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Maddox K, Farrell TM, Pascarella L. Median Arcuate Ligament Syndrome: Where Are We Today? Am Surg 2025; 91:284-291. [PMID: 39418076 DOI: 10.1177/00031348241292728] [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] [Indexed: 10/19/2024]
Abstract
Median arcuate ligament syndrome, or celiac artery compression syndrome (eponym: Dunbar syndrome), has historically been attributed to pathophysiologic vascular compression causing downstream ischemic symptoms of the organs supplied by the celiac trunk. However, the more we learn about the histology, clinical presentation, and treatment outcomes, health care providers are increasingly correlating the symptoms of MALS with the long-term, repetitive compression of the celiac ganglion rather than the celiac trunk. This article provides a comprehensive review of current MALS literature, emphasizing the multidisciplinary approach these patients require in all phases of their care. With most patients with MALS waiting an average of 10.5 months to 2.6 years, 9, 10 our need for better diagnostic protocols and clearer understanding of the pathophysiology of the disease is paramount. Further investigation into patient outcomes, associated conditions, and linked pathophysiology would help better characterize this disease with hopes of moving it from a diagnosis of exclusion to one of standard work-up with decreased time to treatment and symptom relief for patients.
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Affiliation(s)
- Kayden Maddox
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Timothy M Farrell
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Butz F, Haase O, Martin F, Hillebrandt KH, Knitter S, Schöning W, Raschzok N, Pratschke J, Krenzien F. Short and longterm outcome of minimally invasive therapy of median arcuate ligament syndrome. Langenbecks Arch Surg 2024; 409:322. [PMID: 39446176 PMCID: PMC11502543 DOI: 10.1007/s00423-024-03511-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 10/14/2024] [Indexed: 10/25/2024]
Abstract
PURPOSE Median arcuate ligament syndrome (MALS) is a rare disorder caused by compression of the celiac artery (CA) by the median arcuate ligament (MAL). Common symptoms include postprandial abdominal pain, diarrhea, and weight loss. While laparoscopic MAL division has long been considered the procedure of choice, robotic-assisted procedures have been increasingly used since their introduction. Aim of this study was to evaluate peri- and postoperative outcomes after minimally invasive MAL release. METHODS A retrospective analysis of patients undergoing minimally invasive MAL release at the Department of Surgery, Charité - Universitätsmedizin Berlin, between 2014 and 2023 was performed. RESULTS 20 patients met the inclusion criteria and underwent either laparoscopic (n = 3) or robotic (n = 17) MAL release. Most common preoperative symptoms were postprandial abdominal pain (90%), weight loss (45%), diarrhea (30%), and nausea (25%). Comparing laparoscopic and robotic surgery, neither the median duration of surgery (minutes: 98 (90-290) vs. 125 (80-254); p = 0.765), the median length of hospital stay (days: 4 (3-4) vs. 5 (3-6); p = 0.179) and intraoperative blood loss (< 50 ml in both groups, p = 1.0) showed significant differences. Peak systolic velocity in the CA was significantly reduced postoperatively (cm/s: 320 (200-765) vs. 167 (100-500), p < 0.001). Postoperatively, 17 (85%) patients reported symptom improvement, while 4 (20%) patients had no symptom relief at last follow-up. In 3 cases, follow-up imaging showed evidence of respiratory-related CA stenosis. CONCLUSION Despite being complex and challenging procedures, laparoscopic and robotic-assisted MAL release are safe procedures with low risk of postoperative complications and good longterm outcomes.
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Affiliation(s)
- Frederike Butz
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Oliver Haase
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Friederike Martin
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Karl Herbert Hillebrandt
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Sebastian Knitter
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte| Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany.
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Greaser J, Nasrullah A, Thornburgh C. I saw the "hook" sign of median arcuate ligament syndrome. Clin Imaging 2024; 113:110249. [PMID: 39106656 DOI: 10.1016/j.clinimag.2024.110249] [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: 06/27/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/09/2024]
Abstract
The hook sign is a radiologic finding best appreciated on a sagittal view of the celiac artery with computed tomography (CT) that indicates compression of the celiac artery. It refers to the hooked-shape of the proximal celiac artery caused by extrinsic compression by the median arcuate ligament. When seen in a patient with concurrent abdominal symptoms, it suggests median arcuate ligament syndrome (MALS). We saw the sign in a 15-year-old male via duplex ultrasonography and abdominal CT. He underwent laparoscopic release of the median arcuate ligament and had full resolution of his symptoms at follow-up.
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Affiliation(s)
- Josh Greaser
- School of Medicine, University of Missouri, Columbia, MO, United States of America.
| | - Ayesha Nasrullah
- School of Medicine, University of Missouri, Columbia, MO, United States of America; Department of Radiology, University of Missouri Healthcare, Columbia, MO, United States of America
| | - Cody Thornburgh
- School of Medicine, University of Missouri, Columbia, MO, United States of America; Department of Radiology, University of Missouri Healthcare, Columbia, MO, United States of America
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Sarad N, Basilious M, Nag U, Jethmalani N, Agrusa C, Ellozy S, DeRubertis B, Connolly P. Presentation and management of true aneurysms of the pancreaticoduodenal arcade with concomitant celiac artery stenosis using the endovascular approach. J Vasc Surg Cases Innov Tech 2024; 10:101499. [PMID: 38764461 PMCID: PMC11099304 DOI: 10.1016/j.jvscit.2024.101499] [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: 01/26/2024] [Accepted: 03/21/2024] [Indexed: 05/21/2024] Open
Abstract
True aneurysms of the pancreaticoduodenal artery (PDA) arcade are rare but require intervention due to the high risk of rupture. Historically, these aneurysms have been managed with open surgical methods. In this study, we describe a contemporary series of aneurysms treated using a modern approach that includes endovascular and hybrid techniques. All the patients with aneurysms of the PDA arcade in an institutional database were identified between 2008 and 2022. Patients with history of pancreatic resection were excluded. Data on demographics, presenting symptoms, imaging findings, operative approach, and outcomes were collected and reviewed. There were nine patients diagnosed with a PDA aneurysm, and all nine underwent endovascular intervention. Most were men (n = 5; 55.6%) and White (n = 7; 77.8%) and had American Society of Anesthesiologists class II or III. The median aneurysm size was 21 mm (range, 6-42 mm), and five (55.5%) were symptomatic. Of the five symptomatic cases, two presented with rupture and were treated urgently. The median time to intervention for the nonurgent cases was 30 days. All but one patient had concomitant celiac artery stenosis and two of the eight cases (25%) were due to extrinsic compression from median arcuate ligament syndrome. Both patients underwent median arcuate ligament syndrome release before endovascular intervention. Another patient required open surgical bypass before endovascular repair from the supraceliac aorta to hepatic artery using a Dacron graft to maintain hepatic perfusion. Among the eight patients with celiac axis stenosis, five (62.5%) required celiac stent placement within the same operation. Coil embolization of the aneurysm was used for all except for two patients (n = 7 of 9; 77.8%), with one patient receiving embolic plugs and another receiving an 8 × 38-mm balloon-expandable covered stent for aneurysm exclusion. The median operating room time was 134 minutes. All repairs were technically successful without any intraoperative or postoperative complications. The mean follow-up was 30 months. There was no morbidity, mortality, or unplanned secondary reinterventions within 6 months after aneurysm repair. Stent patency and aneurysm size remained stable at 2 years of follow-up. True pancreaticoduodenal artery arcade aneurysms can be safely and effectively treated using endovascular and hybrid techniques. Because many of these aneurysms have concomitant celiac artery stenosis, the use of endovascular technology allows for simultaneous treatment of both the aneurysm and the stenosis with exceptional results.
