1
|
Yadav P, Acharya K, Adhikari AB, Yadav M, Adhikari A, Sah OP. Median arcuate ligament syndrome: A rare case report from Nepal. Int J Surg Case Rep 2024; 120:109809. [PMID: 38796938 PMCID: PMC11152655 DOI: 10.1016/j.ijscr.2024.109809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, leading to a typical symptom triad: postprandial abdominal pain, weight loss, nausea, and vomiting. CASE PRESENTATION A 41-year-old female patient presented to our center with mild postprandial abdominal pain over the epigastric region, and bloating sensation. Ultrasonography of the abdomen showed multiple stones in the gall bladder lumen, and the computed tomography scan showed median arcuate ligament impingement along the proximal aspect of the celiac trunk causing moderate narrowing with post-stenotic dilation. Laparoscopic release of the median arcuate ligament with laparoscopic cholecystectomy was performed. DISCUSSION The diagnosis of Median Arcuate Ligament Syndrome is based on the classical post-prandial symptoms and abdominal imaging technologies like Doppler ultrasonography, computed tomography angiography, or magnetic resonance angiography. Exclusion of other intestinal disorders should be considered before making the diagnosis. Celiac artery decompression through different means is the principle of treatment of this condition. CONCLUSION The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have an established etiology. Celiac artery decompression by releasing the median arcuate ligament is the treatment.
Collapse
Affiliation(s)
- Prashant Yadav
- Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal.
| | - Kshitiz Acharya
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Aramva Bikram Adhikari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Manish Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Aayam Adhikari
- Kist Medical College and Teaching Hospital, Lalitpur, Nepal
| | - Om Prakash Sah
- Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
| |
Collapse
|
2
|
Vi TNH, Tri TT, Duy HP, Kiet PT, Cuong NM, Tuan HX, Duc NM. Laparoscopic treatment for median arcuate ligament syndrome in children: A case report. Radiol Case Rep 2024; 19:2004-2007. [PMID: 38449485 PMCID: PMC10917635 DOI: 10.1016/j.radcr.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
In median arcuate ligament syndrome (MALS), the median arcuate ligament compresses the celiac trunk and surrounding nerves leading to chronic functional abdominal pain and vague gastrointestinal symptoms. MALS can be effectively treated by dividing the arcuate ligament through open surgery or laparoscopy. This is a rare vascular condition and mostly encountered in adult patients. We hereby report a case of a pediatric patient diagnosed with MALS and treated successfully by laparoscopic approach. An 11-year-old girl presented with severe abdominal cramps for 3 months, accompanied by nonbilious vomiting. Computed tomography (CT) angiography demonstrated clear images of celiac trunk compression suggesting MALS. Laparoscopic surgery to cut the ligament and decompress the celiac artery was performed. The patient was discharged on day 7 postoperative with no recurrence of symptoms after 12 months of follow-up. This report suggested the diagnostic value of CT scan, and the safety and the feasibility of laparoscopic surgical techniques to treat MALS in children.
Collapse
Affiliation(s)
- Trinh-Nguyen Ha Vi
- Department of Pediatric Surgery, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Tran Thanh Tri
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplantation, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Ho Phi Duy
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplantation, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Phan Tuan Kiet
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplantation, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Nguyen Manh Cuong
- Department of Pediatrics, Vietnam Military Medical University, Hanoi, Vietnam
| | - Ho Xuan Tuan
- Department of Medical Imaging, Da Nang University of Medical Technology and Pharmacy, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| |
Collapse
|
3
|
Anand S, Mahalingam P, Jayapal L, Suresh S, Ema T. Laparoscopic management of median arcuate ligament syndrome: a video vignette. JOURNAL OF MINIMALLY INVASIVE SURGERY 2024; 27:44-46. [PMID: 38494186 PMCID: PMC10961588 DOI: 10.7602/jmis.2024.27.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 03/19/2024]
Abstract
Median arcuate ligament syndrome (MALS) is a rare condition and a diagnosis of exclusion. We present a 30-year-old man, who had postprandial upper abdominal pain and weight loss of 6 kg in 3 months. His gastroscopy and abdominal ultrasound results were both unremarkable. Computed tomographic angiography showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a 'J' shaped course of artery with poststenotic dilatation and dilated branches of the celiac artery. The patient underwent laparoscopic release of the median arcuate ligament. The intraoperative blood loss was 20 mL and duration of the procedure was 140 minutes. The patient had an uneventful recovery and was discharged on postoperative day 2. The symptoms subsided 2 months following surgery and he started gaining weight. Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method to decompress the celiac artery.
