Inability of conventional imaging findings to predict response to laparoscopic release of the median arcuate ligament in patients with celiac artery compression.

Objective: The objective of this study was to identify duplex ultrasound (DUS) or computed tomography angiography (CTA) imaging findings that can predict clinical response to laparoscopic release of the median arcuate ligament (MAL) in patients with celiac artery compression.

Methods: There were 299 patients who were evaluated for MAL syndrome (MALS) between January 2009 and November 2015. Of these, 29 underwent laparoscopic MAL release and completed 1-year follow-up. The patients' preoperative and postoperative symptoms, use of analgesics, and body mass index were recorded. Patients' demographics and DUS and CTA findings were reviewed. Fisher exact and Student t-tests were used to identify correlation between patient or imaging variables and clinical outcomes.

Results: There were 19 patients (66%) who reported improvement in symptoms, and 18 (62%) decreased their use of analgesics; average body mass index increased by 0.2 (standard deviation, 1.97; range, -3.35 to 5.11). No celiac artery DUS finding (peak celiac artery velocity, angle of deflection, or change in preoperative to postoperative velocity) was predictive of successful clinical outcomes (P > .05). Similarly, no CTA finding (characteristic morphology, cross-sectional area, diameter, or location of the focal stenosis of the celiac artery) was associated with clinical outcomes (P > .05).

Conclusions: Clinical response to laparoscopic MAL release was favorable in two-thirds of patients; however, no specific imaging finding of stenosis was predictive of this response. Given that the severity of stenosis on conventional imaging had no impact on treatment efficacy, vascular compromise may not be the primary cause of pain in patients presenting with this syndrome. Future investigation incorporating the neurogenic basis of MALS pain, such as with diagnostic celiac ganglion blockade, would be helpful in further elucidating the enigmatic pathophysiologic process of MALS.