Vaskulárna medicína 2/2023

Median arcuate ligament syndrome. Laparoscopic treatment

Introduction: Median arcuate ligament syndrome (MALS, Dunbar syndrome) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. Patients can often be misdiagnosed for several years before a correct diagnosis is established, also due to a medical team’s clinical suspicion. The goal of treatment is decompression of celiac trunk either by open, laparoscopic or robotic method along with adjuvant interventional procedures like percutaneous transluminal angioplasty (PTA) and stenting. The advantages of laparoscopic method are small incision, low risk of complications and improved view during surgery. Laparoscopic release of celiac artery has become standard surgical option. Patient pool and methods: Between the years 2006 and 2022, 32 patients were diagnosed and treated with Dunbar syndrome. In this study, 10 men and 22 women ranging from 21 to 69 years were present, with the average age of 36 years. The first 4 patients were treated by means of open surgery and 28 patients with clinical presentation, diagnostic imaging and gastroenterological examination consistent with MALS underwent coeliac trunk deliberation managed by laparoscopy. Results: The average procedure time was 97 minutes. Conversion from laparoscopy to open surgery was necessary in 2 patients, in one case due to massive hemorrhage. Postoperative CT angiography showed residual hemodynamic significant stenosis in 5 cases. In those, successful percutaneous angioplasty – DEB PTA was performed. Postoperatively, clinical symptoms improved in 24 patients (85%), after the first year in 75% of patients. 7 patients (25%) reported persistence or recurrence of difficulties. Conclusions: Laparoscopy offers all the advantages of minimally invasive surgery for patients with MALS. The final surgical aim is, however, always a median arcuate ligament release and decompression of the coeliac nervous plexus. According to our data, the outcome after surgical therapy is considerably improved. A thorough preoperative work-up with a careful patient selection is of paramount importance. Laparoscopic median arcuate ligament release is increasingly regarded as current standard surgical management.

Keywords: median arcuate ligament syndrome, Dunbar syndrome, celiac artery compression, laparoscopic release of celiac artery