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Yadav P, Acharya K, Adhikari AB, Yadav M, Adhikari A, Sah OP. Median arcuate ligament syndrome: A rare case report from Nepal. Int J Surg Case Rep 2024; 120:109809. [PMID: 38796938 PMCID: PMC11152655 DOI: 10.1016/j.ijscr.2024.109809] [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: 04/03/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, leading to a typical symptom triad: postprandial abdominal pain, weight loss, nausea, and vomiting. CASE PRESENTATION A 41-year-old female patient presented to our center with mild postprandial abdominal pain over the epigastric region, and bloating sensation. Ultrasonography of the abdomen showed multiple stones in the gall bladder lumen, and the computed tomography scan showed median arcuate ligament impingement along the proximal aspect of the celiac trunk causing moderate narrowing with post-stenotic dilation. Laparoscopic release of the median arcuate ligament with laparoscopic cholecystectomy was performed. DISCUSSION The diagnosis of Median Arcuate Ligament Syndrome is based on the classical post-prandial symptoms and abdominal imaging technologies like Doppler ultrasonography, computed tomography angiography, or magnetic resonance angiography. Exclusion of other intestinal disorders should be considered before making the diagnosis. Celiac artery decompression through different means is the principle of treatment of this condition. CONCLUSION The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have an established etiology. Celiac artery decompression by releasing the median arcuate ligament is the treatment.
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Affiliation(s)
- Prashant Yadav
- Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal.
| | - Kshitiz Acharya
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Aramva Bikram Adhikari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Manish Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Aayam Adhikari
- Kist Medical College and Teaching Hospital, Lalitpur, Nepal
| | - Om Prakash Sah
- Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
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Ganapathy A, Mohakud S, Rout S, Joy P, Alagappan A, Manokaran A. A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery. Abdom Radiol (NY) 2024:10.1007/s00261-024-04231-w. [PMID: 38494467 DOI: 10.1007/s00261-024-04231-w] [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: 01/05/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL). METHODS Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done. RESULTS Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties. CONCLUSION This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.
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Affiliation(s)
- Arthi Ganapathy
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.
| | - Sudipta Mohakud
- Department of Radiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sipra Rout
- Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Praisy Joy
- Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Alamelu Alagappan
- Department of Radiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Aarthi Manokaran
- Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, India
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Retroperitoneal endoscopic median arcuate ligament incision with interventional radiology: a case report and literature review. Ann Med Surg (Lond) 2023; 85:514-518. [PMID: 36923741 PMCID: PMC10010801 DOI: 10.1097/ms9.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/25/2022] [Indexed: 03/18/2023] Open
Abstract
Compression of the celiac artery (CA) associated with median arcuate ligament compression syndrome can result in aneurysms at the pancreaticoduodenal arcade. If the aneurysm ruptures, treatment with interventional radiology (IVR) is recommended. Subsequently, the median arcuate ligament (MAL) should be incised to prevent the recurrence of the aneurysm. Retroperitoneal endoscopic MAL incision reduces the risk of adhesive bowel obstruction. However, there is few surgical landmark for retroperitoneal MAL incision. We used IVR to detect CA for MAL incision. Case Presentation A 44-year-old man presented to our hospital with complaints of abdominal pain and clouding of consciousness. Contrast-enhanced computed tomography of the abdomen showed contrast leakage from pancreaticoduodenal artery aneurysm, and the CA was compressed by MAL, leading to the diagnosis of pancreaticoduodenal artery aneurysm rupture associated with median arcuate ligament compression syndrome. IVR was performed to block the blood flow to the aneurysm. After 2 months from life-saving IVR, we performed retroperitoneal endoscopic MAL incision with IVR. The patient was discharged 8 days after surgery. Echocardiography and contrast-enhanced computed tomography 2 months after discharge confirmed that the compression and flow of the CA had improved. Clinical Discussion In retroperitoneal endoscopic MAL incision, there has been few landmark to identify MAL and CA. Retroperitoneal procedure with IVR can identify MAL easily. This is a useful technique, and it is important to accumulate more cases to standardize the technique. Conclusion Retroperitoneal endoscopic MAL incision with IVR has not been reported, this procedure can make it easier to detect MAL.
