I didn't have the same MALS pain or stomach problems for around 3 years. Then I started having the same sharp, deep pain on my right side under my ribs after exercise or in the morning after sleeping. I really didn't suspect a recurrence until I started having bouts of nausea as well. None of this was as severe but it started to interfere with my life.

There is some debate in the medical community (and thus patients) about whether MALS is ischemic (blood flow), neurogenic (nerve damage) or both. I would say the consensus now is that typically both are involved. 10-20% of the population have celiac arterial compression by the median arcuate ligament but don't have this syndrome. In my case, the first surgeon didn't cut back the ligament very much or remove much nerve tissue, so I still had compression and then pain as nerves grew back and were compressed along with the artery. At least, that's the theory of my 2nd surgeon. She felt very confident removing band of nerves and trimming back the ligament farther would fix me for good.

If you're feeling symptoms again you should probably seek out a MALS knowledgeable GI specialist or surgeon so you can get the tests redone. Or go back to your first surgeon. It could be something else of course, but no matter how confident the surgeon is, MALS can come back and need additional interventions.