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

Figures & data

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 Measurement points in the stomach and duodenum in the study of perioperative microcirculatory changes in patients with MALS.

Abbreviation: MALS, median arcuate ligament syndrome.

Table 1 Patient Characteristics in the Study on Visible Light Spectroscopy and Laser Doppler Flowmetry During Upper Endoscopy in Patients with Median Arcuate Ligament Syndrome

Patient Characteristics	(n=11)
Reporting weight loss	7 (64)
Weight loss (kg)^a	5±7
Abdominal pain	11 (100)
Debut <30 minutes after a meal	9 (82)
Debut >30 minutes after a meal	2 (18)
Duration of abdominal pain <30 minutes	2 (18)
Duration of abdominal pain 30–60 minutes	3 (27)
Duration of abdominal pain >60 minutes	6 (55)
Diarrhea/obstipation/nausea	9 (81)
Changes in eating habits	8 (73)
Abdominal bruit	8 (73)
Time from debut until diagnosis (months)^b	96 (16–600)

Notes: Values are presented as ^a mean±SD, ^b median (range) or absolute numbers with percentages

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.

Table 2 Baseline Characteristics of Patients with MALS and Control Subjects with Normal Intestinal Circulation (CG1), and Control Subjects with Chronic Mesenteric Ischemia (CMI, CG2)

Variables	MALS	CG1 (Healthy)	p-value	CG2 (CMI)	p-value
	n=11	n=38		n=32
Age (years)	45 (24–72)	60 (20–82)	0.01	73 (53–89)	<0.001
Height (cm)	172±6	169±9	0.22	168±9	0.20
Weight (kg)	62±9	74±16	0.02	64±16	0.89
BMI	21±2	26±5	0.001	22±5	0.43
Female	7 (63)	21(55)	0.73	20(63)	0.52
Smoking history	8(73)	22 (58)	0.49	29(91)	0.16
Ischemic heart disease	0(0)	7 (18)	0.33	13(41	0.02
Atrial fibrillation	0(0)	1 (3)	1	5(16)	0.30
Stroke/TIA	0(0)	3 (8)	1	5(16)	0.30
Diabetes mellitus	0(0)	5 (13)	0.57	12(38)	0.02
Hypertension	1(9)	10 (26)	0.41	22(69)	0.001
Lung disease	2(18)	6 (16)	1	7(22)	1
Intermittent claudication	0(0)	0(0)	–	12(38)	0.02
Medication
Single platelet	0(0)	8 (21)	0.41	23 (72)	<0.001
Double platelet	0(0)	1 (3)	0.49	7(22)	0.40
Statin	0(0)	10 (26)	0.15	28(88)	<0.001

Note: Values Presented as Mean (SD) or Median (Range) or Absolute Numbers with Percentages.

Abbreviations: MALS, median arcuate ligament syndrome; CG1, control group 1; CG2, control group 2.

Table 3 Mean Values of Combined Arterial and Venous Oxygen Saturation (SO₂), Relative Hemoglobin Amount (rHb), Flow and Velocity for the Three Examined Areas in the Stomach and Duodenum, and a Mean of All Areas in Patients with MALS, CG1 and CG2. SO₂ in Percent. Relative Hemoglobin Amount, Flow and Velocity in Arbitrary Units

Variables		Duodenum	p-value	Pylorus and Lesser Curvature	p-value	Greater Curvature	p-value	Total All Areas	p-value
		Mean±SD		Mean±SD		Mean±SD		Mean±SD
SO2	MALS (n=11)	67±8		83±8		78±11		76±6
	CG1 (n=38)	75±8	0.006	84±6	0.76	82±6	0.13	81±4	0.02
	CG2 (CMI) (n=32)	57±14	0.02	74±10	0.01	70±12	0.07	67±9	0.004
rHb	MALS	82±9		82±6		87±5		84±5
	CG1	87±7	0.09	83±8	0.85	86±8	0.76	85±5	0.45
	CG2(CMI)	76±8	0.02	74±9	0.006	78±9	0.004	76±6	0.001
Flow	MALS	308±66		306±86		277±55		297±50
	CG1	316±64	0.72	311±72	0.84	317±98	0.21	314±57	0.37
	CG2(CMI)	285±61	0.29	260±65	0.06	240±65	0.10	262±52	0.06
Velocity	MALS	39±4		38±5		39±5		39±4
	CG1	40±4	0.36	37±3	0.47	38±5	0.59	38±3	0.90
	CG2(CMI)	39±4	0.82	33±4	0.005	34±4	0.006	35±3	0.01

Abbreviations: MALS, median arcuate ligament syndrome; CG1, control group 1 (normal intestinal circulation); CG2, control group 2; CMI, chronic mesenteric ischemia.

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 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.

Table 4 Combined Arterial and Venous Oxygen Saturation (SO₂), Relative Hemoglobin Amount (rHb), Flow and Velocity Before and After Laparoscopic Decompression of the Celiac Artery in Patients with Median Arcuate Ligament Syndrome

Variables (n=11)		Mean±SD	p-value
SO2	Preoperative	76.6±6.2	0.05
	Postoperative	81.0±3.7
rHb	Preoperative	83.8±4.7	0.28
	Postoperative	85.9±3.5
Flow	Preoperative	299.9±49.8	0.65
	Postoperative	313.45±52.6
Velocity	Preoperative	38.47±4.2	0.35
	Postoperative	37.4±4.1

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.

Table 5 Pre- and Post-Intervention Demographics and Characteristics in Patients with Median Arcuate Ligament Syndrome

Patient Number	Gender	Age (Years)	BMI (kg/m^2)	Preoperative Ultrasound	Preoperative CTA	Preoperative Saturation(%)	Treatment	Conversion	Postoperative Ultrasound (m/s)	Postoperative Saturation (%)	Effect of Treatment
1	Female	28	19.1	Not performed	CA stenosis	82.0	Laparoscopic decompression	No	1.7	82.0	Yes
2	Male	69	23.0	1,7 m/s	CA stenosis	73.4	Laparoscopic decompression	No	3.0	83.1	Yes
3	Female	22	22.5	2,5 m/s	CA stenosis	73.7	Laparoscopic decompression	No	1.7	81.0	Yes
4	Female	36	19,5	Not performed	CA stenosis	76.0	Laparoscopic decompression	No	1.9	Not willing	Yes
5	Female	60	21.3	0 m/s	CA occlusion	71.0	Laparoscopic decompression	No	1.5	77.7	Yes
6	Female	40	20.0	1.8 m/s	CA stenosis	77.7	Laparoscopic decompression	No	Not performed	82.3	Yes
7	Male	46	22.7	Technical difficulties	CA stenosis	84.6	Laparoscopic decompression	No	1.8	74.2	Yes
8	Male	24	21.6	2.0 m/s	CA stenosis	83.8	Laparoscopic decompression	No	1.8	84.	Yes
9	Female	45	19.8	2.9 m/s	CA stenosis	79.4	Laparoscopic decompression	No	2.0	87.0	Yes
10	Female	62	16.9	4.0 m/s	CA stenosis	66.0	Laparoscopic decompression	No	1.5	75.8	Yes
11	Male	65	22.6	Not performed	CA stenosis	80.5	Laparoscopic decompression	No	1.5	84.27	Yes
12	Female	65	23.2	Not performed	CA stenosis	78.8	Laparoscopic decompression	No	1.5	78.2	No

Abbreviations: CA, celiac artery; CTA, CT angiography; BMI, body mass index.