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Jensen KK, Bonde P, Storkholm JH, Heerwagen ST, Larsen PN, Eiberg J. Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome. J Surg Case Rep 2020; 2020:rjaa507. [PMID: 33365121 PMCID: PMC7748124 DOI: 10.1093/jscr/rjaa507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Median arcuate ligament syndrome (MALS) is the compression of the celiac artery (CA) by the median arcuate ligament. MALS can cause pseudoaneurysm of the gastroduodenal artery, which can lead to fatal bleeding. A 40-year-old male with no prior medical history presented with symptoms of upper gastrointestinal hemorrhage (UGIH). Severe duodenal bleeding was confirmed although endoscopic hemostasis was impossible and final hemostasis was achieved following a subsequent open duodenotomy. A postoperative computed tomographic angiography (CTA) visualized a significant CA stenosis, post-stenotic dilatation and an aneurysm on a jejunal branch artery. The patient underwent coiling of the gastroduodenal artery, gastroepiploic artery and two pancreaticoduodenal arterial branches. The patient was diagnosed with MALS and 6 months later underwent open resection of the median arcuate ligament. MALS should be considered as a rare cause of upper gastrointestinal bleeding. The literature and proposed treatments are discussed.
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Affiliation(s)
- Kristian K Jensen
- Department of Surgical Gastroeneterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Peter Bonde
- Department of Surgery, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jan H Storkholm
- Department of Surgical Gastroeneterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter N Larsen
- Department of Surgical Gastroeneterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
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Kaszczewski P, Leszczyński J, Elwertowski M, Maciąg R, Chudziński W, Gałązka Z. Combined Treatment of Multiple Splanchnic Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome: A Case Study and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926074. [PMID: 32778636 PMCID: PMC7440745 DOI: 10.12659/ajcr.926074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patient: Female, 45-year-old Final Diagnosis: Multiple splanchnic artery aneurysms secondary to median arcuate ligament syndrome • occlusion of the coeliac trunk • significant stenosis of the superior mesenteric artery Symptoms: Abdominal pain • postprandial abdominal pain • weight loss Medication:— Clinical Procedure: Aorto-hepatic bypass • endovascular aneurysm embolization Specialty: Surgery
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Affiliation(s)
- Piotr Kaszczewski
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jerzy Leszczyński
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Elwertowski
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Rafał Maciąg
- II Division of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Witold Chudziński
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gałązka
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
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Cienfuegos JA, Rotellar F, Hurtado-Pardo L. Median arcuate ligament syndrome and upper gastrointestinal bleeding. Med Clin (Barc) 2020; 155:89-90. [PMID: 31780219 DOI: 10.1016/j.medcli.2019.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 05/02/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Javier A Cienfuegos
- Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, España; Institute of Health Research of Navarra (IdisNA), Pamplona, Navarra, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Navarra, España.
| | - Fernando Rotellar
- Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, España
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Garriboli L, Miccoli T, Damoli I, Rossini R, Sartori CA, Ruffo G, Jannello AM. Hybrid Laparoscopic and Endovascular Treatment for Median Arcuate Ligament Syndrome: Case Report and Review of Literature. Ann Vasc Surg 2019; 63:457.e7-457.e11. [PMID: 31622755 DOI: 10.1016/j.avsg.2019.08.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/30/2019] [Accepted: 08/04/2019] [Indexed: 10/25/2022]
Abstract
Median arcuate ligament syndrome is a rare cause of chronic gastrointestinal ischemia caused by compression of median arcuate ligament on the celiac trunk. A 38-year-old male presented at our institution with unspecific crampy abdominal pain. After several diagnostic examinations, he firstly underwent arcuate ligament resection by laparoscopic approach and 2 months later, he underwent percutaneous transluminal angioplasty with stenting of the stenotic vessel. Postoperatory and follow-up controls showed regular patency of the artery with complete relief of abdominal symptoms. We propose a review of the literature on this uncommon condition, describing different surgical approaches.
