[Diagnosis and treatment of Dunbar syndrome]

The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.

Atypical case of coexistent vascular compression syndromes: median arcuate ligament syndrome and nutcracker syndrome

Vascular compression syndromes, including median arcuate ligament syndrome (MALS) and nutcracker syndrome (NCS), are poorly understood and frequently delayed diagnoses. This case describes a young adult female presenting with chronic vomiting, abdominal pain and weight loss, with dependence on nasogastric feeding. Subsequent to her gastrointestinal symptoms, she developed haematuria and orthostatic intolerance. Investigations confirmed NCS and possible MALS, with superadded gastroparesis and bradygastria. Under the joint care of general and vascular surgeons, she underwent a gastrojejunostomy and panelled renocaval bypass which led to partial resolution of her symptoms. It is hypothesised that gastroparesis may have been caused by MALS via a neurogenic mechanism, or coexistent compression of the duodenum by the superior mesenteric artery. This case highlights the difficulty in diagnosis of vascular compression syndromes, the overlap between the conditions and the potential for multiple coexistent conditions which complicate diagnosis and lead to increased lead-time and morbidity for patients.

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.

A fatal case of massive hemobilia caused by invasive pancreatic cancer with median arcuate ligament syndrome: A case report

INTRODUCTION

In median arcuate ligament syndrome (MALS), the celiac artery is compressed, causing an arcade to develop in the pancreatic head, leading to ischemic symptoms and aneurysms.

PATIENT CONCERNS

The patient was diagnosed with borderline resectable pancreatic cancer (PC) and MALS. Endoscopic biliary drainage with a covered metal stent (CMS) was performed for the obstructive jaundice. After the jaundice improved, a modified FOLFIRINOX regimen was initiated. Several days later, cardiopulmonary arrest occurred after hematemesis occurred. Cardiopulmonary resuscitation was performed, his blood pressure stabilized, and emergent upper endoscopy was performed. The CMS was dislodged and active bleeding was observed in the papillae. The CMS was replaced, and temporary hemostasis was achieved. Contrast-enhanced computed tomography revealed a diagnosis of extravasation from the posterior superior pancreaticoduodenal artery (PSPDA) into the biliary tract. Transcatheter arterial embolization was performed. However, the patient was subsequently diagnosed with hypoxic encephalopathy and died on day 14 of hospitalization.

DIAGNOSIS

Biliary hemorrhage due to invasion of pancreatic cancer from the PSPDA associated with MALS.

INTERVENTION

None.

OUTCOMES

Biliary hemorrhage from the PSPDA was fatal in the patient with invasive PC with MALS.

LESSONS

Since MALS associated with PC is not a rare disease, the purpose of this study was to keep in mind the possibility of fatal biliary hemorrhage.

Prognostic factors for the long term outcome after surgical celiac artery decompression in MALS

BACKGROUND

The median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac artery (ORPHA: 293208). Surgical treatment of MALS aims to restore normal celiac blood flow by laparoscopic celiac artery decompression. However, surgical success rates vary widely between patients, therefore adequate selection of patients is essential to improve surgical outcome. Symptoms of MALS might also overlap with other chronic multi-system disorders such as mast cell activation syndrome (MCAS). So far, no clinical or radiological parameter was found to be predictive of the postoperative outcome. We, therefore, aim to study preclinical parameters in one of the largest MALS cohorts with the focus to identify patients that would benefit from surgical MAL release.

RESULTS

By analyzing 20 MALS patients that underwent surgical celiac artery decompression, we found 60% of patients (12/20) had a postoperative relief of their symptoms and a simultaneous decrease of analgetic use. No demographic, radiologic or operative parameter was able to predict postoperative symptom relief. However, mast cell activation syndrome correlated significantly (p = 0.04) with persistent symptoms after the operation.