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Okobi OE, Afuda BA, Boms M, Ekpemiro CU, Umeh NJ, Nnaji CG, Onyechi NP, Faderin OG, Chiji-Aguma JC, Stephen E, Amadi CO. Median Arcuate Ligament Syndrome: Management and Literature Review. Cureus 2022; 14:e28889. [PMID: 36225522 PMCID: PMC9542491 DOI: 10.7759/cureus.28889] [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: 09/07/2022] [Indexed: 01/17/2023] Open
Abstract
Pain, nausea, vomiting, weight loss, diarrhea, and fatigue are common symptoms of several upper gastroenterological illnesses. However, the presence of unexplained recurring postprandial abdominal pain and vomiting increases the possibility of median arcuate ligament syndrome (MALS). MALS is an uncommon illness characterized by postprandial vomiting, abdominal pain, and weight loss. The compression of the median arcuate ligament on the celiac trunk and/or its surrounding celiac nerve plexus may explain this disease phenomenon. Comprehensive workup for other etiologies may be unrevealing except for the compression of the celiac trunk identified in imaging studies and, perhaps, occasional arterial flow rates in sonography studies in some severe cases. Due to the overlapping symptoms of upper gastroenterological disorders, misdiagnosis may be widespread. Therefore, it is essential to consider MALS while examining a patient with upper gastrointestinal disease. In this case series, we present two cases of MALS with similar clinical trajectories and differences in diagnostic techniques.
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Lu XC, Pei JG, Xie GH, Li YY, Han HM. Median arcuate ligament syndrome with retroperitoneal haemorrhage: A case report. World J Clin Cases 2022; 10:7509-7516. [PMID: 36158028 PMCID: PMC9353894 DOI: 10.12998/wjcc.v10.i21.7509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is relatively rare and is due to extraluminal compression of the coeliac artery by the median arcuate ligament of the diaphragm. Here, we report a case of MALS found in a patient with abdominal pain and retroperitoneal haemorrhage for education and dissemination.
CASE SUMMARY This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.
CONCLUSION MALS is very rare and usually has postprandial abdominal pain, upper abdominal murmur, and weight loss. It is diagnosed by imaging or due to complications. When a patient has abdominal bleeding or PDAA, we should consider whether the patient has celiac trunk stenosis (MALS or other etiology). When abdominal bleeding is combined with an aneurysm, we generally think of aneurysm rupture and hemorrhage first, but it may also be collateral artery rupture and hemorrhage.
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Affiliation(s)
- Xiao-Chen Lu
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Jian-Guo Pei
- Department of Imaging, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Hua Xie
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Yong-Yu Li
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Hong-Mei Han
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
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Laparoscopic Release for Median Arcuate Ligament Compression Syndrome Associated with a Celiac-Mesenteric Trunk. Case Rep Vasc Med 2022; 2022:3595603. [PMID: 35494098 PMCID: PMC9054496 DOI: 10.1155/2022/3595603] [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] [Received: 12/13/2021] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022] Open
Abstract
The median arcuate ligament compression syndrome is a rare entity that occurs in 2 per 100,000 unselected individuals. We present a case where the median arcuate ligament compression syndrome was associated with an equally uncommon anatomic variation—a celiac-mesenteric trunk, which occurs in 0.42-2.7% of unselected individuals. We could find no prior report of a celiac-mesenteric trunk being associated with the median arcuate ligament compression syndrome. This report also adds to the literature to show that a laparoscopic approach to median arcuate ligament release is feasible.