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Affiliation(s)
- Luca Garriboli
- Department of Vascular Surgery, IRCCS Sacro Cuore-Don Calabria, Negrar, VR, Italy.
| | - Tommaso Miccoli
- Department of Vascular Surgery, IRCCS Sacro Cuore-Don Calabria, Negrar, VR, Italy
| | - Isacco Damoli
- Department of Vascular Surgery, IRCCS Sacro Cuore-Don Calabria, Negrar, VR, Italy
| | - Roberto Rossini
- Department of General Surgery, IRCCS Sacro Cuore-Don Calabria, Negrar, VR, Italy
| | | | - Giacomo Ruffo
- Department of General Surgery, IRCCS Sacro Cuore-Don Calabria, Negrar, VR, Italy
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Castagna J, Jeand'heur A, Grillet F, Castelain F, Roux P, Aubin F, Manzoni P, Pelletier F. A challenging diagnosis of exercise-related transient abdominal pain. J Sports Med Phys Fitness 2019; 59:1934-1936. [PMID: 31311236 DOI: 10.23736/s0022-4707.19.09176-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 17-year-old woman, high-performance triathlete, presented transient abdominal pain, face angioedema and sometimes syncope during exercise. Exercise-induced anaphylaxis was suspected at first. Allergic explorations with skin prick tests were negative but wheat flour specific IgE and recombinant rTri a14 (LTP) were weakly positive. However, wheat eviction did not improve the symptoms and stress test after wheat oral challenge did not show any signs of anaphylaxis. An abdominal ultrasound revealed peak expiratory velocities with a stenosis evaluated at 70 to 80 percent with turbulences in the celiac artery, confirmed by computed tomography angiogram. The diagnosis of exercise-induced median arcuate ligament syndrome (MALS) was retained and we discuss here the challenging diagnosis mimicking exercise-induced anaphylaxis.
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Affiliation(s)
- Julie Castagna
- Department of Dermatology and Allergy, Besançon University Hospital, Besançon, France -
| | - Anne Jeand'heur
- Department of Dermatology and Allergy, Besançon University Hospital, Besançon, France
| | - Franck Grillet
- Department of Imaging, Besançon University Hospital, Besançon, France
| | - Florence Castelain
- Department of Dermatology and Allergy, Besançon University Hospital, Besançon, France
| | - Pauline Roux
- Department of Pneumology and Respiratory Explorations, Besançon University Hospital, Besançon, France
| | - François Aubin
- Department of Dermatology and Allergy, Besançon University Hospital, Besançon, France
| | - Philippe Manzoni
- Department of Imaging, Besançon University Hospital, Besançon, France
| | - Fabien Pelletier
- Department of Dermatology and Allergy, Besançon University Hospital, Besançon, France
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Khrucharoen U, Juo YY, Sanaiha Y, Chen Y, Jimenez JC, Dutson EP. Robotic-assisted laparoscopic median arcuate ligament release: 7-year experience from a single tertiary care center. Surg Endosc 2018; 32:4029-4035. [DOI: 10.1007/s00464-018-6218-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
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De'Ath HD, Wong S, Szentpali K, Somers S, Peck T, Wakefield CH. The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:1359-1363. [PMID: 29781769 DOI: 10.1089/lap.2018.0204] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Case reports and small series of the surgical and radiological management of median arcuate ligament syndrome (MALS) have been described, however, long-term outcome data are lacking. The purpose of this study was to review our experience of the laparoscopic management of MALS, and describe the long-term outcomes after surgical intervention. METHODS Data were collected between 2005 and 2016 in a single U.K. institution. All patients with MALS who underwent laparoscopic decompression of the celiac artery were included. Surgical outcomes were recorded from a prospectively collected database. Long-term outcomes were determined by outpatient review and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS Six patients were included. Five were female with a median age of 30 years (22.3-48.3). All six presented with abdominal pain and a bruit. Length of symptoms on presentation was 41 months (19-69). Duplex ultrasonography indicated celiac trunk stenosis in each case, with an elevated peak velocity flow in the celiac trunk of 230 cm/s (210-287.5). All six underwent successful laparoscopic decompression of the celiac artery with no conversions to open. Operating time was 137.3 minutes (95.6-166.3) and intraoperative blood loss was 110 mL (65-225). Length of stay was one day (1-2.3), with no postoperative complications or mortality. Median follow-up was 109.5 months (78-113.5). At this point, all patients remained symptom free with an overall GIQLI score of 129/144 (123.8-134.5). CONCLUSIONS MALS is a rare condition. Laparoscopic decompression of the median arcuate ligament is safe and offers long-term resolution of symptoms, and improvement in patient quality of life.
