Case report
Anaesthetic management of median arcuate ligament syndrome
Manejo anestésico del síndrome del ligamento arcuato medio
E. Álvarez-Fuente
, A. Fadrique Fuentes, R. Poves-Álvarez, E. Gómez-Pesquera, A. Hernández Lozano
Corresponding author
Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Álvarez-Fuente, A. Fadrique Fuentes, R. Poves-Álvarez, E. Gómez-Pesquera, A. Hernández Lozano" "autores" => array:5 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Álvarez-Fuente" "email" => array:1 [ 0 => "elik_elisaalvarez@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Fadrique Fuentes" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Poves-Álvarez" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Gómez-Pesquera" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Hernández Lozano" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo anestésico del síndrome del ligamento arcuato medio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1060 "Ancho" => 1133 "Tamanyo" => 56987 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance angiography in expiration, showing compression of the celiac trunk (TC) by the median arcuate ligament (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome, affects 2 out of every 100,000 people. It is more frequent in young women, and is characterised by the triad of postprandial abdominal pain, weight loss, and nausea and vomiting.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Diagnosis is usually reached by exclusion. Treatment consists of laparoscopic release of the ligament together with angioplasty of the celiac artery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The combination of both techniques, together with the risk of injury to important abdominal and vascular structures, are a challenge for anaesthesiologists, who must adapt to both intraoperative physiological changes and the potential for serious complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 30-year-old woman, with no known allergies, whose only history or note was subclinical hypothyroidism. The patient presented a 1-month history of acute postprandial epigastralgia, loss of 6<span class="elsevierStyleHsp" style=""></span>kg in the last 3 weeks, and slow digestion with occasional vomiting. She had previously been admitted for 2 self-limiting episodes of epigastralgia of unknown cause. Of note on lab tests were gamma glutamyl transpeptidase 60<span class="elsevierStyleHsp" style=""></span>IU/L and alterations in thyroid hormones, compatible with her hypothyroidism. No pathological findings were observed in stool culture. A gastroscopy and abdominal ultrasound revealed no alterations. These studies allowed us to rule out infectious gastritis or pancreatic disease. It was decided to perform magnetic resonance angiography, which, on end-expiration, showed upward “hooked” angulation of the celiac artery and focal narrowing of the vascular lumen with dilatation distal to the narrowed zone (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The symptoms were consistent with the radiological image, and allowed us to reach a diagnosis of MALS. The patient was scheduled for laparoscopic resection of the ligament followed by angioplasty.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On arrival at the operating room, pulse oximetry, non-invasive blood pressure and 5-lead electrocardiogram monitoring was started, and SedLine sensors<span class="elsevierStyleSup">®</span> were placed to monitor level of consciousness. She was premedicated with 1<span class="elsevierStyleHsp" style=""></span>mg midazolam and 2<span class="elsevierStyleHsp" style=""></span>g cefazolin for antibiotic prophylaxis. Anaesthesia was induced with 150<span class="elsevierStyleHsp" style=""></span>μg fentanyl, 50<span class="elsevierStyleHsp" style=""></span>mg lidocaine, 100<span class="elsevierStyleHsp" style=""></span>mg propofol and 50<span class="elsevierStyleHsp" style=""></span>mg rocuronium administered through a central line previously placed on the ward. She was intubated using direct laryngoscopy and a rigid 7.5 tube, with no complications (Mallampati <span class="elsevierStyleSmallCaps">I</span> and Cormack–Lehane type I). Following this, a 16<span class="elsevierStyleHsp" style=""></span>g peripheral line was placed in the right radial artery on the back of the right hand and 4<span class="elsevierStyleHsp" style=""></span>mg dexamethasone was administered.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Hypnosis was maintained with target controlled infusion of between 3 and 3.5<span class="elsevierStyleHsp" style=""></span>μg/ml propofol. Relaxation and analgesia were achieved by infusion of 0.3<span class="elsevierStyleHsp" style=""></span>mg/kg boluses of rocuronium (15<span class="elsevierStyleHsp" style=""></span>mg every 30<span class="elsevierStyleHsp" style=""></span>min) and 600<span class="elsevierStyleHsp" style=""></span>μg of fentanyl.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A tendency towards hypertension and tachycardia was observed during laparoscopic manipulation of the area near the celiac plexus. After releasing the arcuate ligament, the laparoscopic trocars were removed, leaving the ports open for later evaluation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Arteriography was performed via the right femoral artery. Due to the persistence of stenosis in the celiac artery, arterial dilatation was performed by means of angioplasty and stent placement. The patient was given 2500<span class="elsevierStyleHsp" style=""></span>IU of IV heparin sodium. The follow-up angiography showed resolution of the stenosis. The patient was then re-examined laparoscopically and, when no bleeding was observed, it was decided to complete the procedure 5<span class="elsevierStyleHsp" style=""></span>h after the start of surgery. She was given 1800<span class="elsevierStyleHsp" style=""></span>ml lactated Ringer's, with a total urine output of 1500<span class="elsevierStyleHsp" style=""></span>ml. Thirty minutes before extubation, she was given 1<span class="elsevierStyleHsp" style=""></span>g paracetamol, 30<span class="elsevierStyleHsp" style=""></span>mg ketorolac, and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron, and bupivacaine 0.25% with a vasoconstrictor was injected in the ports. The patient was extubated in the operating room without incident, after administration of 25<span class="elsevierStyleHsp" style=""></span>mg protamine sulphate and 150<span class="elsevierStyleHsp" style=""></span>mg sugammadex.