Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn; Heart Center, Kuopio University Hospital, Kuopio, Finland.
J Vasc Surg. 2021 Jun;73(6):2050-2058.e4. doi: 10.1016/j.jvs.2020.10.074. Epub 2020 Nov 27.
To investigate long-term symptom improvement and health-related quality of life (HRQOL) after operative intervention for median arcuate ligament syndrome (MALS).
Clinical data of all consecutive patients treated by operative management of MALS from 1999 to 2018 were reviewed. A cross-sectional questionnaire using the Visick score, the Gastrointestinal Quality of Life Index, and Short Form (SF)-12v2 questionnaires was performed to assess long-term outcomes. The SF-12 HRQOL domains were compared between symptom-free and symptomatic patient groups and to averages for the US general population. Treatment failure was defined as no relief after surgery and Visick category 3 to 4 symptoms. Freedom from symptoms was estimated at 5 years.
A total of 100 patients were treated for MALS (mean age, 38 ± 18 years; 75% female). Open surgical release was performed in 81 and laparoscopic release in 19 patients. The most common presenting symptom was abdominal pain in 99 patients with postprandial exacerbation in 85. There was no mortality. Major adverse events at 30 days had occurred in 21 patients (open 19, laparoscopic 2) including myocardial infarction (n = 1), pancreatitis (n = 2), respiratory failure (n = 4), estimated blood loss of more than 1 L (n = 8), and postoperative ileus (n = 8). One patient treated by laparoscopic release required conversion for an aortic injury, which was treated by primary repair and splenectomy. Forty-six patients responded to the questionnaire with a mean follow-up of 8 ± 4 years. Initial symptom resolution or improvement was reported by 38 patients (83%), whereas 8 patients (17%) reported treatment failure. Seven of the 38 patients (18%) with initial treatment success reported symptom recurrence. The estimated 5-year freedom from symptoms was 67 ± 7%. All SF-12 HRQOL domains were significantly lower and below the average population range in symptomatic patients compared with those who were symptom free, in which all domains were within the average population range. The Gastrointestinal Quality of Life Index scores were also significantly lower in symptomatic patients. Forty respondents (87%) reported that they would still undergo operative management if given the choice, including all respondents who reported symptom recurrence.
The operative management of MALS can be performed with a low rate of complications. Approximately two-thirds of respondents were free of symptoms 5 years after the procedure. Treatment success in symptom-free patients was associated with an improved HRQOL on par with the population average compared with symptomatic patients. The vast majority of respondents would opt to have the operation again if given a choice. However, patients should be well-informed about the possibility of failure to relieve symptoms and symptom recurrence.
探讨正中弓状韧带综合征（MALS）手术干预后的长期症状改善和健康相关生活质量（HRQOL）。
回顾了 1999 年至 2018 年间接受 MALS 手术治疗的所有连续患者的临床数据。使用 Visick 评分、胃肠道生活质量指数（GIQLI）和简短形式（SF）-12v2 问卷进行了横断面问卷调查，以评估长期结果。比较无症状和有症状患者组的 SF-12 HRQOL 域与美国普通人群的平均值。治疗失败定义为手术后无缓解和 Visick 分类 3 至 4 症状。无症状的自由估计为 5 年。
共有 100 例 MALS 患者接受治疗（平均年龄 38 ± 18 岁；75%为女性）。81 例采用开放式手术松解，19 例采用腹腔镜松解。最常见的症状是 99 例腹痛，85 例餐后加重。无死亡病例。30 天内发生 21 例主要不良事件（开放式 19 例，腹腔镜 2 例），包括心肌梗死（n=1）、胰腺炎（n=2）、呼吸衰竭（n=4）、失血量超过 1 L（n=8）和术后肠梗阻（n=8）。1 例接受腹腔镜松解的患者因主动脉损伤需要转为开腹手术，该损伤采用了一期修复和脾切除术。46 例患者对问卷做出了回应，平均随访 8 ± 4 年。38 例患者（83%）报告初始症状缓解或改善，8 例患者（17%）报告治疗失败。38 例初始治疗成功的患者中有 7 例（18%）报告症状复发。估计 5 年无症状的比例为 67 ± 7%。与无症状患者相比，所有 SF-12 HRQOL 域在有症状患者中均显著较低，且低于普通人群范围，其中所有域均在普通人群范围内。在有症状的患者中，胃肠道生活质量指数（GIQLI）评分也明显较低。40 名受访者（87%）表示，如果有选择，他们仍会接受手术治疗，包括所有报告症状复发的受访者。
MALS 的手术治疗可以在较低的并发症发生率下进行。大约三分之二的患者在手术后 5 年内无症状。与有症状的患者相比，无症状患者的治疗成功与人群平均水平相当的 HRQOL 相关。绝大多数患者如果有选择，会再次选择手术。然而，患者应该充分了解无法缓解症状和症状复发的可能性。