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Affiliation(s)
- Henry D De'Ath
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Simon Wong
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Karoly Szentpali
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Shaw Somers
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Tom Peck
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Christian H Wakefield
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
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Laparoscopic Treatment of Median Arcuate Ligament Syndrome: Analysis of Long-Term Outcomes and Predictive Factors. J Gastrointest Surg 2018; 22:713-721. [PMID: 29185149 DOI: 10.1007/s11605-017-3635-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic arcuate ligament release has been demonstrated a valid therapeutic option for arcuate ligament syndrome. Nevertheless, long-term follow-up and predictive factors have not been described for this treatment. METHODS Clinical and surgical data and short- and long-term outcomes together with the impact of the degree of stenosis of the celiac trunk were analyzed in 13 consecutive patients who underwent laparoscopic arcuate ligament release between 2001 and 2013. RESULTS Thirteen patients (12 F/1 M) underwent surgery. The median age was 32 years old, and their mean body mass index was 20.7 (range 14.7-25). The 13 patients presented with intense postprandial abdominal pain. Ten cases were associated with weight loss. The median duration of symptoms was 24 months (range 2-240). Three patients presented symptoms associated with superior mesenteric artery syndrome. Median operative time was 120 min (range 90-240), and there were no conversions to open surgery. Median hospital stay was 3 days (range 2-14). Over a median follow-up of 117 months (range 45-185), nine patients had excellent results although two required endovascular procedures at 70 and 24 months after surgery. Four patients (30.7%) experienced poor outcomes. When we analyzed the impact of the degree of occlusion of the celiac trunk, we observed that in patients with severe occlusion (> 70%), better results were obtained, with complete resolution of symptoms in 71% of cases. CONCLUSION Laparoscopic arcuate ligament release constitutes an excellent treatment for arcuate ligament syndrome. The degree of occlusion of the celiac trunk may be a factor predictive of long-term outcomes.
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Grus T, Lambert L, Vidim T, Grusova G, Klika T. Intraoperative measurement of pressure gradient in median arcuate ligament syndrome as a rationale for radical surgical approach. Acta Chir Belg 2018; 118:36-41. [PMID: 28859519 DOI: 10.1080/00015458.2017.1371490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) describes clinical symptoms in patients with stenosis of the celiac artery due to external compression by the ligament. There is an ongoing debate, whether sole release of the median arcuate ligament warrants long-term relief of the symptoms. MATERIALS AND METHODS Eight patients diagnosed with MALS underwent open surgical treatment beginning with the release of the ligament. Systemic pressure and pressure in the left gastric artery were measured before and after division of the median arcuate ligament and release of the celiac artery. In patients with persistent gradient above 15 mm Hg after the release a PTFE bypass was performed. RESULTS After the release, the pressure gradient decreased from 66 ± 19 to 48 ± 14 mm Hg (p = .001) and therefore in all patients either an aorto-celiac bypass (n = 6) or aorto-hepatic bypass (n = 2) was created. Consequently, the gradient decreased to 7 ± 2 mm Hg (p = .0001). One month postoperatively, three patients were free of symptoms and the rest reported relief of symptoms. CONCLUSIONS Release of the celiac artery resulted in insufficient decrease of pressure gradient, which was achieved by bypassing the segment with favorable mid-term outcome. We believe that the effect of the release should always be assessed to decide on subsequent treatment.
