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Gunjiganvi M, Marthandam S, Murugesan R, Palaniappan R. Feasibility and safety of robotic-assisted surgical approach in median arcuate ligament syndrome-a systematic review. J Robot Surg 2024; 18:318. [PMID: 39122880 DOI: 10.1007/s11701-024-02067-6] [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: 07/03/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
Median arcuate ligament syndrome (MALS) is rare syndrome and is diagnosis of exclusion. Though first robotic median arcuate ligament release (MALR) was described in 2007, there are only a few case reports (CR), case series (CS), and retrospective cohort studies (RCS) in the published literature. The purpose of this study was to assess the feasibility and safety of robotic-assisted MALR (r-MALR). PubMed, Embase, and Cochrane databases were searched (last search December 2023) for articles reporting r-MALR. All studies including CR, CS, RCS reporting technical feasibility (operating time and rate of conversions), safety (intra-operative complications, blood loss, post-operative complications), and outcome (length of stay [LoS]) were included (PROSPERO: CRD42024502792). A total of 23 studies (8-CR, 5-CS, 10-RCS) with total 290 patients were available in the literature. Except 1-RCS, all studies reported age and mean age for CR was 40.38 ± 17.7, 36.08 ± 15.12 for CS, 39.72 ± 7.35 years for RS; except 2-RCS, all studies reported gender distribution and there were 57 males and 214 females. Operating time: 3-CR, 4-CS, 9-RCS reported operating time, and mean time was 111 ± 54, 131.69 ± 7.51, 117.34 ± 35.03 min, respectively. Conversion rate: All studies reported data on conversion and only four (1.37%) cases were converted-one to laparoscopic approach, three to open approach (1-inadvertent celiac arteriotomy, 2-reasons not mentioned). Intraoperative complications: only 5-CR, 4-CS, and 9-RCS reported data on intra-operative complications, and there were only 6 complications (1.5%): 1-inadvertent celiac arteriotomy converted to open; 3-unnamed vascular injuries (2 managed robotically, 1 converted to open); 1-bleeding managed robotically; there were no other reported injuries. Estimated blood loss ranged from 5 to 30 ml. Post-operative complications: 5-CR, 4-CS, 8-RCS described post-operative complications in 21 (7%) patients. Twenty cases were grade I, one was grade IIIa, and all managed successfully. LoS stay: 2-CR, 4-CS, 10-RCS reported LoS and overall, it was 2 days. r-MALR is reasonable, technically feasible, safe, and has acceptable outcomes. In addition, robotic approach provided superior vision, improved dexterity, precise, and easy circumferential dissection.PROSPERO registration: The protocol was registered in the PROSPERO database (CRD42024502792).
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Affiliation(s)
| | | | | | - Raj Palaniappan
- Department of Bariatrics and Metabolic Surgery, Apollo Hospitals, Chennai, India
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Gerull WD, Sherrill W, Awad MM. Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series. Surg Endosc 2022; 37:3956-3962. [PMID: 35999316 DOI: 10.1007/s00464-022-09545-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. METHODS This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. RESULTS A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. CONCLUSIONS Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.
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Affiliation(s)
- William D Gerull
- Department of Minimally Invasive Surgery, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA.
| | | | - Michael M Awad
- Department of Minimally Invasive Surgery, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA
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Chronic Abdominal Pain, an Overlooked Diagnosis of Median Arcuate Ligament Syndrome (MALS). Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2022; 43:95-99. [PMID: 35451292 DOI: 10.2478/prilozi-2022-0009] [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: 11/20/2022]
Abstract
Median arcuate ligament syndrome (MALS) is a rare condition that is often overlooked as a result of its nonspecific symptoms. It is usually presented with nausea, bloating, abdominal postprandial pain, and weight loss. The diagnosis of MALS is usually delayed and made by excluding other causes for the symptoms. The diagnosis of this syndrome is based on clinical presentation and radiological findings on computer tomography angiography (CTA) or magnetic resonance angiography (MRA). Surgery is treatment of choice, with promising results from laparoscopic surgery.
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Ortega AJ, Memon H, Trivedi B, Davis B, McCallum R. Another Sherlock Holmes Mystery: Abdominal Pain Explained by Median Arcuate Ligament Syndrome. J Investig Med High Impact Case Rep 2022; 10:23247096221084911. [PMID: 35313774 PMCID: PMC8948318 DOI: 10.1177/23247096221084911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
| | - Hadiqa Memon
- Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Bhavi Trivedi
- Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Brian Davis
- Texas Tech University Health Sciences Center El Paso, TX, USA
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Kim JE, Rhee PL. Median arcuate ligamentum syndrome: Four case reports. World J Clin Cases 2022; 10:1991-1997. [PMID: 35317133 PMCID: PMC8891776 DOI: 10.12998/wjcc.v10.i6.1991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/12/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligamentum syndrome (MALS) is a disease entity with unclear pathogenesis. If it is not considered in advance, the clinical diagnosis of the disease is very difficult because patients complain of digestive discomfort including pain. However, this characteristic is not specific to MALS. There have been no studies to assist in making a quick diagnosis. The aim of this case series was to recognize that MALS must be considered as a differential factor in the cause of abdominal pain.
