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Experience and Results for Laparoscopic Median Arcuate Ligament Release in Young Patients With Postural Orthostatic Tachycardia Syndrome
Mikael Petrosyan*, Ashanti Franklin, Philip Guzzetta, Hassan Abdullah, Timothy D. Kane

General and Thoracic Surgery, Children's National Medical Center, Washington, DC

The Median Arcuate Ligament Syndrome (MALS) is a rare syndrome resulting in a compression of celiac artery which is associated with severe post prandial abdominal pain, emesis, nausea, and weight loss which may subsequently lead to significant debilitation. We have observed a strong association of MALS in patients with Postural Orthostatic Tachycardia Syndrome (POTS). The aim of this study is to review a single institutional operative experience and outcomes for patients undergoing laparoscopic MAL release.
Patients and Methods:
Between February 2013 and November of 2014, a total of 41 patients underwent laparoscopic MAL release at our hospital. Our operative technique evolved over the series but included ablation of the celiac ganglion plexus during ligament release. Demographics, techniques, complications were collected and analyzed retrospectively.
Forty one patients ages 14-22 years, 6 males (15%) and 35 females (85%) were diagnosed with MALS. A diagnosis of MALS was based on clinical symptoms as well as Ultrasound (US) and/or CT angiography results. All patients carried the diagnosis of POTS and all were on various hypertensive medications. Peak systolic velocities on expiration in the celiac artery were elevated in all patients (range 200-572 cm/sec) prior to operation. Twenty three patients also had evidence of celiac artery origin compression on CT angiography. All patients underwent laparoscopic median arcuate ligament release with intraoperative US evaluation. Average operative time was 110 min. Average length of hospital stay was 2 days. One conversion (2.4%) was required for a bleeding celiac artery. Re-operative rate was 7%. Thirty four (83%) patients had partial or complete symptomatic improvement immediately post op (less than 30 days). Follow up ranged from 1-21 months. POTS symptoms were improved in 38% after MAL release.
In patients with chronic abdominal pain and POTS, the diagnosis of MALS should be considered. In this experience, laparoscopic median arcuate release has provided significant symptomatic improvement (primarily for gastrointestinal and abdominal pain) in these patients. It is possible that the hyper adrenergic state in patients with POTS and concomitant MALS maybe lead to irregular stimulation of the celiac plexus. Although complete elimination of POTS symptoms is not usually found, laparoscopic MAL release may represent a viable therapeutic intervention for this patient population.

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