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Affiliation(s)
- Nakia Sarad
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Mark Basilious
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Uttara Nag
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Nitin Jethmalani
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher Agrusa
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Sharif Ellozy
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Brian DeRubertis
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Peter Connolly
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
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Antony A, Ravindran SK, Jayan NP, Yadukrishna S, Sebastian R, Kumar A, Shyamkumar S. Performing median arcuate ligament release surgery in celiac artery compression syndrome: Insights from a tertiary care hospital. J Minim Access Surg 2024; 20:318-325. [PMID: 39047680 PMCID: PMC11354951 DOI: 10.4103/jmas.jmas_402_23] [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: 12/29/2023] [Revised: 05/07/2024] [Accepted: 05/28/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, is a rare condition characterized by persistent post-meal or post-exercise abdominal discomfort, often more pronounced during expiration. Additional symptoms include nausea, vomiting, and weight loss. AIMS AND OBJECTIVES To document the clinical presentation, diagnostic process, and treatment outcomes of seven patients diagnosed with MALS and to evaluate the effectiveness of surgical release of the median arcuate ligament (MAL) over a follow-up period of at least six months. MATERIALS AND METHODS The study included seven patients diagnosed with MALS from 2019 to 2021. Diagnosis was based on the presence of chronic abdominal pain and associated symptoms, absence of alternative diagnoses after various clinical assessments, and angiographic evidence of CA compression. The primary treatment involved surgical decompression of the CA by releasing the MAL through either open or laparoscopic techniques. RESULTS All seven patients underwent successful surgical release of the MAL. The patients were followed up for at least six months post-surgery. The study evaluated the persistence of symptoms and the need for additional interventions such as revascularization techniques. CONCLUSION Surgical release of the MAL is the primary treatment for MALS, providing relief for many patients. However, long-term follow-up is essential as some patients may continue to experience symptoms post-surgery, necessitating further interventions.
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Affiliation(s)
- Ajil Antony
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
| | | | - N. P. Jayan
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
| | - S. Yadukrishna
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
| | - Robbins Sebastian
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
| | - Akshay Kumar
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
| | - Shwetha Shyamkumar
- Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
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Shenoy G, Thomas M, Ramesh BS. Laparoscopic repair of iatrogenic celiac artery injury during median arcuate ligament release: A retrospection and tips at troubleshooting. J Minim Access Surg 2024; 20:359-362. [PMID: 38214287 PMCID: PMC11354949 DOI: 10.4103/jmas.jmas_253_23] [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: 08/16/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT Median arcuate ligament (MAL) syndrome or celiac artery (CA) compression syndrome previously treated mainly by vascular surgeons using the open approach is now being increasingly performed by general surgeons with training in advanced laparoscopy. Although this approach has all the advantages of minimal access surgery, the procedure is fraught with serious complications like injury to major vascular structures during dissection. Vascular injury by far is the major cause of conversion to open procedure. Herein, we report a laparoscopic repair of iatrogenic CA injury by intra-corporeal suturing during MAL release. We also elaborate the causes, the preventive measures that can be applied to avoid such catastrophic occurrences in future. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release.
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Affiliation(s)
- Ganesh Shenoy
- Department of Minimal Access, GI and Bariatric Surgery, Fortis Hospital, Bengaluru, Karnataka, India
| | - Marina Thomas
- Department of Minimal Access, GI and Bariatric Surgery, Fortis Hospital, Bengaluru, Karnataka, India
| | - B. S. Ramesh
- Department of Minimal Access, GI and Bariatric Surgery, Fortis Hospital, Bengaluru, Karnataka, India
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Yamakado J, Shibata R, Watanabe M. Laparoscopic Median Arcuate Ligament Release During Gastric Tube Reconstruction in Subtotal Esophagectomy for a Patient With Esophageal Cancer Complicated by Median Arcuate Ligament Syndrome: A Case Report. Cureus 2024; 16:e65158. [PMID: 39176314 PMCID: PMC11339579 DOI: 10.7759/cureus.65158] [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] [Accepted: 07/22/2024] [Indexed: 08/24/2024] Open
Abstract
A 74-year-old man was diagnosed with squamous cell carcinoma of the lower thoracic esophagus following an upper gastrointestinal endoscopy during a health check-up, which revealed a type 0-IIc tumor. Biopsy confirmed squamous cell carcinoma, with suspicion of submucosal invasion. The patient was referred to our department. Contrast-enhanced computed tomography of the chest and abdomen showed no apparent lymph node or distant metastasis. Severe stenosis at the origin of the celiac artery, likely due to the median arcuate ligament, was observed. No abdominal symptoms were noted at rest or after meals, leading to the diagnosis of thoracic esophageal cancer with asymptomatic median arcuate ligament syndrome. Subsequently, laparoscopic median arcuate ligament release was performed during gastric tube reconstruction in subtotal esophagectomy.
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Affiliation(s)
- Jin Yamakado
- Surgery, Fukuoka University Chikushi Hospital, Fukuoka, JPN
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Volokitin M, Bergman A. Post-surgical Median Arcuate Ligament Syndrome (MALS) Symptom Exacerbation Treated With Osteopathic Manipulative Treatment (OMT): A Case Report. Cureus 2024; 16:e61509. [PMID: 38957265 PMCID: PMC11218518 DOI: 10.7759/cureus.61509] [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] [Accepted: 05/31/2024] [Indexed: 07/04/2024] Open
Abstract
Median arcuate ligament syndrome (MALS, also known as celiac artery compression syndrome, celiac axis syndrome, celiac trunk compression syndrome, Dunbar syndrome, or Harjola-Marable syndrome) is a rare condition characterized by abdominal pain attributed to the compression of the celiac artery and celiac ganglia by the median arcuate ligament. Pain can occur post-prandially and may be accompanied by weight loss, nausea, or vomiting. Following angiographic diagnosis, current definitive treatment may include open or laparoscopic decompression surgery with celiac ganglion removal (if affected), which has been found to provide relief. In this case report, we outline a young female patient with a MALS diagnosis and subsequent surgery, but whose pain recurred in various stress-related instances even after surgical intervention. After a particular pain episode, osteopathic manipulative treatment (OMT) was applied, with a focus on restoring autonomic balance through the use of various gentle osteopathic treatment techniques. A significant reduction in pain was reported post-treatment, followed by complete pain resolution, indicating a great benefit to the incorporation of OMT into the treatment plan of MALS patients in future osteopathic practice.
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Affiliation(s)
- Mikhail Volokitin
- Osteopathic Manipulative Medicine, Touro College of Osteopathic Medicine, New York, USA
| | - Amanda Bergman
- Osteopathic Manipulative Medicine, Touro College of Osteopathic Medicine, New York, USA
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Matsumoto K, Shinozaki H, Shinozaki S, Yukisawa S, Kimata M, Terauchi T, Sata N. Clinical outcomes after surgical decompression of median arcuate ligament syndrome-An observational study. Indian J Gastroenterol 2024; 43:638-644. [PMID: 38733498 DOI: 10.1007/s12664-024-01560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/26/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND AND OBJECTIVES Median arcuate ligament syndrome is caused by compression and stenosis of the celiac artery. Incision of the median arcuate ligament improves persistent abdominal symptoms. The study aimed at evaluating the outcomes in patients who underwent median arcuate ligament syndrome decompression using a self-report questionnaire. METHODS This single-center retrospective study included patients with median arcuate ligament syndrome who underwent decompression surgery between April 2021 and February 2023. The medical records were retrospectively reviewed. RESULTS Ten patients were included in the study. Laparotomy and laparoscopic surgeries were performed in seven and three patients, respectively. The median operation time was 147 minutes. The median hospitalization period after the operation was seven days. The degrees of celiac artery stenosis before and after surgery were compared and the per cent diameter stenosis did not significantly improve; five of 10 patients (50%) had > 50% stenosis in the celiac artery after the operation. Compared to the baseline, the scores of upper gastrointestinal symptoms significantly improved during the six months' period (p < 0.001). Additionally, we evaluated the influence of post-operative per cent diameter stenosis and divided the patients into two groups (≥ 50% vs, < 50%). The scores of upper gastrointestinal (GI) symptoms in both groups improved significantly from baseline. However, the symptomatic improvement at six months in the post-operative per cent diameter stenosis < 50% group was significantly greater than that in the ≥ 50% group (p = 0.016). The scores of lower gastrointestinal symptoms did not change significantly during the six-month period. CONCLUSION Decompression surgery for median arcuate ligament syndrome could improve upper gastrointestinal symptoms regardless of the post-operative per cent diameter stenosis.