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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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Peng C, Liu J, He W, Qin W, Yuan T, Kan Y, Wang K, Wang S, Shi Y. Numerical simulation in the abdominal aorta and the visceral arteries with or without stenosis based on 2D PCMRI. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3569. [PMID: 34967124 DOI: 10.1002/cnm.3569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/10/2021] [Accepted: 12/27/2021] [Indexed: 06/14/2023]
Abstract
It is important to obtain accurate boundary conditions (BCs) in hemodynamic simulations. This article aimed to improve the accuracy of BCs in computational fluid dynamics (CFD) simulation and analyze the differences in hemodynamics between healthy volunteers and patients with visceral arterial stenosis (VAS). The geometric models of seven cases were reconstructed using the magnetic resonance angiogram (MRA) or computed tomography angiogram (CTA) imaging data. The physiological flow waveforms obtained from 2D Phase Contrast Magnetic Resonance Imaging (PCMRI) were imposed on the aortic inlet and the visceral arteries' outlets. The individualized RCR values of the three-element Windkessel model were imposed on the aortic outlet. CFD simulations were run in the open-source software: svSolver. Two specific time points were selected to compare the hemodynamics of healthy volunteers and patients with VAS. The results suggested that blood in the stenotic visceral arteries flowed at high speed throughout the cardiac cycle. The low pressure is distributed at stenotic lesions. The wall shear stress (WSS) reached 4 Pa near stenotic locations. The low time average wall shear stress (TAWSS), high oscillatory shear index (OSI), and high relative residence time (RRT) concentrated in the abdominal aorta. Besides, the ratios of the areas with low TAWSS, high OSI, and high RRT to the computational domain were higher in patients with VAS than which in the healthy volunteers. The individualized BCs were used for hemodynamic simulations and results suggest that patients with stenosis have a higher risk of blood retention and atherosclerosis formation in the abdominal aorta.
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Affiliation(s)
- Chen Peng
- Department of Aeronautics and Astronautics, Institute of Biomechanics, Fudan University, Shanghai, China
| | - Junzhen Liu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei He
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Qin
- Department of Aeronautics and Astronautics, Institute of Biomechanics, Fudan University, Shanghai, China
| | - Tong Yuan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuanqing Kan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Keqiang Wang
- Institute of Panvascular Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengzhang Wang
- Department of Aeronautics and Astronautics, Institute of Biomechanics, Fudan University, Shanghai, China
- Institute of Biomedical Engineering Technology, Academy for Engineering and Technology, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Almeida JI, Coelho MN, Armas I, Soares C, Santos T, Freitas C. Median arcuate ligament syndrome: A case report of a rare disease. Int J Surg Case Rep 2022; 90:106686. [PMID: 34973626 PMCID: PMC8728423 DOI: 10.1016/j.ijscr.2021.106686] [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: 11/28/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, which may trigger a typical symptom triad: postprandial abdominal pain, weight loss, nausea and vomiting. CLINICAL CASE A 58-year-old male was admitted to the emergency department due to abdominal pain, vomiting, fever and diarrhea. On admission, the patient was tachycardic, had abdominal distension, no peritoneal irritation signs, and a serum lactate level of 5 mmol/L. The computed tomography (CT) scan showed gastric and intestinal pneumatosis associated with pneumoportia. Conservative treatment with intravenous fluids, antibiotics and low molecular weight heparin, was initiated. The reassessment CT scan showed resolution of the gastric and intestinal pneumatosis and a severe stenosis of the initial portion of the celiac trunk with associated angulation. After recovery from the acute episode, an abdominal duplex ultrasound and an aortoiliac arteriography in forced inspiration and expiration was performed, corroborating the diagnosis of MALS. A laparoscopic decompression of the celiac trunk was performed. DISCUSSION Symptoms of MALS closely mimic other abdominal disorders, and it should be considered in the differential diagnosis. Currently, there are no international guidelines on MALS diagnostic criteria. Treatment is focused on decompression of the median arcuate ligament constriction of the celiac artery, with or without celiac lymph node removal. CONCLUSION MALS diagnostic and therapeutic approach must be patient focused. Laparoscopic decompression is an effective treatment and can provide immediate symptomatic relief, associated with the benefits of the less invasive nature of the procedure.
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Affiliation(s)
| | | | - Isabel Armas
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Carlos Soares
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal; Faculty of Medicine of Porto University, Portugal
| | - Tatiana Santos
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Carla Freitas
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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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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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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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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Dowgiałło-Gornowicz N, Grochowska W, Lech P, Saluk S, Michalik M. Laparoscopic treatment of rare median arcuate ligament syndrome – medium-term follow-up. POLISH JOURNAL OF SURGERY 2021; 93:25-29. [DOI: 10.5604/01.3001.0015.4214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<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.
