title: Contemporary management of median arcuate ligament syndrome provides early symptom improvement.
abstract: OBJECTIVE
  Optimal diagnosis and management of median arcuate ligament (MAL) syndrome (MALS) remains unclear in contemporary practice. The advent and evolution of laparoscopic and endovascular techniques has redirected management toward a less invasive therapeutic algorithm. This study examined our contemporary outcomes of patients treated for MALS.
  
  
  METHODS
  All patients treated for MALS at Dartmouth-Hitchcock Medical Center from 2000 to 2013 were retrospectively reviewed. Demographics and comorbidities were recorded. Freedom from symptoms and freedom from reintervention were the primary end points. Return to work or school was assessed. Follow-up by clinic visits and telephone allowed quantitative comparisons among the patients.
  
  
  RESULTS
  During the study interval, 21 patients (24% male), with a median age of 42 years, were treated for MALS. All patients complained of abdominal pain in the presence of a celiac stenosis, 16 (76%) also reported weight loss at the time of presentation, and 57% had a concomitant psychiatric history. Diagnostic imaging most commonly used included duplex ultrasound (81%), computed tomography angiography (66%), angiography (57%), and magnetic resonance angiography (5%). Fourteen patients (67%) underwent multiple diagnostic studies. All patients underwent initial laparoscopic MAL release. Seven patients (33%) underwent subsequent celiac stent placement in the setting of recurrent or unresolved symptoms with persistent celiac stenosis at a mean interval of 49 days. Two patients required surgical bypass after an endovascular intervention failed. The 6-month freedom from symptoms was 75% and freedom from reintervention was 64%. Eighteen patients (81%) reported early symptom improvement and weight gain, and 66% were able to return to work.
  
  
  CONCLUSIONS
  A multidisciplinary treatment approach using initial laparoscopic release and subsequent stent placement and bypass surgery provides symptom improvement in most patients treated for MALS. The potential placebo effect, however, remains uncertain. A significant minority of patients will require reintervention, justifying longitudinal surveillance and prudent patient selection. Patients can anticipate functional recovery, weight gain, and return to work with treatment.
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: jesse.a.columbo@hitchcock.org.
authors.forename: Jesse A
authors.initials: JA
authors.lastname: Columbo
authors.affiliation: Section of Minimally Invasive Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Thadeus
authors.initials: T
authors.lastname: Trus
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Brian
authors.initials: B
authors.lastname: Nolan
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip
authors.initials: P
authors.lastname: Goodney
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Eva
authors.initials: E
authors.lastname: Rzucidlo
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Richard
authors.initials: R
authors.lastname: Powell
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Daniel
authors.initials: D
authors.lastname: Walsh
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: David
authors.initials: D
authors.lastname: Stone
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000046:Academic Medical Centers; D000293:Adolescent; D000328:Adult; D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation; D002445:Celiac Artery / Q000002:abnormalities* / Q000601:surgery; D003251:Constriction, Pathologic / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods*; D003952:Diagnostic Imaging / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D000074742:Median Arcuate Ligament Syndrome; D008875:Middle Aged; D009513:New Hampshire; D011237:Predictive Value of Tests; D012008:Recurrence; D012189:Retrospective Studies; D062707:Return to Work; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D015430:Weight Gain; D015431:Weight Loss; D055815:Young Adult