IYSC13 - Median Arcuate Ligament Release with Celiac Ganglionectomy for Management of Chronic Disabling Abdominal Pain in Patients With and Without Celiac Artery Compression - A Case Series

Objectives: The current accepted surgical treatment for median arcuate ligament syndrome (MALS) is by division or release of the MAL(MALR), but current treatment strategies are known to remain inconsistently effective with variable recurrence rates. Treatment algorithms typically rely on the demonstration of celiac artery compression before offering patients surgical intervention. We sought to decrease reliance on abnormal arterial imaging as inclusion criteria and to see whether ganglionectomy in patients without celiac compression would provide symptom relief.

Methods: We retrospectively reviewed all patients who underwent MALR/CG between 2020-2021 by one vascular surgeon at a tertiary institution. All patients had chronic disabling abdominal pain of unclear etiology despite a thorough gastrointestinal workup and reported improvement/resolution of symptoms after undergoing a celiac plexus block (CPB). Through an upper midline incision, the MAL was divided, the celiac artery (and its branches) were skeletonized circumferentially, and an extensive ganglionectomy was performed lateral to the aorta (including retrocaval exposure). No arterial reconstruction/revascularization was performed.

Results: During the one-year study period, sixteen patients underwent open surgical MALR/CG, of which one patient (6.3%) underwent reoperative celiac ganglionectomy. Mean age was 28.6 (± 9.8) years, 88% were female, with an average symptom duration of 33 months(IQR 11-69). During preoperative work-up, eight patients(50%) had evidence of celiac-artery compression by preoperative imaging studies. Immediately following open MALR/CG, all patients(100%) reported relief to be similar to that following CPB, of which fifteen patients(94%) reported complete relief of their epigastric/postprandial pain symptoms.
The median length of stay was 6 days(IQR 5-7) and one patient(6.3%) developed postoperative wound infection. Median follow-up was 86 days(IQR 41-124) and, three patients(19%) developed symptom recurrence. Of these three patients, one did not demonstrate celiac artery compression preoperatively.

Conclusions: In this small series, patients with chronic disabling abdominal pain who responded to a CPB benefitted from performance of open MALR/CG regardless of the presence of celiac artery compression. Future investigation with extended follow-up is required to assess long-term durability.