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Affiliation(s)
- Kenji Matsumoto
- Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | | | - Satoshi Shinozaki
- Shinozaki Medical Clinic, 6-1-13 Kiyoharadai, Utsunomiya, Tochigi, 321-3223, Japan.
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.
| | - Seigo Yukisawa
- Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Masaru Kimata
- Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Toshiaki Terauchi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
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Don-Pedro D. Celiac Artery Compression Syndrome in an Adolescent Male. Cureus 2024; 16:e60580. [PMID: 38894788 PMCID: PMC11184354 DOI: 10.7759/cureus.60580] [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] [Accepted: 05/09/2024] [Indexed: 06/21/2024] Open
Abstract
Celiac artery compression syndrome is not frequent in the pediatric population. The syndrome may entail long-standing abdominal pain, recurrent vomiting, bloating, weight loss, and an abdominal bruit, which in the case of our patient, was an incidental finding. Notably, patients may be asymptomatic. Our patient is a 16-year-old male who presented with concerns about multiple, non-tender chest lymph nodes lasting for two weeks. He had also lost 80 lbs. over one year. On examination, however, an abdominal bruit was discovered, and a diagnostic workup was significant for celiac artery compression following a magnetic resonance angiography of the abdomen. Due to his significant weight loss and mediastinal lymphadenopathy, a chest computed tomography (CT) scan was done to rule out malignancy. The chest CT scan was reported as normal. Additionally, a renal duplex ultrasound was done to rule out renal artery stenosis, considering he had presented with elevated blood pressure; this was also unremarkable. Although this patient had a history of marijuana use, his assessment did not show marked dependence. Substance abuse and atherosclerotic vascular disease can be predisposing factors for celiac artery compression syndrome in older individuals. However, compression of the celiac trunk by the median arcuate ligament is a congenital anomaly more appreciated in younger age groups. The patient was referred to vascular surgery for possible median arcuate ligament release.
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11
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M Koshy R, Chee RKW, Wilson MP, Singh R, Mathew RP, Tu W, Low G. Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review. Abdom Radiol (NY) 2024; 49:1747-1761. [PMID: 38683215 DOI: 10.1007/s00261-024-04315-7] [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: 02/26/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 05/01/2024]
Abstract
Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.
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Affiliation(s)
- Reshma M Koshy
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada.
| | - Ryan K W Chee
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Mitchell P Wilson
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Ranjit Singh
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Rishi P Mathew
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Wendy Tu
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
| | - Gavin Low
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, T6G2B7, Canada
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Lu LY, Eastment JG, Sivakumaran Y. Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm. J Clin Med 2024; 13:2598. [PMID: 38731126 PMCID: PMC11084382 DOI: 10.3390/jcm13092598] [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: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?
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Affiliation(s)
- Lawrence Y. Lu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Jacques G. Eastment
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
| | - Yogeesan Sivakumaran
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of Vascular Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
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Shnayder-Adams MM, Masotti M, Sanogo ML. Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block. J Vasc Interv Radiol 2024; 35:558-562. [PMID: 38181971 DOI: 10.1016/j.jvir.2023.12.569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.
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Affiliation(s)
- Michelle M Shnayder-Adams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Maria Masotti
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Mamadou L Sanogo
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, Ann Arbor, Michigan.
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Chidambaram R, Soares J, Hicks R, Samuelson S, Tibballs J, Ferguson J, Jansen S. Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone. J Med Imaging Radiat Oncol 2024; 68:289-296. [PMID: 38437188 DOI: 10.1111/1754-9485.13631] [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: 10/18/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. METHODS A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. RESULTS Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. CONCLUSION Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.
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Affiliation(s)
- Rama Chidambaram
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Julian Soares
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rhiannon Hicks
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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15
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Anand S, Mahalingam P, Jayapal L, Suresh S, Ema T. Laparoscopic management of median arcuate ligament syndrome: a video vignette. JOURNAL OF MINIMALLY INVASIVE SURGERY 2024; 27:44-46. [PMID: 38494186 PMCID: PMC10961588 DOI: 10.7602/jmis.2024.27.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 03/19/2024]
Abstract
Median arcuate ligament syndrome (MALS) is a rare condition and a diagnosis of exclusion. We present a 30-year-old man, who had postprandial upper abdominal pain and weight loss of 6 kg in 3 months. His gastroscopy and abdominal ultrasound results were both unremarkable. Computed tomographic angiography showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a 'J' shaped course of artery with poststenotic dilatation and dilated branches of the celiac artery. The patient underwent laparoscopic release of the median arcuate ligament. The intraoperative blood loss was 20 mL and duration of the procedure was 140 minutes. The patient had an uneventful recovery and was discharged on postoperative day 2. The symptoms subsided 2 months following surgery and he started gaining weight. Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method to decompress the celiac artery.
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Affiliation(s)
- Santhosh Anand
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Preethi Mahalingam
- Department of Medical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Loganathan Jayapal
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Siddhesh Suresh
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Tasgaonkar Ema
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
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16
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DeCicco J, Raja F, Ganesan S, El-Hayek K. First description of a histopathologic grading system and relationship to outcomes after robotic median arcuate ligament release with celiac ganglionectomy and lymphadenectomy. Surgery 2024; 175:822-832. [PMID: 37925266 DOI: 10.1016/j.surg.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/28/2023] [Accepted: 09/06/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Two dominating theories regarding median arcuate ligament syndrome include vascular and neurogenic etiologies from celiac artery and ganglion compression, respectively. Celiac ganglionectomy is not routine during surgery, and specimens are rarely excised; therefore, the extent of nerve involvement and histopathology are unknown. Our study aims to characterize histopathologic findings in median arcuate ligament syndrome, establish a histopathologic grading system, and correlate with clinical outcomes. METHODS Robotic median arcuate ligament release, celiac ganglionectomy, and lymphadenectomy were performed with specimens excised and stained using hematoxylin & eosin, trichrome, and S100. Neurofibrosis, adiposity, and reactive changes were described, a grading scale was developed, and results were analyzed with clinical outcomes. RESULTS Fifty-four patients were evaluated, of whom 36 met inclusion criteria (81% female, 34.9 [25.9-47.5] years, body mass index 23.5 [19.6-28.1] kg/m2). Histopathologic evaluation revealed fibrosis (hematoxylin & eosin and trichrome median score 1.5 [0-2.5]), reactive lymphadenopathy (89%), intraparenchymal nerves (31%), and lipogranulomas (31%). Greater fibrosis was associated with a lack of preoperative celiac plexus block relief (100% vs. 30%, P = .044) and lower postoperative celiac artery velocities (198 vs 323 cm/s, P = .02). Intraparenchymal nerves were associated with greater decreases in pre to postoperative velocities (161 vs 84 cm/s, P = .037). Symptoms improved in 28 patients (78%). CONCLUSION We developed the first histopathologic grading system and identified unique findings of intraparenchymal nerves and lipogranulomas. Histopathologic abnormalities were associated with objective improvement and symptomatic relief postoperatively. These findings support nerve compression and inflammation as predominant contributors to median arcuate ligament syndrome pain, celiac ganglia resection to treat symptoms, and continued histopathologic analysis to better elucidate median arcuate ligament syndrome etiology.
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Affiliation(s)
- Jamie DeCicco
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. https://twitter.com/jamiepdecicco
| | - Fnu Raja
- Department of Pathology, The MetroHealth System, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH. https://twitter.com/fnuraja
| | - Santhi Ganesan
- Department of Pathology, The MetroHealth System, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kevin El-Hayek
- Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH; Northeast Ohio Medical University, Rootstown, OH.
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17
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Takagi T, Morita Y, Matsumoto A, Ida S, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report. Surg Case Rep 2024; 10:41. [PMID: 38358535 PMCID: PMC10869672 DOI: 10.1186/s40792-024-01817-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: 11/06/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Median arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region. Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically. CASE PRESENTATION A 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved. CONCLUSIONS Reports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.
