From the Guidelines
The initial treatment approach for median arcuate ligament syndrome should focus on supportive treatment with analgesics and continued diagnostic evaluation for alternate causes of abdominal pain. This approach is based on the understanding that the incidence and existence of abdominal symptoms due to compression of the celiac artery by the median arcuate ligament are debatable 1. The use of analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can help manage pain symptoms, while further diagnostic evaluation can help rule out other potential causes of abdominal pain.
Some key considerations for the initial treatment approach include:
- Pain management with medications such as NSAIDs or neuromodulating agents
- Dietary modifications, including small, frequent, low-fat meals to reduce postprandial pain
- Nutritional support for patients with significant weight loss
- Conservative management should be attempted for at least 2-3 months before considering more invasive options
It's also important to note that surgical intervention, such as laparoscopic or robotic-assisted median arcuate ligament release, may be considered as the next step in treatment if conservative management fails to provide adequate symptom relief 1. However, this should only be considered after a thorough diagnostic evaluation and confirmation of the diagnosis. The use of percutaneous transluminal angioplasty with stent placement is not recommended as a first-line treatment, and may even be contraindicated unless ligament release has been performed first 1.
From the Research
Initial Treatment Approach for Median Arcuate Ligament Syndrome
The initial treatment approach for median arcuate ligament syndrome (MALS) typically involves surgical intervention to decompress the celiac trunk.
- The most reliable treatment comprises open surgical treatment with division of the median arcuate ligament, removal of surrounding celiac ganglion, evaluation of the celiac artery with pressure measurements or ultrasound, and celiac artery reconstruction if indicated 2.
- Laparoscopic and endovascular interventions are novel treatments and may be considered in select patients who cannot undergo an open surgical procedure 2.
- Laparoscopic approach has been proposed as the option of choice for the treatment of MALS, with advantages including short operative time, shorter hospital stay, and low rate of conversion to open surgery 3.
- Robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking 4.
Considerations for Treatment
Before offering intervention for MALS, a thorough gastrointestinal evaluation should be performed, including consideration of diagnostic temporary percutaneous celiac ganglion block 2.
- Patients who are on chronic narcotics preoperatively have a lower likelihood of postoperative symptom relief and therefore should be evaluated by a pain specialist preoperatively 2.
- The treatment approach for MALS must be patient-focused, bearing in mind the multiple clinical presentations and treatment options 5.
Treatment Outcomes
Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery, and can provide effective symptom relief 4.
- Patients treated nonoperatively appear to have worse outcomes 4.
- Future prospective studies should directly compare long-term symptomatic and quality of life outcomes after nonoperative management with outcomes after open, laparoscopic, endoscopic retroperitoneal, and robotic celiac artery decompression to enable the development of evidence-based guidelines for the management of MALS 4.