Collapse
Affiliation(s)
- Santhosh Anand
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Preethi Mahalingam
- Department of Medical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Loganathan Jayapal
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Siddhesh Suresh
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| | - Tasgaonkar Ema
- Department of Surgical Gastroenterology, Apollo Main Hospital, Chennai, India
| |
Collapse
|
4
|
Dang JQ, Wang QQ, Yang YL, Shang L, Bian QT, Xiang HJ. Median arcuate ligament syndrome complicated with gallbladder stones: A case report. World J Clin Cases 2023; 11:7881-7887. [DOI: 10.12998/wjcc.v11.i32.7881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/11/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament (MAL). It can cause symptoms of postprandial abdominal pain, weight loss, and nausea and vomiting.
CASE SUMMARY A 55-year-old woman was admitted due to abdominal pain, nausea and vomiting. On admission, the patient presented with epigastric pain that worsened after eating, without signs of peritoneal irritation. Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk, local luminal stenosis with angular “fishhook” changes, which changed significantly during forceful inspiration and expiration; gallbladder stones; and multiple cysts in the liver. Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s. After diagnosis of MALS was confirmed, an arch ligament release procedure was performed. MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases. Awareness of MALS should be improved to avoid misdiagnosis. The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery.
CONCLUSION The diagnosis and treatment of MALS must be individualized, and MAL release is effective and provides immediate symptomatic relief.
Collapse
Affiliation(s)
- Jun-Qiang Dang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qing-Qiang Wang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Yan-Ling Yang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Lin Shang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qi-Tian Bian
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Hong-Jun Xiang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| |
Collapse
|
5
|
Upshaw W, Richey J, Ravi G, Chen A, Spillers NJ, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Overview of Median Arcuate Ligament Syndrome: A Narrative Review. Cureus 2023; 15:e46675. [PMID: 37942382 PMCID: PMC10629207 DOI: 10.7759/cureus.46675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/07/2023] [Indexed: 11/10/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.
Collapse
Affiliation(s)
- Will Upshaw
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - John Richey
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Gurjot Ravi
- Medicine, Ross University School of Medicine, Shreveport, USA
| | - Adrian Chen
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Noah J Spillers
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| |
Collapse
|
6
|
Laparoscopic Release for Median Arcuate Ligament Compression Syndrome Associated with a Celiac-Mesenteric Trunk. Case Rep Vasc Med 2022; 2022:3595603. [PMID: 35494098 PMCID: PMC9054496 DOI: 10.1155/2022/3595603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022] Open
Abstract
The median arcuate ligament compression syndrome is a rare entity that occurs in 2 per 100,000 unselected individuals. We present a case where the median arcuate ligament compression syndrome was associated with an equally uncommon anatomic variation—a celiac-mesenteric trunk, which occurs in 0.42-2.7% of unselected individuals. We could find no prior report of a celiac-mesenteric trunk being associated with the median arcuate ligament compression syndrome. This report also adds to the literature to show that a laparoscopic approach to median arcuate ligament release is feasible.