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Affiliation(s)
- Tomas Grus
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lukas Lambert
- Department of Radiology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomas Vidim
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Surgery, Regional Hospital Kolin, Kolin, Czech Republic
| | - Gabriela Grusova
- Fourth Department of Medicine, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomas Klika
- Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
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Wang XM, Hua XP, Zheng GL. Celiac Artery Compression Syndrome Evaluated with 3-D Contrast-Enhanced Ultrasonography: a New Approach. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:243-250. [PMID: 29079396 DOI: 10.1016/j.ultrasmedbio.2017.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/22/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
This study was performed to estimate the value of 3-D contrast-enhanced ultrasonography (3-D-CEUS) in the diagnosis of celiac artery compression syndrome (CACS). Patients suspected of having CACS were assessed with 3-D-CEUS and contrasted with computed tomography angiography. Diagnostic accuracy was evaluated with a receiver operating characteristic curve. Three-dimensional CEUS revealed 19 positive and 9 negative cases. In the negative group, the contrast agent did not change with respiration. In the positive group, the contrast agent exhibited a hook-shaped stenosis on expiration and returned to normal on inspiration. Computed tomography angiography indicated 1 false-positive case and 1 false-negative case. The sensitivity and specificity of 3-D-CEUS were 95% and 89%, respectively. The area under the receiver operating characteristic curve was 0.982 (p <0.01). In conclusion, 3-D-CEUS can accurately reveal the characteristic hooked appearance and dynamic nature of CACS with respiration, and thus, it represents a new, non-invasive approach to CACS diagnosis.
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Affiliation(s)
- Xian-Ming Wang
- Department of Ultrasound, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China
| | - Xian-Ping Hua
- Department of Cardiovascular Medicine, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China.
| | - Guo-Liang Zheng
- Department of Radiology, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China
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Ho KKF, Walker P, Smithers BM, Foster W, Nathanson L, O'Rourke N, Shaw I, McGahan T. Outcome predictors in median arcuate ligament syndrome. J Vasc Surg 2017; 65:1745-1752. [DOI: 10.1016/j.jvs.2016.11.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
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Affiliation(s)
- Ronald V Marino
- Winthrop University Hospital, Mineola, NY, USA Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Robert C Lee
- Winthrop University Hospital, Mineola, NY, USA Stony Brook University School of Medicine, Stony Brook, NY, USA
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Haskins IN, Harr JN, Brody F. Exercise-related transient abdominal pain secondary to median arcuate ligament syndrome: a case report. J Sports Sci 2015; 34:1246-9. [DOI: 10.1080/02640414.2015.1106006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Exercise-related transient abdominal pain (ETAP), commonly referred to as ‘stitch’, is an ailment well known in many sporting activities. It is especially prevalent in activities that involve repetitive torso movement with the torso in an extended position, such as running and horse riding. Approximately 70 % of runners report experiencing the pain in the past year and in a single running event approximately one in five participants can be expected to suffer the condition. ETAP is a localized pain that is most common in the lateral aspects of the mid abdomen along the costal border, although it may occur in any region of the abdomen. It may also be related to shoulder tip pain, which is the referred site from tissue innervated by the phrenic nerve. ETAP tends to be sharp or stabbing when severe, and cramping, aching, or pulling when less intense. The condition is exacerbated by the postprandial state, with hypertonic beverages being particularly provocative. ETAP is most common in the young but is unrelated to sex or body type. Well trained athletes are not immune from the condition, although they may experience it less frequently. Several theories have been presented to explain the mechanism responsible for the pain, including ischemia of the diaphragm; stress on the supportive visceral ligaments that attach the abdominal organs to the diaphragm; gastrointestinal ischemia or distension; cramping of the abdominal musculature; ischemic pain resulting from compression of the celiac artery by the median arcuate ligament; aggravation of the spinal nerves; and irritation of the parietal peritoneum. Of these theories, irritation of the parietal peritoneum best explains the features of ETAP; however, further investigations are required. Strategies for managing the pain are largely anecdotal, especially given that its etiology remains to be fully elucidated. Commonly purported prevention strategies include avoiding large volumes of food and beverages for at least 2 hours prior to exercise, especially hypertonic compounds; improving posture, especially in the thoracic region; and supporting the abdominal organs by improving core strength or wearing a supportive broad belt. Techniques for gaining relief from the pain during an episode are equivocal. This article presents a contemporary understanding of ETAP, which historically has received little research attention but over the past 15 years has been more carefully studied.
