Outcomes of surgical versus conservative treatment in pediatric median arcuate ligament syndrome

OBJECTIVES: Median arcuate ligament syndrome (MALS) involves compression of the celiac artery and presents with gastrointestinal symptoms. We evaluated outcomes after surgical versus conservative management in pediatric MALS. METHODS: We reviewed charts of symptomatic patients aged 7-21 years diagnosed by ultrasound and/or computed tomography angiogram. Outcomes were categorized as resolved, improved, unchanged, or worsened at most recent follow-up and compared between conservative and surgical treatment groups. RESULTS: Among 34 patients (median age 15 years, 79% female, 94% Caucasian), common symptoms included abdominal pain (85%) and nausea (71%); 36% had psychiatric disorders, 56% met criteria for disorders of gut-brain interaction (DGBI). Ten received conservative therapy (100% pharmacologic, 80% behavioral, 30% botulinum toxin, 20% neurostimulation) with a median follow-up of 5 months. Outcomes were resolution (20%), improvement (40%), unchanged (40%), and none worsened. Of 24 surgical patients (median hospital stays: 4 days), outcomes were: resolution (21%), improved (33%), unchanged (17%), worsened (29%); not significantly different from conservative group (p = 0.21). Postoperative complications occurred in 21%. At median 20-day postoperative follow-up, 52% reported resolution, 35% improved, 9% unchanged, 4% worsened. Pain location differed by group (p = 0.005); other demographics and long-term outcomes did not (p > 0.05). Baseline comorbidities and treatment modalities were not significantly associated with outcome (p > 0.05). CONCLUSION: In our cohort, 60% of children with MALS improved with conservative DGBI-directed therapy and 54% improved with decompression surgery at long-term follow-up, despite a robust short-term postoperative response (87%). Prospective studies are needed to guide patient selection and assess long-term outcomes.