CONCLUSIONS

Overall, laparoscopic MAL release can provide immediate symptomatic relief. Despite the missing predictive value of demographic and imaging data, our data show a correlation between persistent symptoms and a co-existing mast cell activation syndrome. This suggests that MCAS symptoms might be interpreted as MALS symptoms in the presence of celiac artery stenosis and therefore surgical treatment should be evaluated carefully. Overall, the selection of patients who are most likely to respond to surgical MAL release may best be accomplished by an interdisciplinary team of gastroenterologists, radiologists and surgeons.

Trauma-Induced Median Arcuate Ligament Syndrome is an Under-Recognized Source of Chronic Abdominal Pain

Median arcuate ligament syndrome (MALS) can be a debilitating condition resulting in epigastric pain, nausea, difficulty eating due to postprandial pain, weight loss, and malnutrition in otherwise healthy individuals. The pain is caused by the compression of the celiac artery and neural ganglia by the median arcuate ligament as it attaches from the spine to the diaphragm. Diagnostic imaging, either duplex or angiography, can show the abnormality however, vague symptoms can lead to a missed diagnosis. While MALS is a known anatomical variation in the population, to our knowledge, has not been identified to be caused by trauma. Here, we present 4 patients who developed MALS following abdominal or spinal trauma whom all required surgery to alleviate lifestyle-limiting pain.

Prevalence and Characteristics of Patients with Median Arcuate Ligament Syndrome in a Cohort Diagnosed with Celiac Artery Compression

BACKGROUND

Median arcuate ligament syndrome (MALS) is a frequent differential diagnosis in patients with postprandial abdominal symptoms, but diagnosis remains challenging. The aim of this study was to identify characteristics of patients who had MALS compared with non-MALS patients among a cohort of patients diagnosed with celiac artery compression (CAC).

STUDY DESIGN

An IRB-approved retrospective chart review (2000 to 2021) of patients at our institution with a discharge diagnosis of CAC was performed. Medical record review for clinical symptoms and findings consistent with MALS was performed.

RESULTS

Two hundred ninety-three patients with a diagnosis of CAC were identified; 59.7% were women, and average age was 63.9 ± 20.2 years. Sixty-nine (23.5%) patients with CAC had MALS. There were no significant differences in sex or race between MALS and non-MALS patients, but MALS patients were younger (55.7 vs 68.1, p < 0.001). There was no significant difference in gastrointestinal comorbidities between the 2 groups. Patients with MALS were less likely to have diabetes (12.5% vs 26.9%), renal disease (4.6% vs 8.2%), hypertension (41.5% vs 70.3%), mesenteric atherosclerotic disease (14% vs 61.9%), and peripheral artery disease (15.0% vs 39.7%).

CONCLUSIONS

We demonstrate a novel observation that MALS patients tend to have fewer atherosclerotic characteristics than non-MALS patients with CAC. Patients in our study with MALS were more likely to be younger, women, and presenting with epigastric pain. MALS patients had a significantly lower incidence of diabetes, hypertension, renal disease, mesenteric artery disease, and peripheral arterial disease compared with the non-MALS group. An important clinically relevant feature of MALS patients may be their lack of atherosclerotic phenotype compared with non- MALS patients with CAC.

Robotic Approach for Median Arcuate Ligament Relief: A Case Report and Literature Review

Introduction: There are very few reported cases of robotic surgery for median arcuate ligament syndrome. This clinical condition develops when the root of the celiac trunk is compressed by the median arcuate ligament of the diaphragm. The symptoms that typically accompany this syndrome are: discomfort and pain in the upper abdominal region, particularly after eating, and weight loss. During the diagnostic process, it is important to rule out other potential causes and demonstrate compression using any imaging technique available. Transecting the median arcuate ligament is the primary focus of the surgical treatment. We report a case of robotic MAL release, focusing on the particular aspects of the surgical technique. A literature review was also performed on the topic of robotic approach for MALS. Clinical case: A 25-year-old woman presented with sudden onset severe upper abdominal pain after physical activity and eating. She was then diagnosed with median arcuate ligament syndrome by imagistic means with computer tomography, doppler ultrasound, and angiographic computed tomography. After conservative management and careful planning, we performed robotic division of median arcuate ligament. The patient was discharged from the hospital without any complaint on the second day after surgery. Subsequent imaging studies revealed no residual celiac axis stenosis. Conclusion: The robotic approach is a safe and feasible treatment modality for median arcuate ligament syndrome.

