High and low inferior mesenteric artery ligation in laparoscopic low anterior rectal resections: A retrospective study

Abstract

BackgroudThe high or low inferior mesenteric artery (IMA) ligation in rectal cancer remains a great debate. This study retrospectively discussed the outcomes of the perioperative period, defecation and urinary function and long-term prognosis in rectal cancer patients with high or low IMA ligation.MethodsThis study enrolled 220 consecutive rectal cancer cases, including 134 with high IMA ligation and 86 with low ligation. A comparison between the two groups was made for anastomotic leakage, low anterior resection syndrome (LARS), international prostate symptom score (IPSS), 5-year disease-free survival (DFS) and 5-year overall survival (OS).ResultsLow-ligation group had a longer operative time, and larger intraoperative blood loss. No significant difference was noted in anastomotic leakage incidence. In multivariable analysis, the male gender and tumor located at the lower rectum were identified as risk factors for anastomotic leakage. No significant differences were observed between groups in their LARS and IPSS questionnaire responses. The high-ligation vs. the low-ligation 5-year OS and DFS were 78.3% vs. 82.4% and 72.4% vs. 76.6%, respectively, which were not statistically different.ConclusionThe ligation level of the IMA had no significant effect on the anastomotic leakage incidence, defecation, urinary function, and long-term prognosis.

High Ligation of the Inferior Mesenteric Artery in Left-Sided Colon and Rectal Cancer Resection: Rates of Success and Outcomes

“…The necessity of high ligation in surgery for low leftsided colon, rectal, and anal cancers is currently under controversy. There has been discrepancy in results in the recent analyses, with some showing non-inferiority of low ligation across all metrics, 3,4,15 some studies demonstrating increased lymph node yield or positive lymph node yield in high ligation, 9,10,12 and many studies showing that low ligation has lower complication rates in the form of anastomotic leaks, strictures, genitourinary dysfunction, or other major complications. 6,7,10,11,13,14,16 Cadaver studies have not shown that high ligation of the IMA is truly necessary for adequate mobilization.…”

“…6,7,10,11,13,14,16 Cadaver studies have not shown that high ligation of the IMA is truly necessary for adequate mobilization. 1,20 Recent studies show that low ligation does not improve the oncologic or survival benefits in surgery for left-sided colon and rectal cancer, 4,7,9,[12][13][14][15] though some conflicting data exists, especially in reference to node harvest. [8][9][10]12 Our study was in line with these findings, in that our patients who received an inadvertent low ligation when high ligation was intended did not have significant differences in lymph node yield or recurrence.…”

“…Most previous studies that analyzed high ligation vs low ligation used descriptions of ligation level to determine the two groups. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] Further, the studies that did perform radiographic analysis only tend to measure success rates rather than outcomes in successful and unsuccessful groups, 18 or involved a small number of patients. 19 To our knowledge, our study also provides the largest cohort of patients undergoing analysis of rates of successful vs unsuccessful high ligation during left-sided and rectal resections.…”

“…The limitations of this study include the fact that the postoperative CT scans obtained were with IV contrast but were not performed as angiography (CTA). While CTs without a dedicated angiography phase are likely adequate The American Surgeon™ 90 (4) to evaluate the IMA, the phase of the scan and decreased volume of contrast could potentially lead to incorrect analysis of the level of ligation due to incomplete contrast opacification. 20 Another limitation is the use of operative templates for a vast majority of the surgeries, and while the operative notes were not identical, it is possible that the described level of ligation is not accurate with respect to the true attempted intraoperative level of ligation.…”

“…1,2 Most studies compare the high ligation technique to low ligation in terms of long-term outcomes or operative morbidity, with the results of these studies being mixed. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] Despite lack of consensus as to which approach is best, the American Society of Colon and Rectal Surgeons advocates for high ligation of the IMA. 17 At our institution, high ligation of the IMA is routinely performed in most low left-sided colon and rectal cancers.…”