Jeffrey N Harr, MD, MPH, Fred Brody, MD, MBA. The George Washington University
Median arcuate ligament syndrome (MALS) was first described in 1963. Since then, MALS has remained somewhat ambiguous and difficult to definitively diagnose and treat. In large part, this is due to the limited data from large series of median arcuate ligament releases. This study presents a large series of patients with MALS and provides short-term clinical follow-up.
A prospective database was established for patients undergoing laparoscopic median arcuate ligament releases. Patients are initially evaluated in clinic, and obtain a celiac artery ultrasound (U/S) with a subsequent MRA or aortagram depending on the U/S results and symptoms. Once the diagnosis is suspected, patients proceed with a laparoscopic MAL release. Patients also complete a pre-and post-operative SF-36 form, and a repeat celiac artery U/S is completed at 6-months follow-up. A paired t-test was performed with a p<0.05 determining significance.
A laparoscopic MAL release was attempted in 41 patients, and complete follow-up data is available for 26 patients. The mean age is 35 years with a mean follow-up time of 8.1 months. The results demonstrate a successful laparoscopic approach, with one conversion to open surgery. Pre-operative and 6-month post-operative celiac artery ultrasounds revealed no significant difference in velocities before and after surgery. However, pre and post-operative SF-36 scores revealed statistically significant improvement in all SF-36 parameters. A greater than 20% improvement was obtained in five scales including role-physical, bodily pain, vitality, social function, and role-emotional.
Our data indicate that significant symptom improvement can be reliably achieved with a laparoscopic MAL release. Although there was a lack of change in pre and post-operative celiac artery velocities, there was a clinically significant improvement in SF-36 measurements, indicating a neurogenic etiology, secondary to celiac plexus compression, as opposed to an ischemic process. Currently, we are looking at prognostic factors that can help determine which patients achieve greater symptom amelioration. With 12-month follow-up data, we plan to create a predictive formula to predict success.