Collapse
|
7
|
Almeida JI, Coelho MN, Armas I, Soares C, Santos T, Freitas C. Median arcuate ligament syndrome: A case report of a rare disease. Int J Surg Case Rep 2022; 90:106686. [PMID: 34973626 PMCID: PMC8728423 DOI: 10.1016/j.ijscr.2021.106686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, which may trigger a typical symptom triad: postprandial abdominal pain, weight loss, nausea and vomiting. CLINICAL CASE A 58-year-old male was admitted to the emergency department due to abdominal pain, vomiting, fever and diarrhea. On admission, the patient was tachycardic, had abdominal distension, no peritoneal irritation signs, and a serum lactate level of 5 mmol/L. The computed tomography (CT) scan showed gastric and intestinal pneumatosis associated with pneumoportia. Conservative treatment with intravenous fluids, antibiotics and low molecular weight heparin, was initiated. The reassessment CT scan showed resolution of the gastric and intestinal pneumatosis and a severe stenosis of the initial portion of the celiac trunk with associated angulation. After recovery from the acute episode, an abdominal duplex ultrasound and an aortoiliac arteriography in forced inspiration and expiration was performed, corroborating the diagnosis of MALS. A laparoscopic decompression of the celiac trunk was performed. DISCUSSION Symptoms of MALS closely mimic other abdominal disorders, and it should be considered in the differential diagnosis. Currently, there are no international guidelines on MALS diagnostic criteria. Treatment is focused on decompression of the median arcuate ligament constriction of the celiac artery, with or without celiac lymph node removal. CONCLUSION MALS diagnostic and therapeutic approach must be patient focused. Laparoscopic decompression is an effective treatment and can provide immediate symptomatic relief, associated with the benefits of the less invasive nature of the procedure.
Collapse
Affiliation(s)
| | | | - Isabel Armas
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Carlos Soares
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal; Faculty of Medicine of Porto University, Portugal
| | - Tatiana Santos
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Carla Freitas
- General Surgery Unit of Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| |
Collapse
|
8
|
Römer C, Fischer T, Haase O, Möckel M, Hamm B, Lerchbaumer MH. Assessment of celiac artery compression using color-coded duplex sonography. Clin Hemorheol Microcirc 2021; 76:413-423. [PMID: 32675404 DOI: 10.3233/ch-200903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a rare condition due to compression of the celiac artery (CA) by an anatomically abnormal median arcuate ligament. With ultrasonography (US) as first-line diagnostic modality in patients with unclear abdominal pain, there is limited data on its diagnostic performance in MALS. OBJECTIVE To investigate the value of CA peak systolic velocity (PSV) in the workup of patients with suspected MALS. METHODS Patients with diagnosis of MALS between 2009 and 2019 were referred by Department of Visceral Surgery after clinical and gastroenterological workup. Diagnosis was confirmed by surgery or further cross-sectional imaging. B-mode US findings and PSV in the CA during various respiratory states were compared between patients with a final MALS diagnosis and patients not meeting the diagnostic criteria. RESULTS Patients with proven MALS (n = 10) had higher median CA PSV during normal inspiratory breath-hold (239 [IQR, 159-327] vs. 138 [IQR, 116-152] cm/s; p < #x003C;< #x200A;0.001), and expiratory breath-hold (287 [IQR, 191-412] vs. 133 [IQR, 115-194] cm/s; p < #x003C;< #x200A;0.001) compared to patients without MALS (n = 26). CA PSV in both inspiratory breath-hold (AUC 0.88, 95% CI 0.77-1.00) and expiratory breath-hold (AUC 0.89, 95% CI 0.78-1.00) was of diagnostic value for confirming MALS. The best diagnostic performance (100% sensitivity, 80% specificity) was found for the combination of CA PSVexpiration + 2.4 · PSVinspiration > 550 cm/s . CONCLUSIONS Since results on optimal cutoff values are inconsistent, a combination of CA PSVs during breathing maneuvers may help to diagnose or rule out MALS.
