Treatment of median arcuate ligament syndrome: outcome of laparoscopic approach

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.

Outcomes of Median Arcuate Ligament Release: A Single Institution Retrospective Review

OBJECTIVES

Median arcuate ligament syndrome (MALS) is an uncommon diagnosis that is often associated with variable clinical presentation and inconsistent response to treatment. Due to the nature of MALS, the optimal treatment modality and predictors of outcomes remain unclear.

METHODS

A retrospective review was performed of all median arcuate ligament release (MALR) procedures at a single academic institution between 2000-2020. Variables examined included patient demographics, symptom characteristics, operative technique (open, robotic, laparoscopic), patient symptoms prior to release, symptom relief within 1 year, and recurrence of symptoms between release and last clinical follow-up.

RESULTS

During the study period, 47 patients (75% female, mean age 42.1 years) underwent MALR with 19 (36%) robotic, 18 (34%) open, 14 (26%) laparoscopic, and 2 (4%) laparoscopic converted to open procedures. Abdominal pain, weight loss, and nausea and vomiting were the most common symptoms. Postoperatively, 19 (40%) had complete symptom relief within one year, 18 (38%) had partial relief, and 10 (21%) had no symptom improvement. 6 were excluded due to loss of follow-up. Laparoscopic and open procedures had the highest rate of complete symptom relief by year one with 7 (58%) and 8 (50%) respectively. 21 (57%) patients had recurrence with the greatest rate of recurrence seen among laparoscopic (80%), compared to robotic (57%) and open (38%). Patients reporting a weight loss of 20 pounds or more prior to surgery were more likely to have partial or complete symptom relief after one year compared to those reporting less than 20-pound weight loss (92% vs 64%). Furthermore, 84% of patients younger than 60 years old reported partial or complete symptom relief compared to only 56% of those older than 60.

CONCLUSION

MALS continues to be a rare disorder with widely variable surgical outcomes, requiring further study. While our patients presented with several gastrointestinal symptoms, the most common was postprandial pain. Our center employed laparoscopic, open, and robotic operative techniques with varying success rates, in terms of symptom relief and recurrence. Consistent with current literature, our study found greater surgical success among patients younger than 60 years regardless of operative technique. This suggests the need for better predictors to determine which patients are the most likely to have complete or prolonged remission of symptoms following MALR.

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.

A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study

BACKGROUND

Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. Appropriately selected patients can benefit from a laparoscopic or open median arcuate ligament release. Institutional series have reported the outcomes of open and laparoscopic techniques but there are no nationwide analysis comparing both techniques and overall trends in treatment.

METHODS

Cross-sectional study using the American College of Surgeons-National Surgical Quality Improvement Project from 2010 to 2020. Celiac artery compression syndrome cases were identified by International Classification of Diseases (ICD) codes and categorized as open or laparoscopic. Trends in the use of each technique and 30-day complications were compared between the groups.

RESULTS

A total of 578 open cases (76%) and 185 laparoscopic cases (24%) were identified. There was an increase adoption of the laparoscopic approach, with 22% of the cases employing this technique at the end of the study period, compared to 7% at the beginning of the study period. The open group had a higher prevalence of hypertension (26% vs 18%, p = 0.04) and bleeding disorders (5% vs 2%, p 0.03). Laparoscopic approach had a shorter length of stay (2.3 days vs 5.2 days, p < 0.0001), lower major complication rates (0.5% vs 4.0%, p = 0.02) and lower reoperation rates (0% vs 2.6%, p = 0.03). Overall mortality was 0.1%.

CONCLUSION

Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.

DUNBAR SYNDROME: CLINICAL MANIFESTATION IN ADULTS, DIAGNOSTIC PROBLEMS (CASE REPORT)

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.

Another Sherlock Holmes Mystery: Abdominal Pain Explained by Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome, is a rare gastrointestinal condition with an estimated incidence of 2 per 100 000 population. Predominantly in female patients, this syndrome is characterized by the compression of the celiac artery at its origin from the aorta by the median arcuate ligament, which at the same time is entrapping the celiac plexus, causing upper abdominal pain, notably postprandial pain, as well as nausea, vomiting, food aversion, and weight loss. We present a case of abdominal pain secondary to MALS that was appropriately diagnosed after requiring narcotic medication, which responded to surgical therapy.

A diagnostic workup and laparoscopic approach for median arcuate ligament syndrome

Background

Median arcuate ligament syndrome (MALS) is a rare disorder characterized by the compression of the coeliac trunk and plexus by fibrous arches of the median ligament. It commonly occurs in young women with postprandial epigastric pain, weight loss and nausea. We present a single surgeon experience on the diagnostic approach and management of MALS with a focus on laparoscopic surgery.

Methods

A retrospective review of adult patients diagnosed with MALS during a 10‐year period (2011–2021) was conducted at Bankstown‐Lidcombe hospital in New South Wales, Australia.

Results

MALS was diagnosed in six patients (mean 46 years, range: 27–74 years old), all confirmed on mesenteric duplex ultrasound and computed tomography angiography. The most common presentations were women with post‐prandial pain, exercise induced pain and an average weight loss of 14.5 kg. The median interval from onset of symptoms to surgical referral was 10.5 months. The average BMI was 24.1 kg/m² and most had a grade III American Society of Anaesthesiologist physical status. All patients underwent laparoscopic release of median arcuate ligament with one patient requiring endovascular stenting. The mean operative time was 119 minutes with two minor post‐operative complications, but no mortalities. The median hospital length of stay was 3.5 days with a median follow up of 3.5 years.

Conclusion

Laparoscopic median arcuate ligament release with endovascular support for selected cases provides sound clinical resolution of symptoms and long‐term results.

Median Arcuate Ligament Syndrome is Effectively Relieved with Minimally Invasive Surgery

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.

Celiac Artery Compression Syndrome: A Unique Presentation

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, celiac axis syndrome, and Dunbar Syndrome, is a rare disorder that results from compression of the celiac artery by the median arcuate ligament. The following is a case that depicts an interesting presentation of a patient diagnosed with this rare condition. A 44-year-old male with a history of mutism was brought in by his family for weight loss of 100 lbs with intermittent abdominal pain, weakness and lethargy over a period of five years. His family reported that he had poor nutritional intake, and could only eat a small amount before he seemed to be in pain, and eventually refused to eat. He had no other prior medical history except for mutism, no family history of malignancy, no history of trauma, surgeries, smoking or substance use, and did not take any medications. Physical exam was largely unremarkable. Mesenteric vascular duplex demonstrated severe grade stenosis of the celiac trunk with post-stenotic velocity of 520 cm/sec. Contrast enhanced computed tomography angiography revealed acute angle J-configuration of the takeoff of the celiac axis, with stenosis at its origin and focal post-stenotic dilatation, confirming the diagnosis of CACS.

CACS is an elusive diagnosis that should be considered in patients where other causes of abdominal pain and weight loss have been ruled out. The disease can present with the classic triad of post-prandial abdominal pain, weight loss, and an abdominal bruit. Imaging modalities including mesenteric vascular duplex, computed tomography abdominal angiography, magnetic resonance angiography and celiac artery angiography can help make the diagnosis. Treatment involves surgical decompression via division of the median arcuate ligament, with most patients experiencing significant and long-lasting relief from their symptoms.

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.