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
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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:OBJECTIVE:Optimal 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. METHODS:All 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. RESULTS:During 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. CONCLUSIONS:A 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:Median arcuate ligament syndrome (MALS) is a rarely diagnosed condition resulting from compression of the celiac trunk (CT) by the median arcuate ligament (MAL) of the diaphragm. Ischemia due to reduced blood flow through the CT and/or neuropathic pain resulting from celiac ganglion compression may result in a range of gastrointestinal symptoms, including nausea, postprandial discomfort, and weight loss. However, the mechanism of compression and its anatomical correlates have been incompletely delineated. It has been hypothesized that CT angle of origination may be more acute in individuals with MALS. Here, frequency of anatomical variation in the MAL and CT were assessed in 35 cadaveric subjects (17M/18F), including the vertebral level of origin of CT and superior mesenteric artery (SMA), the distance between CT and MAL and SMA, the angles of origination of CT and SMA, the diameter at the CT base, and MAL/CT overlap. Females exhibited significantly higher rates of inferred MAL/CT overlap than males. Significant correlations were revealed between MAL/CT overlap and angles of origination of the CT and SMA. Vertebral level of origin of the CT in individuals with MAL/CT overlap was not significantly more superior than in those without. This study also revealed a significant relationship between MAL/CT overlap and angle of origination of the CT, which has clinical implications for understanding the anatomy associated with MALS.
| S-EPMC7168915 | biostudies-literature
Project description:Background Chronic mesenteric ischemia (CMI) due to either atherosclerosis of the mesenteric arteries or median arcuate ligament syndrome (MALS) is an underdiagnosed entity. The etiology of MALS and its existence have been debated and questioned. We aimed to identify plasma biomarkers indicating mesenteric ischemia in patients with CMI and MALS. Methods Plasma α-glutathione S-transferase (α-GST), intestinal fatty acid-binding protein (I-FABP), citrulline, and ischemia modified albumin (IMA) were analyzed in fifty-eight patients with CMI (Group A, n=44) and MALS (Group B, n=14) before and after revascularization. The plasma levels of these potential biomarkers were compared with those of healthy individuals (Group C, n=16). Group comparison was performed with the Mann–Whitney U-test. Cross-tabulation and its derivatives were obtained. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were calculated. Results Plasma levels of α-GST were significantly raised in the patients with CMI (7.8 ng/mL, p<0.001) and MALS (8.4 ng/mL, p<0.001), as compared with the control Group C (3.3 ng/mL). The threshold for normal median plasma α-GST levels of 4 ng/mL yielded a sensitivity of 93% and 86%, specificity of 86% and 88%, respectively, for the diagnosis of CMI due to atherosclerosis and MALS. AUC of ROC curves was 0.96 (p<0.0001) for CMI and 0.85 (p<0.002) for MALS. The patient groups did not differ from the healthy controls in any other biomarkers. Conclusion Plasma α-GST levels are elevated in CMI and MALS patients. Elevated plasma levels of α-GST suggest ischemia as the etiology of MALS.
| S-EPMC9315055 | biostudies-literature
Project description:Median arcuate ligament syndrome and superior mesenteric artery syndrome are well-known abdominal compression syndromes, the coexistence of which is rarely described in literature. In addition, due to the common pathogenesis, anterior nutcracker syndrome may occur simultaneously to superior mesenteric artery syndrome. To our knowledge, this is the first case reporting combination of these 3 syndromes detected with ultrasound, Computed Tomography and upper gastrointestinal fluoroscopic exam. A 69-year-old man came to our attention for rapid weight loss, postprandial epigastric pain and recurrent vomiting for at least 6 months. Doppler ultrasound showed both celiac artery and left renal vein stenosis with simultaneous left varicocele. Computed tomography showed a reduction of aortomesenteric space causing both left renal vein and duodenal stenosis, this latter confirmed by upper gastrointestinal fluoroscopic exam. The diagnosis of these three vascular compression syndromes (MALS, SMAS, and anterior NCS) has been formulated, based on clinical and imaging findings. We assumed that the postprandial crises caused by median arcuate ligament syndrome may induce a reduction of meals consumption and progressive weight loss which can be a cause of anterior nutcracker syndrome and superior mesenteric artery syndrome onset. Doppler ultrasound, in expert hands, allows to accurately diagnosing these syndromes which are often underestimated. Failure to recognize it and inadequate treatment could have serious consequences for patients' health.
