Decompression Of Celiac Artery Research Articles

Prognostic factors for the long term outcome after surgical celiac artery decompression in MALS

BackgroundThe median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac artery (ORPHA: 293208). Surgical treatment of MALS aims to restore normal celiac blood flow by laparoscopic celiac artery decompression. However, surgical success rates vary widely between patients, therefore adequate selection of patients is essential to improve surgical outcome. Symptoms of MALS might also overlap with other chronic multi-system disorders such as mast cell activation syndrome (MCAS). So far, no clinical or radiological parameter was found to be predictive of the postoperative outcome. We, therefore, aim to study preclinical parameters in one of the largest MALS cohorts with the focus to identify patients that would benefit from surgical MAL release.ResultsBy analyzing 20 MALS patients that underwent surgical celiac artery decompression, we found 60% of patients (12/20) had a postoperative relief of their symptoms and a simultaneous decrease of analgetic use. No demographic, radiologic or operative parameter was able to predict postoperative symptom relief. However, mast cell activation syndrome correlated significantly (p = 0.04) with persistent symptoms after the operation.ConclusionsOverall, laparoscopic MAL release can provide immediate symptomatic relief. Despite the missing predictive value of demographic and imaging data, our data show a correlation between persistent symptoms and a co-existing mast cell activation syndrome. This suggests that MCAS symptoms might be interpreted as MALS symptoms in the presence of celiac artery stenosis and therefore surgical treatment should be evaluated carefully. Overall, the selection of patients who are most likely to respond to surgical MAL release may best be accomplished by an interdisciplinary team of gastroenterologists, radiologists and surgeons.

Detailed anatomy and procedure of celiac artery decompression in median arcuate ligament syndrome.

Median arcuate ligament (MAL) syndrome is a clinical syndrome caused by the compression of the celiac artery (CA) by the MAL. This study aimed to present the detailed anatomy and a step-by-step procedure of CA decompression for MAL syndrome. The CA decompression procedure involves exposing the diaphragmatic crura and aorta, taping the left gastric artery, and dividing the compressive tissues. The MAL and ganglionic tissue, which form a broad band with multiple layers overlying the CA, comprise the compressive tissues. Therefore, the compressive tissues overlying the CA are encircled and divided one by one until the CA stenosis is released. CA decompression is confirmed with intraoperative duplex ultrasonography of the CA, with a return to normal peak systolic velocities without variation between deep inspiration and expiration. This report presents the detailed anatomy and procedural steps for CA decompression in MAL syndrome.

Repeated operations in patients with unsatisfactory results of celiac artery compression syndrome treatment

Purpose of the study . The reasons for the unsatisfactory results of surgical treatment of patients with celiac artery compression syndrome (CACS) and the role of repeated interventions allows to achieve a lasting improvement in most of them. The purpose of the study is to clarify the reasons for the unsatisfactory outcomes of surgical treatment of patients with CACS and the nature and significance of repeated operations. Patients and methods . From 860 patients with CASC who were operated on over the past 25 years 82 patients were selected with unsatisfactory treatment results. Initial conventional abdominal surgery was performed in 26 (31.7%) patients without a positive outcome before decompression of celiac artery (DCA). Primary operations were performed in 82 patients with proven CASC, of which 69 (84.1%) had DCA in open approach, isolated in 43 (52.4%) and combined in 26 (31.7%). Embolization of PDA aneurysm in one (1.2%) patient. In other medical institutions 15 (18.3%) patients were operated, among them 3 (3.7%) patients had DCA in open approach, in 4 (4.9%) laparoscopic DCA, in 6 (7.3%) angioplasty and emergency stenting and two (2.4%) reconstructive operations, all technically and clinically unsuccessful. Results . After DCA in open approach 51 (73.9%) patients of 69 patients had normal celiac artery flow. 4 patients had unresolved stenosis of the celiac artery and 15 relapsed its stenosis, one of them with residual stenosis after DCA twice, which amounted to 0.5% and 1.7%, respectively of 860 patients. Repeated operations were performed in 51 (62.2%) patients out of 82 to restore the celiac artery in 28 (34.2%), among them 4 (4.9%) in combination with interventions on the abdominal organs. Abdominal operations with concomitant diseases of the gastrointestinal tract with normal flow in celiac artery in 21 (25.6%).Scalenotomy in two (2.4%). Of 28 patients, re-revascularization of the celiac artery was successful as a result of open decompression in 7 out of 8, bypass surgery in 9 out of 10 and balloon angioplasty and with stenting in two out of 7. One had an effective primary DCA and the other resected PDA aneurysm. 19 patients out of 25 showed a good result after operations on the abdominal organs. Conclusion . The unsatisfactory results of surgical treatment of patients with CASC are associated with inadequate restoration of celiac artery restenosis and/or concomitant diseases of the abdominal organs. Repeated vascular operations are mainly: decompression of celiac artery in open approach, bypass surgery and balloon angioplasty and stenting, and/or abdominal mainly: cholecystectomy, NissenFP, and Strong surgery are of primary importance in the treatment of patients with CASC.

2762 Median Arcuate Ligament Syndrome: A Rare but Overlooked Cause of Post-Prandial Abdominal Pain

INTRODUCTION: Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is defined as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. The median arcuate ligament is a fibrous arch that crosses the aorta and links the crura of the diaphragm. This ligament typically passes superior to the origin of the celiac artery, however about 10% of the population (with strong female predominance) has a low-lying ligament that causes compression of the celiac trunk that is usually asymptomatic. We report a case of median arcuate ligament syndrome presenting similar to chronic mesenteric ischemia but without the typically associated cardiovascular risk factors. CASE DESCRIPTION/METHODS: A 54-year-old woman with no significant past medical history presented to the emergency department with a 6-month history of post-prandial abdominal pain associated with nausea, nonbilious emesis, sitophobia and a 60lb weight loss in the past 6 months. Vital signs were unremarkable. Her physical exam was entirely benign aside from mild epigastric tenderness to deep palpation. Labs were significant for a WBC 11.4, Hb 19.0 (baseline 13-15), K + 2.9. Gastroenterology was consulted and the patient underwent EGD which showed normal appearance of the esophagus, stomach, and duodenum with negative biopsies. Due to concern for mesenteric ischemia, the patient underwent CT Angiography of the abdomen which demonstrated 70% stenosis of the proximal celiac artery highly suggestive of median arcuate ligament syndrome. All other vessels were patent. DISCUSSION: Median arcuate ligament syndrome is a rare cause of post-prandial abdominal pain and weight loss that can often be challenging to diagnosis unless suspected by the clinician. Many patients undergo extensive workups for abdominal pain before being diagnosed. This syndrome presents similar to chronic mesenteric ischemia however many of these patients lack the typical cardiovascular risks factors associated with mesenteric ischemia as the demographic for MALS is typically middle-aged females ranging from age 40-60 years old. Patients are also often misdiagnosed with functional dyspepsia. Patients diagnosed with this disease should undergo laparoscopic celiac artery decompression which cures the majority of the patients with symptom recurrence occurring in approximately 6% of patients.

Unexplained Chronic Abdominal Pain Manifesting as Celiac Artery Compression Syndrome

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, is a rare condition which causes chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament with resultant ischemia. Clinical presentation involves the triad of upper abdominal pain, weight loss and epigastric bruit in examination. The diagnosis is one of exclusion. The purpose of this case report is to describe a common presentation of an infrequently described rare disorder in literature. A 28-year-old healthy female presented to the emergency department (ED) with recurrent progressively worsening post-prandial sharp right upper quadrant abdominal pain for the past four months. Her pain has been associated with a 10-pound weight loss and intermittent episodes of nausea and vomiting without any fever, chills, diarrhea, or loss of appetite. She reported to no improvement with use of antacids, antiemetics and analgesics. She previously underwent outpatient ultrasonography revealing gallstones and esophagogastroduodenoscopy (EGD) revealing mild gastritis. Examination, laboratory studies, repeat ultrasound and computerized tomography (CT) scan revealed no acute abnormalities, including no gallstones. Due to nature of her chronic pain to be postprandial, a duplex ultrasound was ordered, which revealed elevated systolic velocities of the celiac artery, suggesting celiac artery stenosis and subsequently confirmed with angiography. Patient underwent a laparoscopic celiac artery decompression with a median arcuate ligament resection release. Patient was discharged following an uneventful postoperative period during her hospitalization. CACS is a rare syndrome. The pathophysiology, while not completely understood, is believed to be celiac arterial compression by variations in median arcuate ligament position. Patients are typically asymptomatic as the incidence of attributable clinical symptoms is much lower than the imaging finding. However, we present a case of a patient with chronic post-prandial pain and weight loss, in the absence of any obvious etiology, found to have a rare diagnosis of median arcuate ligament compressing on the celiac artery. We encourage clinicians to consider celiac artery compression syndrome in patients with chronic abdominal pain without a clearly established etiology.

