November 04, 2009

Combined Laparoscopic and Endovascular Treatment vs. Open Celiac Ganglionectomy in Patients with Median Arcuate Ligament Syndrome- A Ten Year Review

Allan W. Tulloch, MD, Juan C. Jimenez, MD, Peter F. Lawrence, MD, Erik P. Dutson, MD, Wesley S. Moore, MD, David A. Rigberg, MD, Hugh A. Gelabert, MD, Brian G. Derubertis, MD, William J. Quinones-Baldrich, MD.
UCLA, Los Angeles, CA, USA.

OBJECTIVES: Median arcuate ligament syndrome is a rare disorder characterized by abdominal pain and compression of the celiac artery. Traditional management consists of open MAL division, with or without arterial reconstruction. We present our outcomes using a combined laparoscopic and endovascular approach and compare them to patients treated with open MAL lysis during the same period.
METHODS:A prospective database of all patients with MALS treated at UCLA from January 1999 to present was collected.
RESULTS: Thirteen patients with MALS were treated. All patients underwent an extensive preoperative GI workup with ten undergoing laparoscopic lysis of the MAL and celiac ganglion (LL). Five patients were treated in the open surgery group (OS). There were no deaths or reoperations in either group. Mean time to feeding was 0.8 + 0.5 days vs. 2 + 1.4 days (p<.01) in the LL and OS groups, respectively. Mean hospitalization was lower in the LL group compared with the OS group (2.4+0.7 vs. 6.4 + 1.5 days) (p <.01). Five LL (71%) and five OS (100%) patients had immediate symptom resolution. Two patients with persistent symptoms following LL underwent angiography demonstrating persistent celiac stenosis, and angioplasty was performed. Mean follow up was 21 + 16 months in the LL group and 34 + 29 months in the OS group. Three LL patients (38%) and one OS patient (20%) developed late recurrence of symptoms. Of these patients, three underwent repeat angioplasty.
CONCLUSIONS: Combined laparoscopic and endovascular treatment of MAL syndrome provides an excellent alternative to open repair. While both open and laparoscopic techniques can be performed with minimal patient morbidity, late recurrence of abdominal pain was seen in both groups. LL was associated with shorter hospitalization and faster time to feeding. Angioplasty of persistent celiac artery stenoses was not associated with improvement of abdominal pain in either group. Recurrent symptoms were generally milder and less weight loss noted. Prediction of clinical success with both approaches remains difficult in these patients.

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