Laparoscopic decompression of a stricture of the celiac artery caused by the median arcuate ligament in a gastric cancer patient: A case of report

A case of laparoscopic distal gastrectomy and median arcuate ligament release for a gastric cancer patient with median arcuate ligament syndrome

Background

The median arcuate ligament syndrome (MALS) is a disease in which the celiac artery is compressed by the arcuate ligament and causes stenosis. If abdominal pain or an aneurysm is observed in the head of the pancreas, it is necessary to release the arcuate ligament, and recently laparoscopic surgery has been reported. However, the indication for treatment in asymptomatic cases is unknown. The treatment for asymptomatic MALS in patients with gastric cancer who are indicated for surgery is also novel.

Case presentation

A 70-year-old female was found with early gastric cancer in the middle body of the stomach. An enhanced CT scan showed no metastasis, but a gallstone and stenosis of the celiac artery due to the MALS were found. The patient underwent releasing median arcuate ligament after lymph node dissection. A median arcuate ligament was located on the ventral side of the left gastric artery stump, and the celiac artery was exposed when cutting it off. The operation time was 4 h and 59 min, and the bleeding was 6 ml. It took about 5 min to dissect the medial arcuate ligament. The postoperative course was satisfactory, and the patient was discharged 7 days after the operation. CT scan and 3-D CT angiography were performed about 2 months after the operation, and the findings revealed that the celiac artery's stenosis resolved.

Conclusion

The patient underwent laparoscopic gastrectomy and simultaneously the median arcuate ligament release under an excellent visual field. Therefore, median arcuate ligament release may be considered if MALS is found in a gastrectomy case.

Laparoscopic treatment of median arcuate ligament syndrome: a systematic review

INTRODUCTION

Median arcuate ligament syndrome (MALS) is an uncommon condition caused by the extrinsic compression of the celiac trunk (CT) and celiac ganglion, secondary to an anatomical abnormality of the median arcuate ligament fibers. It is characterized by postprandial epigastric pain, chronic abdominal pain, weight loss, nausea and vomiting. MALS is typically diagnosed after the exclusion of other, more common conditions; however, a variety of imaging and diagnostic modalities, including Duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry and angiography can suggest findings consistent with MALS.

EVIDENCE ACQUISITION

Laparoscopic approach has been proposed as the option of choice for the treatment of these patients. A systematic review of the international literature regarding this modality of treatment is presented here.

EVIDENCE SYNTHESIS

The review included 504 cases, and several principles are suggested to improve the management. The advantages of this minimally invasive technique include short operative time (136.0 minutes, range 70-242), shorter hospital stay (3.8 days, range 0.5-7) and low rate of conversion to open surgery (4.2%).

CONCLUSIONS

Various treatment modalities are available to decompress the celiac trunk. Although open surgery has been traditionally accepted as the gold standard, laparoscopic division of the MALS has proven equal results. Others have described different treatment modalities, including bypass surgery and endovascular procedures (angioplasty or stent placement). Laparoscopic approaches to correct MALS are feasible and safe. It may be the preferred modality of treatment in view of its lack of morbidity, shorter hospital stay and good results.