Thoolen Stijn J J, van der Vliet Walderik J, Kent Tara S, Callery Mark P, Dib Martin J, Hamdan Allen, Schermerhorn Marc L, Moser A James
Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
J Vasc Surg. 2015 May;61(5):1278-84. doi: 10.1016/j.jvs.2014.10.084. Epub 2015 Jan 16.
Celiac artery compression by the median arcuate ligament (MAL) is a potential cause of postprandial abdominal pain and weight loss that overlaps with other common syndromes. Robotic technology may alter the current paradigm for surgical intervention. Open MAL release is often performed with concurrent bypass for celiac stenosis due to the morbidity of reintervention, whereas the laparoscopic approach is associated with high rates of conversion to open due to bleeding. We hypothesized that a robot-assisted technique might minimize conversion events to open, decrease perioperative morbidity, and defer consideration of vascular bypass at the initial operative setting.
We retrospectively analyzed patients treated for MAL syndrome by a multidisciplinary team at a tertiary medical center between September 2012 and December 2013. Diagnosis was based on symptom profile and peak systolic velocity (PSV) >200 cm/s during celiac artery duplex ultrasound imaging. All patients underwent robot-assisted MAL release with simultaneous circumferential neurolysis of the celiac plexus. Postoperative celiac duplex and symptom profiles were reassessed longitudinally to monitor outcomes.
Nine patients (67% women) were evaluated for postprandial pain (100%) and weight loss (100%). All patients had celiac stenosis by mesenteric duplex ultrasound imaging (median PSV, 342; range, 238-637 cm/s), and cross-sectional imaging indicated a fishhook deformity in five (56%). Robot-assisted MAL release was completed successfully in all nine patients (100%) using a standardized surgical technique. Estimated blood loss was <50 mL, with a median hospital stay of 2 days (range, 2-3 days). No postoperative complications of grade ≥3, readmissions or reoperations were observed. All patients (100%) improved symptomatically at the 25-week median follow-up. Three patients experienced complete resolution on postoperative celiac duplex ultrasound imaging, and six patients showed an improved but persistent stenosis (PSV >200 cm/s) compared with preoperative velocities (P < .05 by Wilcoxon signed rank). No patients required additional treatment.
Robot-assisted MAL release can be performed safely and effectively with avoidance of conversion events and minimal morbidity. Potential factors contributing to success are patient selection by a multidisciplinary team and replication of the open surgical technique by means of robot-assisted dexterity and visualization. The need for delayed reintervention for persistently symptomatic celiac stenosis is uncertain.
正中弓状韧带（MAL）对腹腔干的压迫是餐后腹痛和体重减轻的一个潜在原因，其症状与其他常见综合征有重叠。机器人技术可能会改变当前的手术干预模式。由于再次干预存在一定风险，开放MAL松解术常同时进行腹腔干狭窄旁路手术；而腹腔镜手术方法则因出血导致较高的中转开放手术率。我们推测，机器人辅助技术可能会减少中转开放手术的发生率，降低围手术期发病率，并在初次手术时无需考虑血管旁路手术。
我们回顾性分析了2012年9月至2013年12月期间在一家三级医疗中心由多学科团队治疗的MAL综合征患者。诊断基于症状特征以及腹腔干双功超声成像时收缩期峰值流速（PSV）>200 cm/s。所有患者均接受了机器人辅助的MAL松解术，并同时对腹腔丛进行环形神经松解。术后对腹腔干双功超声和症状特征进行纵向重新评估以监测治疗效果。
9例患者（67%为女性）接受了餐后疼痛（100%）和体重减轻（100%）的评估。所有患者经肠系膜双功超声成像均显示有腹腔干狭窄（PSV中位数为342；范围为238 - 637 cm/s），横断面成像显示5例（56%）呈鱼钩样畸形。采用标准化手术技术，所有9例患者（100%）均成功完成了机器人辅助的MAL松解术。估计失血量<50 mL，中位住院时间为2天（范围为2 - 3天）。未观察到≥3级的术后并发症、再次入院或再次手术情况。在中位随访25周时，所有患者（100%）症状均有改善。3例患者术后腹腔干双功超声成像显示完全缓解，6例患者与术前流速相比，狭窄有所改善但仍持续存在（PSV>200 cm/s）（Wilcoxon符号秩检验P <.05）。无患者需要额外治疗。
机器人辅助的MAL松解术可安全有效地进行，避免了中转手术情况，且发病率极低。取得成功的潜在因素包括多学科团队对患者的选择，以及通过机器人辅助的灵活性和可视化来复制开放手术技术。对于持续性有症状的腹腔干狭窄是否需要延迟再次干预尚不确定。
