Long-Term Symptom Improvement and Health-Related Quality of Life After Operative Management of Median Arcuate Ligament Syndrome

Abstract

To investigate long-term patient-reported symptom improvement and health-related quality of life measures after operative interventions for median arcuate ligament syndrome (MALS). We reviewed the clinical data of all consecutive patients treated by operative management for symptomatic MALS from 1999 to 2018. Long-term outcomes were assessed using Visick score, Gastrointestinal Quality of Life Index and the Short Form (SF)-12v2 questionnaires. Physical and mental component scores and SF-12 health domains were compared to the average for the US general population. Freedom from symptomatic recurrence was analyzed. There were 100 patients treated for MALS (mean age 38 ± 18 years; 75% female) with open release in 81 and laparoscopic release in 19. Symptoms were abdominal pain in 99 patients with postprandial exacerbation in 85. There was no mortality. Major adverse events at 30 days occurred in 21 patients (open 19%, laparoscopic 2%), including myocardial infarction (1%), pancreatitis (2%), respiratory failure (4%), estimated blood loss of more than 1L (8%), and postoperative ileus (8%). One patient treated by laparoscopic release required conversion for an aortic injury, which was treated by primary repair and splenectomy (Table). At 10 years, freedom from recurrence was 64 ± 6%. A total of 46 patients responded to the survey with a mean follow-up of 8 ± 4 years. Symptom resolution or improvement was reported by 38 patients (83%), persistent unsatisfactory symptoms by 5 (11%) and unchanged or worsening symptoms by 3 (7%). The SF-12 scores were below the general population for the physical component scores, role–physical, bodily pain, vitality and social functioning domains (Fig). Forty patients (87%) reported that they would still like to undergo operative management if given the choice. Operative management for MALS can be performed with low rate of complications with freedom from symptom recurrent of 64% at 10 years. Patients with MALS had lower health-related quality of life physical component scores compared to the general population. The vast majority of patients (87%) would opt to have the operation again if given a choice.TableBaseline characteristics, clinical features, operative details, major adverse events, and follow-up symptoms in 100 patients surgically treated for median arcuate ligament syndrome (MALS)All patients (n = 100)Demographics Mean age, years38.1 ± 18.1 Female sex25 (25) BMI (kg/m2)22.6 ± 4.0Cardiovascular risk factors Tobacco use23 (23) Hypertension19 (19) Dyslipidemia14 (14)Gastrointestinal conditions Gastroesophageal reflux disease35 (35) Irritable bowel syndrome14 (14) Food intolerances12 (12) History of gastritis18 (18)Other conditions Coronary artery disease8 (8) Peripheral vascular disease8 (8) Migraines25 (25) History of mental illness37 (37)Clinical features Abdominal pain99 (99)Epigastric location75 (75)Constant pain35 (35)Postprandial exacerbation85 (85) Weight loss67 (67)Amount of weight loss, kg8.0 ± 8.7Period of weight loss, months6.8 ± 13.0 Epigastric bruits71 (71) Duration of symptoms, months35.2 ± 37.7Operative details Open procedure81 (81) Laparoscopic procedure19 (19) Conversion to open2 (2) Estimated blood loss, mL425.9 ± 1694.6 Blood transfusion8 (8) HDU admission6 (6) Length of hospital stay, days4.3 ± 3.3MAE Any MAE21 (21) EBL >1 L8 (8) Myocardial infarction1 (1) Respiratory failure4 (4) Pancreatitis2 (2) Postoperative ileus8 (8) Wound/incisional complications7 (7)Follow-up symptoms Immediate postoperative symptom improvement, n = 8150 (72)First clinical follow-up, months, n = 513.8 ± 8.2Symptoms improved or resolved35 (69)Symptoms unchanged or worsened17 (3)Latest follow-up, months, n = 8918.2 ± 28.5Symptoms improved or resolved22 (43)Symptoms recurred33 (37)Symptoms unchanged or worsened19 (16)Survey follow-up, years7.8 ± 4.3Symptoms improved or resolved29 (63)Symptoms recurred9 (20)Symptoms unchanged or worsened8 (17)MAE, Major adverse event.Values are number (%) or mean ± standard deviation. Open table in a new tab