CASE SUMMARY We described cases in which four patients complained of abdominal pain over a long period but in whom a diagnosis of MALS could not be made. If the gastroenterologist does not take into account abdominal pain in advance, the patient is considered an asymptomatic gallstone patient and has their gallbladder removed despite imaging evaluation. The patient may also be considered a psychiatric patient and may be administered psychiatric drugs over a long period. In all four cases in this report, the patients experienced abdominal pain. In three cases, the diagnosis was possible by the clinician’s judgment considering both clinical symptoms and imaging techniques shortly after the onset of symptoms. However, in one case that lasted over 20 years, a clear diagnosis was not possible. Even after complaining of colicky pain and performing a cholecystectomy, the diagnosis was made only after the symptoms persisted. In all four cases, the symptoms were relieved by neuromodulators.
CONCLUSION MALS is a rare disease and it is easy to miss because it is not malignant, but patients can suffer from pain over a long period. For the accurate diagnosis of a patient complaining of abdominal pain, the diagnosis must be differentiated. In addition, as there are asymptomatic patients, patients who need treatment should be carefully selected, and improvement with medical treatment can be expected. Large-scale studies are also needed.
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Affiliation(s)
- Ji Eun Kim
- Division of Gastroenterology, Samsung Medical Center, Seoul 06351, South Korea
| | - Poong Lyul Rhee
- Division of Gastroenterology, Samsung Medical Center, Seoul 06351, South Korea
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Scharf M, Thomas KA, Sundaram N, Ravi SJK, Aman M. Median Arcuate Ligament Syndrome Masquerading as Functional Abdominal Pain Syndrome. Cureus 2021; 13:e20573. [PMID: 35103152 PMCID: PMC8775141 DOI: 10.7759/cureus.20573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
Median arcuate ligament syndrome refers to anatomical compression of the celiac artery and/or ganglion by fibrous attachments of the median arcuate ligament. It typically presents as a vague constellation of abdominal symptoms that are often initially attributed to various other gastrointestinal pathologies; thus, it can be very difficult to diagnose. We present a case of median arcuate ligament syndrome in a 68-year-old woman, whose diagnosis and treatment were delayed by many years as her symptoms were taught to be the result of functional abdominal pain syndrome, ultimately corrected by laparoscopic decompression of the celiac axis. This case demonstrates that surgical decompression of the celiac axis is an effective treatment for median arcuate ligament syndrome and the importance of continuing to reassess the clinical picture of patients labeled with functional abdominal pain syndrome.
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Li S, Luo J, Yin L, Yan C, Zhu Y, Wang J, Gao Z, Liu Z, Chen B. Aneurysmal celiac trunk dissection caused by median arcuate ligament syndrome successfully treated by endovascular technique: a case report. AME Case Rep 2021; 5:37. [PMID: 34805756 DOI: 10.21037/acr-20-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 06/29/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Sen Li
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaqing Luo
- Department of General Surgery, Changxing People Hospital, Huzhou, China
| | - Li Yin
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Yan
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuhua Zhu
- Department of General Surgery, Changxing People Hospital, Huzhou, China
| | - Jian Wang
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiwei Gao
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Chen
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Mansilha A. The increasing impact of International Angiology journal publications. INT ANGIOL 2021; 40:267-269. [PMID: 34528771 DOI: 10.23736/s0392-9590.21.04742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kafadar MT, Oguz A, Aday U, Bilge H, Basol Ö. Median arcuate ligament (Dunbar) syndrome: Laparoscopic management and clinical outcomes of a single centre. J Minim Access Surg 2021; 17:363-368. [PMID: 33885017 PMCID: PMC8270033 DOI: 10.4103/jmas.jmas_265_20] [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] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Mehmet Tolga Kafadar
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Abdullah Oguz
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Ulas Aday
- Department of Gastrointestinal Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Hüseyin Bilge
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Ömer Basol
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
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Farina R, Foti PV, Conti A, Iannace FA, Pennisi I, Santonocito S, Fanzone L, Mazzone G, Palmucci S, Basile A. The Role of Ultrasound in Dunbar Syndrome: Lessons Based on a Case Report. Am J Case Rep 2020; 21:e926778. [PMID: 33161411 PMCID: PMC7656089 DOI: 10.12659/ajcr.926778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patient: Male, 55-year-old Final Diagnosis: Dunbar syndrome Symptoms: Epigastric pain • weight loss Medication: — Clinical Procedure: None Specialty: Gastroenterology and Hepatology • Radiology
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Affiliation(s)
- Renato Farina
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Andrea Conti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Francesco Aldo Iannace
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Isabella Pennisi
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Serafino Santonocito
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Luigi Fanzone
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Giuseppe Mazzone
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Stefano Palmucci
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
| | - Antonio Basile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Catania University, Catania, Italy
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Paleti S, Boppanna V, Sobani ZA, McCarthy D, Rustagi T. Compression Regression: A Rare but Curable Cause of Postprandial Abdominal Pain. Dig Dis Sci 2020; 65:401-404. [PMID: 31974909 DOI: 10.1007/s10620-020-06086-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - Vaishnavi Boppanna
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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