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was admitted to the postanaesthesia care unit (PACU) with a RASS of 0. She remained haemodynamically stable during her stay in the PACU, without the need for vasopressors or antihypertensives, apyretic, and with urine output of ≥1<span class="elsevierStyleHsp" style=""></span>ml/kg/h. The physical examination was unremarkable. The changes in the analytical parameters showed no alterations of interest (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). She required high doses of analgesics during the evening and the following morning (27<span class="elsevierStyleHsp" style=""></span>mg morphine chloride on demand in 2–3<span class="elsevierStyleHsp" style=""></span>mg boluses, additional analgesia with 1<span class="elsevierStyleHsp" style=""></span>g paracetamol and 30<span class="elsevierStyleHsp" style=""></span>mg ketorolac every 8<span class="elsevierStyleHsp" style=""></span>h), and was discharged from the unit 36<span class="elsevierStyleHsp" style=""></span>h after admission, with no complications. Oral intake was started on the ward 40<span class="elsevierStyleHsp" style=""></span>h after surgery.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The median arcuate ligament is a fibrous arch formed by the left and right diaphragmatic crura. It encircles the aorta and passes over the celiac trunk at the level of the first lumbar vertebra. In 10%–24% of the population,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> the ligament passes anterior to the celiac artery, and this, in some cases, produces medium arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome. Clinically, it is characterised by the triad of postprandial abdominal pain, weight loss, and nausea and vomiting. It is more common in women between the ages of 30 and 50.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Several theories have been put forward to explain the pathophysiology of the syndrome, including compression of the celiac artery producing focal ischaemia, and therefore, pain. There is also believed to be a certain neuropathic component, since chronic compression could cause overstimulation of the celiac ganglion.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MALS is a diagnosis of exclusion. Diagnostic tests include colour Doppler ultrasound of the celiac artery. Gruber found that a maximum expiratory peak flow velocity of ≥350<span class="elsevierStyleHsp" style=""></span>cm/s and a change of >210% in the amplitude of the peak flow velocity between inspiration and expiration, together with celiac trunk defection-angle of 50°, had a sensitivity of 83% and a specificity of 100% for the diagnosis of MALS.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Lateral mesenteric angiography is considered the gold standard test in the diagnosis of MALS. Compression of the celiac trunk is observed on inspiration, and poststenotic dilation on expiration. Computed tomography angiography is also useful, since it allows the images to be reconstructed in 4 dimensions, and good results have been obtained with magnetic resonance angiography in children and young adults.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Open surgery is the method traditionally used for the treatment of MALS. However, this has now been replaced by laparoscopic surgery, due to the advantages of this technique: smaller incision and less postoperative morbidity (including paralytic ileus, pain, bleeding, postsurgical adhesions) and shorter recovery time. Laparoscopy is not without its drawbacks: intraoperative bleeding is harder to control, there is a risk of incomplete release of the ligament, and a greater risk of damaging the abdominal aorta due to the difficulty of performing laparoscopic dissection.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In laparoscopic surgery, most clinicians prefer general anaesthesia with orotracheal intubation, since this allows the anaesthesiologist to modify ventilation parameters based on the changes that may occur. Intraoperative monitoring was performed with pulse oximetry, capnography, invasive and non-invasive blood pressure, and central venous access to control any acute bleeding that may occur. We decided to perform total intravenous anaesthesia, which was maintained with target controlled infusion of propofol, due to its antiemetic properties. Total intravenous anaesthesia with propofol was chosen over halogenated anaesthetics for its antiemetic action, because the patient, according to the Apfel model, had an 80% risk of postoperative nausea and vomiting (PONV). For the same reason, we administered 4<span class="elsevierStyleHsp" style=""></span>mg dexamethasone and 4<span class="elsevierStyleHsp" style=""></span>mg of ondansetron<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> prophylaxis against PONV.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Analgesic requirements were very high: 15<span class="elsevierStyleHsp" style=""></span>μg/kg fentanyl, together with minor analgesics. Peak hypertension and tachycardia coincided with surgical manipulation of the arcuate ligament and the celiac trunk. To improve postoperative pain management in laparoscopic surgery, studies recommend injecting long-acting analgesics at the site of the ports, extracting as much residual intraperitoneal CO<span class="elsevierStyleInf">2</span> as possible, intraperitoneal subdiaphragmatic injection of local anaesthetic, and possibly, epidural analgesia.