December 12, 2008

Minimally Invasive Laparoscopic and Endovascular Treatment of Median Arcuate Ligament Syndrome (MALS)- A 4-Year Review

Juan C. Jimenez, MD, Peter F. Lawrence, MD, Erik Dutson, MD, Brian G. Derubertis, MD, David A. Rigberg, MD, William J. Quinones-Baldrich, MD.
UCLA, Los Angeles, CA, USA.

OBJECTIVES:
MALS is a rare disorder characterized by chronic abdominal pain and extrinsic celiac artery compression. Traditional treatment includes open lysis of the MAL and/or surgical reconstruction of the celiac artery. Reports of laparoscopic MAL division are limited to case studies. We present the outcomes of patients with MALS treated with combined laparoscopic and endovascular approach.

METHODS:
Since 2004, records of patients with MALS treated with laparoscopic lysis of the MAL and celiac plexus, combined with selective angioplasty and/or stenting of the celiac artery were reviewed.

RESULTS:
Seven patients with MALS underwent an extensive GI workup followed by laparoscopic lysis of the MAL with complete celiac ganglionectomy. Six patients were female and one was male. Pain was persistent in five (74%) of patients and postprandial in six (86%). Mean preoperative weight loss was 19.7 + 20.9 lbs. Technical success was 100%. No deaths occurred and no reoperations were performed. Mean time to feeding was 1.17 + 0.4 days. Five patients (71%) remain asymptomatic. All patients with persistent symptoms (29%) underwent visceral angiography and two required stenting. Two patients (29%) remained symptomatic without angiographic evidence of celiac stenosis. Mean follow up was 22.7 + 17.6 months. One patient with recurrent symptoms required repeat angioplasty due to in-stent intimal hyperplasia.

CONCLUSIONS: This is the largest series of patients with MALS reported using a minimally invasive approach. We advocate laparoscopic lysis in symptomatic patients with evidence of extrinsic celiac artery compression. Angiography should be performed in patients with persistent symptoms. Angioplasty and/or stenting should be performed if a residual stenosis exists. Although prediction of clinical success remains difficult, this minimally invasive staged treatment approach provides excellent symptom relief in selected patients.

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