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“Re: Management of Median Arcuate Ligament Syndrome: A New Paradigm”
Letter to the Editor ‘‘Re: Management of Median Arcuate Ligament Syndrome: A New Paradigm’’ Oss-Veghel, Enschede, The Netherlands
REPLY In a recent article in the Annals of Vascular Surgery, Duffy et al.1 reviewed the management of and the clinical success of minimal invasive surgery in median arcuate ligament (MAL) syndrome. The existence of the MAL syndrome, also known as the celiac artery compression syndrome (CACS), was open for debate because many reasoned that an isolated respiration-dependent celiac artery stenosis could not result in symptoms. Duffy et al. clearly describe in their review article the clinical presentation, the work-up, and treatment (minimal invasive) for CACS. They reviewed the results of laparoscopy for the treatment of CACS from several case reports. To complete their review, we would like to highlight the three larger studies2-4 that describe the laparoscopic and endoscopic release in CACS, published several months before the publication of Duffy et al. We realize that the article by Duffy et al. was probably accepted for publication just before the publication of these large trials. The clinical and angiographic results after laparoscopic and endoscopic release in CACS were described in three separate studies (n ¼ 77; follow-up between 20 and 44 months). The conversion rate to open surgery varied between 13-27% in the transabdominal laparoscopic group,2,3 as compared with 2% in the retroperitoneal endoscopic release group.4 The main reason for conversion was intraoperative bleeding. In the largest series,4 after retroperitoneal endoscopic release, unimpeded vessel anatomy during respiration was observed on angiography in 78%. Six patients with persisting intraluminal stenoses after release underwent supplementary endovascular angioplasty resulting in a primary-assisted anatomic patency of 89%. It is crucial to ensure that the release is complete. Angioplasty can be used to determine the presence of residual ligament compression. The patients-freefrom-symptoms rates where 89%,4 93%,2 and 100%3 after a median follow-up of 20, 44, and 28 months, respectively. Duffy et al., on the basis of their experience, state that the operation should divide all fibrous bands of the MAL, including the celiac ganglion fibers around the celiac artery, leaving the celiac trunk completely free circumferentially. However, in our endoscopic approach,4 only the left crus was divided and therefore the right branches of
the plexus and the right crus were kept intact. We have shown that this is strongly associated with restoration of blood flow, disappearance of ischemia, and resolution of symptoms.4,5 An advantage of this approach is that it minimizes the occurrence of gastroesophageal reflux disease (GERD). We observed GERD in 9% after open CACS release as opposed to 0% in the retroperitoneal approach.4,5 Furthermore, Duffy et al. mentioned peroperative assessment of the artery by laparoscopic ultrasound imaging after decompression. It is arguable whether general anesthetic with muscle relaxation makes it possible to assess respiration-dependent flow changes. For this reason, we perform a digital subtraction angiography and if necessary an endovascular treatment of persisting stenoses the day after surgery. The review article by Duffy et al. and the three recently published studies show the feasibility and efficacy of laparoscopic and endoscopic celiac artery release in combination with endovascular treatment of persisting intraluminal stenoses in CACS. Selecting patients on the basis of a history of chronic abdominal symptoms, abnormal gastric exercise tonometry, and a respiration-dependent significant compression of the celiac artery remains of utmost importance before defining an intervention. Andre van Petersen,1 Robbert Meerwaldt,2 Roland Beuk,2 Jeroen Kolkman,1 Robert Geelkerken,2,* 1
Department of Vascular Surgery, Ziekenhuis Bernhoven, Oss-Veghel, The Netherlands 2 Working group on Splanchnic Ischemia, Medisch Spectrum Twente, Enschede, The Netherlands * Correspondence to: Robert Geelkerken, Department of Vascular Surgery, Medisch Spectrum Twente, PO box 50.000, 7500 KA Enschede, The Netherlands. E-mail: [email protected] REFERENCES 1. Duffy AJ, Panait L, Eisenberg D, Bell RL, Roberts KE, Sumpio B. Management of median arcuate ligament syndrome: a new paradigm. Ann Vasc Surg 2009;23:778-784. 2. Roseborough GS. Laparoscopic management of celiac artery compression syndrome. J Vasc Surg 2009;50:124-133. 3. Baccari P, Civilini E, Dordoni L, Melissano G, Nicoletti R, Chiesa R. Celiac artery compression syndrome managed by laparoscopy. J Vasc Surg 2009;50:134-139. 4. van Petersen AS, Vriens BH, Huisman AB, Kolkman JJ, Geelkerken RH. Retroperitoneal endoscopic release in the
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700 Letter to the Editor
management of celiac artery compression syndrome. J Vasc Surg 2009;50:140-147. 5. Mensink PB, van Petersen AS, Kolkman JJ, Otte JA, Huisman AB, Geelkerken RH. Gastric exercise tonometry:
Annals of Vascular Surgery
the key investigation in patients with suspected celiac artery compression syndrome. J Vasc Surg 2006;44:277-281.