Collapse
Affiliation(s)
- Claudia Römer
- Department of Emergency Medicine (CVK, CCM) and Department of Cardiology (CVK), Charité Universitiy Medicine, Berlin, Germany
| | - Thomas Fischer
- Department of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Oliver Haase
- Department of General, Visceral and Transplantation Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Möckel
- Department of Emergency Medicine (CVK, CCM) and Department of Cardiology (CVK), Charité Universitiy Medicine, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Markus Herbert Lerchbaumer
- Department of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
9
|
Bustos R, Papamichail M, Mangano A, Valle V, Giulianotti PC. Robotic approach to treat Median Arcuate Ligament syndrome: a case report. J Surg Case Rep 2020; 2020:rjaa088. [PMID: 32440331 PMCID: PMC7232935 DOI: 10.1093/jscr/rjaa088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/26/2020] [Indexed: 11/24/2022] Open
Abstract
The Median Arcuate Ligament (MAL) syndrome is the symptomatic compression of the celiac trunk by the MAL and other ganglionic periaortic tissue. Despite its rarity, this condition is significant from a clinical, diagnostic and management standpoint and it is usually a diagnosis of exclusion. A 61-year-old female with history of intermittent postprandial epigastric pain was diagnosed with MAL syndrome during CT scan imaging (no other causes of pain were identified). Patient successfully underwent robotic MAL release with symptoms improvement after surgery. The robotic approach is feasible and may allow a very precise and delicate dissection with release of the MAL.
Collapse
Affiliation(s)
- Roberto Bustos
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Michail Papamichail
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Valentina Valle
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
10
|
Bayat I, Wang J, Ho P, Bird D. Intravascular ultrasound-guided laparoscopic division of the median arcuate ligament. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:147-151. [PMID: 32154471 PMCID: PMC7056607 DOI: 10.1016/j.jvscit.2020.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/19/2020] [Indexed: 12/29/2022]
Abstract
Median arcuate ligament syndrome is a rare and poorly understood condition that can have a significant impact on the quality of life of patients. Diagnosis is often difficult and delayed because of the need to exclude other pathologic processes. Treatment strategies traditionally involve open or laparoscopic division of the median arcuate ligament, with or without vascular reconstruction. This report portrays a case of median arcuate ligament syndrome with compression of two visceral arteries and distal embolic complications. A novel hybrid technique is described using intravascular ultrasound technology to aid in laparoscopic median arcuate ligament division. This allowed real-time intravascular visualization of the compressive segment, guided release of the ligament fibers, and demonstrated confirmation of decompression.
Collapse
Affiliation(s)
- Iman Bayat
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Judy Wang
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Prahlad Ho
- Department of Hematology, Northern Health, Melbourne, Victoria, Australia
| | - David Bird
- Department of General Surgery, Northern Health, Melbourne, Victoria, Australia
| |
Collapse
|
11
|
Georgopoulou V, Gouridou E, Pyrpasopoulou A, Kozanidou A, Papadopoulos C, Tzikas S, Sidiropoulou M. An unusual cause of epigastric pain and diaphoresis. Heliyon 2020; 6:e03509. [PMID: 32140607 PMCID: PMC7049636 DOI: 10.1016/j.heliyon.2020.e03509] [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: 08/10/2019] [Revised: 12/24/2019] [Accepted: 02/25/2020] [Indexed: 12/04/2022] Open
Abstract
The median arcuate ligament, or celiac artery compression syndrome is a rare syndrome, caused by extrinsic compression of the celiac trunk by the median arcuate ligament. Its symptomatology mainly comprises of visceral angina. Differential diagnosis includes cardiovascular angina, other vascular events and causes of vagotonia. The case reported here refers to a middle aged male patient who presented with intermittent epigastric pain and diaphoresis after a long drive. Diagnosis was made radiologically, during computed tomography scan angiography, which revealed a hook-like appearance of the celiac artery partially loosened during inspiration. Careful history and cautious reviewing of the imaging may refrain from further, unnecessary, diagnostic investigations.