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Affiliation(s)
- Darren Morton
- Faculty of Education and Science, Lifestyle Research Centre, Avondale College of Higher Education, PO Box 19, Cooranbong, NSW, 2265, Australia,
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de Lara FV, Higgins C, Hernandez-Vila EA. Median arcuate ligament syndrome confirmed with the use of intravascular ultrasound. Tex Heart Inst J 2014; 41:57-60. [PMID: 24512402 DOI: 10.14503/thij-12-2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Median arcuate ligament syndrome, a rarely reported condition, is characterized by postprandial abdominal pain, nausea, vomiting, and weight loss. Its cause is unclear. We present the case of a 45-year-old woman who had intermittent chronic positional abdominal pain without weight loss. Magnetic resonance angiograms and computed tomograms revealed stenosis of the celiac artery. Ostial compression was confirmed on catheter angiographic and intravascular ultrasonographic images. Intravascular ultrasound revealed far greater stenosis than did the initial imaging methods and confirmed a diagnosis of median arcuate ligament syndrome. In lieu of surgery, the patient underwent a celiac ganglion block procedure that substantially relieved her symptoms. To our knowledge, this is the first report of the use of intravascular ultrasound in the diagnosis of median arcuate ligament syndrome. We recommend using this imaging method preoperatively in other suspected cases of the syndrome, to better identify patients who might benefit from corrective surgery.
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Sgroi MD, Kabutey NK, Krishnam M, Fujitani RM. Pancreaticoduodenal artery aneurysms secondary to median arcuate ligament syndrome may not need celiac artery revascularization or ligament release. Ann Vasc Surg 2014; 29:122.e1-7. [PMID: 24930977 DOI: 10.1016/j.avsg.2014.05.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 05/18/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed. METHODS Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up. RESULTS PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment. CONCLUSION Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.
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Affiliation(s)
- Michael D Sgroi
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA.
| | - Nii-Kabu Kabutey
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
| | - Mayil Krishnam
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
| | - Roy M Fujitani
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
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Sultan S, Hynes N, Elsafty N, Tawfick W. Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization. Vasc Endovascular Surg 2013; 47:614-9. [PMID: 23942948 DOI: 10.1177/1538574413500536] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.
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Affiliation(s)
- Sherif Sultan
- 1Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
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Celiac artery compression syndrome: an experience in a single institution in taiwan. Gastroenterol Res Pract 2012; 2012:935721. [PMID: 22988453 PMCID: PMC3439958 DOI: 10.1155/2012/935721] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 07/29/2012] [Accepted: 07/29/2012] [Indexed: 11/30/2022] Open
Abstract
Celiac artery compression syndrome (CACS) or median arcuate ligament (MAL) syndrome is a rare vascular disease. The clinical manifestations of CACS include the triad of postprandial pain, vomiting, and weight loss. The pathogenesis of CACS is the external compression of celiac artery by the MAL or celiac ganglion. Moreover, some authors also reported the compression with different etiologies, such as neoplasms of pancreatic head, adjacent duodenal carcinoma, vascular aneurysms, aortic dissection, or sarcoidosis. In the literature, most cases of CACS were reported from Western countries. In contrast, this disease was seldom reported in Oriental countries or regions, including Taiwan. Superior mesenteric artery syndrome (SMAS) is also a rare disease characterized by compression of the third portion of the duodenum by the SMA. The clinical features of SMAS are postprandial pain, vomiting, and weight loss. To date, there are no guidelines to ensure the proper treatment of patients with CACS because of its low incidence. Thus, tailored therapy for patients with CACS remains a challenge as well as the prediction of clinical response and prognosis. The aim of our present study was to investigate the clinical features, the association with SMAS, treatments, and outcomes of patients with CACS in a single institution in Taiwan.
