Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients

Abstract

BACKGROUND In orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce. AIM To evaluate the feasible surgical management of MALS to reduce complications in OLT patients. METHODS Data for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner. RESULTS Eight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory. CONCLUSION The preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.

Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

“…Another important consideration about MALS occurs in the case of orthotopic liver transplantation. In these patients, MALS is considered a predisposing factor for hepatic artery thrombosis, due to the hemodynamic compromises in the hepatic artery[ 19 ]. Specifically, the compression from the median arcuate ligament is responsible for a reduction of blood velocities in the hepatic artery.…”

“…This vascular compromise may contribute to reduced blood supply to the liver graft, biliary complications, and hepatic artery thrombosis[ 20 ]. In a recent retrospective study regarding patients receiving orthotopic liver transplantation, the presence of MALS dictated different management for the graft to be preserved and the procedure to be a success[ 19 ]. According to Li et al [ 19 ], if flow from the hepatic artery is found to be reduced, the gastroduodenal arteries and the collateral branches should be preserved.…”

“…In a recent retrospective study regarding patients receiving orthotopic liver transplantation, the presence of MALS dictated different management for the graft to be preserved and the procedure to be a success[ 19 ]. According to Li et al [ 19 ], if flow from the hepatic artery is found to be reduced, the gastroduodenal arteries and the collateral branches should be preserved. Still, there is much debate regarding the surgical technique used in patients receiving orthotopic liver transplantation while suffering from MALS.…”

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

“…Various open approaches to arterial reconstruction have been described during PD including jejunal artery-to-GDA, middle colic artery-to-GDA, celiac trunk to hepatic artery, aorto-hepatic artery, reimplantation of the celiac trunk, and bypass grafting [9,[48][49][50]. The release of MAL in OLT patients with portal hypertension carries significant risk due to the presence of gastroesophageal varices and extensive collateral blood flow between the celiac trunk and SMA [4,31,51]. In some patients with extensive collateral supplies, preservation of collateral arteries and GDA without performing MAL release may provide adequate blood flow in the hepatic artery [51].…”

“…The release of MAL in OLT patients with portal hypertension carries significant risk due to the presence of gastroesophageal varices and extensive collateral blood flow between the celiac trunk and SMA [4,31,51]. In some patients with extensive collateral supplies, preservation of collateral arteries and GDA without performing MAL release may provide adequate blood flow in the hepatic artery [51]. However, if surgical release fails to restore hepatic artery flow, options for hepatic artery reconstruction will be limited.…”