Abstract
Introduction:
Median arcuate ligament syndrome (MALS) is a rare entity and is often a diagnosis of exclusion. 1 Richards et al. reported a patient experiencing MALS after a Roux-en-Y gastric bypass with 100 lb weight loss; however, reports of this event are quite infrequent. 2 It has also previously been shown that the Linx™ device is a safe and effective option in patients with de novo gastroesophageal reflux disease (GERD) after a laparoscopic sleeve gastrectomy. 3 This video presents a case of a young woman with symptoms of chronic pain caused by MALS as well as GERD. The technical steps are described in detail.
Patient and Method:
The patient is a 32-year-old woman who presented to the emergency room with complaints of burning chest pain, nausea with blood-tinged vomiting, and abdominal pain for 1 day. Her surgical history included a laparoscopic sleeve gastrectomy that resulted in 125 lb weight loss. She later reported having intermittent postprandial abdominal pain since her surgery. A comprehensive work-up revealed a hooked appearance of the celiac trunk on computed tomography and subsequent duplex ultrasonography of the aorta and branches revealed elevated flow velocities of the celiac artery with expiration (221 cm/second) that resolved with inspiration (127 cm/second). An esophagram demonstrated spontaneous GERD to the level of the proximal esophagus that prompted findings of mild esophagitis with a small hiatal hernia on upper endoscopy. Together, this work-up was deemed satisfactory for establishing her diagnoses. The procedure was performed laparoscopically using three 5 mm trocars, one 12 mm trocar, and a liver retractor. Initially, several adhesions were lysed from her previous gastrectomy involving the liver, stomach, and spleen. After the esophagus was mobilized into the abdomen, the celiac axis including the artery and plexus was dissected free of all compressive tissue. Next, the bilateral crus were plicated using a silk Endostitch™ and the Linx magnetic sphincter augmentation device was installed.
Results:
The patient did well and was discharged on postoperative day 2. No immediate complications were exhibited, and she was largely relieved from her symptomatology at her 2-week outpatient follow-up visit. A postoperative esophagram demonstrated resolution of her previous spontaneous reflux and a postoperative computed tomography demonstrated a marked expansion of the craniocaudal diameter of the celiac artery from 4.0 to 7.9 mm.
Conclusion:
Although a rare diagnosis, MALS can be diagnosed with a directed history and stepwise work-up. MALS should be included in the differential diagnosis in the postbariatric surgery patient with symptoms of postprandial abdominal pain. Symptoms of reflux can also be seen postbariatric surgery. Overall, GERD and MALS should not be considered as mutually exclusive in this setting. A laparoscopic median arcuate ligament release with installation of the Linx magnetic sphincter is a safe and effective one-stage procedure to alleviate celiac artery compression and GERD in the setting of prior sleeve gastrectomy.
No competing financial interests exist.
Runtime of video: 9 min 4 secs
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