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ter Steege RWF, Kolkman JJ. Review article: the pathophysiology and management of gastrointestinal symptoms during physical exercise, and the role of splanchnic blood flow. Aliment Pharmacol Ther 2012; 35:516-28. [PMID: 22229513 DOI: 10.1111/j.1365-2036.2011.04980.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 11/09/2011] [Accepted: 12/16/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence of exercise-induced gastrointestinal (GI) symptoms has been reported up to 70%. The pathophysiology largely remains unknown. AIM To review the physiological and pathophysiological changes of the GI-tract during physical exercise and the management of the most common gastrointestinal symptoms. METHODS Search of the literature published in the English and Dutch languages using the Pubmed database to review the literature that focused on the relation between splanchnic blood flow (SBF), development of ischaemia, postischaemic endotoxinemia and motility. RESULTS During physical exercise, the increased activity of the sympathetic nervous system (SNS) redistributes blood flow from the splanchnic organs to the working muscles. With prolonged duration and/or intensity, the SBF may be decreased by 80% or more. Most studies point in the direction of increased SNS-activity as central driving force for reduction in SBF. A severely reduced SBF may frequently cause GI ischaemia. GI-ischaemia combined with reduced vagal activity probably triggers changes in GI-motility and GI absorption derangements. GI-symptoms during physical exercise may be prevented by lowering the exercise intensity, preventing dehydration and avoiding the ingestion of hypertonic fluids. CONCLUSIONS Literature on the pathophysiology of exercise-induced GI-symptoms is scarce. Increased sympathetic nervous system activity and decreased splanchnic blood flow during physical exercise seems to be the key factor in the pathogenesis of exercise-induced GI-symptoms, and this should be the target for symptom reduction.
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Affiliation(s)
- R W F ter Steege
- Department of Gastroenterology, University Medical Centre Groningen, The Netherlands.
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Kohn GP, Bitar RS, Farber MA, Marston WA, Overby DW, Farrell TM. Treatment Options and Outcomes for Celiac Artery Compression Syndrome. Surg Innov 2011; 18:338-43. [DOI: 10.1177/1553350610397383] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported. Methods. A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction. Results. Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence. Conclusion. In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.
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Affiliation(s)
- Geoffrey P. Kohn
- Monash University, Melbourne, Victoria, Australia
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Raghid S. Bitar
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mark A. Farber
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - D. Wayne Overby
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Seconds from disaster: lessons learned from laparoscopic release of the median arcuate ligament. Surg Endosc 2009; 23:1121-4. [DOI: 10.1007/s00464-008-0256-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 08/19/2008] [Accepted: 11/17/2008] [Indexed: 01/04/2023]
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Laparoscopic treatment of celiac artery compression syndrome: case series and review of current treatment modalities. J Gastrointest Surg 2009; 13:293-8. [PMID: 18818978 DOI: 10.1007/s11605-008-0702-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 09/08/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Compression of the celiac artery by the diaphragmatic crura, the median arcuate ligament, or the fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). ANATOMY First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. CLINICAL PRESENTATION Patients commonly present with a wide variety of symptoms resulting in multiple diagnostic tests. DIAGNOSIS A firm diagnosis is difficult to establish, and treatment is equally challenging. These challenges are illustrated by the following case series, and evidence supporting current treatment modalities is reviewed. TREATMENT We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.
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MANGHAT NE, MITCHELL G, HAY CS, WELLS IP. The median arcuate ligament syndrome revisited by CT angiography and the use of ECG gating — a single centre case series and literature review. Br J Radiol 2008; 81:735-42. [DOI: 10.1259/bjr/43571095] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Celiac Revascularization as a Requisite for Treating the Median Arcuate Ligament Syndrome. Ann Vasc Surg 2008; 22:571-4. [DOI: 10.1016/j.avsg.2008.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 01/17/2008] [Accepted: 02/13/2008] [Indexed: 11/19/2022]
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Affiliation(s)
- Audra A Duncan
- Division of Vascular Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55902, USA.