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This is why we believe that epidural anaesthesia would have been indicated, as it has been shown to speed up the return to normal gastrointestinal transit, and reduces pain on movement in the first 24<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> However, we decided against it in this case, as we did not anticipate such intense postoperative pain, and because of the risk of haemorrhage when releasing the ligament.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the postoperative period, one of the largest studies in patients undergoing MALS repair surgery reported an average hospital stay of 9 days, with no mortality. The only complication was 1 case of acute renal failure together with pneumonia 3 days after surgery. In the foregoing series, patients also underwent celiac ganglion sympathectomy, after which they presented self-limiting diarrhoea in the first 48<span class="elsevierStyleHsp" style=""></span>h; this symptom is an important indicator of the success of the procedure. In our case, this procedure was not performed. Pain was resolved within a few days after surgery in most patients. In others, it continued as a result of the persistence of stenosis of the celiac trunk in the short term, and in the long term as a result of adherences.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Based on our experience with this patient, we believe that admission to the PACU after surgery is important due to the potential difficulty in controlling postoperative pain. As our patient did not receive epidural anaesthesia, we believe that patient-controlled analgesia, combining continuous perfusion and on-demand boluses of morphine, was the best alternative in this young, collaborative patient. After MALS surgery, it is also important to start oral intake to assess the effectiveness of the corrective procedure, and for this purpose good pain management is essential.</p><p id="par0090" class="elsevierStylePara elsevierViewall">MALS is a rare entity. Anaesthesiologists must ensure the patient is correctly monitored, prevent the appearance of haemorrhagic complications, and establish an effective intra- and postoperative analgesic protocol that facilitates the start of oral intake and enables these patients to recover their nutritional status.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1124183" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1058856" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1124182" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1058855" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack382689" "titulo" => "Acknowledgements" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-24" "fechaAceptado" => "2018-06-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1058856" "palabras" => array:6 [ 0 => "Arcuate ligament" 1 => "Anaesthesia" 2 => "Pain" 3 => "Surgery" 4 => "Diagnosis" 5 => "Laparoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1058855" "palabras" => array:6 [ 0 => "Ligamento arcuato" 1 => "Anestesia" 2 => "Dolor" 3 => "Cirugía" 4 => "Diagnóstico" 5 => "Laparoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a rare and unusual clinical disorder. Its symptoms are non-specific, which complicates its diagnosis, and a multidisciplinary approach is required to treat the disorder. The ligament is circumferentially cleared by laparoscopy. Selective angiography and endovascular techniques may be used after laparoscopy. Vital organs and important vascular structures can be injured during the surgery. The combination of different procedures, as well as the high risk of damage, make this process a significant challenge for the anaesthetist. During corrective surgery for median arcuate ligament syndrome, general anaesthesia must be adapted to the various haemodynamic and ventilatory requirements, and strict control of pain established, as oral tolerance is a key factor in the post-operative recovery of these patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El síndrome del ligamento arcuato medio, o síndrome de compresión del tronco celíaco, es un cuadro clínico poco frecuente. La especificidad de sus síntomas hace difícil su diagnóstico. En el caso descrito la corrección quirúrgica del síndrome del ligamento arcuato medio precisó un abordaje multidisciplinar. Inicialmente se realizó una descompresión laparoscópica y, posteriormente, control angiográfico y procedimientos endovasculares. La combinación de diferentes técnicas intervencionistas, asociada al riesgo de lesión de órganos y estructuras vasculares importantes, convirtieron esta enfermedad en un reto para el anestesiólogo. Durante la cirugía de corrección del síndrome del ligamento arcuato medio, la anestesia general ha de adaptarse a los diferentes requerimientos hemodinámicos y ventilatorios, y se ha de establecer un estrecho control del dolor, ya que el inicio de la tolerancia oral es un factor clave en la recuperación postoperatoria de estos pacientes.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Álvarez-Fuente E, Fadrique Fuentes A, Poves-Álvarez R, Gómez-Pesquera E, Hernández Lozano A. Manejo anestésico del síndrome del ligamento arcuato medio. Rev Esp Anestesiol Reanim. 2018;65:597–600.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1060 "Ancho" => 1133 "Tamanyo" => 56987 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance angiography in expiration, showing compression of the celiac trunk (TC) by the median arcuate ligament (arrow).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">8<span class="elsevierStyleHsp" style=""></span>h post-admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">16<span class="elsevierStyleHsp" style=""></span>h post-admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PACU discharge \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GOT (UI/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lactate (mmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GOT (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Platelets (10<span class="elsevierStyleSup">3</span>/μl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">166 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">159 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">175 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">147 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">aPTT ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">INR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fibrinogen (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">224 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">255 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">161 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1915481.