Contemporary management of median arcuate ligament syndrome provides early symptom improvement

Abstract

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.

Fig 1

Kaplan-Meier 6-month freedom from (A) symptoms and (B) reintervention. SE, Standard error.

Fig 2

A, Intraoperative photograph shows the laparoscopic approach to the celiac axis. B, Laparoscopic division of median arcuate ligament (MAL) fibers. Note celiac stenosis and poststenotic dilatation (arrow).

Fig 3

A, Diagnostic angiography shows a persistent celiac artery defect (arrow) after laparoscopic median arcuate ligament (MAL) release in the setting of recurrent symptoms. B, Technically successful celiac artery stenting of the persistent defect.

Fig 4

Multidisciplinary clinical diagnostic and therapeutic algorithm. CT, Computed tomography; GI, gastrointestinal; MAL, median arcuate ligament; PTA, percutaneous transluminal angioplasty.