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Guttman OT, Rosenblatt MA, Mims T. Median arcuate ligament syndrome--a novel treatment using an intrathecal morphine pump to relieve intractable visceral pain. Pain Pract 2008; 8:133-7. [PMID: 18194349 DOI: 10.1111/j.1533-2500.2007.00166.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Median arcuate ligament syndrome, which presents with intractable visceral pain, is difficult to both diagnose and treat. This case report describes the first use of an intrathecal morphine pump as an effective therapeutic intervention. CLINICAL FEATURES We describe a 39-year-old female who presented with a four-year history of misdiagnosed debilitating abdominal pain. After multiple failed attempts at medical management and surgeries, a trial of intrathecal narcotics provided significant relief. Six months after insertion of an intrathecal morphine pump, the patient was pain-free and had resumed all activities of daily living. CONCLUSION The use of an intrathecal narcotic pump should be considered for treatment of patients with intractable visceral pain secondary to median arcuate ligament syndrome.
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Affiliation(s)
- Oren T Guttman
- Department of Anesthesiology and Pain Medicine, The Mount Sinai School of Medicine, New York, New York 10029, USA.
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Delis KT, Gloviczki P, Altuwaijri M, McKusick MA. Median arcuate ligament syndrome: open celiac artery reconstruction and ligament division after endovascular failure. J Vasc Surg 2007; 46:799-802. [PMID: 17903658 DOI: 10.1016/j.jvs.2007.05.049] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Accepted: 05/23/2007] [Indexed: 11/23/2022]
Abstract
Median arcuate ligament syndrome (MALS) is a rare disorder resulting from extrinsic compression and narrowing of the celiac artery, and--less often--the superior mesenteric artery, by the relatively low insertion of the ligament and/or prominent fibrous bands or ganglionic periaortic tissue of the celiac nervous plexus. We report on a young woman who after three consecutive attempts of endovascular therapy with balloon angioplasty and stenting for MALS, each followed by gross symptom recurrence and a cumulative weight loss of 10 kg, underwent open surgical division of the ligament and reconstruction of the celiac artery. Despite the initial response of MALS to endovascular therapy, the extrinsic pressure exerted on the celiac artery by the surrounding dense fibrous/ganglionic tissue resulted in slippage of the stents and/or failure of their material. These findings militate against the use of balloon angioplasty and stenting primarily in patients with MALS without prior release of the extrinsic compression on the celiac (and/or superior mesenteric) artery by dividing the surrounding median arcuate ligament and/or ganglionic tissue with open or laparoscopic surgery.
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Abstract
Side stitch is an acute, localized, sharp, transient pain that occurs during exercise, most often in runners or swimmers, but also in those participating in team sports, and less often in cyclists. The pain is vexing and performance-limiting, but fleeting and benign. Three theories compete to explain it: diaphragmatic ischemia, stress on peritoneal ligaments, and irritation of the parietal peritoneum. The differential diagnosis seems broad, but the classic side stitch is so unique in its features and setting that a reasonable working diagnosis can be made from a careful history and physical examination. Practical tips, although anecdotal, offer lasting solutions.
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Affiliation(s)
- E Randy Eichner
- University of Oklahoma Health Sciences Center, 5505 N. Stonewall Drive, Oklahoma City, OK 73111, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the important recent advances in this fast developing field of pain mechanisms. It is now recognized that acute tissue and neural injuries can result in nociceptor sensitization (primary hyperalgesia) and spinal cord hyperexcitability or central sensitization that results in secondary hyperalgesia and allodynia. RECENT FINDINGS New findings regarding peripheral and central sensitization are presented in this review. Newer ideas on pain modulation, pain states and pain syndromes, mechanisms of chronic pain, newer opioid and non opioid medications including newer N-methyl-D-asparate antagonists, cyclooxygenase-2 inhibitors and membrane stabilizing analgesics as well as pain control at the genetic level are discussed. SUMMARY The research of the last decade has focused on the biochemical and structural plasticity of the nervous system following tissue and nerve injury. The mechanisms involved in the transition from acute to chronic pain are complex with the involvement of interacting receptor systems and intracellular ion flux, second messenger systems, new synaptic connections and apoptosis.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06824, USA.
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