Latest Progresses in Surgical Treatment of Median Arcuate Ligament Syndrome / 中国医学科学院学报

Median arcuate ligament syndrome(MALS)is compression of the celiac trunk by the median arcuate ligament.Median arcuate ligament release is the corner stone for the surgical treatment of MALS.Open surgery,laparoscopic surgery,and robot-assisted surgery have been developed,among which laparoscopic surgery has been proposed as the preferred approach in view of its minimal trauma and short hospital stay.Auxiliary celiac plexus neurolysis could further alleviate the patient's discomfort.Moreover,vascular reconstitution is of vital importance in the case of persistent stenosis in the celiac artery despite of median arcuate ligament decompression.Vascular reconstruction has satisfactory long-term patency rate,while endovascular treatment is less invasive.This article aims to summarize the consensuses and advances and shed light on the surgical treatment of MALS.

A dangerous surgical masquerade - medial arcuate ligament syndrome as acute coronary syndrome: a case report

Median arcuate ligament syndrome is an uncommon cause for abdominal pain and weight loss, caused by median arcuate ligament compressing the celiac plexus or artery. Median arcuate ligament is the continuation of the posterior diaphragm which passes superior to celiac artery and surrounds the aorta. In this case report, A 67 year old male presented with complaints of sudden onset chest pain and loss of weight for the past 6 months. CECT thorax and abdomen it showed features of focal stenosis of coeliac axis and post stenotic dilation of the coeliac trunk suggesting median arcuate ligament syndrome. Laparoscopic median arcuate ligament release was done to relieve the patient from symptoms. Diagnosis of median arcuate ligament syndrome should be considered in a patient presenting with chest pain and weight loss with normal cardiac status and unexplained etiology.

Treatment of median arcuate ligament syndrome: outcome of laparoscopic approach / Tratamento da síndrome do ligamento arqueado mediano: resultado da abordagem laparoscópica

ABSTRACT Background: Median arcuate ligament syndrome(MALS) is a rare condition thatmay cause significant clinical manifestations, including abdominal pain and weight loss. Its diagnosis may be difficult and very often delayed. The laparoscopic approach became the standard treatment of MALS. Aim: To assess the outcome of laparoscopic treatment in patients with MALS. Method: The data of sixpatients with MALS who were subjected to laparoscopic sectioning of the median arcuate ligament were retrospectively reviewed.The following data were evaluated: age, gender, clinical and diagnostic tests findings, ASA score, operative findings and complications, postoperative complications and mortality, hospital stay duration, and hospital readmission.The diagnosis of MALS was established by CT angiography and/or MR angiography. Results: There were four (66.7%) women and two (33.3%) men aged from 32 to 60 years. The main symptoms were epigastric pain (100%) and weight loss (66.7%). The findings of high-grade stenosis of the proximal celiac axis and poststenotic dilation confirmed on angiography confirmed the diagnosis in all patients. Surgical procedure was uneventful in all patients. The only postoperative complication was urinary retention that occurred in a male. At three-month follow-up, all patients were asymptomatic. Conclusion: Laparoscopic treatment of MALS is safe and effective in relieving the clinical manifestations of patients.

RESUMO Racional: A síndrome do ligamento arqueado mediano (SLAM) é condição rara que pode causar manifestações clínicas significativas, incluindo dor abdominal e perda de peso. Seu diagnóstico pode ser difícil e muitas vezes estabelecido tardiamente. A abordagem laparoscópica tornou-se o tratamento padrão para ela. Objetivo: Avaliar o resultado do tratamento laparoscópico em pacientes com SLAM. Método: Os dados de seis pacientes com SLAM submetidos a ressecção laparoscópica do ligamento arqueado mediano foram revisados ​​retrospectivamente. Os seguintes dados avaliados foram: idade, gênero, resultados dosexames clínicos e complementares, escore ASA, achados e complicações operatórias, complicações e mortalidade pós-operatórias, tempo de internação e readmissão hospitalar. O diagnóstico de SLAM foi estabelecido por angiotomografia e/ou angiorressonância. Resultados: Havia quatro (66,7%) mulheres e dois (33,3%) homens com idades entre 32 e 60 anos. Os principais sintomas foram dor epigástrica (100%) e perda de peso (66,7%). Os achados de estenose de alto grau do tronco celíaco proximal e dilatação pós-estenótica observados na angiografia confirmaram o diagnóstico em todos os pacientes. O procedimento cirúrgico transcorreu sem intercorrências em todos os pacientes. A única complicação pós-operatória foi retenção urinária, que ocorreu em um homem. No seguimento de três meses, todos os pacientes estavam assintomáticos. Conclusão: O tratamento laparoscópico da SLAM é seguro e eficaz no alívio das manifestações clínicas dos pacientes.

Celiac artery compression: Dunbar syndrome / Síndrome da compressão da artéria celíaca (síndrome de Dunbar)

Celiac artery compression syndrome, also referred to as median arcuate ligament syndrome, celiac axis syndrome or Dunbar syndrome is a rare disorder consequent to extrinsic compression of the celiac trunk by the median arcuate ligament. Doppler ultrasound, multi-slice computed tomography angiography, magnetic resonance angiography, or invasive selective angiography can identify stenosis of the initial segment of the celiac artery and confirm diagnosis. Treatment options include open surgical or videolaparoscopic section of the median arcuate ligament and the fibers of the celiac plexus, or percutaneous transluminal angioplasty via an endovascular approach. We report herein an interesting case of a 38-year-old woman diagnosed with this rare condition and successfully treated with the surgical strategy

A síndrome da compressão da artéria celíaca, também denominada síndrome do ligamento arqueado mediano, síndrome do eixo celíaco ou síndrome de Dunbar, é uma doença rara causada pela compressão extrínseca do tronco celíaco pelo ligamento arqueado mediano. Ultrassonografia Doppler, angiotomografia computadorizada, angiorressonância magnética ou angiografia seletiva invasiva conseguem identificar a estenose do segmento inicial da artéria celíaca e confirmar o diagnóstico. As opções de tratamento incluem secção videolaparoscópica ou laparotômica (a céu aberto) do ligamento arqueado mediano e das fibras do plexo celíaco, assim como angioplastia transluminal percutânea. Relatamos o interessante caso de uma mulher de 38 anos de idade diagnosticada com essa rara condição e adequadamente tratada pela estratégia cirúrgica

Median Arcuate Ligament Syndrome in a Pediatric Patient: A Rare Case Report.

