Addition of antireflux procedure to median arcuate ligament release: A significant difference?

Introduction: Median arcuate ligament syndrome (MALS) is a rare but debilitating gastrointestinal disorder. Division of the ligament (obstructing flow to the celiac artery) cures the symptoms, and a celiac ganglionectomy is also performed. Retroesophageal dissection causes dilatation of the hiatus. Severe gastroesophageal reflux disease (GERD) in the first six patients (Group A) led us to add an antireflux procedure in (Group B) 18 patients. Manometric and 24 h pH data support this. This article has been reported in line with SQUIRE guidelines. Materials and Methods: Over 7 years, we encountered 24 patients with MALS. The diagnosis was clinched by CT angiography, by the characteristic “Hook sign”. We have devised a standard operating strategy, involving retroesophageal mobilization, diaphragmatic crural exposure dividing the MAL, clearing out the perivascular neural tissue around the celiac axis, and exposing the celiac artery origin and its branches. The procedure was completed by crural approximation; Toupet fundoplication was performed in Group B patients. Relief from MALS symptomatology was obtained in all patients. Group A patients had severe reflux. Results: All patients were pain free within the 1st month of follow-up and regained normal weight by 6 months. Postoperative reflux symptoms initially were seen in four patients in Group B and all six patients in Group A. By the 6th month postprocedure, all Group B patients were symptom free and all Group A patients had persistent GERD. Conclusion: To our knowledge, there is no reported series in English literature with a formal protocol for MALS. Our approach provides an efficacious solution to a debilitating disorder. The addition of fundoplication has shown significant improvement in reflux symptoms.