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Affiliation(s)
- Toru Takagi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
- Division of Surgical Care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, 1-20-1 Handayama, Chuo-ku, 431-3192, Japan.
| | - Akio Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Shinya Ida
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryuta Muraki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryo Kitajima
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Satoru Furuhashi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Makoto Takeda
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Department of Perioperative Functioning Care & Support, Hamamatsu University School of Medicine, Hamamatsu, 1-20-1 Handayama, Chuo-ku, 431-3192, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Woestemeier A, Semaan A, Kalff JC, Lingohr P. [Diagnosis and treatment of Dunbar syndrome]. Schmerz 2024; 38:6-11. [PMID: 37989790 DOI: 10.1007/s00482-023-00766-x] [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] [Accepted: 10/09/2023] [Indexed: 11/23/2023]
Abstract
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.
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Affiliation(s)
- Anna Woestemeier
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Alexander Semaan
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Jörg C Kalff
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Philipp Lingohr
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
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19
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Braet DJ, Pourak K, Davis FM, Eliason JL, Vemuri C. Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk. J Vasc Surg Cases Innov Tech 2023; 9:101348. [PMID: 37965115 PMCID: PMC10641679 DOI: 10.1016/j.jvscit.2023.101348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/21/2023] [Indexed: 11/16/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.
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Affiliation(s)
- Drew J. Braet
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kian Pourak
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Frank M. Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan L. Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Chandu Vemuri
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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20
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Hsu CK, Hsu WT, Young WL, Wu SY. A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report. BMC Urol 2023; 23:191. [PMID: 37980517 PMCID: PMC10657610 DOI: 10.1186/s12894-023-01361-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/07/2023] [Indexed: 11/20/2023] Open
Abstract
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.
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Affiliation(s)
- Chun-Kai Hsu
- Department of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist, New Taipei City, 231, Taiwan
- Department of Urology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wen-Tsang Hsu
- Department of Urology, Keelung Hospital, Ministry of Health & Welfare, Keelung, Taiwan
| | - Wan-Ling Young
- Department of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist, New Taipei City, 231, Taiwan
| | - Shu-Yu Wu
- Department of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist, New Taipei City, 231, Taiwan.
- Department of Urology, School of Medicine, Tzu Chi University, Hualien, Taiwan.
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21
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Dang JQ, Wang QQ, Yang YL, Shang L, Bian QT, Xiang HJ. Median arcuate ligament syndrome complicated with gallbladder stones: A case report. World J Clin Cases 2023; 11:7881-7887. [DOI: 10.12998/wjcc.v11.i32.7881] [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: 09/04/2023] [Revised: 10/11/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament (MAL). It can cause symptoms of postprandial abdominal pain, weight loss, and nausea and vomiting.
CASE SUMMARY A 55-year-old woman was admitted due to abdominal pain, nausea and vomiting. On admission, the patient presented with epigastric pain that worsened after eating, without signs of peritoneal irritation. Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk, local luminal stenosis with angular “fishhook” changes, which changed significantly during forceful inspiration and expiration; gallbladder stones; and multiple cysts in the liver. Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s. After diagnosis of MALS was confirmed, an arch ligament release procedure was performed. MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases. Awareness of MALS should be improved to avoid misdiagnosis. The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery.
CONCLUSION The diagnosis and treatment of MALS must be individualized, and MAL release is effective and provides immediate symptomatic relief.
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Affiliation(s)
- Jun-Qiang Dang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qing-Qiang Wang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Yan-Ling Yang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Lin Shang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qi-Tian Bian
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Hong-Jun Xiang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
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22
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DeCicco J, Raja F, Ganesan S, El-Hayek K. First description of a histopathologic grading system and relationship to outcomes after robotic median arcuate ligament release with celiac ganglionectomy and lymphadenectomy. Surgery 2023. [DOI: https:/doi.org/10.1016/j.surg.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
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23
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Upshaw W, Richey J, Ravi G, Chen A, Spillers NJ, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Overview of Median Arcuate Ligament Syndrome: A Narrative Review. Cureus 2023; 15:e46675. [PMID: 37942382 PMCID: PMC10629207 DOI: 10.7759/cureus.46675] [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] [Received: 08/15/2023] [Accepted: 10/07/2023] [Indexed: 11/10/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.
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Affiliation(s)
- Will Upshaw
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - John Richey
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Gurjot Ravi
- Medicine, Ross University School of Medicine, Shreveport, USA
| | - Adrian Chen
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Noah J Spillers
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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24
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Hannouneh ZA, Alahdab G, Hijazi A, Harfoush G, Alsayed C, Kanaan S, Jamouz R. Median arcuate ligament syndrome in an old male: a case report with 3-year follow-up. Ann Med Surg (Lond) 2023; 85:5145-5148. [PMID: 37811024 PMCID: PMC10553071 DOI: 10.1097/ms9.0000000000001152] [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] [Received: 06/21/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare compression syndrome that poses a challenge to many clinicians due to its ambiguous symptoms. It is predominantly common in females in their 30s to 50s. Case presentation A 74-year-old male presented with generalized chronic postprandial abdominal pain, anorexia, and weight loss of 6 kg for the past 2 months. Physical examination, abdominal ultrasound, endoscopy, and colonoscopy were all unremarkable. His laboratory workup and tumor marker tests were within normal ranges. Finally, a multi-slice computed tomography (MSCT), an advanced computed tomography with multiple detectors resulting in faster and higher resolution imaging, outlined external compression on the celiac artery (CA) by the median arcuate ligament (MAL). The release of the CA from the MAL was done laparoscopically. Symptoms improved significantly postoperatively. During the follow-up period of 3 years, the patient did not regain his lost weight but had no other complaints. Clinical discussion Due to its vague manifestations, MALS is diagnosed only after extensive evaluation and exclusion. This challenging diagnosis outlines the need for refined diagnostic guidelines. An MSCT plays a crucial role in confirming the diagnosis. Currently, more physicians prefer laparoscopic release of the MAL compared to an open approach. Conclusion Despite MALS predominance in females, the diagnosis of MALS should be considered in males with postprandial abdominal pain and unexplained weight loss. An MSCT, along with other imaging modalities, can provide a comprehensive view of celiac compression. Laparoscopic decompression of the CA is an ideal treatment option.
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Affiliation(s)
- Zein Alabdin Hannouneh
- Faculty of Medicine, Al Andalus University for Medical Sciences, Tartus Syrian Arab Republic
| | - Gieth Alahdab
- Faculty of Medicine, Al Andalus University for Medical Sciences, Tartus Syrian Arab Republic
| | - Amjad Hijazi
- Faculty of Medicine, Al Andalus University for Medical Sciences, Tartus Syrian Arab Republic
| | - Ghaith Harfoush
- Faculty of Medicine, Al Andalus University for Medical Sciences, Tartus Syrian Arab Republic
| | | | | | - Rafah Jamouz
- Department of Medical Imaging and Diagnostic Radiology, Faculty of Medicine, Tishreen University Hospital, Lattakia, Syrian Arab Republic
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Sunohara D, Miura T, Nomoto F, Itagaki T, Komatsu T, Mochidome T, Kasai T, Ikeda U. Effectiveness of endovascular therapy using stents in a patient with celiac artery compression syndrome due to the median arcuate ligament: A case report. J Cardiol Cases 2023; 28:128-131. [PMID: 37671263 PMCID: PMC10477046 DOI: 10.1016/j.jccase.2023.05.005] [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: 11/16/2022] [Revised: 04/23/2023] [Accepted: 04/28/2023] [Indexed: 09/07/2023] Open
Abstract
Celiac artery compression syndrome (CACS) is a disease caused by celiac artery compression by the median arcuate ligament (MAL), resulting in intestinal ischemic symptoms. However, a clear method for the invasive treatment of CACS has not yet been established because of limited treatment indications. In particular, only a few reports of endovascular therapy (EVT) using stents as the initial invasive treatment are available. Here, we report a case where EVT was performed using a stent in the celiac artery, resulting in good outcomes. A 59-year-old male patient presented to our hospital with postprandial abdominal pain and was diagnosed with MAL-induced CACS since the abdominal contrast computed tomography examination showed stenosis of a celiac artery origin. He was aware of the abdominal pain symptoms; therefore, we decided to treat CACS with EVT as an invasive treatment. A bare metal stent was placed in the celiac artery, whose lumen was well dilated using intravascular ultrasound. Consequently, he no longer felt abdominal pain and had good stent patency after 15 months. Minimally invasive EVT may be considered the first-line treatment for CACS. Learning objective The efficacy of endovascular therapy (EVT) using stents for the invasive treatment of celiac artery compression syndrome (CACS) resulting from the compression of the median arcuate ligament has not yet been established. Specifically, the efficacy of EVT using stents for CACS is unknown. We can safely perform EVT with stent placement using intravascular ultrasound for maintaining long-term patency. Therefore, minimally invasive EVT may be considered the first-line treatment for CACS.
