Impact of the presence of median arcuate ligament on biliary complications after liver transplantation

Abstract

Introduction The presence of median arcuate ligament (MAL) during orthotopic liver transplantation (OLT) may cause a significant reduction in the arterial hepatic flow. The aim of the present study is to investigate the impact of MAL on biliary complications in patients who underwent OLT. Methods We performed a retrospective case‐control study among patients who underwent OLT in Geneva University Hospital between 2007 and 2017, depending on the presence or absence of MAL. The matching was performed according to age, gender, lab‐MELD score at the time of OLT and type of donor (living or dead). The presence of MAL was assessed by an expert liver radiologist on the preoperative CT angiographic evaluation. Results The incidence of MAL was 6.1% (19 patients). Baseline characteristics were comparable between the two groups. No significant difference in biliary complications was found between patients with and without MAL (37% and 24%, respectively). No patient presented hepatic artery thrombosis. After logistic regression, in patients with MAL, the MAL release and gastroduodenal artery preservation compared to no treatment, showed an odds ratio for post‐OLT biliary complications of 1.5 and 1.25, respectively. There was no difference in overall graft survival and in hazard for biliary complications between patients with and without MAL. Conclusion In the present study, we did not find any difference in the prevalence of biliary and arterial complications between patients with and without MAL. The choice of MAL treatment did not influence in a significant way the overall outcome and development of complications. However, if, at the end of arterial reconstruction, the arterial flow is not adequately established, MAL needs to be treated with the least invasive technique.

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

“…Gialamas et al demonstrated no statistically significant difference in graft survival or post-operative biliary complications between patients with and without MALS in their retrospective case-control study [30]. They concluded that if the arterial flow to the graft is adequately established, the choice of treating MALS might not influence the overall outcome and development of complications [30]. Another single-center European study also showed no differences in short-and long-term outcomes between OLT patients with surgically treated MALS or without MALS [31].…”

“…Reduced blood flow predisposes the graft to hepatic arterial thrombosis, a dreadful complication that can lead to cholangitis, poor graft function, graft loss, and death [29]. The prevalence of MALS during OLT is reported to be up to 10%, and contemporary well-powered studies on its management are scarce in the literature [30][31][32][33]. Gialamas et al demonstrated no statistically significant difference in graft survival or post-operative biliary complications between patients with and without MALS in their retrospective case-control study [30].…”

“…The prevalence of MALS during OLT is reported to be up to 10%, and contemporary well-powered studies on its management are scarce in the literature [30][31][32][33]. Gialamas et al demonstrated no statistically significant difference in graft survival or post-operative biliary complications between patients with and without MALS in their retrospective case-control study [30]. They concluded that if the arterial flow to the graft is adequately established, the choice of treating MALS might not influence the overall outcome and development of complications [30].…”