Median arcuate ligament syndrome: case presentation and video-illustrated laparoscopic management.
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ABSTRACT:
SUBMITTER: El Asmar A
PROVIDER: S-EPMC5134203 | biostudies-literature | 2016 Dec
REPOSITORIES: biostudies-literature
Publications
Median arcuate ligament syndrome: case presentation and video-illustrated laparoscopic management.
El Asmar Antoine A El Rassi Ziad Z
Clinical case reports 20161111 12
Laparoscopic release of the median arcuate ligament, to relieve symptomatic compression of the celiac trunk, is the ideal approach when performed in a specialized center, by a surgeon with the adequate experience in advanced laparoscopic surgery. ...[more]
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Project description: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.
| S-EPMC10961588 | biostudies-literature
Project description:Median arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap-MALR) procedures are rare. In this study, we performed lap-MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap-MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato-biliary-pancreatic surgery, and one symptomatic case. In all cases, lap-MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap-MALR procedure in the treatment of MALS-related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression.
| S-EPMC11533021 | biostudies-literature
Project description:Median arcuate ligament syndrome (MALS) poses a rare challenge in diagnosis and management. We present a case of MALS in a 50-year-old male with recurrent epigastric pain, vomiting, and diarrhea. Diagnostic imaging revealed celiac artery stenosis and gastroduodenal artery collateral dilatation. Robotic-assisted median arcuate ligament release successfully alleviated symptoms. Utilizing the da Vinci X system (Intuitive Surgical, Inc.), the procedure involved meticulous dissection of the celiac artery and surrounding tissue. Postoperative duplex ultrasound confirmed improved arterial flow. Literature underscores the diagnostic hurdles of MALS and the advantages of minimally invasive approaches over conventional open surgery. The robotic approach may help smoothen the learning curve associated with this procedure, by providing improved operative flexibility. Patient outcomes are excellent, with long-term symptom relief in most cases.
| S-EPMC11416888 | biostudies-literature
Project description:ObjectiveOptimal diagnosis and management of median arcuate ligament (MAL) syndrome (MALS) remains unclear in contemporary practice. The advent and evolution of laparoscopic and endovascular techniques has redirected management toward a less invasive therapeutic algorithm. This study examined our contemporary outcomes of patients treated for MALS.MethodsAll patients treated for MALS at Dartmouth-Hitchcock Medical Center from 2000 to 2013 were retrospectively reviewed. Demographics and comorbidities were recorded. Freedom from symptoms and freedom from reintervention were the primary end points. Return to work or school was assessed. Follow-up by clinic visits and telephone allowed quantitative comparisons among the patients.ResultsDuring the study interval, 21 patients (24% male), with a median age of 42 years, were treated for MALS. All patients complained of abdominal pain in the presence of a celiac stenosis, 16 (76%) also reported weight loss at the time of presentation, and 57% had a concomitant psychiatric history. Diagnostic imaging most commonly used included duplex ultrasound (81%), computed tomography angiography (66%), angiography (57%), and magnetic resonance angiography (5%). Fourteen patients (67%) underwent multiple diagnostic studies. All patients underwent initial laparoscopic MAL release. Seven patients (33%) underwent subsequent celiac stent placement in the setting of recurrent or unresolved symptoms with persistent celiac stenosis at a mean interval of 49 days. Two patients required surgical bypass after an endovascular intervention failed. The 6-month freedom from symptoms was 75% and freedom from reintervention was 64%. Eighteen patients (81%) reported early symptom improvement and weight gain, and 66% were able to return to work.ConclusionsA multidisciplinary treatment approach using initial laparoscopic release and subsequent stent placement and bypass surgery provides symptom improvement in most patients treated for MALS. The potential placebo effect, however, remains uncertain. A significant minority of patients will require reintervention, justifying longitudinal surveillance and prudent patient selection. Patients can anticipate functional recovery, weight gain, and return to work with treatment.
| S-EPMC5292272 | biostudies-literature
Project description:Objectives: Median arcuate ligament syndrome is a complex disorder potentially caused by variation in the position of the median arcuate ligament. Symptomology involves chronic abdominal pain, nausea, and malnourishment. Pain management modalities and short-term outcomes for patients undergoing operative surgery for median arcuate ligament syndrome have yet to be fully evaluated. Our hospital implemented a pain management consultation program in 2017 focused on perioperative pain management. The objective of this study is to assess if the introduction of a pain management consultation program concurrent with median arcuate ligament syndrome surgery impacts patient outcomes and post-operative pain management strategies in these patients. Methods: De-identified data was collected retrospectively from our hospital’s electronic medical records system, identifying median arcuate ligament syndrome patients and using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes from September 2017 to August 2021. Patients were grouped into the “consultation” cohort if they had scheduled and attended a pre-operative pain consultation. Pre-operative and discharge medications, pain scores, and demographics were collected to evaluate if the initiative impacted outcomes. Results: Median arcuate ligament syndrome patients who had a pre-operative pain management consultation had higher rates of pre-operative opioid (35.5%; p = 0.01) and non-opioid use (60.7%; p < 0.001). Patients without a pre-operative consultation that did not use opioids pre-operatively were more likely to be discharged on one or more opioids. Differences were also found for psychiatric medication at discharge (p < 0.001) with patients receiving pain consultation indicating higher percentages of use. Conclusion: Special consideration on prescribing pain medication should be part of discharge planning for median arcuate ligament syndrome patients. Addition of a pain management consultation can aid in these decisions.