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Affiliation(s)
- Daisuke Sunohara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | - Takashi Miura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
- Department of Internal Medicine and Cardiology, Miura Heart Clinic, Nagano, Japan
| | - Fumika Nomoto
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | | | | | | | - Toshio Kasai
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | - Uichi Ikeda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
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Fitzpatrick S, Dunlap E, Nagarsheth K. Trauma-Induced Median Arcuate Ligament Syndrome is an Under-Recognized Source of Chronic Abdominal Pain. Am Surg 2023; 89:3950-3952. [PMID: 37259508 DOI: 10.1177/00031348231157869] [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] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
| | - Eleanor Dunlap
- University of Maryland Medical System, Baltimore, MD, USA
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de Campos SML, Pessoa RP, Pelegrini JPDA, Silveira HF, Diniz MFL, Bianchini MP, Lopes LS, da Costa MEVMM. Dunbar syndrome - case report. J Vasc Bras 2023; 22:e20230030. [PMID: 37576738 PMCID: PMC10421585 DOI: 10.1590/1677-5449.202300301] [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] [Received: 02/27/2023] [Accepted: 05/04/2023] [Indexed: 08/15/2023] Open
Abstract
Dunbar syndrome is diagnosed by excluding other possible causes of abdominal pains. Surgical treatment comprises complete dissection of the ligament and the surrounding nerve ganglion. This report describes the case of a previously healthy 45-year-old male patient who presented with epigastric abdominal pain irradiating to the back and weakness. Initially, abdominal computed tomography was ordered, showing arteriopathy of the celiac trunk and mesenteric artery with stenosis. The patient underwent surgical treatment because of the refractory pain, but findings were nonspecific. It was necessary to continue workup with serial angiotomography to follow the case. After around 6 months, thickening of the arcuate ligament was found, with compression of the proximal third of the celiac trunk and 80% stenosis. The patient therefore underwent laparoscopy to relieve celiac trunk compression, with satisfactory postoperative recovery.
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Giakoustidis A, Moschonas S, Christodoulidis G, Chourmouzi D, Diamantidou A, Masoura S, Louri E, Papadopoulos VN, Giakoustidis D. Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience. World J Gastrointest Surg 2023; 15:1048-1055. [PMID: 37405099 PMCID: PMC10315115 DOI: 10.4240/wjgs.v15.i6.1048] [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: 12/27/2022] [Revised: 02/05/2023] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
The median arcuate ligament syndrome (MALS) is recognized as a rare clinical entity, characterized by chronic post-prandial abdominal pain, nausea, vomiting, and unintentional weight loss. Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. Patients can often be misdiagnosed for several years before a correct diagnosis is established, also due to a medical team’s clinical suspicion. We present a case series of two patients who suffered from MALS and were treated successfully. The first patient is a 32-year-old woman, presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years. The second patient, a 50-year-old woman, presented with similar symptomatology, with the symptoms lasting for the last five years. Both cases were treated by laparoscopic division of the median arcuate ligament fibers, which alleviated extrinsic pressure from the celiac artery. Previous cases of MALS were retrieved from PubMed, to assemble a better diagnostic algorithm and propose a treatment method of choice. The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice, along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.
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Affiliation(s)
- Alexandros Giakoustidis
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Stavros Moschonas
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
| | | | - Danae Chourmouzi
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Anna Diamantidou
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Sophia Masoura
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Eleni Louri
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Vasileios N Papadopoulos
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
| | - Dimitrios Giakoustidis
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
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29
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Chan SM, Weininger G, Kozhimala M, Sumpio BJ, Levine LJ, Harris S, Zheng S, Ochoa Chaar CI, Guzman RJ, Sumpio BE. Utility of Hook Sign in the Diagnosis of Median Arcuate Ligament Syndrome. Ann Vasc Surg 2023:S0890-5096(23)00186-3. [PMID: 37023920 DOI: 10.1016/j.avsg.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/18/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Median arcuate ligament syndrome (MALS) is a clinical syndrome caused by compression of the celiac artery by the median arcuate ligament (MAL) that often manifests with non-specific abdominal pain. Identification of this syndrome is often dependent on imaging of compression and upward bending of the celiac artery by lateral CTA, the so-called "hook sign." The purpose of this study was to assess the relationship of radiologic characteristicss of the celiac artery to clinically relevant MALS. DESIGN Single-center retrospective study METHODS: An IRB-approved retrospective chart review from 2000-2021 of 293 patients at a tertiary academic center diagnosed with celiac artery compression (CAC) was performed. Patient demographics and symptoms of 69 patients who were diagnosed with symptomatic MALS were compared to 224 patients without MALS (but with CAC) per electronic medical record review. CTA images were reviewed and the fold angle (FA) was measured. The presence of a hook sign (defined as a visual fold angle < 135 degrees) was recorded as well as stenosis (defined as >50% of luminal narrowing on imaging). Wilcoxon rank sum test and Chi-squared were utilized for comparative analysis. Logistic model was run to relate the presence of MALS with comorbidities and radiographic findings. RESULTS Imaging was available in 59 patients (25 males, 34 females) and 157 patients (60 males, 97 females) with and without MALS respectively. Patients with MALS were more likely to have a more severe FA (120.7 ± 33.6 vs. 134.8 ± 27.9, P = 0.002). Males with MALS were also more likely to have a more severe FA compared with males without MALS (111.1 ± 33.7 vs. 130.4 ± 30.4, P = 0.015). In patients with BMI > 25, MALS patients also had narrower FA compared with patients without MALS (112.6 ± 30.5 vs. 131.7 ± 30.3, P = 0.001). The FA was negatively correlated with BMI in patients with CAC . The hook sign and stenosis were associated with diagnosis of MALS (59.3% vs. 28.7%, P < 0.001, and 75.7% vs. 45.2%, P < 0.001, respectively). In logistic regression, pain, stenosis and a narrow FA were statistically significant predictors of the presence of MALS. CONCLUSIONS The upward deflection of the celiac artery in patients with MALS is more severe compared with patients without MALS. Consistent with prior literature, this bending of the celiac artery is negatively correlated with BMI in patients with and without MALS. When demographic variables and comorbidities are considered, a narrow FA is a statistically significant predictor of MALS. Regardless of MALS diagnosis, a hook sign was associated with narrower FA. While demographics and imaging findings may inform MALS diagnosis, clinicians should not rely on a visual assessment of a hook sign but should quantitatively measure the anatomic bending angle of the celiac artery to assist with the diagnosis and understand the outcomes.
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Affiliation(s)
- Shin Mei Chan
- Yale University School of Medicine, New Haven, CT, 06511
| | - Gabe Weininger
- Yale University School of Medicine, New Haven, CT, 06511
| | - Meagan Kozhimala
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, 02114
| | - Louis J Levine
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06511
| | - Sean Harris
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Sijin Zheng
- Yale University School of Medicine, New Haven, CT, 06511
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511
| | - Bauer E Sumpio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, 06511.
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Chen AJ, Yeh S, Dhindsa Y, Lawrence PF, Woo K. Outcomes of Median Arcuate Ligament Release: A Single Institution Retrospective Review. Ann Vasc Surg 2023:S0890-5096(23)00145-0. [PMID: 36924990 DOI: 10.1016/j.avsg.2023.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/12/2022] [Accepted: 02/25/2023] [Indexed: 03/17/2023]
Abstract
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.