Collapse
|
12
|
Acampora C, Di Serafino M, Iacobellis F, Trovato P, Barbuto L, Sangiuliano N, Costigliola L, Romano L. Insight into Dunbar syndrome: color-Doppler ultrasound findings and literature review. J Ultrasound 2020; 24:317-321. [PMID: 31925730 DOI: 10.1007/s40477-019-00422-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/13/2019] [Indexed: 01/28/2023] Open
Abstract
Dunbar syndrome, also known as median arcuate ligament syndrome, is a rare clinical condition due to the external compression of the celiac trunk by the median arcuate ligament causing abdominal angina. We report a case of Dunbar syndrome and its borderline imaging findings focused on the crucial diagnostic role of color-Doppler ultrasound. We also reviewed the current literature, delineating the clinical manifestations and the diagnostic workup of the Dunbar syndrome with the objective to increase the knowledge of this clinical entity as a cause of postprandial abdominal pain and to underline the pivotal role of color-Doppler ultrasound to avoid incorrect or delayed diagnosis.
Collapse
Affiliation(s)
- Ciro Acampora
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy.
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Piero Trovato
- Department of Advanced Biomedical Sciences, "Federico II" University Hospital, Naples, Italy
| | - Luigi Barbuto
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Nicola Sangiuliano
- Department of General Surgery II Division, "Antonio Cardarelli" Hospital, Naples, Italy
| | - Luciana Costigliola
- Department of General Surgery II Division, "Antonio Cardarelli" Hospital, Naples, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| |
Collapse
|
13
|
San Norberto EM, Romero A, Fidalgo-Domingos LA, García-Saiz I, Taylor J, Vaquero C. Laparoscopic treatment of median arcuate ligament syndrome: a systematic review. INT ANGIOL 2019; 38:474-483. [PMID: 31580040 DOI: 10.23736/s0392-9590.19.04161-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Alejandro Romero
- Department of General Surgery, Valladolid University Hospital, Valladolid, Spain
| | | | - Irene García-Saiz
- Department of Anesthesia and Critical Care, Rio Hortega University Hospital, Valladolid, Spain
| | - James Taylor
- Department of Cardiac Surgery, Valencia General University Hospital, Valencia, Spain
| | - Carlos Vaquero
- Department Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
| |
Collapse
|
14
|
Aneurysms of Pancreaticoduodenal Artery due to Median Arcuate Ligament Syndrome, Treated by Open Surgery and Laparoscopic Surgery. Case Rep Surg 2019; 2019:1795653. [PMID: 30733883 PMCID: PMC6348794 DOI: 10.1155/2019/1795653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/13/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction There are many possible causes of an abdominal visceral aneurysm, including the obstruction of the celiac artery by the median arcuate ligament (MAL). We report two cases of an aneurysm of the pancreaticoduodenal artery due to MAL syndrome that we treated surgically. Case Presentation Case 1: a 66-year-old Japanese woman was diagnosed with a rupture of an aneurysm of the inferior pancreaticoduodenal artery. Because of the difficulty of endovascular therapy, we performed an emergency operation. We chose an abdominal operation, and the postoperative course was uneventful. Case 2: a 75-year-old Japanese man presented at our hospital with acute abdominal pain, nausea, and cold sweat. Our experience of treating MAL syndrome in case 1 enabled us to diagnose the disease accurately. We chose laparoscopic surgery, and the postoperative course was uneventful. Discussion There are several treatment choices for an aneurysm of the pancreaticoduodenal artery due to MAL syndrome. We have performed only a release of the MAL for treatment, but it is difficult to conclude whether only releasing the MAL is enough to ensure a positive long-term prognosis. Regular follow-up is needed in such cases. Conclusion Laparoscopic surgery can be considered one of the options for MAL syndrome.
