Columbo Jesse A, Trus Thadeus, Nolan Brian, Goodney Philip, Rzucidlo Eva, Powell Richard, Walsh Daniel, Stone David
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Section of Minimally Invasive Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
J Vasc Surg. 2015 Jul;62(1):151-6. doi: 10.1016/j.jvs.2015.01.050. Epub 2015 Mar 7.
Optimal diagnosis and management of median arcuate ligament (MAL) syndrome (MALS) remains unclear in contemporary practice. The advent and evolution of laparoscopic and endovascular techniques has redirected management toward a less invasive therapeutic algorithm. This study examined our contemporary outcomes of patients treated for MALS.
All patients treated for MALS at Dartmouth-Hitchcock Medical Center from 2000 to 2013 were retrospectively reviewed. Demographics and comorbidities were recorded. Freedom from symptoms and freedom from reintervention were the primary end points. Return to work or school was assessed. Follow-up by clinic visits and telephone allowed quantitative comparisons among the patients.
During the study interval, 21 patients (24% male), with a median age of 42 years, were treated for MALS. All patients complained of abdominal pain in the presence of a celiac stenosis, 16 (76%) also reported weight loss at the time of presentation, and 57% had a concomitant psychiatric history. Diagnostic imaging most commonly used included duplex ultrasound (81%), computed tomography angiography (66%), angiography (57%), and magnetic resonance angiography (5%). Fourteen patients (67%) underwent multiple diagnostic studies. All patients underwent initial laparoscopic MAL release. Seven patients (33%) underwent subsequent celiac stent placement in the setting of recurrent or unresolved symptoms with persistent celiac stenosis at a mean interval of 49 days. Two patients required surgical bypass after an endovascular intervention failed. The 6-month freedom from symptoms was 75% and freedom from reintervention was 64%. Eighteen patients (81%) reported early symptom improvement and weight gain, and 66% were able to return to work.
A multidisciplinary treatment approach using initial laparoscopic release and subsequent stent placement and bypass surgery provides symptom improvement in most patients treated for MALS. The potential placebo effect, however, remains uncertain. A significant minority of patients will require reintervention, justifying longitudinal surveillance and prudent patient selection. Patients can anticipate functional recovery, weight gain, and return to work with treatment.
在当代临床实践中，正中弓状韧带（MAL）综合征（MALS）的最佳诊断和治疗仍不明确。腹腔镜和血管内技术的出现与发展已将治疗方向转向侵入性较小的治疗方案。本研究探讨了我们当代治疗MALS患者的疗效。
对2000年至2013年在达特茅斯-希区柯克医疗中心接受MALS治疗的所有患者进行回顾性研究。记录人口统计学和合并症情况。主要终点为症状缓解和无需再次干预。评估患者恢复工作或上学的情况。通过门诊就诊和电话随访对患者进行定量比较。
在研究期间，21例患者（24%为男性）接受了MALS治疗，中位年龄为42岁。所有患者在存在腹腔干狭窄时均主诉腹痛，16例（76%）患者在就诊时还报告有体重减轻，57%的患者有合并精神病史。最常用的诊断性影像学检查包括双功超声（81%）、计算机断层血管造影（66%）、血管造影（57%）和磁共振血管造影（5%）。14例患者（67%）接受了多项诊断性检查。所有患者均接受了初次腹腔镜下MAL松解术。7例患者（33%）在出现复发或未缓解症状且腹腔干狭窄持续存在的情况下，平均在49天后接受了腹腔干支架置入术。2例患者在血管内介入治疗失败后需要进行外科搭桥手术。6个月时症状缓解率为75%，无需再次干预率为64%。18例患者（81%）报告早期症状改善且体重增加，66%的患者能够恢复工作。
采用初次腹腔镜松解术、随后进行支架置入术和搭桥手术的多学科治疗方法可使大多数接受MALS治疗的患者症状得到改善。然而，潜在的安慰剂效应仍不确定。相当一部分患者需要再次干预，这证明了长期监测和谨慎选择患者的合理性。患者可预期通过治疗实现功能恢复、体重增加并重返工作岗位。
