Management of median arcuate ligament syndrome: a new paradigm

Median arcuate ligament (MAL) syndrome is an anatomic and clinical entity characterized by extrinsic compression on the celiac axis, which leads to postprandial epigastric pain, vomiting, and weight loss. Although characterized a few decades ago, the existence of this syndrome is still challenged by several authors. We reviewed the management of MAL syndrome, with special emphasis on the minimally invasive approaches. We also report the first case of successful combination of minimally invasive surgery and endovascular therapy in the treatment of this syndrome. A PubMed search was carried out to identify articles in English from 1963 to 2008 using the keywords "median arcuate ligament syndrome" and "celiac artery compression syndrome." Additional articles were identified by a manual search of the references from the key articles. All clinical and experimental studies that contained material applicable to the topic were considered. Classic treatment of the condition is represented by open MAL release. However, permanent changes in the celiac artery wall lead to poor long-term outcomes, and associated complex vascular procedures have been employed. Laparoscopic treatment of MAL syndrome was reported in five cases. All patients had resolution of symptoms, but long-term follow-up is not available. Laparoscopic release of arcuate ligament syndrome with intraoperative duplex ultrasound may be used in patients with symptoms suggestive of the diagnosis. In patients with persistent celiac flow abnormalities noted on duplex ultrasound or postoperative imaging, celiac angioplasty and stenting are advocated. If this option is not available or does not relieve symptoms, vascular reconstruction should be employed.