Hanaki Takehiko, Sakamoto Teruhisa, Yata Shinsaku, Murakami Yuki, Fujiwara Yoshiyuki
Department of Gastroenterological Surgery, Tottori University, Faculty of Medicine, Yonago, JPN.
Division of Radiology, Tottori University, Faculty of Medicine, Yonago, JPN.
Cureus. 2021 Feb 24;13(2):e13540. doi: 10.7759/cureus.13540.
Median arcuate ligament (MAL) syndrome (MALS), also known as celiac artery (CA) compression syndrome and Dunbar syndrome, occurs because of extraluminal compression of the CA root by the MAL, which is part of the diaphragm. In MALS, a malposition of the MAL compresses the CA and causes nonspecific symptoms, including epigastric pain after eating, weight loss, nausea, and vomiting and can sometimes cause visceral aneurysms. Typically, in MALS, various chronic ischemic symptoms and visceral aneurysms due to changes in arterial blood flow are observed; however, in acute-onset MALS, acute organ failure due to ischemic changes may be problematic. Surgical treatment is the recommended treatment for MALS, but the optimal treatment of acute MALS that occurs after laparotomy remains controversial because of its rarity. Here, we present the first case of acute MALS, which occurred after pancreaticoduodenectomy (PD) that was successfully treated with interventional radiology (IVR) without reoperation.
A 75-year-old man presented with liver infarction after subtotal stomach-preserving PD using the Child method plus Braun enteroenterostomy. As a result of contrast-enhanced computed tomography for the investigation of elevated hepatic cytolysis-related enzymes on the first postoperative day, he was diagnosed with acute MALS resulting from gastrointestinal reconstruction after PD. The patient underwent IVR to restore blood flow of the CA, and an intraluminal stent was inserted. Despite the development of ischemic gastropathy, splenic infarction, and pancreatic fistula, the patient was eventually discharged on postoperative day 82 without any disability.
Many studies have reported open, laparoscopic, and robot-assisted MAL incisions for MALS, but few reports have detailed the treatment for postoperative MALS. Here, we report the first case of acute MALS developed after PD that was successfully treated with endovascular CA stenting. For acute MALS after PD, early endovascular treatment may be more useful than re-laparotomy.
正中弓状韧带（MAL）综合征（MALS），也称为腹腔干（CA）压迫综合征和邓巴综合征，是由于作为膈肌一部分的MAL对CA根部进行管腔外压迫所致。在MALS中，MAL位置异常会压迫CA并引起非特异性症状，包括进食后上腹部疼痛、体重减轻、恶心和呕吐，有时还会导致内脏动脉瘤。通常，在MALS中，会观察到由于动脉血流变化引起的各种慢性缺血症状和内脏动脉瘤；然而，在急性发作的MALS中，缺血性改变导致的急性器官衰竭可能会成为问题。手术治疗是MALS的推荐治疗方法，但由于其罕见性，剖腹手术后发生的急性MALS的最佳治疗方法仍存在争议。在此，我们报告首例急性MALS病例，该病例发生在胰十二指肠切除术（PD）后，通过介入放射学（IVR）成功治疗，无需再次手术。
一名75岁男性在采用Child法加Braun肠肠吻合术行保留胃大部切除术的PD后出现肝梗死。术后第一天，因肝细胞溶解相关酶升高进行增强CT检查，结果诊断为PD后胃肠道重建导致的急性MALS。患者接受IVR以恢复CA血流，并插入腔内支架。尽管出现了缺血性胃病、脾梗死和胰瘘，但患者最终在术后第82天出院，无任何残疾。
许多研究报道了针对MALS的开放、腹腔镜和机器人辅助MAL切开术，但很少有报道详细介绍术后MALS的治疗方法。在此，我们报告首例PD后发生的急性MALS，通过血管内CA支架置入术成功治疗。对于PD后的急性MALS，早期血管内治疗可能比再次剖腹手术更有用。
