Open Surgical Decompression and Revascularization of the Celiac Axis for Median Arcuate Ligament Syndrome in the Modern Era of Minimally Invasive Surgery.

BACKGROUND

Median arcuate ligament syndrome (MALS) is a complex vascular condition that results in generalized abdominal pain resulting from compression of the celiac artery (CA). Early reports of the treatment of MALS described open surgical release of the MAL and decompression of the CA. The treatment of MALS has evolved over the past 2 decades, and laparoscopic as well as robotic techniques have been utilized. These studies enrolled patients treated by multiple surgeons from several institutions using a variety of techniques. This study was undertaken to examine and report contemporary surgical results, clinical response and outcomes from open decompression, and revascularization of the celiac axis for MALS performed by a single surgeon using a standardized surgical technique.

METHODS

Between March 2017 and May 2024, patients diagnosed with MALS associated with chronic abdominal pain were treated with open surgical decompression and CA bypass and were retrospectively reviewed. Data collected included demographics, morbidity, mortality, operative variables, and anatomic and clinical responses to surgery. Preoperative CA diameter stenosis was measured, graded (I-IV), and compared to postoperative stenosis levels. Patients' clinical response to surgery was determined at several points in the postoperative period by questionnaires at office follow-up as well as telehealth visits. Associations between preoperative and operative variables with anatomic and clinical outcomes were evaluated and analyzed.

RESULTS

Sixty-two patients met the inclusion criteria and underwent open surgical release of the MAL using a standardized technique. Five patients required an additional aorto-celiac bypass (8.1%). Twelve (19.4%) were males and 50 (80.6%) were females. The median age was 40.6 (range, 15-71 years). Presenting symptoms were generalized abdominal pain in 62 (100%), postprandial pain in 48 (77.4%), and weight loss in 38 (61.3%). Preoperative grading of the level of the CA stenosis revealed severe stenosis (>99%) grade IV in three (4.8%), high grade stenosis (70-99%) grade III in 48 (77.4%), and moderate stenosis (50-69%) grade II in 11 (17.7%). Thirty-day mortality and reoperations were zero. Median hospital length of stay (LOS) was 3 days (range, 1-8 days). Fifty (83.3%) were found to have a reduced stenosis of the CA to grade I (<50%). Fifty-three (88.3%) patients were deemed to have had a favorable response. Seven patients (11.3%) were judged to have an unfavorable response. Two patients were lost to follow-up. Average follow-up of the remaining 60 patients was 28.8 months.

CONCLUSION

Open surgical decompression is an effective method for the treatment of MALS and is associated with low morbidity. Most patients experienced significant reduction in abdominal pain and overall sustained clinical improvement with restoration to normal CA diameters after decompression.