A Case Series of Median Arcuate Ligament Syndrome With Varied Presentations

Median arcuate ligament syndrome (MALS) is characterized by the constriction of the celiac trunk caused by fibrous connections originating from the median arcuate ligament (MAL) and diaphragmatic crura. It presents with symptoms often leading to misdiagnosis. In this study, we present three cases of MALS, with distinct manifestations. These cases were diagnosed through comprehensive investigations and managed successfully using laparoscopic decompression. The diagnosis of MALS poses challenges due to its variable presentations and overlap with other conditions. Diagnostic imaging techniques such as Doppler ultrasound, computed tomography (CT) scans and angiography play a role in confirming the diagnosis. Laparoscopic decompression has proven to be a treatment option that relieves symptoms and restores blood flow. This series highlights the importance of considering MALS as a cause for abdominal pain cases. Early detection and the use of diagnostic techniques can result in favorable outcomes.

Median arcuate ligament syndrome in a patient with frontal lobe syndrome

A boy aged 19 years presented to emergency room with severe postprandial upper abdominal pain and recent significant weight loss, with history of decompressive craniotomy for post-traumatic frontal lobe haemorrhage. CT scan revealed an acute indentation of coeliac artery with high-grade stenosis and post-stenotic dilatation, diagnostic of median arcuate ligament syndrome (MALS). MALS, a diagnosis of exclusion, is identified using patient's accurate symptomatic description. Exclusion of other causes of abdominal angina in a patient with frontal lobe syndrome was a challenging job, as they lack critical decision-making ability. Hence, the decision to proceed with the complex laparoscopic procedure was made by the patient's parents and the surgeon, with the patient's consent. Laparoscopic release of the median arcuate ligament resulted in relief of the patient symptoms much to the relief of his parents and the surgeon.

Median Arcuate Ligament Syndrome and Its Associated Conditions

The risk factors and associated conditions of median arcuate ligament syndrome (MALS) have not been well characterized in the literature. In this study, we aim to investigate the presentation and outcomes of MALS patients with an emphasis on the prevalence of other uncommon disorders. To this end, data of patients with MALS who underwent surgery between 2013 and 2018 were collected and compiled into a retrospective database and analyzed. Eleven patients were identified. Seven of these eleven patients underwent diagnostics to evaluate gastric emptying. Five of these seven patients (71.4%) had radiographic evidence of delayed gastric emptying. Four of the eleven patients (36.4%) were found to have anatomic abnormalities of their visceral vasculature. Two of the eleven patients (18.2%) were found to have connective tissue disorders, both with Ehlers-Danlos syndrome. Three of the eleven (27.3%) had a diagnosis of postural orthostatic tachycardia syndrome. This is the first case series reporting on an association between MALS and delayed gastric emptying. We also explored the relationship between MALS and visceral vascular abnormalities, Ehlers-Danlos syndrome, and postural orthostatic tachycardia syndrome. It is notable that these conditions are more prevalent in the MALS population than in the general population, suggesting a possible pathophysiologic relationship.

Median arcuate ligament syndrome and arterial anastomotic bleeding inducing hepatic artery thrombosis after liver transplantation: A case report

RATIONALE

Median arcuate ligament (MAL) may compress the coeliac trunk inducing median arcuate ligament syndrome (MALS). MALS is a risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients.

PATIENT CONCERNS

A thin female complained about upper abdominal pain for two months.

DIAGNOSES

The patient was diagnosed as primary biliary cirrhosis.

