What is the appropriate disposition for median arcuate ligament syndrome?

From the Guidelines

Surgical release of the median arcuate ligament is the recommended disposition for median arcuate ligament syndrome, as it has been associated with symptomatic relief in 84.6% of patients. The decision to reconstruct the celiac artery remains debatable, but studies have shown that subsequent reconstruction may be necessary to provide complete symptomatic relief and prevent the development of splanchnic artery aneurysms 1.

Key Considerations

• Surgical release of the median arcuate ligament has been shown to result in complete resolution of symptoms in 75% of patients at 6 months 1.
• A study evaluating long-term outcomes in 44 patients who received operative management for MAL syndrome reported persistent resolution of clinical symptoms in 76% of patients who underwent some form of revascularization, such as primary reanastomosis or interposition grafting, in addition to decompression, compared with 53% of patients who received decompression alone 1.
• The primary surgical approach is laparoscopic or robotic-assisted release of the median arcuate ligament to decompress the celiac artery, often combined with celiac ganglion neurolysis.
• Patients should be evaluated by a vascular surgeon or specialist with experience in MALS treatment.
• Post-surgical follow-up should include assessment of symptom improvement and vascular imaging to confirm adequate decompression of the celiac artery.

Additional Recommendations

• For patients with significant symptoms affecting quality of life, surgical intervention is typically recommended.
• Conservative management with pain control medications and dietary modifications may be sufficient for mild cases.
• The use of computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) should be considered prior to catheter angiography 1.
• Percutaneous transluminal angioplasty with stent placement may be considered as a second-line intervention in patients with recurrent or persistent symptoms despite surgical decompression and where there is evidence of celiac artery narrowing 1.

From the Research

Disposition for Median Arcuate Ligament Syndrome

The disposition for median arcuate ligament syndrome (MALS) can be approached through various treatment modalities, including:

• Laparoscopic division of the median arcuate ligament 2, 3
• Open surgery 4, 5
• Robotic ligament release 6
• Celiac ganglionectomy 4, 5
• Celiac artery revascularization 4, 5
• Angioplasty or stent placement 2, 4

Advantages of Laparoscopic Approach

The laparoscopic approach has been shown to have several advantages, including:

• Short operative time (136.0 minutes, range 70-242) 2
• Shorter hospital stay (3.8 days, range 0.5-7) 2
• Low rate of conversion to open surgery (4.2%) 2
• Lower postoperative complication rates 3
• Improved clinical outcomes 3

Clinical Outcomes

Clinical outcomes for MALS treatment have been reported to be favorable, with:

• Symptom relief achieved in 85% of patients 5
• Late recurrence of symptoms reported in 6.8% of patients in the open group and 5.7% of patients in the laparoscopic group 5
• Successful laparoscopic decompression of the celiac artery achieved in 96.6% of cases 3
• Improved but persistent stenosis shown in 66.7% of patients after robot-assisted MAL release 6