTA) and stenting. Surgical is the mainstay of treatment. This approach is based on open, laparoscopic or robotic release of compressed ligament along with celiac ganglionectomy and celiac artery revascularization. The role of interventional radiology is limited to angioplasty and stenting to open the stenosis rather than addressing the underlying compression of celiac trunk which has resulted in the symptoms. However, both the diagnosis and therapeutic intervention remains challenging. Extensive evaluation of etiology and pathophysiology of MALS and addressing the same through minimally invasive techniques may yield best prognosis in future. In this review article, we discuss briefly about the MALS in terms of etiology, diagnosis and its management including the role of interventional radiology.

Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective

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.

Laparoscopic treatment of median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS) refers to a clinical syndrome caused by compression of the median arcuate ligament due to the fibers of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. If MALS is suspected, invasive digital subtraction angiography and computed tomography angiography or magnetic resonance angiography (MRA) can be used to verify the location of the celiac trunk. A disrupted or increased blood flow in the proximal end of the celiac trunk can be detected with doppler ultrasound, indicating stenosis. Treatment needs to alleviate celiac trunk compression. A common procedure involves separation of the ligament fibers and other surrounding tissues around the beginning of the celiac trunk. This can be achieved by either laparotomy or laparoscopic surgery. Patient prognosis is good, with a cure rate of about 80%.

Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS) is a condition characterized by pain in the abdominal region attributed to compression of the celiac artery by the median arcuate ligament of the diaphragm during expiration. MALS is also known as celiac artery compression syndrome, celiac axis syndrome, or Dunbar syndrome. Pain may result from the tight pressing on the celiac nerves in the area. The patient usually presents with symptoms such as postprandial epigastric pain, weight loss, and, occasionally, an abdominal bruit. Furthermore, some individuals may experience nausea and vomiting. It may be an etiology of a rare disorder, chronic mesenteric ischemia.

A patient presenting with stress-induced epigastric pain

The median arcuate ligament passes the truncus coeliacus superior to its ostium. If it is thickened and located too low, it can cause external compression and stenosis of the truncus coeliacus, leading to postprandial abdominal pain and vomiting. This combination of symptoms is called median arcuate ligament syndrome. We report the case of a 79-year-old patient who suffered from chronic epigastric pain, which was initially assumed to be caused by either coronary artery disease or atherosclerotic stenosis of the coeliac artery. Angiography excluded coronary artery disease, but showed severe external stenosis of the truncus. The patient underwent laparoscopic release of the median arcuate ligament, which resulted in relief of his symptoms. The median arcuate ligament syndrome should be considered in patients with epigastric stress-induced pain. Further underlying pathologies, especially coronary artery disease, as life-threatening diagnosis have to be initially excluded.

Median arcuate ligament syndrome confirmed with the use of intravascular ultrasound

Median arcuate ligament syndrome, a rarely reported condition, is characterized by postprandial abdominal pain, nausea, vomiting, and weight loss. Its cause is unclear. We present the case of a 45-year-old woman who had intermittent chronic positional abdominal pain without weight loss. Magnetic resonance angiograms and computed tomograms revealed stenosis of the celiac artery. Ostial compression was confirmed on catheter angiographic and intravascular ultrasonographic images. Intravascular ultrasound revealed far greater stenosis than did the initial imaging methods and confirmed a diagnosis of median arcuate ligament syndrome. In lieu of surgery, the patient underwent a celiac ganglion block procedure that substantially relieved her symptoms. To our knowledge, this is the first report of the use of intravascular ultrasound in the diagnosis of median arcuate ligament syndrome. We recommend using this imaging method preoperatively in other suspected cases of the syndrome, to better identify patients who might benefit from corrective surgery.

MR angiography of the abdomen and pelvis

Magnetic resonance (MR) angiographic techniques optimize the visualization of the vasculature at MR imaging. MR angiography has several advantages over Doppler ultrsonography and computed tomographic angiography, with adaptable protocols to answer specific clinical questions. Novel noncontrast MR angiographic techniques now enable assessment of the abdominopelvic vasculature without administration of gadolinium-based contrast media. This article reviews MR angiographic techniques and discusses applications for arterial and venous evaluation in the abdomen and pelvis.

[Laparoscopic treatment of median arcuate ligament syndrome (MALS) -- case report]

CASE REPORT

The authors report a case of a 34-year-old woman who had postprandial abdominal pain for years. During the course of her examination lactose intolerance and hiatus hernia was diagnosed. After ineffective conservative treatment CT angiography (CTA) and digital substraction angiography (DSA) was performed and showed significant celiac artery stenosis. Percutaneous transluminal angioplasty (PTA) was unsuccessful as extravasal mechanical compression was present, therefore, laparoscopic decompression and surgical division of MAL fibres were carried out. The postoperative period was characterized by a complete relief of previous symptoms and repeated CTA showed normal blood flow.

DISCUSSION

The authors emphasize the importance of the measurement of peak velocity of celiac trunk with Colour Duplex abdominal ultrasonography, the examination has 100% sensitivity and 83% specificity. The Duplex ultrasonography is less expensive than the "gold standard" diagnostic methods like CT and DS angiography, and can lead us to early diagnosis. Laparoscopic surgery is safe and low expense method for celiac artery decompression, however, sometimes it is difficult to reveal the exact reason and thus setting up the proper operation plan.

Celiac Artery Compression Syndrome

Celiac artery compression syndrome, also known as median arcuate ligament syndrome and Dunbar syndrome, is a rare cause of chronic mesenteric ischemia. Ischemia results from external compression of the proximal celiac artery during respiration, typically during expiration, by the median arcuate ligament just below the diaphragm. The author reviews the current literature to highlight the most common signs and symptoms, the imaging features, and the treatment options associated with celiac artery compression syndrome.

Open surgical decompression of celiac axis compression by division of the median arcuate ligament

Median arcuate ligament syndrome is a rare cause of abdominal pain which results from compression of the celiac artery (CA) or rarely, the superior mesenteric artery by a ligament formed by the right and left crura of the diaphragm. We report a case of open surgical decompression of the CA by division of the median arcuate ligament for a 37-year-old female patient who had suffered from chronic postprandial epigastric pain and severe weight loss. We described clinical features, characteristic angiographic findings and details of the surgical procedure for the patient with this rare vascular problem.

Physiology and pathophysiology of splanchnic hypoperfusion and intestinal injury during exercise: strategies for evaluation and prevention

Physical exercise places high demands on the adaptive capacity of the human body. Strenuous physical performance increases the blood supply to active muscles, cardiopulmonary system, and skin to meet the altered demands for oxygen and nutrients. The redistribution of blood flow, necessary for such an increased blood supply to the periphery, significantly reduces blood flow to the gut, leading to hypoperfusion and gastrointestinal (GI) compromise. A compromised GI system can have a negative impact on exercise performance and subsequent postexercise recovery due to abdominal distress and impairments in the uptake of fluid, electrolytes, and nutrients. In addition, strenuous physical exercise leads to loss of epithelial integrity, which may give rise to increased intestinal permeability with bacterial translocation and inflammation. Ultimately, these effects can deteriorate postexercise recovery and disrupt exercise training routine. This review provides an overview on the recent advances in our understanding of GI physiology and pathophysiology in relation to strenuous exercise. Various approaches to determine the impact of exercise on the individual athlete's GI tract are discussed. In addition, we elaborate on several promising components that could be exploited for preventive interventions.