From the Guidelines
Surgical release of the median arcuate ligament is the recommended treatment for acute medial arcuate syndrome, with a reported symptomatic relief in 84.6% of patients. This condition, also known as median arcuate ligament syndrome (MALS) or celiac artery compression syndrome, occurs when the median arcuate ligament compresses the celiac artery and celiac ganglion, causing abdominal pain, weight loss, and postprandial discomfort 1. Diagnosis requires a combination of imaging studies including Doppler ultrasound, CT angiography, or MR angiography to demonstrate the characteristic "hooked" appearance of the celiac artery with post-stenotic dilation.
Treatment Approach
The treatment approach for acute medial arcuate syndrome should focus on surgical release of the median arcuate ligament to decompress the celiac artery. Laparoscopic decompression is the preferred surgical approach with lower morbidity than open surgery 1. Some patients may require additional endovascular intervention if vascular changes have become fixed. Nutritional support and a graduated diet progression are important components of postoperative care to address weight loss and malnutrition that commonly accompany this syndrome.
Comparison of Treatment Options
A retrospective study comparing surgical and nonoperative approaches to MAL syndrome found that 93% of patients who received operative management reported improvement in symptoms, compared to only a third of patients who were managed nonoperatively 1. While nonoperative approaches, such as counseling, analgesia, and dietary modifications, may be considered, the evidence suggests that surgical release of the median arcuate ligament is the most effective treatment option for achieving symptomatic relief.
Key Considerations
- Surgical release of the median arcuate ligament is the recommended treatment for acute medial arcuate syndrome
- Laparoscopic decompression is the preferred surgical approach
- Additional endovascular intervention may be necessary for some patients
- Nutritional support and a graduated diet progression are important components of postoperative care
- Nonoperative approaches may be considered, but are generally less effective than surgical treatment 1
From the Research
Definition and Symptoms of Acute Medial Arcuate Syndrome
- Acute medial arcuate syndrome, also known as median arcuate ligament syndrome (MALS), is a condition characterized by the compression of the celiac artery by the median arcuate ligament, leading to symptoms such as abdominal pain, nausea, vomiting, and weight loss 2, 3, 4.
- The symptoms of MALS can be similar to those of other conditions, making diagnosis challenging, and a thorough gastrointestinal evaluation is necessary to rule out other possible causes 2, 4.
Diagnosis of Acute Medial Arcuate Syndrome
- Diagnosis of MALS can be difficult, as up to 25% of the population may have radiological compression of the celiac artery, but only 1% of the population have corresponding symptoms 4.
- Diagnostic tests such as duplex ultrasound, angiography, and gastric exercise tonometry may be used to aid in diagnosis, but there is no single "rule in test" for MALS 3, 4.
- A diagnostic pathway and treatment algorithm for MALS have been proposed to help guide primary care physicians in the assessment, diagnosis, and management of the condition 4.
Treatment Options for Acute Medial Arcuate Syndrome
- Surgical management of MALS involves decompression of the median arcuate ligament's constriction of the celiac artery, and may include open, laparoscopic, or robotic surgical intervention 2, 3, 5.
- Nonoperative management of MALS may result in worse outcomes, and patients who are on chronic narcotics preoperatively may have a lower likelihood of postoperative symptom relief 2, 5.
- A staged treatment approach may be necessary in some cases, such as when compression of both the celiac artery and the superior mesenteric artery is present 6.