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Affiliation(s)
- Alina J Chen
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Savannah Yeh
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yasmeen Dhindsa
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Karen Woo
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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31
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Wan ZD, Cai J, Huang BR, Li CM, Shang CB, Lei HW. Precise diagnosis and successful surgical intervention of the median arcuate ligament syndrome: A case report. Int J Surg Case Rep 2023; 104:107949. [PMID: 36889155 PMCID: PMC10015225 DOI: 10.1016/j.ijscr.2023.107949] [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: 09/27/2022] [Revised: 01/27/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The median arcuate ligament syndrome (MALS) is a rare disorder that produces a spectrum of symptoms due to compression of the arcuate ligament, clinically manifested primarily by abdominal pain, nausea, vomiting, and weight loss. The mechanism of these symptoms has not yet been revealed, and the current treatment methods are still somewhat controversial. CASE PRESENTATION We present a 54-year-old woman who presented with intermittent epigastric pain for nine months. During the onset, she lost 7.5 kg. After routine examinations in a nearby hospital, no abnormality was found. She was referred to us. CTA showed compression of the celiac artery. Further selective celiac angiography at the end of inspiration and expiration confirmed MALS. After consultation with the patient, the decision to have a laparotomy was made. The celiac artery was completely skeletonized, and external compression on the artery was released. Postoperative symptoms improved significantly. One-year follow-up after the operation, she had a weight gain of 4.8 kg and was satisfied with the surgical results. CLINICAL DISCUSSION The manifestations of MALS are varied and challenging. Our patient presented with weight loss and intermittent abdominal pain. The mutual confirmation of multiple investigations can provide a more comprehensive overview of celiac artery compression. We confirmed using ultrasonography, CT angiography, and selective digital subtraction angiography in this case. The celiac artery compression was relieved after open surgery. Our patient's symptoms improved significantly after surgery. We hope our treatment method can provide a reference for MALS diagnosis and treatment. CONCLUSION It is challenging to diagnose MALS. Cross-confirmation of multiple examinations can provide a more comprehensive view of celiac compression. Surgical decompression of the celiac artery (open or laparoscopic surgery) may be an effective therapy for MALS, especially in centers with experience.
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Affiliation(s)
- Zheng-Dong Wan
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Jie Cai
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Bi-Run Huang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Cheng-Ming Li
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Chun-Bo Shang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Hong-Wei Lei
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China.
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32
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Median arcuate ligament syndrome treated by laparoscopy after a failed balloon angioplasty: A case report. Asian J Surg 2023; 46:1289-1290. [PMID: 36041892 DOI: 10.1016/j.asjsur.2022.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/17/2022] [Indexed: 11/20/2022] Open
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DeCarlo C, Woo K, van Petersen AS, Geelkerken RH, Chen AJ, Yeh SL, Kim GY, Henke PK, Tracci MC, Schneck MB, Grotemeyer D, Meyer B, DeMartino RR, Wilkins PB, Iranmanesh S, Rastogi V, Aulivola B, Korepta LM, Shutze WP, Jett KG, Sorber R, Abularrage CJ, Long GW, Bove PG, Davies MG, Miserlis D, Shih M, Yi J, Gupta R, Loa J, Robinson DA, Gombert A, Doukas P, de Caridi G, Benedetto F, Wittgen CM, Smeds MR, Sumpio BE, Harris S, Szeberin Z, Pomozi E, Stilo F, Montelione N, Mouawad NJ, Lawrence P, Dua A. Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort. J Vasc Surg 2023; 77:567-577.e2. [PMID: 36306935 DOI: 10.1016/j.jvs.2022.10.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, Netherlands
| | - Alina J Chen
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Savannah L Yeh
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Gloria Y Kim
- Division of Vascular Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Division of Vascular Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Matthew B Schneck
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Dirk Grotemeyer
- Department of Vascular Surgery, Hôpitaux Robert Schuman - Hopital Kirchberg, Luxembourg, MN
| | - Bernd Meyer
- Department of Vascular Surgery, Hôpitaux Robert Schuman - Hopital Kirchberg, Luxembourg, MN
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Parvathi B Wilkins
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Sina Iranmanesh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Bernadette Aulivola
- Division of Vascular and Endovascular Surgery, Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL
| | - Lindsey M Korepta
- Division of Vascular and Endovascular Surgery, Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL
| | - William P Shutze
- Division of Vascular Surgery, Department of Surgery, The Heart Hospital Plano, Plano, TX
| | - Kimble G Jett
- Division of Vascular Surgery, Department of Surgery, The Heart Hospital Plano, Plano, TX
| | - Rebecca Sorber
- Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Graham W Long
- Division of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Paul G Bove
- Division of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mark G Davies
- Division of Vascular and Endovascular Surgery, Long School of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX
| | - Dimitrios Miserlis
- Division of Vascular and Endovascular Surgery, Long School of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX
| | - Michael Shih
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jeniann Yi
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ryan Gupta
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jacky Loa
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David A Robinson
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen Maastricht, RWTH, University Hospital Aachen, Aachen, Germany
| | - Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Center Aachen Maastricht, RWTH, University Hospital Aachen, Aachen, Germany
| | - Giovanni de Caridi
- Division of Vascular and Endovascular Surgery, Department of Biomorf, University of Messina, Messina, Italy
| | - Filippo Benedetto
- Division of Vascular and Endovascular Surgery, Department of Biomorf, University of Messina, Messina, Italy
| | - Catherine M Wittgen
- Division of Vascular Surgery, Department of Surgery, St. Louis University, St. Louis, MO
| | - Matthew R Smeds
- Division of Vascular Surgery, Department of Surgery, St. Louis University, St. Louis, MO
| | - Bauer E Sumpio
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Sean Harris
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Enikő Pomozi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Francesco Stilo
- Division of Vascular Surgery, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy
| | - Nunzio Montelione
- Division of Vascular Surgery, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy
| | - Nicolas J Mouawad
- Division of Vascular and Endovascular Surgery, Department of Surgery, McLaren Health System, Bay City, MI
| | - Peter Lawrence
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Brenner DM, Brandt LJ, Fenster M, Hamilton MJ, Kamboj AK, Oxentenko AS, Wang B, Chey WD. Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists. Clin Gastroenterol Hepatol 2023; 21:264-279. [PMID: 36180010 DOI: 10.1016/j.cgh.2022.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/28/2023]
Abstract
Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.
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Affiliation(s)
- Darren M Brenner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Lawrence J Brandt
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Marc Fenster
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Matthew J Hamilton
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
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Jonas JP, Rössler F, Ghafoor S, Kobe A, Pfammatter T, Schlag C, Gutschow CA, Petrowsky H, Müller PC, Oberkofler CE. Surgical therapy of celiac axis and superior mesenteric artery syndrome. Langenbecks Arch Surg 2023; 408:59. [PMID: 36690823 PMCID: PMC9870837 DOI: 10.1007/s00423-023-02803-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Compression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome. METHODS A systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up. RESULTS Twenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0-217) and 31 ml (21-50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1-12) for CAS and 5 days (1-10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms. CONCLUSION Failure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.
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Affiliation(s)
- J P Jonas
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - F Rössler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Ghafoor
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - A Kobe
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - T Pfammatter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - C Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - C A Gutschow
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - H Petrowsky
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - P C Müller
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C E Oberkofler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland.
- Vivévis AG-Visceral, Tumor, Robotic Surgery, Clinic Hirslanden, Zurich, Switzerland.