Collapse
|
15
|
Fujiwara Y, Higashida M, Kubota H, Watanabe Y, Ueno M, Uraoka M, Okamoto Y, Mineta S, Okada T, Tsuruta A, Kusunoki H, Ueno T. Laparoscopic treatment of median arcuate ligament syndrome in a 16-year-old male. Int J Surg Case Rep 2018; 52:79-83. [PMID: 30336385 PMCID: PMC6197958 DOI: 10.1016/j.ijscr.2018.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/01/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION MALS(Median Arcuate Ligament Syndrome) is rare disease. We experienced the case of MALS and successfully treated by laparoscopic approach. PRESENTATION OF CASE A 16-year-old male was admitted to our hospital with postprandial epigastric pain that had been present for 3 years. Abdominal three-dimensional computed tomographic angiography showed stenosis of the celiac trunk, and abdominal Doppler ultrasonography showed that the blood flow in the celiac trunk varied between inspiration and expiration. Hence, the patient was diagnosed with median arcuate ligament syndrome. Laparoscopic decompression of the celiac trunk was performed by division of the ligament and partial excision of the celiac plexus. Intraoperative Doppler ultrasonography showed markedly improved flow in the celiac artery. The patient was discharged from hospital on postoperative day 7, and has no recurrent symptoms at 12 months postoperatively. DISCUSSION This case was most youngest male MALS treated by laparoscopic approach. CONCLUSION Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method for decompression of the celiac artery.
Collapse
Affiliation(s)
| | | | - Hisako Kubota
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | | | - Michi Ueno
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | - Mio Uraoka
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | - Yuko Okamoto
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | - Shumei Mineta
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | - Toshimasa Okada
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | - Atsushi Tsuruta
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| | | | - Tomio Ueno
- Department of Digestive Surgery, Kawasaki Medical School, Japan
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Podda M, Gusai GP, Balestra F, Argenio G, Pulighe F, Di Saverio S, De Nisco C. Robotic-assisted approach to Median Arcuate Ligament Syndrome with left gastric artery originating directly from the aorta. Report of a case and review of the current mini-invasive treatment modalities. Int J Med Robot 2018; 14:e1919. [DOI: 10.1002/rcs.1919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/23/2018] [Accepted: 04/01/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Mauro Podda
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Gian Pietro Gusai
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Francesco Balestra
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Giulio Argenio
- Department of General and Oncological Surgery; SS Antonio e Biagio e Cesare Arrigo Hospital; Alessandria Italy
| | - Fabio Pulighe
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Salomone Di Saverio
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District Bologna, Italy and Consultant Surgeon; Addenbrookes Hospital - University of Cambridge; UK
| | - Carlo De Nisco
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| |
Collapse
|
18
|
Landen S, Ballet T, Delugeau V, Landen C. Laparoscopic approach to median arcuate ligament syndrome (with video). J Visc Surg 2018; 155:159-161. [DOI: 10.1016/j.jviscsurg.2017.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
19
|
Lainas P, Fuks D, Gaujoux S, Machroub Z, Fregeville A, Perniceni T, Mal F, Dousset B, Gayet B. Preoperative imaging and prediction of oesophageal conduit necrosis after oesophagectomy for cancer. Br J Surg 2017; 104:1346-1354. [PMID: 28493483 DOI: 10.1002/bjs.10558] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/27/2017] [Accepted: 03/07/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Oesophageal conduit necrosis following oesophagectomy is a rare but life-threatening complication. The present study aimed to assess the impact of coeliac axis stenosis on outcomes after oesophagectomy for cancer. METHODS The study included consecutive patients who had an Ivor Lewis procedure with curative intent for middle- and lower-third oesophageal cancer at two tertiary referral centres. All patients underwent preoperative multidetector CT with arterial phase to detect coeliac axis stenosis. The coeliac artery was classified as normal, with extrinsic stenosis due to a median arcuate ligament or with intrinsic stenosis caused by atherosclerosis. RESULTS Some 481 patients underwent an Ivor Lewis procedure. Of these, ten (2·1 per cent) developed oesophageal conduit necrosis after surgery. Coeliac artery evaluation revealed a completely normal artery in 431 patients (91·5 per cent) in the group without conduit necrosis and in one (10 per cent) with necrosis (P < 0·001). Extrinsic stenosis of the coeliac artery due to a median arcuate ligament was found in two patients (0·4 per cent) without conduit necrosis and five (50 per cent) with necrosis (P < 0·001). Intrinsic stenosis of the coeliac artery was found in 11 (2·3 per cent) and eight (80 per cent) patients respectively (P < 0·001). Eight patients without (1·7 per cent) and five (50 per cent) with conduit necrosis had a single and thin left gastric artery (P < 0·001). CONCLUSION This study suggests that oesophageal conduit necrosis after oesophagectomy for cancer may be due to pre-existing coeliac axis stenosis.
