Ehab Sorial University of Kentucky

Department of General and Vascular surgery September 15, 2010

36 year old male patient presented with abdominal pain and 80 pounds weight loss over a one year period

Pain is unrelated to meals but worsens with food intake

Patient is a chronic smoker He has a h/o antiphospholipid syndrome, a

h/o remote stroke and he has PFO He is on Coumadin for anticoagulation

Upper endoscopy normal Lower endoscopy normal SB capsule endoscopy unremarkable CT abdomen and pelvis is unremarkable Gall blabber ultrasound is normal

Decompression and release of MAL at the proximal celiac artery

Left brachial percutaneous approach

Intra-operative celiac arteriogram and measurement of pressure gradient across the celiac stenosis with gradient of 40-50mmHg detected

Patients pain subsided Patient started to gain weight within 3 months. Three and nine month follow up mesenteric

duplexes shows normal velocities in the celiac stent.

Chronic Atherosclerotic Non-atherosclerotic e.g. MALS Acute Occlusive Embolic Thrombotic Non-Occlusive Mesenteric Venous Thrombosis

Abdominal pain which may be related to meals Pain is mainly in the epigastrium May be accompanied by weight loss May be associated with an abdominal bruit Occasional diarrhea and nausea

ABDOMINAL PAIN ATTRIBUTED TO COMPRESSION OF THE CELIAC GANGLIA.

ABDOMINAL PAIN ATTRIBUTED TO COMPRESSION OF THE CELIAC ARTERY WHICH CAUSES ISCHEMIA.

It is estimated that in 10-24% of normal, asymptomatic individuals the median arcuate ligament crosses in front of (anterior to) the celiac artery, causing some degree of compression.

Approximately 1% of these individuals exhibit severe compression associated with symptoms of MALS.

The syndrome most commonly affects individuals between 20 and 40 years old.

Is more common in women, particularly thin women.

Median arcuate ligament syndrome is a diagnosis of

exclusion R/o all common causes of abdominal pain and weight

loss Upper and lower endoscopy. Gallbladder evaluation Evaluation for GERD

SMA PSV >275cm/s EDV > 45cm/s Celiac PSV >200cm/s EDV > 55cm/s Reverse Splenic/Hepatic flow

1-Focal narrowing of proximal celiac artery with poststenotic dilatation 2-Indentation on superior aspect of celiac artery 3-Hook-shaped contour of celiac artery

Decompression of the celiac artery Open release of MAL Laparoscopic release of MAL

Removal of celiac ganglia Celiac revascularization

Aorto-celiac bypass Patch angioplasty Endovascular stent angioplasty

According to Duncan et Al (2008) Mayo clinic, studied 51 patients who underwent open surgical treatment for MALS, 44 had follow-up at an average of nine years following therapy, 75% remained asymptomatic at follow-up.

In this study, predictors of favorable outcome included:

Age from 40 to 60 years Lack of psychiatric condition or alcohol use Abdominal pain that was worse after meals Weight loss greater than 20 lb

Laparoscopic vs open celiac

ganglionectomy in patients with median arcuate ligament syndrome, a retrospective study by Tulloch et Al. at UCLA, 2010

Laparoscopic and open techniques are comparable.

Laparoscopic decompression offer less hospital stay and decreased time to feeding.

Late but milder recurrence of symptoms is frequently seen after both approaches.

Median Arcuate ligament syndrome(Celiac artery compression syndrome)CaseWork upCTA abdomenMesenteric angiographyLaparotomyLeft brachial percutaneous approachCeliac angioplastyPostopAnatomyAnatomyMedian arcuate ligamentMesenteric ischemic syndromesMALS, presentationMALSEpidemiologyDiagnosisDuplexCTA/MRAArteriographyInjection of Vasodilator During Angiography Kalapatapu et Al, University of Arkansas 2008TreatmentPrognosisRelease of MALLaparoscopic decompressionCeliac revascularizationAngioplastySlide Number 28Slide Number 29