title: Median Arcuate Ligament Syndrome Is Not a Vascular Disease.
abstract: BACKGROUND
  Median arcuate ligament syndrome (MALS) is a rare disorder characterized by postprandial abdominal pain, weight loss, and celiac stenosis. Diagnosis can be challenging, leading to a delay in treatment. We report on our continued experience using a laparoscopic approach for this uncommon diagnosis.
  
  
  METHODS
  This is an Institutional Review Board-approved, prospectively collected retrospective analysis of patients treated with laparoscopic MAL release at our institution. Data collected included patient demographics, preoperative symptoms, operative approach, and postoperative outcomes. Patients were then contacted to complete a postoperative survey designed to assess the improvement of symptoms and overall patient satisfaction.
  
  
  RESULTS
  A total of 39 patients (33 women and 6 men) underwent laparoscopic MAL release from March 2007 to July 2014. Mean age was 40.6 years (range, 17-77 years). Thirty of 39 patients had a postoperative celiac axis ultrasound. Twenty-three had a patent celiac axis on postoperative duplex. Of the remaining 7, 5 with residual celiac axis stenosis and 1 with occlusion, reported complete resolution of their symptoms. One remaining patient with occlusion remained symptomatic. Thirty-three of 39 (84.6%) reported symptom relief after surgery. Nine of 33 (27.3%) responders had cardiovascular risk factors versus 4 of 6 (67%) nonresponders. Five patients with atypical presentations underwent preoperative diagnostic celiac plexus block using local anesthetic, with 4 reporting symptom reliefs after block. These 4 patients also reported postoperative symptom relief. One patient of 39 received a postoperative celiac stent placement and remained symptomatic. There were 4 conversions to open surgery (10.3%) and no deaths.
  
  
  CONCLUSIONS
  Laparoscopic MAL release continues to be a safe and effective means of managing MALS. Our data suggest that the symptoms associated with MALS are not related to vascular compromise, and atherosclerotic risk factors may predict poorer outcomes. Symptomatic relief is seen in the vast majority of patients undergoing this procedure. However, patient selection remains critically important in obtaining optimal results.
authors.affiliation: Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: john.m.weber@gmail.com.
authors.forename: John M
authors.initials: JM
authors.lastname: Weber
authors.affiliation: Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Mena
authors.initials: M
authors.lastname: Boules
authors.affiliation: Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Fong
authors.affiliation: Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Abraham
authors.affiliation: Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio.
authors.forename: James
authors.initials: J
authors.lastname: Bena
authors.affiliation: Department of General Surgery, Digestive Disease Institute Cleveland Clinic, Cleveland, Ohio Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
authors.forename: Kevin
authors.initials: K
authors.lastname: El-Hayek
authors.affiliation: Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Matthew
authors.initials: M
authors.lastname: Kroh
authors.affiliation: Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Woosup Michael
authors.initials: WM
authors.lastname: Park
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002318:Cardiovascular Diseases / Q000150:complications*; D002445:Celiac Artery / Q000002:abnormalities* / Q000601:surgery; D003251:Constriction, Pathologic / Q000175:diagnosis* / Q000209:etiology* / Q000601:surgery; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D000074742:Median Arcuate Ligament Syndrome; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult