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Management of vascular complications during nonvascular operations
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Kush Sharma, M. Ashraf Mansour
The median arcuate ligament is a fibrous band of the diaphragmatic crus surrounding the celiac artery origin and the insertion at the celiac axis can cause extrinsic compression of the celiac access.29 Since first described in 1963, median arcuate ligament syndrome (MALS), also known as celiac artery compression (Dunbar's syndrome), has been controversial due to the poor understanding of its pathophysiology and patient variability with presentation and treatment.30 The gold standard traditional therapy has been open surgical decompression, but since 2000 there has been an increased incidence of laparoscopic or robotic decompression.31 Laparoscopic approach has been increasingly favorable due to faster recovery and less morbidity; however, there is reported increased risk of significant arterial bleeding reported in some series to 7.4%.29 More recently, small series of robot-assisted decompression for MALS have shown fewer incidences of bleeding and conversion to open surgery.29 Despite these findings, the risk of arterial injury during decompression is still present and vascular surgeons should be prepared to step in, if needed.
Vascular Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Yiu-Che Chan, John Wang, Julian Wong, Edward Choke, Tjun Tang
What is median arcuate ligament syndrome, and how do you treat it?The median arcuate ligament of the diaphragm compresses the origin of the coeliac axis. This can lead to reduced flow, chronic abdominal pain and mesenteric ischaemia.Unless the SMA is also diseased, it should provide sufficient collateral flow to obviate symptoms.Endovascular stenting is unlikely to relieve symptoms due to the extrinsic compression.Open or laparoscopic division of the ligament is the definitive treatment.
Late Results Following Operative Repair for Celiac Artery Compression Syndrome
Published in Juan Carlos Jimenez, Samuel Eric Wilson, 50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know, 2020
Juan Carlos Jimenez, Samuel Eric Wilson
Dr. Reilly and colleagues’ landmark 1985 study validated a surgical treatment protocol for patients with Median Arcuate Ligament Syndrome (MALS) for the first time in the vascular surgery literature. They demonstrated improved outcomes with MAL release, celiac ganglionectomy and more extensive arterial reconstruction compared with MAL release, and ganglionectomy alone. Their excellent outcomes were impressive despite the absence of routine use of CT angiography, endovascular techniques and devices, and laparoscopic or robotic surgery. The 32% failure (to alleviate symptoms) rate in Dr. Reilly's entire patient cohort supports similar outcomes in recent studies in the current literature including our own experience with treating these patients.1,2 This is not an operation where certain complete symptomatic relief should be advertised to patients, and MAL release, either open or minimally invasive, should only be a last resort for patients who have failed all medical treatments.
Intraoperative measurement of pressure gradient in median arcuate ligament syndrome as a rationale for radical surgical approach
Published in Acta Chirurgica Belgica, 2018
Tomas Grus, Lukas Lambert, Tomas Vidim, Gabriela Grusova, Tomas Klika
Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, describes clinical symptoms in patients with stenosis of the CA [1]. Patients with MALS suffer from postprandial abdominal pain that begins no later than 2 h after food intake and subsides about 6–10 h after the meal. In advanced cases, abdominal pain may be provoked by mere fluid intake. Other symptoms include nausea, vomiting after a meal, diarrhea, and substantial weight loss [2]. The diagnosis of MALS must be supported by imaging of the stenosis. Typically, the CA is flattened in the anterior–posterior direction and the artery first turns caudally forming a J-shaped appearance in sagittal plane or projection [3]. The stenosis is more pronounced on expiratory acquisitions, because CA assumes a more cranial position. In the pathophysiology of this entrapment syndrome, apart from the compression by MAL, fibrosis of the surrounding tissue including the coeliac ganglion and the CA wall have been described [2].
Image in transplantation surgery: median arcuate ligament in liver transplantation
Published in Acta Chirurgica Belgica, 2020
Morgan Vandermeulen, Martin Moïse, Nicolas Meurisse, Pierre Honoré, Michel Meurisse, Paul Meunier, Olivier Detry
Median arcuate ligament is a fibro-tendinous vault at the base of the diaphragm connecting left and right diaphragmatic crura and forming the anterior margin of the aortic hiatus [2]. Its localization is variable and in case of low insertion at or below the origin of the celiac trunk, extrinsic vascular compression can occur (Figure 2). This anatomical entity can be detected in 2–50% of patients and is most of the time asymptomatic [1,3–5]. Nonetheless, low MAL insertion is controversially believed to cause MAL syndrome (association of post-prandial epigastric pain, weight loss and nausea or vomiting), first described by Dunbar et al. [6]. In their series, Jurim et al. found celiac compression syndrome in 10% of 193 patients undergoing LT [3].
Inferior pancreaticoduodenal artery aneurysms and Dunbar syndrome. Experience with the open surgery
Published in Acta Chirurgica Belgica, 2021
Predrag Pavić, Inga Đaković Bacalja, Ali Allouch, Tomislav Meštrović
Pancreaticoduodenal artery aneurysms are rare visceral aneurysms accounting for only less than 2% of all splanchnic aneurysms [2,5] and can be associated with the trauma, surgery, pancreatitis, rarely as part of systemic vasculitis or with the celiac trunk stenosis [4]. Median arcuate ligament is relatively common incidental finding on cross sectional imaging but rarely causing symptoms or complications due to extensive collateral pathway [6]. As its complications, splanchnic aneurysms can occur. Their significance rises from high mortality rates (26–50%) caused by unrecognized ruptures [7].