| S-EPMC10226036 | biostudies-literature
Project description:ObjectiveTo evaluate the outcomes of robot assisted laparoscopic surgery for median arcuate ligament syndrome (MALS) relief.MethodsThis was a single centre and retrospective study, including all consecutive patients with symptomatic MALS treated with robot assisted laparoscopic surgery. Symptom relief and quality of life (QoL) were evaluated post-operatively. A comparison between the peak systolic velocity (PSV) of the coeliac artery (CA) measured pre-operatively and post-operatively was carried out.ResultsNine interventions were performed. No conversion to laparotomy was required. There was post-operative abdominal pain relief in eight patients and QoL was improved in seven patients. Post-operatively, the CA PSV decreased (175 (IQR 160 - 195) cm/s vs. 365 (IQR 350 - 419) cm/s; p < .001).ConclusionMALS relief with robot assisted laparoscopy is safe and provides satisfactory outcomes in terms of symptom relief and CA compression release.
| S-EPMC9399280 | biostudies-literature
Project description:Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.
| S-EPMC10726322 | biostudies-literature
Project description:ObjectiveMedian arcuate ligament syndrome (MALS) is a vascular condition that is treated surgically. MALS is a diagnosis of exclusion and therefore often requires that pediatric patients undergo an exhaustive number of tests and potential experiences with misdiagnosis before receiving an accurate diagnosis and treatment. The purpose of the current mixed-methods study was to assess the pediatric patient- and parent-reported experience of (a) coping with and managing symptoms associated with MALS and (b) the diagnostic, treatment, and recovery process for pediatric MALS.MethodsNine postsurgical pediatric patients (M age = 20.11 ± 3.59; all <18 at time of surgery) and 6 parents participated in semistructured focus groups and completed self-report questionnaires about their experiences and current functioning.ResultsFour themes emerged: (a) the impact of MALS (physical and psychosocial), (b) uncertainties and feeling misunderstood, (c) extensive medical tests, and (d) mental health impacts, with an additional three themes related to specific querying (i.e., appreciation, recommendations, and interdisciplinary treatment team). With the exception of variable long-term physical impacts, patients and their parents reported fairly consistent experiences, and the content of these themes was consistent with self-reported quantitative data.ConclusionsThe current study highlights the resilience and resources seemingly required for effective diagnosis and intervention for pediatric MALS. The need for increased knowledge about MALS, the inclusion of an interdisciplinary treatment team, and long-term follow-up for pediatric patients with MALS are implicated.
| S-EPMC10419102 | biostudies-literature
Project description:BackgroundThe pathophysiology of median arcuate ligament syndrome (MALS) is poorly understood. The diagnostic process remains inadequately standardized, with an absence of precise criteria to guide therapeutic management.MethodsWe studied consecutive subjects referred to the Department of Angiology at the University Hospital of Zurich over the past 17 years due to suspected MALS. We focused on (1) the imaging criteria that led to diagnosis, notably the results of color duplex ultrasound and the consistency with different imaging tests; (2) the clinical consequences focusing on symptom resolution.ResultsWe included 33 subjects; in 8 subjects (24.2%), the diagnosis of MALS was retained. The median expiration peak systolic velocity (PSV) on ultrasound was 3.05 (Q1; 2.1-Q3; 3.3). To confirm the sonographic results, either a CT or MRI was performed on all patients, with consistent findings confirming a significant stenosis. Seven patients underwent surgery, all involving arcuate ligament release. Four procedures were laparoscopic, one was via laparotomy, and two were robot-assisted. Additionally, two patients required angioplasty with stenting as a secondary intervention. Only two (28.6%) of the seven operated patients experienced a relief of symptoms. None experienced a relief of symptoms following secondary angioplasty, despite stent patency. The prevalence of psychiatric disorders was comparable between patients with retained and rejected diagnoses, 38% and 36%, respectively.ConclusionsOur study confirmed sonography and CT/MRI consistency. However, most patients with MALS did not benefit from invasive treatment. The majority (83%) of patients without MALS were diagnosed with alternative conditions, mainly functional disorders.
| S-EPMC11417693 | biostudies-literature
Project description:IntroductionPancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications.Cases presentationCase 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate.ConclusionCeliac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.
| S-EPMC10351187 | biostudies-literature