| S-EPMC8026914 | biostudies-literature
Project description:Purpose:Physiological tests may aid in diagnosing median arcuate ligament syndrome (MALS). MALS is a symptomatic compression of the celiac artery causing symptoms similar to chronic mesenteric ischemia (CMI) of atherosclerotic etiology. Simultaneous use of visible light spectroscopy (VLS) and laser doppler flowmetry (LDF) during upper endoscopy may detect microcirculatory changes in these patients. Patients and Methods:In a single-center, prospective comparative cohort, 25 patients were evaluated for MALS. Patients with a consensus diagnosis of MALS (n=15) underwent a gastroscopy assisted, transmucosal microcirculatory assessment with LDF and VLS. Results were compared to individuals with normal intestinal circulation (n=38) evaluated with duplex ultrasonography, and to patients with chronic mesenteric ischemia (n=32). Treatment response was evaluated clinically at 1, 3, 6, and 12 months, and with ultrasound, VLS and LDF at three months. Health-related quality of life (QoL) was assessed with Euroqol (EQ-5D-5L), preoperatively, and 12 months postoperatively. Results:Preoperative mean transmucosal oxygen saturation was significantly lower in patients with MALS (SO2 76±6), as compared to healthy individuals (SO2 81±4), p=0.02. An overall significant improvement in SO2 after surgical decompression of the celiac artery was found (SO2 81±3.7, p=0.05). Eleven (92%) patients with clinical improvement after laparoscopic decompression had a definitive diagnosis of MALS. Median follow-up was 18 months (4-24 months). Four of the five dimensions investigated with EQ-5D-5L improved. Conclusion:VLS detected a significantly lower baseline transmucosal SO2 in patients with MALS as compared to control subjects with normal intestinal circulation. An improvement in SO2 after laparoscopic decompression was found, supporting a possible ischemic etiology in our patient population.
| S-EPMC7493022 | biostudies-literature
Project description:IntroductionWhilst endometriosis is a relatively common condition, deeply infiltrating endometriosis (DIE) of the bladder is less so, and when medical treatment fails, surgical management is an effective option. We present a case report and surgical video of a patient undergoing combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder.DesignCase report (Canadian Task Force Classification III) and step-by-step explanation of the surgery using video. Exemption was granted from the local institutional review board.Presentation of caseWe present a case report and surgical video of a 36-year-old nulliparous patient presenting with a 12-month history of sudden onset cyclical dysuria and haematuria. Imaging demonstrated a deeply infiltrating endometriotic nodule involving the bladder. The patient underwent a combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. The procedure was uneventful and the patient progressed to a full recovery.DiscussionDIE is a highly invasive form of endometriosis which is defined arbitrarily as endometriosis infiltrating beneath the peritoneum by 5mm or greater. When medical therapy is declined or fails, surgical excision by partial cystectomy would appear to be the most effective management option. A combination of cystoscopy and laparoscopy has been shown to be a safe and feasible procedure, with a low rate of complications. It represents the ideal way by which to identify the resection limits for complete excision of the lesion, and allows for optimal repair of the bladder defect.ConclusionCombined laparoscopic and cystoscopic partial cystectomy for excision of deeply infiltrating bladder endometriosis is a safe and feasible procedure in our institution.
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Project description:Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.
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Project description:Vertical banded gastroplasty (VBG) was one of the most common bariatric surgeries worldwide in the beginning of the 21st century. However, recently we have increasingly encountered its long-term complications. We present two cases of VBG mesh erosion, alongside videos for their management. The first is of a 35-year-old female that presented 10 years after her VBG, while the second is of a 38-year-old female presenting 9-years post hers. Patient one presented with weight regain, regurgitation, epigastric pain, and dysphagia. CT imaging showed staple-line dehiscence and foreign body inside the stomach. Patient 2's presentation was of weight regain. Upon further workup, she was diagnosed with mesh erosion. In case 1, an endoscopic approach was taken using Soehendra lithotriptor device, while for case 2, a laparoscopic approach was undertaken. Endoscopic management of mesh erosion post-VBG is not only safe and feasible but also less invasive and time-consuming than the laparoscopic technique.
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