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Affiliation(s)
- Natalia Dowgiałło-Gornowicz
- Department of General, Minimally Invasive and Old Age Surgery, University of Warmia and Masuria in Olsztyn, Poland
| | - Weronika Grochowska
- Department of General, Minimally Invasive and Old Age Surgery, University of Warmia and Masuria in Olsztyn, Poland
| | - Paweł Lech
- Department of General, Minimally Invasive and Old Age Surgery, University of Warmia and Masuria in Olsztyn, Poland
| | - Sławomir Saluk
- Department of General, Minimally Invasive and Old Age Surgery, University of Warmia and Masuria in Olsztyn, Poland
| | - Maciej Michalik
- Department of General, Colorectal and Oncological Surgery, Nicolaus Copernicus University in Toruń, Poland
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Saito H, Sawada K, Ogawa J, Hashimoto M, Oshima M, Hada M, Kato Y, Oyama K, Kotake M, Hara T. Laparoscopic treatment for celiac artery stenosis caused by median arcuate ligament compression with Adachi V type vascular anomaly: a case report. Surg Case Rep 2021; 7:140. [PMID: 34106354 PMCID: PMC8190227 DOI: 10.1186/s40792-021-01226-3] [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: 05/02/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS), which results from compression of the median arcuate ligament (MAL), is a rare cause of abdominal pain and weight loss. Treatment is dissection of the MAL; however, the laparoscopic procedure is not yet established and it involves the risk of major vascular injury, especially in cases with an anomaly. CASE PRESENTATION A 47-year-old man was evaluated at the hospital for epigastric pain. Contrast computed tomography scan revealed stenosis of the celiac artery origin due to the MAL. An Adachi V type vascular anomaly was also observed. Laparoscopic treatment was performed to release pressure on the celiac artery. Laparoscopic ultrasonography was used to less invasively confirm the release of the MAL. Despite a concomitant Adachi V type vascular anomaly, surgery was safely performed using the laparoscopic magnification view and intraoperative ultrasonography. Follow-up ultrasonography confirmed the celiac artery stenosis has not recurred. CONCLUSIONS A rare case of MALS with an Adachi V type vascular anomaly is presented and the laparoscopic treatment is detailed.
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Affiliation(s)
- Hiroshi Saito
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan.
| | - Koichiro Sawada
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Jyunichi Ogawa
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Masashi Hashimoto
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Masahiro Oshima
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Masahiro Hada
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Yosuke Kato
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Kaeko Oyama
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Masanori Kotake
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
| | - Takuo Hara
- Department of Surgery, Koseiren Takaoka Hospital, Eirakutyou 5-10, Takaoka, Toyama, Japan
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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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16
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Coelho JCU, Hosni AVE, Claus CM, Aguilera YSH, Abot GP, Freitas ATCD, Costa MARD. Treatment of median arcuate ligament syndrome: outcome of laparoscopic approach. ACTA ACUST UNITED AC 2020; 33:e1495. [PMID: 32428132 PMCID: PMC7236320 DOI: 10.1590/0102-672020190001e1495] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 02/08/2023]
Abstract
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.
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Abstract
PURPOSE OF REVIEW Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders. RECENT FINDINGS There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.
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Affiliation(s)
| | - Paul Feuerstadt
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA. .,Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, CT, USA.
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18
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Bayat I, Wang J, Ho P, Bird D. Intravascular ultrasound-guided laparoscopic division of the median arcuate ligament. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:147-151. [PMID: 32154471 PMCID: PMC7056607 DOI: 10.1016/j.jvscit.2020.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/19/2020] [Indexed: 12/29/2022]
Abstract
Median arcuate ligament syndrome is a rare and poorly understood condition that can have a significant impact on the quality of life of patients. Diagnosis is often difficult and delayed because of the need to exclude other pathologic processes. Treatment strategies traditionally involve open or laparoscopic division of the median arcuate ligament, with or without vascular reconstruction. This report portrays a case of median arcuate ligament syndrome with compression of two visceral arteries and distal embolic complications. A novel hybrid technique is described using intravascular ultrasound technology to aid in laparoscopic median arcuate ligament division. This allowed real-time intravascular visualization of the compressive segment, guided release of the ligament fibers, and demonstrated confirmation of decompression.
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Affiliation(s)
- Iman Bayat
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Judy Wang
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Prahlad Ho
- Department of Hematology, Northern Health, Melbourne, Victoria, Australia
| | - David Bird
- Department of General Surgery, Northern Health, Melbourne, Victoria, Australia
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