Perioperative Microcirculatory Changes Detected with Gastroscopy Assisted Laser Doppler Flowmetry and Visible Light Spectroscopy in Patients with Median Arcuate Ligament Syndrome

Simen Tveten Berge, Nathkai Safi, Asle W Medhus, Jon O Sundhagen, Jonny Hisdal, Syed S H Kazmi, Simen Tveten Berge, Nathkai Safi, Asle W Medhus, Jon O Sundhagen, Jonny Hisdal, Syed S H Kazmi

Abstract

Purpose: Physiological tests may aid in diagnosing median arcuate ligament syndrome (MALS). MALS is a symptomatic compression of the celiac artery causing symptoms similar to chronic mesenteric ischemia (CMI) of atherosclerotic etiology. Simultaneous use of visible light spectroscopy (VLS) and laser doppler flowmetry (LDF) during upper endoscopy may detect microcirculatory changes in these patients.

Patients and methods: In a single-center, prospective comparative cohort, 25 patients were evaluated for MALS. Patients with a consensus diagnosis of MALS (n=15) underwent a gastroscopy assisted, transmucosal microcirculatory assessment with LDF and VLS. Results were compared to individuals with normal intestinal circulation (n=38) evaluated with duplex ultrasonography, and to patients with chronic mesenteric ischemia (n=32). Treatment response was evaluated clinically at 1, 3, 6, and 12 months, and with ultrasound, VLS and LDF at three months. Health-related quality of life (QoL) was assessed with Euroqol (EQ-5D-5L), preoperatively, and 12 months postoperatively.

Results: Preoperative mean transmucosal oxygen saturation was significantly lower in patients with MALS (SO2 76±6), as compared to healthy individuals (SO2 81±4), p=0.02. An overall significant improvement in SO2 after surgical decompression of the celiac artery was found (SO2 81±3.7, p=0.05). Eleven (92%) patients with clinical improvement after laparoscopic decompression had a definitive diagnosis of MALS. Median follow-up was 18 months (4-24 months). Four of the five dimensions investigated with EQ-5D-5L improved.

Conclusion: VLS detected a significantly lower baseline transmucosal SO2 in patients with MALS as compared to control subjects with normal intestinal circulation. An improvement in SO2 after laparoscopic decompression was found, supporting a possible ischemic etiology in our patient population.

Keywords: abdominal pain; endoscopy; functional test; mesenteric ischemia; vascular surgery.

Conflict of interest statement

The authors report no conflicts of interest in this work.

© 2020 Berge et al.

Figures

Figure 1
Figure 1
CTA sagittal plane of a patient with MALS taken in deep expiration. An external compression of the celiac artery and a normal anatomy of the superior mesenteric artery is demonstrated. Abbreviations: MALS, median arcuate ligament syndrome; CTA, computed tomography angiography.
Figure 2
Figure 2
Measurement points in the stomach and duodenum in the study of perioperative microcirculatory changes in patients with MALS. Abbreviation: MALS, median arcuate ligament syndrome.
Figure 3
Figure 3
Flow chart of the inclusion process and outcomes in the study of perioperative microcirculatory changes in patients with MALS. Abbreviations: MALS, median arcuate ligament syndrome; CMI, chronic mesenteric ischemia.
Figure 4
Figure 4
Box-plot of preoperative combined arterial and venous oxygen saturation in CG1 (n=38), CG2 (CMI, n=32) and patients with MALS (n=11). The thick black line represents the median, the blue box represents the 25–75th percentile and the bars are minimum and maximum points (excluding outliers). Abbreviations: CG1, control group 1; CG2, control group 2; CMI, chronic mesenteric ischemia; MALS, median arcuate ligament syndrome.
Figure 5
Figure 5
ROC curve of a mean of all measurements of saturation in both the stomach and duodenum in patient with MALS (n=11) compared to CG1 (n=38). Abbreviations: ROC, receiver operated characteristics; MALS, median arcuate ligament syndrome; CG1, control group 1; AUC, area under the curve; CMI, chronic mesenteric ischemia.
Figure 6
Figure 6
Combined arterial and venous oxygen saturation (%), before and after (n=11, p=0.05) laparoscopic decompression of the CA in patients with MALS. Each line represents one patient. Abbreviations: MALS, median arcuate ligament syndrome; CA, celiac artery.

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