median arcuate ligament syndrome ( mals , also called celiac axis compression syndrome or dunbar syndrome ) is known to be caused by compression of celiac artery ( ca ) by a fibrous arch that originates from the diaphragmatic crura on either side of the aortic hiatus and passes superior to the origin of the celiac axis . though it is still debated whether the compression of the ca can cause chronic mesenteric ischemia or not , there have been anecdotal case reports of surgical decompression of ca by dividing the medial arcuate ligament ( mal ) .
the common clinical features of mals are chronic postprandial abdominal pain characteristically augmented by full expiration , nausea or vomiting , weight loss and audible epigastric bruit .
the diagnosis of mals usually depends on the clinical features and radiologic finding of the focal narrowing at the proximal celiac axis on a lateral view of conventional aortography or computed tomography ( ct ) .
while open surgical release of mal has been used for the treatment of this syndrome , laparoscopic release has been reported recently .
however , it was usually ineffective owing to the refractory extrinsic compression of the ca by the tight ligament structure .
we would like to report a case of surgical treatment of mals describing its clinical features , characteristic findings of diagnostic imaging study , and details of our surgical procedure .
a 37-year - old female patient presented with chronic epigastric pain lasting 6 months , food phobia and weight loss of 10 kg during the previous 4 months .
the pain was cramping aggravated after meals , and persisted for 20 - 30 minutes after meals .
there were no other gastrointestinal symptoms such as diarrhea , constipation , gastrointestinal bleeding and nausea or vomiting .
as past history , she underwent coil embolization of the bilateral ovarian veins at another hospital 2 months before visiting us under the impression of pelvic congestion syndrome , which did not improve her abdominal symptoms . physical examination showed mild abdominal tenderness at both lower quadrants without muscle rigidity .
laboratory test showed normal range including serum amylase , liver enzyme and complete blood cell count .
gastro - duodenoscopy showed chronic atrophic gastritis and 18-fluorodeoxyglucose positron emission tomography - ct showed no spe cific lesion with abnormal hot uptake .
1 ) showed downward angulation of ca and superior mesenteric artery ( sma ) close to their origins by the compression . to decompress ca , we approached through the upper mid line incision and lesser sac .
postoperatively , epigastric postprandial pain was resolved and the patient could return to a normal diet . on a follow - up
mal was first described by lipshutz   as an anatomic structure that caused ca compression in 1917 .
thereafter , harjola   and dunbar et al .   described it as a clinical syndrome causing nausea , vomiting and postprandial pain in 1963 and 1965 .
the origin of ca and mal varies in its location from t11 to l1 , and occasionally , their locations are in conflict with each other when mal extends inferiorly or ca originates su periorly . during deep inspiration in the erect position
during expiration , the condition is opposite , and compression causes the symptom and is thus called mals .
at this point , it is proposed that mals is related with neurogenic pain from the compression and intermittent ischemia of splanchnic nerve plexus .
this pain can be caused either by nerve stimulation leading to vasoconstriction or by direct sympathetic fiber irritation .
splanchnic nerve plexus is an autonomic nerve plexus supplying upper abdominal organs ( stomach , liver , gallbladder , pancreas ) .
this is located in front of diaphragmatic crura around the origin of ca and sma . to make a diagnosis of mals , other common causes of abdominal pain
routine laboratory blood tests including amylase , lipase and tumor markers for hidden malignancy , esophago - gastro - duodenoscopy , liver , pancreas and kidney ultrasonography are usually used .
a typical feature is focal narrowing of ca with poststenotic dilatation aggravated during deep inspiration . nowadays
standard treatment of mals is an open surgical division of mal followed by a dramatic symptom relief .
recently , a lapa roscopic approach can be attempted but carries the risk of arterial injury and massive hemorrhage .
three series of case reports showed mean rates of open conversion due to bleeding at about 20% , but despite that , laparoscopic treatment showed no other morbidity or mortality and shortened hospital stay .
this is probably due to the extraluminal compression by mal , which should be solved outside of the ca . in cases of recurrent symptom after surgical decompression of ca , angioplasty is beneficial .
 median arcuate ligament syndrome is a rare cause of abdominal pain which results from compression of the celiac artery ( ca ) or rarely , the superior mesenteric artery by a ligament formed by the right and left crura of the diaphragm . 
 we report a case of open surgical decompression of the ca by division of the median arcuate ligament for a 37-year - old female patient who had suffered from chronic postprandial epigastric pain and severe weight loss . 
 we described clinical features , characteristic angiographic findings and details of the surgical procedure for the patient with this rare vascular problem . 