Institutionalized Adoption of a Protocol for the Management of Median Arcuate Ligament Syndrome Correlates with Improved Surgical Outcomes.

Median arcuate ligament syndrome (MALS) is a rarely diagnosed and treated etiology of abdominal pain with no established diagnostic approach. The effectiveness of our institutional protocol in identifying these patients was investigated by analyzing their surgical outcomes. A retrospective review was conducted of patients treated for MALS at our institution from 2001 to 2022. Patients were considered for a diagnosis of MALS if there was evidence of abdominal pain (unprovoked, provoked by eating and physical activity) and celiac artery dynamic compression on diagnostic imaging. During the study period, an institutionalized management protocol was developed for these patients. Patients were then categorized as having positive surgical outcomes if their symptoms improved or resolved entirely during the latest follow-up visit, while those whose symptoms remained unchanged or worsened were classified as having negative outcomes. Of the patients considered for MALS diagnosis, a patient was confirmed positive if there is either a positive provocative mesenteric angiogram, celiac plexus block, or both, along with a negative gastroenterology workup. Comparative analysis was performed using a chi-square test. Multivariable logistic regression models were performed to evaluate the association between risk factors and symptom relief with the adjusted follow-up length. All tests were two-sided, with p-value <0.05 considered statistically significant. A total of 163 patients with a mean follow-up duration of 17.7 + 23.4 months were included in the study. Patients who were part of the protocol had a higher rate of improvement in their abdominal pain (65.9% vs 50.0 %, p < 0.04). Furthermore, patients diagnosed positive by the protocol experienced greater relief of abdominal pain compared to patients with a negative diagnosis (77.8% vs 52.5%, p = 0.014). By using a standardized protocol, patients who received a positive diagnosis demonstrated symptomatic improvement in their outcomes. Further investigation is warranted on a larger scale to assess its generalizability for the management of this challenging patient population.

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