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Kuboki D, Koide A, Taguchi S, Yamazaki H, Lefor AK, Tabuchi T. Simultaneous laparoscopic treatment of median arcuate ligament syndrome and segmental adenomyomatosis of the gallbladder: A case report. Int J Surg Case Rep 2023; 103:107869. [PMID: 36640462 PMCID: PMC9840348 DOI: 10.1016/j.ijscr.2022.107869] [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: 10/02/2022] [Revised: 12/29/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Daigo Kuboki
- Department of Surgery, Kitaibaraki City Hospital, 1050, Sekimotoshimo, Sekinami-cho, Kitaibaraki-shi, Ibaraki, Japan; Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, Japan.
| | - Ayaki Koide
- Department of Surgery, Kitaibaraki City Hospital, 1050, Sekimotoshimo, Sekinami-cho, Kitaibaraki-shi, Ibaraki, Japan
| | - Satoshi Taguchi
- Department of Surgery, Kitaibaraki City Hospital, 1050, Sekimotoshimo, Sekinami-cho, Kitaibaraki-shi, Ibaraki, Japan
| | - Hironobu Yamazaki
- Department of Surgery, Kitaibaraki City Hospital, 1050, Sekimotoshimo, Sekinami-cho, Kitaibaraki-shi, Ibaraki, Japan; Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, Japan
| | - Takafumi Tabuchi
- Department of Surgery, Kitaibaraki City Hospital, 1050, Sekimotoshimo, Sekinami-cho, Kitaibaraki-shi, Ibaraki, Japan
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Romero-Velez G, Barajas-Gamboa JS, Pantoja JP, Corcelles R, Rodriguez J, Navarrete S, Park WM, Kroh M. A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study. Surg Endosc 2023; 37:140-147. [PMID: 35854125 PMCID: PMC9296109 DOI: 10.1007/s00464-022-09431-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Gustavo Romero-Velez
- Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code F20, Cleveland, OH, 44195, USA.
| | - Juan S Barajas-Gamboa
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Juan Pablo Pantoja
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ricard Corcelles
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Salvador Navarrete
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Woosup M Park
- Hearth and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mathew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Abu-Hilal AHH, Adawi Y, Abu-ghosh M, Abu-hilal LH, Al Shawwa KN, AbuKeshek T, Maree M. A Case Series of Median Arcuate Ligament Syndrome With Varied Presentations. J Investig Med High Impact Case Rep 2023; 11:23247096231211055. [PMID: 37950350 PMCID: PMC10640803 DOI: 10.1177/23247096231211055] [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: 08/29/2023] [Revised: 10/08/2023] [Accepted: 10/15/2023] [Indexed: 11/12/2023] Open
Abstract
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.
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Schneider M, Longchamp J, Uldry E, Corpataux JM, Kefleyesus A, Halkic N. Systematic hybrid laparoscopic and endovascular treatment of median arcuate ligament syndrome: A single-center experience. Front Surg 2023; 10:1169681. [PMID: 37151859 PMCID: PMC10154560 DOI: 10.3389/fsurg.2023.1169681] [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] [Received: 02/19/2023] [Accepted: 03/23/2023] [Indexed: 05/09/2023] Open
Abstract
Background Median arcuate ligament syndrome (MALS) is caused by celiac trunk (CT) compression by the median arcuate ligament. Clinically, this pathology varies from postprandial pain (Dunbar syndrome) to a life-threatening hemorrhage because of a rupture of a gastroduodenal artery aneurysm (GAA). Due to the low prevalence of this disease, there is no standard management for MALS. Material and method This was a single-center, retrospective study of 13 patients. Two groups were identified on the basis of the initial clinical presentation: those operated for a GAA rupture (bleeding group-BG) and those operated electively for Dunbar syndrome (Dunbar syndrome group-DG). The primary endpoint was 30-day postoperative complications of a systematic laparoscopic release of the median arcuate ligament and stenting during the same procedure. Results Seven patients (54%) underwent elective surgery. Six patients (46%) underwent semiurgent repair under elective conditions post-embolization for GAA bleeding. The total operative time was longer in the BG (p = 0.06). Two patients in the BG suffered early major complications and needed reintervention, and those in the DG had a lower comprehensive complication index. No mortality was reported at 30 days. Overall median length of stay was 5 days (IQR: 3.5-15.3). Patients in the DG had a significantly shorter length of stay (p = 0.02). At 6 months, the primary and secondary CT stent patencies were 82% and 100%, respectively. There were no high-flow GAA recurrences. Conclusions A combined approach of laparoscopic release of the median arcuate ligament and stenting during the same procedure is feasible and safe, and this approach must be systematically discussed in symptomatic patients.
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Affiliation(s)
- Michael Schneider
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Correspondence: Michael Schneider
| | - Justine Longchamp
- Department of Vascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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40
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Abstracts presented at the 26th Annual Congress of the Belgian Society of Internal Medicine, 9-10 December 2022, Dolce La Hulpe, La Hulpe, Belgium. Acta Clin Belg 2022. [DOI: 10.1080/17843286.2022.2149807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Muacevic A, Adler JR, Dawoud H, Elkot AN. Celiac Artery Compression Syndrome as an Uncommon Cause of Intractable Postprandial Abdominal Pain: A Case Report. Cureus 2022; 14:e32434. [PMID: 36644036 PMCID: PMC9833008 DOI: 10.7759/cureus.32434] [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] [Accepted: 12/12/2022] [Indexed: 12/14/2022] Open
Abstract
Celiac artery compression syndrome (CACS) is an uncommon and poorly understood condition. Compression of the celiac artery by the median arcuate ligament causes intractable postprandial abdominal pain, weight loss, vomiting, and nausea. We present a case of a 68-year-old male who suffered recurrent severe episodes of postprandial abdominal pain associated with occasional nausea, vomiting, and elevated blood pressure. The diagnostic workup was significant for celiac artery compression on computed tomography angiography. Diagnosis of CACS was made after the exclusion of the other possible pathologies, and the patient was referred to the surgical team for further management for median arcuate ligament release on an elective basis.
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Metz FM, Blauw JTM, Brusse-Keizer M, Kolkman JJ, Bruno MJ, Geelkerken RH. Systematic Review of the Efficacy of Treatment for Median Arcuate Ligament Syndrome. Eur J Vasc Endovasc Surg 2022; 64:720-732. [PMID: 36075541 DOI: 10.1016/j.ejvs.2022.08.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Since the first description of the median arcuate ligament syndrome (MALS), the existence for the syndrome and the efficacy of treatment for it have been questioned. METHODS A systematic review conforming to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted, with a broader view on treatment for MALS including any kind of coeliac artery release, coeliac plexus resection, and coeliac plexus blockage, irrespective of age. Online databases were used to identify papers published between 1963 and July 2021. The inclusion criteria were abdominal symptoms, proof of MALS on imaging, and articles reporting at least three patients. Primary outcomes were symptom relief and quality of life (QoL). RESULTS Thirty-eight studies describing 880 adult patients and six studies describing 195 paediatric patients were included. The majority of the adult studies reported symptom relief of more than 70% from three to 228 months after treatment. Two adult studies showed an improved QoL after treatment. Half of the paediatric studies reported symptom relief of more than 70% from six to 62 months after laparoscopic coeliac artery release, and four studies reported an improved QoL. Thirty-five (92%) adult studies and five (83%) paediatric studies scored a high or unclear risk of bias for the majority of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) items. The meaning of coeliac plexus resection or blockage could not be substantiated. CONCLUSION This systematic review suggests a sustainable symptom relief of more than 70% after treatment for MALS in the majority of adult and paediatric studies; however, owing to the heterogeneity of the inclusion criteria and outcome parameters, the risk of bias was high and a formal meta-analysis could not be performed. To improve care for patients with MALS the next steps would be to deal with reporting standards, outcome definitions, and consensus descriptions of the intervention(s), after which an appropriate randomised controlled trial should be performed.
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Affiliation(s)
- Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands.
| | - Juliëtte T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Marjolein Brusse-Keizer
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Jeroen J Kolkman
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Department of Gastroenterology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
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Blauw JTM, Metz FM, Brusse-Keizer M, Rijnja P, Bruno MJ, Geelkerken RH. Coeliac Artery Release or Sham Operation in Patients Suspected of Having Median Arcuate Ligament Syndrome: The CARoSO study. Eur J Vasc Endovasc Surg 2022; 64:573-574. [PMID: 35948164 DOI: 10.1016/j.ejvs.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Juliette T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Marjolein Brusse-Keizer
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Pepijn Rijnja
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre and University, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands.
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Chen SR, Tsai MC, Wang CC. A Rare Cause of Chronic Abdominal Pain and Weight Loss. Gastroenterology 2022; 163:e31-e32. [PMID: 35728690 DOI: 10.1053/j.gastro.2022.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Sih-Ruei Chen
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taiwan
| | - Ming-Chang Tsai
- School of Medicine, Chung Shan Medical University, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taiwan
| | - Chi-Chih Wang
- School of Medicine, Chung Shan Medical University, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taiwan.
