Ehab Sorial

University of Kentucky
Department of General and Vascular surgery
September 15, 2010

36 year old male patient presented with

abdominal pain and 80 pounds weight loss
over a one year period
Pain is unrelated to meals but worsens with
food intake
Patient is a chronic smoker
He has a h/o antiphospholipid syndrome, a
h/o remote stroke and he has PFO
He is on Coumadin for anticoagulation

Upper endoscopy normal

Lower endoscopy normal
SB capsule endoscopy unremarkable
CT abdomen and pelvis is unremarkable
Gall blabber ultrasound is normal

Decompression and release of MAL at the

proximal celiac artery

Left brachial percutaneous

approach

Intra-operative
celiac arteriogram
and measurement of
pressure gradient
across the celiac
stenosis with
gradient of
40-50mmHg
detected

Patients pain subsided

Patient started to gain weight within 3 months.
Three and nine month follow up mesenteric
duplexes shows normal velocities in the celiac
stent.

Chronic
Atherosclerotic
Non-atherosclerotic e.g. MALS

Acute
Occlusive
Embolic
Thrombotic
Non-Occlusive
Mesenteric Venous Thrombosis

Abdominal pain which may be related to meals

Pain is mainly in the epigastrium
May be accompanied by weight loss
May be associated with an abdominal bruit
Occasional diarrhea and nausea

ABDOMINAL PAIN ATTRIBUTED TO

COMPRESSION OF THE CELIAC GANGLIA.

ABDOMINAL PAIN ATTRIBUTED TO COMPRESSION OF THE

CELIAC ARTERY WHICH CAUSES ISCHEMIA.

It is estimated that in 10-24% of

normal, asymptomatic
individuals the median arcuate
ligament crosses in front of
(anterior to) the celiac artery,
causing some degree of
compression.
Approximately 1% of these
individuals exhibit severe
compression associated with
symptoms of MALS.
The syndrome most commonly
affects individuals between 20
and 40 years old.
Is more common in women,
particularly thin women.

Median arcuate ligament syndrome is a diagnosis of

exclusion
R/o all common causes of abdominal pain and weight
loss
Upper and lower endoscopy.
Gallbladder evaluation
Evaluation for GERD

SMA
Celiac

PSV >275cm/s
EDV > 45cm/s
PSV >200cm/s
EDV > 55cm/s

Reverse Splenic/Hepatic flow

1-Focal narrowing of proximal

celiac artery with poststenotic
dilatation
2-Indentation on superior aspect of
celiac artery
3-Hook-shaped contour of celiac
artery

Decompression of the celiac artery

Open release of MAL

Laparoscopic release of MAL

Removal of celiac ganglia

Celiac revascularization

Aorto-celiac bypass
Patch angioplasty
Endovascular stent angioplasty

According to Duncan et Al (2008) Mayo clinic, studied 51 patients

who underwent open surgical treatment for MALS, 44 had followup at an average of nine years following therapy, 75% remained
asymptomatic at follow-up.
In this study, predictors of favorable outcome included:
Age from 40 to 60 years
Lack of psychiatric condition or alcohol use
Abdominal pain that was worse after meals
Weight loss greater than 20 lb

Laparoscopic vs open celiac

ganglionectomy in patients with
median arcuate ligament syndrome,
a retrospective study by Tulloch et
Al. at UCLA, 2010
Laparoscopic and open techniques
are comparable.
Laparoscopic decompression offer
less hospital stay and decreased
time to feeding.
Late but milder recurrence of
symptoms is frequently seen after
both approaches.