DOI: 10.1016/j.avsg.2010.03.008
REPLY In a recent article in the Annals of Vascular Surgery, Duffy et al.1 reviewed the management of and the clinical success of minimal invasive surgery in median arcuate ligament (MAL) syndrome. The existence of the MAL syndrome, also known as the celiac artery compression syndrome (CACS), was open for debate because many reasoned that an isolated respiration-dependent celiac artery stenosis could not result in symptoms. Duffy et al. clearly describe in their review article the clinical presentation, the work-up, and treatment (minimal invasive) for CACS. They reviewed the results of laparoscopy for the treatment of CACS from several case reports. To complete their review, we would like to highlight the three larger studies2-4 that describe the laparoscopic and endoscopic release in CACS, published several months before the publication of Duffy et al. We realize that the article by Duffy et al. was probably accepted for publication just before the publication of these large trials. The clinical and angiographic results after laparoscopic and endoscopic release in CACS were described in three separate studies (n ¼ 77; follow-up between 20 and 44 months). The conversion rate to open surgery varied between 13-27% in the transabdominal laparoscopic group,2,3 as compared with 2% in the retroperitoneal endoscopic release group.4 The main reason for conversion was intraoperative bleeding. In the largest series,4 after retroperitoneal endoscopic release, unimpeded vessel anatomy during respiration was observed on angiography in 78%. Six patients with persisting intraluminal stenoses after release underwent supplementary endovascular angioplasty resulting in a primary-assisted anatomic patency of 89%. It is crucial to ensure that the release is complete. Angioplasty can be used to determine the presence of residual ligament compression. The patients-freefrom-symptoms rates where 89%,4 93%,2 and 100%3 after a median follow-up of 20, 44, and 28 months, respectively. Duffy et al., on the basis of their experience, state that the operation should divide all fibrous bands of the MAL, including the celiac ganglion fibers around the celiac artery, leaving the celiac trunk completely free circumferentially. However, in our endoscopic approach,4 only the left crus was divided and therefore the right branches of
the plexus and the right crus were kept intact. We have shown that this is strongly associated with restoration of blood flow, disappearance of ischemia, and resolution of symptoms.4,5 An advantage of this approach is that it minimizes the occurrence of gastroesophageal reflux disease (GERD). We observed GERD in 9% after open CACS release as opposed to 0% in the retroperitoneal approach.4,5 Furthermore, Duffy et al. mentioned peroperative assessment of the artery by laparoscopic ultrasound imaging after decompression. It is arguable whether general anesthetic with muscle relaxation makes it possible to assess respiration-dependent flow changes. For this reason, we perform a digital subtraction angiography and if necessary an endovascular treatment of persisting stenoses the day after surgery. The review article by Duffy et al. and the three recently published studies show the feasibility and efficacy of laparoscopic and endoscopic celiac artery release in combination with endovascular treatment of persisting intraluminal stenoses in CACS. Selecting patients on the basis of a history of chronic abdominal symptoms, abnormal gastric exercise tonometry, and a respiration-dependent significant compression of the celiac artery remains of utmost importance before defining an intervention. Andre van Petersen,1 Robbert Meerwaldt,2 Roland Beuk,2 Jeroen Kolkman,1 Robert Geelkerken,2,* 1
Department of Vascular Surgery, Ziekenhuis Bernhoven, Oss-Veghel, The Netherlands 2 Working group on Splanchnic Ischemia, Medisch Spectrum Twente, Enschede, The Netherlands * Correspondence to: Robert Geelkerken, Department of Vascular Surgery, Medisch Spectrum Twente, PO box 50.000, 7500 KA Enschede, The Netherlands. E-mail: [email protected] REFERENCES 1. Duffy AJ, Panait L, Eisenberg D, Bell RL, Roberts KE, Sumpio B. Management of median arcuate ligament syndrome: a new paradigm. Ann Vasc Surg 2009;23:778-784. 2. Roseborough GS. Laparoscopic management of celiac artery compression syndrome. J Vasc Surg 2009;50:124-133. 3. Baccari P, Civilini E, Dordoni L, Melissano G, Nicoletti R, Chiesa R. Celiac artery compression syndrome managed by laparoscopy. J Vasc Surg 2009;50:134-139. 4. van Petersen AS, Vriens BH, Huisman AB, Kolkman JJ, Geelkerken RH. Retroperitoneal endoscopic release in the
699
700 Letter to the Editor
management of celiac artery compression syndrome. J Vasc Surg 2009;50:140-147. 5. Mensink PB, van Petersen AS, Kolkman JJ, Otte JA, Huisman AB, Geelkerken RH. Gastric exercise tonometry:
Annals of Vascular Surgery
the key investigation in patients with suspected celiac artery compression syndrome. J Vasc Surg 2006;44:277-281.
DOI: 10.1016/j.avsg.2010.03.008