The median arcuate ligament (MAL) syndrome is an infrequently described condition caused by compression of the celiac artery by the extended fibers of the MAL resulting in the classic triad of postprandial epigastric pain, nausea/vomiting, and weight loss. Mostly seen in young female adults there is no reported estimate in the pediatric age group. We report the case in a 15-year-old girl and discuss the surgical aspects of importance.

Multi-slice Spiral CT Manifestations of Celiac Artery Compression of Median Arcuate Ligament / 中国医学影像学杂志

Purpose Median arcuate ligament (MAL) compression is the most common reason for celiac artery stenosis or occlusion, celiac artery compression of asymptomatic MAL is often misdiagnosed. This study aims to evaluate the multi-slice spiral CT manifestations of the celiac artery compression of median arcuate ligament. Materials and Methods CT features of 26 patients with celiac artery compression of median arcuate ligament were retrospectively studied. Eleven cases were symptomatic and fifteen cases were asymptomatic. Results In 14 cases (53.8%), the location of compression was at the level of superior 1/3 of the L1 vertebral body. There was statistic difference in location of the origin of compression between the celiac artery narrowing group and the non-narrowing group (P<0.05). CT manifestations included: narrowing of the celiac artery were observed in 26 patients on sagittal reformatted images with hollow on the anterior wall; a characteristic hooked appearance was observed. Narrowed celiac artery on the transverse images was seen in 21 patients, and a soft-tissue band extending across the anterior aspect of artery in 12 of them. Poststenotic dilatation was revealed in 20 patients. Collateral circulation was seen in 8 patients. Conclusion Multi-slice spiral CT can be helpful in demonstrating the location of celiac artery compression of median arcuate ligament and tell the characteristic imaging features.

Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

Clinical and Radiologic Review of Uncommon Cause of Profound Iron Deficiency Anemia: Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome is an anatomic and clinical entity characterized by dynamic compression of the proximal celiac artery by the median arcuate ligament, which leads to postprandial epigastric pain, vomiting, and weight loss. These symptoms are usually nonspecific and are easily misdiagnosed as functional dyspepsia, peptic ulcer disease, or gastropathy. In this report, we presented a 72-year-old male patient with celiac artery compression syndrome causing recurrent abdominal pain associated with gastric ulcer and iron deficiency anemia. This association is relatively uncommon and therefore not well determined. In addition, we reported the CT angiography findings and three-dimensional reconstructions of this rare case.

Open surgical decompression of celiac axis compression by division of the median arcuate ligament / 대한외과학회지

Median arcuate ligament syndrome is a rare cause of abdominal pain which results from compression of the celiac artery (CA) or rarely, the superior mesenteric artery by a ligament formed by the right and left crura of the diaphragm. We report a case of open surgical decompression of the CA by division of the median arcuate ligament for a 37-year-old female patient who had suffered from chronic postprandial epigastric pain and severe weight loss. We described clinical features, characteristic angiographic findings and details of the surgical procedure for the patient with this rare vascular problem.

Celiac Axis Compression Syndrome

External compression of the celiac artery by the median arcuate ligament of the diaphragm has been reported to result in a varient of chronic intestinal ischemia since 1963 by Harjola. Diaphragmatic compression of the celiac axis is frequently reversible and varies with respiration. The diagnosis remains one of exclusion and should be made only with very careful deliberation. Authors experienced only one case of celiac axis syndrome at Yeungnam University Hospital recently and reviewed literatures. A 29-year-old young tall and slender man complained of prolonged postprandial epigastric pain and an epigastric bruit especially during expiration for 10 years. Angiography demonstrated significant narrowing at the origin of the celiac artery. At operation, 1 cm distal portion of the celiac artery to the origin was found to be compressed by the median arcuate ligament of the diaphragm and ganglion nerve fibers, and these were divided. After division of the ligament, the blood flow through the celiac axis was increased and common hepatic artery was dilated grossly. Seven days later after surgery, abdominal pain was recurred following oral intake. So, we performed cine-angiogram of the celiac axis and found persistent the stenotic lesion, and then we performed percutaneous transluminal balloon dilatation. After this procedure, the patient has remained well and free of pain.

Treatment of celiac artery stenosis with interventional techniques / 介入放射学杂志

90%) of CA. The stenotic segments were dilated and stented during the same session. One patient with balloon expandable Palmaz stent placed in the proximal celiac artery, the another with 2 wallstents deployed in the CA trunk. The postprocedural arteriograms showed good dilation of the lesions with immediate improvement of CA blood flow. Follow-up Doppler ultrasound scans showed normal flow patterns in the CA. Three months after the procedures, their upper gastrointestinal symptoms had resolved and regained body weights. They remained well and free of symptoms, at 16 months and 26 months follow-up, respectively, after the procedure.Conclusions CA stenosis can successfully be treated with angioplasty and stenting.