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Objectives: With the advancement in minimally invasive and endovascular surgical procedures, the treatment paradigm for
Median Arcuate Ligament Syndrome (MALS) has shifted, advocating laparoscopic release, followed by endovascular interventions as an adjunct. Recently, many groups have performed laparoscopic MAL release with celiac artery stenting for symptomatic relief, but it is still unclear which patients require vascular therapy and within what time frame.
Methods: From September 2011 to August 2012, we collected six patients with symptomatic evidence of MALS. We performed laparoscopic MAL release without routine adjunctive vascular procedures. In patients who were also found to have a hiatal hernia , we re-approximated the crura to repair the hernia.
Results: All patients were female and 19 to 48 years old. The duration of symptoms lasted four days to two years. All patients presented with pain and nausea, and four with vomiting. Two of the six patients also sustained significant weight loss. All
six patients underwent a laparoscopic MAL release by a single surgeon. In five of the six patients, the bulk of the ligament was constituted by fibrous ligaments of the left crura, and three of the patients were found to have a hiatal hernia. Five of the six patients described complete resolution of their symptoms within two weeks to three months of their surgery. One patient’s abdominal pain completely resolved at four months but recurred at eight months, prompting an angiogram and placement of a celiac artery stent. She continued to have pain and was found to have gastric ulcers from a pancreatic gastrinoma, the treatment of which resolved her symptoms.
Conclusions: Varied results have been reported regarding endovascular interventions after laparoscopic MAL release, but their algorithms have also differed. In the largest series to date, post-operative angiography was an established adjunct, so more patients were identified for further intervention.
In our series, however, we followed the patients clinically to determine whether they would need any endovascular procedures. We found that often laparoscopic MAL release alone is an efficacious surgical procedure for patients with chronic abdominal pain and nausea due to compression of the celiac artery. Resolution of symptoms took up to three months. Early re-imaging of the celiac artery may lead to unnecessary interventions.