Median Arcuate Ligament Release: Global Improvement Score

Benjamin Biteman, MD, Fredrick Brody, MD. The George Washington University

Introduction: Median arcuate ligament syndrome is a rare disorder resulting from compression of the celiac artery and associated nervous fibers by the insertion of the diaphragmatic muscle fibers. The first median arcuate ligament release was performed in 1963. The largest series gathered involving open operative intervention was 15 patients. The syndrome includes weight loss, posprandial abdominal pain, nausea, vomiting and food fear. Radiographic compression of the MAL is found in 20% of patients. Studies have recently suggested MALS as a neurogenic problem rather than vascular. The diagnostic workup and laparoscopic technique for a MAL release at our institution is presented.

Methods: Initial workup includes detailed history and physical, dynamic ultrasound with baseline, peak inspiratory and peak expiratory velocities and assessment of quality of flow. If MALS is suspected, preoperative SF-36 questionnaire is completed and operative intervention is undertaken. A video is presented of our operative approach.

Results: This study includes 47 patients, the largest single center volume of its kind, 31 patients with greater than 12 months of follow up. Mean age of 35 and mean BMI of 23. One conversion to laparotomy, six readmissions and an average length of stay of 3 days. Conclusions have been drawn to the neurogenic cause of MAL.  Measures of quality of life from the SF-36 questionnaire have shown statistical significant improvement among the patients followed greater than 12 months.  Our study has developed a benefit global improvement score to preoperatively assess which patients will benefit from median arcuate ligament release. The score is calculated from preoperative dynamic ultrasound velocities, narcotic usage and answers provided to quality of life measures.

Conclusion: The technique described has been used in a relatively large group of patients diagnosed with MAL syndrome. Our outcomes data support preoperative assessment to determine who will benefit from performing operative release. We continue to follow progress of patients and test the validity of our global improvement score.