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LAPAROSCOPIC MEDIAN ARCUATE LIGAMENT RELEASE IN SETTING OF PRIOR FOREGUT SURGERY
Andrew T. Strong*1, Hana Fayazzadeh1, John Rodriguez1, Matthew Kroh2, Woosup M. Park3, Kevin M. El-Hayek1
1Department of General Surgery, Cleveland Clinic, Cleveland, OH; 2Digestive Disease Insititute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; 3Vascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Introduction: Median arcuate ligament MALsyndrome is a neurovascular disorder that causes post-prandial pain in patients. Laparoscopic MAL release with celiac plexus neurolysis successfully relieves symptoms for many patients. However, for patients with prior foregut operations, minimally invasive exposure of the aorta is challenging. Here, we sought to define safety and efficacy of performing laparoscopic MAL release in patients with prior foregut surgery.
Methods: Patients with prior foregut operations were identified from a prospectively maintained database of patients undergoing MAL release from January 2007 to November 2017. Patient demographics, co-morbid conditions, diagnostic tests, operative details and 30-day complications were analyzed.
Results: During the study period, 120 patients underwent laparoscopic MAL release, of whom 16 (13%) met inclusion criteria. The 16 patient cohort was 87.5% female, with a mean age of 37.3 years and a mean body mass index of 25.7 kg/m2. Comorbidities included psychiatric disorders (43.8%), gastroesophageal reflux disease (37.5%), opioid dependence (25%), diabetes (12.5%), and gastroparesis (12.5%). Preceding foregut operations included prior attempted MAL release (56.3%), hiatal hernia repair or fundoplasty (18.8%), gastric bypass (12.5%), duodenojejunostomy (6.3%), open gastrostomy tube (6.3%), and partial hepatectomy (6.3%). All patients underwent pre-operative mesenteric duplex ultrasound with a mean flow velocity of 307.4±133.6 cm/s at the celiac origin, and included 43.8% with a fixed stenosis. All patients underwent a pre-operative celiac plexus block and had relief of abdominal pain. There were 2 conversions to laparotomy (12.5%) to control intraoperative hemorrhage. The median operative time was 81 minutes (IQR 67-93), and median length of stay was 2 days (IQR 1-4). Complications occurred in 3 patients including acute hemorrhage requiring blood transfusion (6.3%), ileus (6.3%) and one patient who had a prolonged hospitalization for conversion disorder and recurrent supraventricular tachycardia. There was one readmission within 30 days (6.3%) and no mortalities. Among patients with follow-up available, pain was improved in all but one (89.0%). At a mean follow up of 7.6 month s, pain improved in 89.0% patients. The velocity at the celiac origin decreased by an average of 105.1 cm/s.
Conclusion: Laparoscopic MAL release is a safe and effective therapy for patients with prior foregut operations. When performed by a multidisciplinary team in a high volume center, conversion and complication rates are similar to those patients without prior foregut surgery. Further studies should focus on indicators which may predict need for open release.
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