Collapse
Affiliation(s)
- P Lainas
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - D Fuks
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France.,Université Paris Descartes, Paris, France
| | - S Gaujoux
- Department of Digestive Surgery, Hôpital Cochin, Paris, France.,Université Paris Descartes, Paris, France
| | - Z Machroub
- Intensive Care Unit, Hôpital Cochin, Paris, France
| | - A Fregeville
- Department of Radiology, Institut Mutualiste Montsouris, Paris, France
| | - T Perniceni
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - F Mal
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - B Dousset
- Department of Digestive Surgery, Hôpital Cochin, Paris, France.,Université Paris Descartes, Paris, France
| | - B Gayet
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France.,Université Paris Descartes, Paris, France
| |
Collapse
|
20
|
Hybrid (laparoscopy + stent) treatment of celiac trunk compression syndrome (Dunbar syndrome, median arcuate ligament syndrome (MALS)). Wideochir Inne Tech Maloinwazyjne 2016; 11:236-239. [PMID: 28194242 PMCID: PMC5299080 DOI: 10.5114/wiitm.2016.64070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/11/2016] [Indexed: 01/14/2023] Open
Abstract
Introduction Celiac trunk (CT) compression syndrome caused by the median arcuate ligament (MAL) is a rarely diagnosed disease because of its nonspecific symptoms, which cause a delay in the correct diagnosis. Intestinal ischemia occurs, which causes symptoms of abdominal angina. One method of treatment for this disease is surgical release of the CT – the intersection of the MAL. Laparoscopy is the first step of the hybrid technique combined with percutaneous angioplasty and stenting of the CT. Aim To demonstrate the usefulness and advantages of the laparoscopic approach in the treatment of Dunbar syndrome. Material and methods Between 2013 and 2016 in the General and Minimally Invasive Surgery Department of the Medical Sciences Faculty of the University of Warmia and Mazury in Olsztyn, 6 laparoscopic procedures were performed because of median arcuate ligament syndrome. During the laparoscopy the MAL was cut with a harmonic scalpel. One month after laparoscopy 5 patients had Doppler percutaneous angioplasty of the CT with stent implantation in the Vascular Surgery Department in Pomeranian Medical University in Szczecin. Results In one case, there was a conversion of laparoscopic surgery to open due to unmanageable intraoperative bleeding. In one case, postoperative ultrasound examination of the abdominal cavity demonstrated the presence of a large hematoma in the retroperitoneal space. All patients reported relief of symptoms in the first days after the operation. Conclusions The hybrid method, combining laparoscopy and angioplasty, seems to be a long-term solution, which increases the comfort of the patient, brings the opportunity for normal functioning and minimizes the risk of restenosis.
Collapse
|
21
|
Vasiliadis HS, Teuscher R, Kleinschmidt M, Marrè S, Heini P. Temporary liver and stomach necrosis after lateral approach for interbody fusion and deformity correction of lumbar spine: report of two cases and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:257-66. [DOI: 10.1007/s00586-016-4562-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 12/01/2022]
|