INTERVENTIONS

The patient received two liver transplantations. During the first liver transplantation, the hepatic artery (HA) pulsations were normal. Doppler B ultrasonography showed normal blood flow in the HA in the first week. A 4 cm hematoma was detected in the first porta hepatis. On the ninth day, the hematoma had increased to 9 cm along with development of HAT. Exploratory laparotomy was performed. Bleeding at the site of arterial anastomosis was considered to be the reason for the hematoma. Doppler imaging revealed no blood flow in the liver. Computed tomography angiography demonstrated MALS. Salvage liver transplantation combined with dissection of MAL was performed. The maximum velocity of HA increased to 87 cm/s.

OUTCOMES

The patient was discharged from the hospital 17 days after the second transplantation. At discharge, the liver function was normal and Doppler showed good blood flow in the HA.

LESSONS

MALS can cause HAT after liver transplantation. Before the liver transplantation, we should use Doppler B ultrasonography and sagittal CT imaging to judge whether the patient is with MALS. Also, before arterial anastomosis in liver transplantation is conducted, we should observe the impacts on the HA caused by pre-blocking gastroduodenal artery, which determines if we are supposed to do MAL dissection or bridge HA with aorta.

Median Arcuate Ligament Syndrome - Literature Review and Case Report

INTRODUCTION

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms (postprandial epigastric pain, nausea, weight loss, anorexia and diarrhea). However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients. Besides the extrinsic vascular compression, MALS has a multifactorial etiology and it has been suggested as a neurogenic disease resulting in altered sensation and pain from the somatic nerves in the splanchnic plexus. MALS is a diagnosis of exclusion, so other causes must be excluded. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical approach, in refractory cases with residual stenosis of celiac trunk.

OBJECTIVE

To report a case of MALS and to review current literature.

METHODS

The authors report a clinical case and present a literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers.

RESULTS

A 34-year-old woman, previously healthy, recurred to a General Practitioner with a recurrent epigastric pain, exacerbated by ingestion, without relieving factors, in the previous 6 months. Patient also reported anorexia and unprovoked weight loss of 8Kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Computed Tomography Angiography (CTA) abdomen revealed a focal 80% stenosis of the celiac trunk, located 8mm from its origin in aorta and a post- -stenotic enlargement of 9mm. An open decompression of the celiac trunk was performed. Through an 8cm median supraumbilical laparotomy, supraceliac abdominal aorta was approached. The compressive band across the celiac trunk was identified and cut. Further dissection was performed until the celiac artery became completely exposed and its branches identified. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without recurrence of the abdominal pain. 1 month later, the patient remained asymptomatic. A long-term follow-up with annual duplex scan and clinical evaluation must be done, in order to evaluate the need of a revascularization due to persistent stenosis or aneurysmal degeneration.

CONCLUSION

MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of therapy.

Median Arcuate Ligament Syndrome of Diaphragm - Literature Review and Case Report

OBJECTIVES

To report a case of median arcuate ligament syndrome (MALS) and to review current literature.

METHODS

Case report and literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers.

RESULTS

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms. However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients, so MALS is a diagnosis of exclusion. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical release of median arcuate ligament. A 34-year-old woman, previously healthy, presented with a epigastric pain, mainly postprandial, for 6 months, associated to anorexia and unprovoked weight loss of 8kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Abdomino-pelvic computed tomography angiography revealed a focal 80% stenosis of proximal celiac trunk. An open decompression of the celiac trunk was performed. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without abdominal pain recurrence.

CONCLUSION

MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of treatment.

[Median arcuate ligament syndrome]

The median arcuate ligament syndrome is a rare entity and poorly described in Danish literature. The syndrome is a diagnosis of exclusion and is characterized by chronic abdominal pain, postprandial pain and weight loss. It is believed that the median arcuate ligament, being a fibrous structure of diaphragm, compresses the coeliac trunk thus causing stenosis and malperfusion of the gastrointestinal organs. Until recently, there has been some reluctance to consider intervention with revascularization or ligament release. Within the latest decade minimally invasive techniques, including laparoscopic release of the median arcuate ligament, have shown promising results.