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Evolution of analytical data.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinicoanatomical study of the arcuate ligament of the diaphragm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.H. Lindner" 1 => "E. Kemprud" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Surg" "fecha" => "1971" "volumen" => "103" "paginaInicial" => "600" "paginaFinal" => "605" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5117015" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic treatment for median arcuate ligament syndrome: the usefulness of intraoperative Doppler ultrasound to confirm the decompression of the celiac artery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Tsujimoto" 1 => "S. Hiraki" 2 => "N. Sakamoto" 3 => "Y. Yaguchi" 4 => "I. Kumano" 5 => "K. Yoshida" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SLE.0b013e318243a3ab" "Revista" => array:6 [ "tituloSerie" => "Surg Laparosc Endosc Percutan Tech" "fecha" => "2012" "volumen" => "22" "paginaInicial" => "e71" "paginaFinal" => "e75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22487643" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Median arcuate syndrome – review of this rare disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E.N. Kim" 1 => "K. Lamb" 2 => "D. Relles" 3 => "N. Moudgill" 4 => "P.J. DiMuzio" 5 => "J.A. Eisenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamasurg.2016.0002" "Revista" => array:6 [ "tituloSerie" => "JAMA Surg" "fecha" => "2016" "volumen" => "151" "paginaInicial" => "471" "paginaFinal" => "477" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26934394" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Median arcuate ligament syndrome: it is not always gastritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Kuruvilla" 1 => "G. Murtaza" 2 => "A. Cheema" 3 => "H.M.S. Arshad" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/2324709617728750" "Revista" => array:4 [ "tituloSerie" => "J Investig Med High Impact Case Rep" "fecha" => "2017" "volumen" => "5" "itemHostRev" => array:3 [ "pii" => "S1552526014024923" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome del ligamento arcuato medio: a propósito de tres casos revisión de la literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. San Norberto" 1 => "J. Montes" 2 => "A. Romero" 3 => "E. Núñez" 4 => "C. Vaquero" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Angiologia" "fecha" => "2012" "volumen" => "64" "paginaInicial" => "167" "paginaFinal" => "172" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Celiac compression syndrome: tailored therapy based on intraoperative findings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.J. Takach" 1 => "J.J. Livesay" 2 => "G.J. Resul" 3 => "D.A. Cooley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Surg" "fecha" => "1996" "volumen" => "183" "paginaInicial" => "606" "paginaFinal" => "610" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8957463" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estratificación del riesgo, profilaxis y tratamiento de las náuseas y vómitos postoperatorios" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Bel Marcoval" 1 => "P. Gambús Cerrillo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2006" "volumen" => "53" "paginaInicial" => "301" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16827070" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nuevas tendencias en el tratamiento del dolor postoperatorio en cirugía general y digestiva" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.T. Santeularia" 1 => "E. Català" 2 => "M. Genové" 3 => "M. Revuelta" 4 => "M.V. Moral" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ciresp.2009.03.028" "Revista" => array:6 [ "tituloSerie" => "Cir Esp" "fecha" => "2009" "volumen" => "86" "paginaInicial" => "63" "paginaFinal" => "71" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19586620" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidural local anesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting, and pain after abdominal surgery: a Cochrane review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Guay" 1 => "M. Nishimori" 2 => "S.L. Kopp" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000001628" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2016" "volumen" => "123" "paginaInicial" => "1591" "paginaFinal" => "1602" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27870743" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Sultan" 1 => "N. Hynes" 2 => "N. Elsafty" 3 => "W. Tawfick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1538574413500536" "Revista" => array:6 [ "tituloSerie" => "Vasc Endovascular Surg" "fecha" => "2013" "volumen" => "47" "paginaInicial" => "614" "paginaFinal" => "619" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23942948" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack382689" "titulo" => "Acknowledgements" "texto" => "<p id="par0100" class="elsevierStylePara elsevierViewall">We would like to thank the staff of the Anaesthesiology and Critical Care Department of the University Hospital of Valladolid.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000010/v1_201812070615/S2341192918301689/v1_201812070615/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000010/v1_201812070615/S2341192918301689/v1_201812070615/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301689?idApp=UINPBA00004N" ]
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