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Anatomy, Physiology, and Dysfunction of the Diaphragm
Published in Massimo Zambon, Ultrasound of the Diaphragm and the Respiratory Muscles, 2022
Posteriorly, the diaphragm muscle fibres are organized in two paired crura, which originate from the anterior aspects of L1–L3 and are joined by the median arcuate ligament. Hypertrophy or lower displacement of this fibrous structure may cause the median arcuate ligament syndrome (MALS, also known as celiac artery compression syndrome, celiac axis syndrome, celiac trunk compression syndrome, or Dunbar syndrome).
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].
Gastroscopy assisted laser Doppler flowmetry and visible light spectroscopy in patients with chronic mesenteric ischemia
Published in Scandinavian Journal of Clinical and Laboratory Investigation, 2019
Simen T. Berge, Nathkai Safi, Asle W. Medhus, Kim Ånonsen, Jon O. Sundhagen, Jonny Hisdal, Syed S. H Kazmi
During a period of 24 months, a total of 104 patients were referred to the Department of Vascular Surgery, Oslo University Hospital, Aker, for evaluation of mesenteric ischemia (Figure 2). Of these, 40 patients were included in the study. Of the remaining 64 not eligible for inclusion, 13 had median arcuate ligament syndrome (MALS), an external compression of the celiac artery by the arcuate ligament without atherosclerotic changes, eight were asymptomatic on referral (incidental find of changes to the intestinal arteries on CT angiography), 17 presented with AMI, and 24 had no significant changes to the intestinal arteries on CT angiography. Two patients refused to undergo upper endoscopy.