Brett M Baker, MD, MBA, MS, John F Kelly, MD, Donald R Czerniach, MD. Department of Surgery, University of Massachusetts Memorial Health Care, University Of Massachusetts Medical School
Median Arcuate Ligament Syndrome (MALS) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. Patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. Diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. Standard of care for MALS patients is laparoscopic celiac artery dissection with release of the median arcuate ligament.
At our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with CT angiogram, MR angiogram, Arteriogram, or multiple modalities. All but one patient had multiple diagnostic imaging modalities, with the most common being CT angiogram; eight patients had invasive imaging. The mean age at presentation was 58.7 years in men and 47.8 years in women. On average, male patients presented with a longer duration of symptoms, 17.7 years (range 3-30 years), as compared to women, 3.3 years (range 1-15 years). Symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. All male patients reported at least two symptoms, most commonly nausea and post-prandial pain. In female patients, 82% reported having three or more symptoms. Notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by 73%. Pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, 156 cm/s versus 345 cm/s. Post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative 210 cm/s for an average of 112 cm/s after decompression. In all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament.
In total, 79% of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. Of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. Our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87881
Program Number: P187
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster