A 16-year-old female is found to have celiac artery compression from median arcuate ligament syndrome on CT angiogram. She is active in volleyball and has chronic pain following eating and after exercise. She has lost 30 lbs over the last 6 months. She has been seen by a multi-disciplinary team and has been found to have elevated peak systolic velocities of the celiac artery on mesenteric duplex. A celiac plexus block did provide temporary relief of her symptoms. What is the best surgical option for the treatment of this patient?

 

a Release of median arcuate ligament

 

b Celiac artery bypass with prosthetic graft

 

c Celiac artery bypass with vein graft

 

d Release of ligament with celiac plexus neurolysis

 

e Celiac artery stenting

D

D

Correct answer

d Release of ligament with celiac plexus neurolysis

 

Median arcuate ligament syndrome (MALS), or celiac artery compression syndrome, was first described in 1917 and again in 1963. It is a rare condition that typically occurs in young women and presents with post-prandial epigastric pain, weight loss and nausea. In high-functioning athletes, it can also cause symptoms following exercise. The non-specific symptoms and finding of celiac artery compression in asymptomatic patients has raised the question of the validity of the diagnosis. Initially felt to be of a vascular etiology, more recently it has been proposed that there is a neurologic component potentially due to the compression and inflammation of the surrounding celiac plexus. The diagnosis of MALS is felt to be a diagnosis of exclusion and recommendations for the workup are meant to rule out more common causes of abdominal pain and weight loss. A multi-disciplinary team approach has also been found to be beneficial. Patients who are noted to be candidates for surgery include those with post-prandial pain and a weight loss of over 10kgs. Surgical intervention has shown to be successful in 70-80% of patients in some reports. In this patient who presents with findings concerning for MALS who saw benefit with a celiac artery plexus block, a laparoscopic release of the median arcuate ligament along with neurolysis of the celiac artery plexus would be first line surgical therapy.