A predictive model for patients with median arcuate ligament
· James A. Randall
· Richard L. Amdur
· Anton N. Sidawy
Received: 14 February 2018 / Accepted: 9 May 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Background Due to the rarity of median arcuate ligament (MAL) syndrome, patient selection for surgery remains diﬃcult.
This study provides a predictive model to optimize patient selection and predict outcomes following a MAL release.
Methods Prospective data from patients undergoing a MAL release included demographics, radiologic studies, and SF-36
questionnaires. Successful postoperative changes in SF-36 was deﬁned as an improvement > 10% in the total SF-36 score. A
logistic regression model was used to develop a clinically applicable table to predict surgical outcomes. Celiac artery (CA)
blood ﬂow velocities were compared pre- and postoperatively and Pearson correlations were examined between velocities
and SF-36 score changes.
Results 42 patients underwent a laparoscopic MAL release with a mean follow-up of 28.5 ± 18.8 months. Postoperatively,
all eight SF-36 scales improved signiﬁcantly. The logistic regression model for predicting surgical beneﬁt was signiﬁcant
(p = 0.0244) with a strong association between predictors and outcome (R
= 0.36). Age and baseline CA expiratory velocity
were signiﬁcant predictors of improvement and predicted clinical improvement. There were signiﬁcant diﬀerences between
pre- and postoperative CA velocities. Postoperatively, the bodily pain scale showed the most signiﬁcant increase (64%,
p < 0.0001). A table was developed using age and preoperative CA expiratory velocities to predict clinical outcomes.
Conclusions Laparoscopic MAL produces signiﬁcant symptom improvement, particularly in bodily pain. This is one of the
ﬁrst studies that uses preoperative data to predict symptom improvement following a MAL release. Age and baseline CA
expiratory velocity can be used to guide postoperative expectations in patients with MAL syndrome.
Keywords Median arcuate ligament · Syndrome · Release · Celiac artery · Laparoscopy · Model
Median arcuate ligament (MAL) syndrome was deﬁned orig-
inally in 1963 and an increasing number of reports regarding
MAL syndrome have appeared in the literature over the last
several decades [1–12]. Despite the increasing number of
reports, most articles detail isolated case reports or small
series. Moreover, few articles articulate preoperative factors
that correlate with clinical outcomes. This latter dilemma is
critically important as anatomic compression of the celiac
artery (CA) may be found in up to 24% of asymptomatic
individuals on radiographic studies and up to one-third of
patients in autopsy studies show CA compression [13, 14].
Therefore, radiologic ﬁndings consistent with MAL in a
patient with abdominal pain may represent an incidental
In 2004, investigators from the Netherlands described
a unique preoperative physiological test that documented
exercise induced gastric pH changes in symptomatic patients
with radiographic ﬁndings consistent with MAL. These
changes in gastric physiology correlated with clinical out-
comes following a MAL release . While these investiga-
tors conﬁrmed the eﬃcacy of gastric exercise tonometry [16,
17], no other investigators have utilized this preoperative
study to predict clinical outcomes. Other than this preop-
erative gastric test, the diagnosis of MAL syndrome relies
mainly on signs and symptoms from the clinical history and
various radiographic studies including ultrasound, magnetic
resonance arteriography (MRA), and aortograms.
and Other Interventional Techniques
* Fred Brody
Department of Surgery, The George Washington University
Medical Center, Washington, DC, USA
Department of Surgery, The Veterans Aﬀairs Medical Center
and George Washington University Medical Center, 50 Irving
St., Washington, DC 20422, USA