Median Arcuate Ligament Syndrome: A Single-Center Experience with 23 Patients.

Median arcuate ligament syndrome (MALS) is a rare entity that occurs when the median arcuate ligament of the diaphragm is low-lying, causing a compression to the underlying celiac trunk. We reviewed the vascular changes associated with MALS in an effort to emphasize the seriousness of this disease and the complications that may result. This is a retrospective descriptive analysis of 23 consecutive patients diagnosed with MALS between January 1, 2012 and December 31, 2015 at a tertiary medical center. Computed tomographic (CT) scans, medical records, and patient follow-up were reviewed. The number of patients included herein was 23. The median age was 56years (17-83). Sixteen patients (69.6%) had a significant arterial collateral circulation. Eleven patients (47.8%) were found to have visceral artery aneurysms; 4 patients (36.4%) bled secondary to aneurysm rupture. All ruptured aneurysms were treated with endovascular approach. The severity of the hemodynamic changes appears to be greater with complete occlusion, CONCLUSIONS: MALS causes pathological hemodynamic changes within the abdominal vasculature. Follow-up is advised for patients who develop a collateral circulation. Resulting aneurysms should preferably be treated when the size ratio approaches three. Treatment of these aneurysms can be done via an endovascular approach coupled with possible celiac artery decompression to restore physiologic blood flow.

Laparoscopic treatment of celiac artery compression syndrome in children and adolescents.

The celiac artery compression syndrome (CACS) is a rarely diagnosed disorder, which is characterized by chronic abdominal pain and vegetative symptoms. The role of surgical treatment in celiac artery decompression has been discussed controversially by numerous authors. After first casuistic descriptions of a laparoscopic treatment in adults we established this novel minimally invasive procedure for treatment in children and adolescents. Between 2005 and 2014 we operated 58 patients (47 female, 11 male) from 7 to 25 years who had been diagnosed with celiac artery compression. The patients presented with severe chronic abdominal pain, vegetative symptoms and a reduced quality of life. Doppler sonography showed an increased blood flow velocity of the celiac artery with maximum of 190 - 450 cm/s (mean 259 cm/s).MR angiography demonstrated a characteristic hook-shaped appearance of the celiac artery with severe localized compression. All patients underwent laparoscopic decompression of the celiac artery. We observed complications in 3 patients (5,2 %). Postoperatively all patients (100 %) were immediately free of abdominal pain. Doppler sonography showed a marked reduction in celiac blood flow velocity to 70 - 190 cm/s postoperatively (mean 178 cm/s). A return of vessel diameters to normal dimensions was documented by postoperative MR angiography. During a median follow up of 62 months we observed a recurrence of the celiac artery compression in 4 patients (6,9 %). Laparoscopic treatment of celiac artery compression syndrome offers a novel, safe, reliable and, compared to open surgery, less invasive approach. The surgical treatment is indicated in patients with characteristic symptoms and typical findings at Doppler sonography and MRA after exclusion of other abdominal pathologies. The work-up of chronic abdominal pain in children and adolescents should include a color Doppler sonography to look for celiac artery compression.

The Use of Gastric Tonometry in the Assessment of Celiac Artery Compression Syndrome

This report describes the use of gastric tonometry to measure gastric mucosal ischemia/intestinal mucosa pH (pHi) in a patient treated for celiac artery compression syndrome. Significant gastric mucosal ischemia was demonstrated prior to celiac artery decompression as indicated by a pHi of 7.29. The ischemia was relieved by celiac artery decompression, with an increase in the pHi to 7.48. The patient experienced complete relief of his symptoms after surgical decompression and remains asymptomatic 14 months after surgery. Gastric tonometry provides an objective measurement of intestinal perfusion and ischemia in the treatment of celiac artery compression syndrome.