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Two cases of pancreaticoduodenal aneurysm with median arcuate ligament syndrome treated with coil embolization and median arcuate ligament incision. Radiol Case Rep 2022; 17:3663-3668. [PMID: 35936877 PMCID: PMC9352807 DOI: 10.1016/j.radcr.2022.07.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
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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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Gialamas E, Assalino M, Elkrief L, Apostolidou‐Kiouti F, Piveteau A, Oldani G, Compagnon P, Berney T. Impact of the presence of median arcuate ligament on biliary complications after liver transplantation. Clin Transplant 2022; 36:e14771. [PMID: 35818793 PMCID: PMC9787474 DOI: 10.1111/ctr.14771] [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: 03/31/2022] [Revised: 06/10/2022] [Accepted: 07/04/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The presence of median arcuate ligament (MAL) during orthotopic liver transplantation (OLT) may cause a significant reduction in the arterial hepatic flow. The aim of the present study is to investigate the impact of MAL on biliary complications in patients who underwent OLT. METHODS We performed a retrospective case-control study among patients who underwent OLT in Geneva University Hospital between 2007 and 2017, depending on the presence or absence of MAL. The matching was performed according to age, gender, lab-MELD score at the time of OLT and type of donor (living or dead). The presence of MAL was assessed by an expert liver radiologist on the preoperative CT angiographic evaluation. RESULTS The incidence of MAL was 6.1% (19 patients). Baseline characteristics were comparable between the two groups. No significant difference in biliary complications was found between patients with and without MAL (37% and 24%, respectively). No patient presented hepatic artery thrombosis. After logistic regression, in patients with MAL, the MAL release and gastroduodenal artery preservation compared to no treatment, showed an odds ratio for post-OLT biliary complications of 1.5 and 1.25, respectively. There was no difference in overall graft survival and in hazard for biliary complications between patients with and without MAL. CONCLUSION In the present study, we did not find any difference in the prevalence of biliary and arterial complications between patients with and without MAL. The choice of MAL treatment did not influence in a significant way the overall outcome and development of complications. However, if, at the end of arterial reconstruction, the arterial flow is not adequately established, MAL needs to be treated with the least invasive technique.
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Affiliation(s)
- Eleftherios Gialamas
- Division of Transplantation, Department of SurgeryGeneva University HospitalsGenevaSwitzerland
| | - Michela Assalino
- Division of Transplantation, Department of SurgeryGeneva University HospitalsGenevaSwitzerland,Unit of Digestive and Hepato‐Pancreatic‐Biliary SurgeryHenri Mondor University Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP)CréteilFrance
| | - Laure Elkrief
- Hepatogastroenterology UnitRegional University Hospital Centre ToursToursFrance,Division of Hepato‐GastroenterologyGeneva University HospitalsGenevaSwitzerland
| | - Fani Apostolidou‐Kiouti
- Department of Hygiene, Social‐Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health SciencesAristotle University of ThessalonikiThessalonikiGreece
| | - Arthur Piveteau
- Department of RadiologyGeneva University HospitalsGenevaSwitzerland
| | - Graziano Oldani
- Division of Transplantation, Department of SurgeryGeneva University HospitalsGenevaSwitzerland
| | - Philippe Compagnon
- Division of Transplantation, Department of SurgeryGeneva University HospitalsGenevaSwitzerland
| | - Thierry Berney
- Division of Transplantation, Department of SurgeryGeneva University HospitalsGenevaSwitzerland
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Vovchuk IM, Khromykh KV, Formanchuk TV, Chyhir IV. DUNBAR SYNDROME: CLINICAL MANIFESTATION IN ADULTS, DIAGNOSTIC PROBLEMS (CASE REPORT). WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1801-1804. [PMID: 35962702 DOI: 10.36740/wlek202207135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Igor M Vovchuk
- VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | | | | | - Iryna V Chyhir
- VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
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49
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Aisu Y, Okada T, Sumii A, Ganeko R, Okamura R, Nishigori T, Itatani Y, Hisamori S, Tsunoda S, Hida K, Kawada K, Obama K, Sakai Y. Laparoscopic surgery for median arcuate ligament syndrome using real-time stereotactic navigation. Asian J Endosc Surg 2022; 15:443-448. [PMID: 34569161 DOI: 10.1111/ases.12990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/12/2021] [Accepted: 09/14/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In median arcuate ligament syndrome (MALS), a hyperplastic MAL causes compression and stenosis of the celiac artery (CA). The treatment involves releasing the external pressure on this artery by dissecting the ligament. However, it is difficult to identify the artery because of its deep anatomical location. Stereotactic navigation provides real-time information regarding the surgical instrument's location on computed tomography (CT) images. We utilized this system to overcome the difficulty of anatomical identification. MATERIALS AND SURGICAL TECHNIQUE We present a case of aneurysm rupture caused by MALS, which was treated with laparoscopic MAL dissection with real-time stereotactic navigation. Surgery was performed in a hybrid operating room with three-dimensional C-arm CT (Artis Zeego, Siemens) and an installed Curve navigation system (BrainLab). Preoperative CT images were aligned with intraoperative C-arm CT-like images and the surgical instrument position was projected onto preoperative CT images. After the left gastric artery isolation, the fibrous tissue surrounding the left gastric artery was dissected toward the CA while confirming the location of the CA and aortic wall using the navigation system. The CA's diameter was dilated from 1.8 to 2.6 mm with intraoperative angiography. DISCUSSION This is the first report of laparoscopic MAL dissection using real-time stereotactic navigation. Although navigation setting was time-intensive, this system helped us understand the anatomical structures and in safely and precisely dissecting the MAL.
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Affiliation(s)
- Yuki Aisu
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoaki Okada
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Atsuhiko Sumii
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riki Ganeko
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Okamura
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiro Itatani
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeo Hisamori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Kawada
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazutaka Obama
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Gastrointestinal Surgery, Osaka Red Cross Hospital, Osaka, Japan
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50
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Kazmi SSH, Safi N, Berge ST, Kazmi M, Sundhagen JO, Hisdal J. Laparoscopic Surgery for Median Arcuate Ligament Syndrome (MALS): A Prospective Cohort of 52 Patients. Vasc Health Risk Manag 2022; 18:139-151. [PMID: 35356549 PMCID: PMC8959725 DOI: 10.2147/vhrm.s350841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background The selection of patients with MALS for surgical treatment depends upon the reliability of the symptom interpretation and the diagnostic work-up. We aimed to follow up the results of the laparoscopic decompression of the patients with MALS. Patients and Methods In a single-center, 52 consecutive MALS patients were followed-up, prospectively, after transperitoneal laparoscopic decompression. MALS was diagnosed with a computed tomography angiography (CTA) verified stenosis, ≥50% of the celiac artery (CA), and with duplex ultrasound, a peak systolic velocity (PSV) ≥2.0 m/s. Postoperative, CTA, and duplex ultrasound were performed, and the patients were followed-up at 3, 6, 12 months, and yearly after that. Results Mean age of the patients was 47 ±21 years, and 65% were females. The patients had a mean weight loss of 8.4 ±7.2 kg. Fifty-one patients had the laparoscopic operation with a mean operation time of 102 ± 28 minutes. Forty-seven patients (90%) achieved relief from the symptoms either completely (67%) or partially (23%) at 3–6 months of follow-up. Significant improvement in postoperative PSV was found compared to the preoperative values, p<0.001. Five patients (10%) with no immediate effect of the operation, but two of them became free from symptoms during the mean study follow-up of 2.4 ± 2 years. Five patients (10%) had operative complications, including one trocar injury to the liver, one pneumothorax, and three cases of bleeding from the branches of CA. Two patients died of cancer disease during the study period. Only two patients (4%) had symptoms relapse, both later treated successfully. Conclusion Laparoscopic transperitoneal decompression provides most of the patients a persistent relief from MALS symptoms.
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Affiliation(s)
- Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Simen Tveten Berge
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway
| | - Marryam Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Faculty 2, Poznan University of Medical Sciences, Poznan, Poland
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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