Open surgical decompression of celiac axis compression by division of the median arcuate ligament
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.\nAs 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.\nPhysical 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. There was also no abnormality in fluorescent antinuclear antibody and antineutrophil cytoplasm antibody. Gastro-duodenoscopy showed chronic atrophic gastritis and 18-fluorodeoxyglucose positron emission tomography-CT showed no spe cific lesion with abnormal hot uptake.\nAbdominal CT angiography () showed downward angulation of CA and superior mesenteric artery (SMA) close to their origins by the compression.\nTo decompress CA, we approached through the upper mid line incision and lesser sac. We found CA was tightly compressed by MAL with poststenotic dilatation (). After division of the fibrous structure, we found that arterial blood flow increased significantly and recovered without bruit.\nPostoperatively, epigastric postprandial pain was resolved and the patient could return to a normal diet. On a follow-up abdominal CT angiography (), we found patent CA with mild residual stenosis.