High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection

Abstract

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR).Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis.Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation.Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Discontinuity of marginal artery at splenic flexure and rectosigmoid junction: A systematic review and meta‐analysis

“…For instance, Dworlin and Allen‐Mersh demonstrated significant reduction in sigmoid colon serosal blood flow following ligation of the IMA [48]. Three other studies have yielded similar findings [46, 49, 50]. Whether the reduction in colonic perfusion after high ligation of IMA confers a higher risk of anastomotic leakage post‐colectomy is yet to be demonstrated [51, 52].…”

Feasibility of preservation of superior rectal artery plus dissection of lymph nodes around inferior mesenteric artery in laparoscopic resection for sigmoid colon cancer

“…A recent study performed real-time indocyanine green fluorescence angiography to measure fluorescence time as a marker of blood flow in the proximal and distal stumps before anastomosis. The results showed that IMA high ligation significantly prolonged fluorescence time in the sigmoid colon during anterior rectal resection compared with low ligation, which indicates that IMA high ligation induced significant colon stump hypoperfusion ( 4 ). This finding possibly explains why IMA high ligation resulted in a high rate of AL.…”

“…High ligation of IMA with D3 lymph node dissection can improve the survival rate of patients ( 2 , 3 ). However, insufficient perfusion of stumps after high ligation of IMA may lead to anastomotic ischemia ( 4 – 6 ). The blood supply of the proximal and distal stumps of anastomosis is an important factor affecting its healing.…”

Laparoscopic D3 lymph node dissection with left colic artery and first sigmoid artery preservation in rectal cancer

“…According to anatomy, HT may have a better oncological outcome due to a more extended apical lymph node dissection, while LT may have a better anastomotic blood supply due to LCA preservation. “HT or LT” has been a hot research topic in recent years [ 14 , 19 – 22 ]. Although many previous studies believe that the two ligation methods had little effect on the oncological outcomes, we still could not deny the importance of D3 lymph node dissection because of the low-grade quality evidences of these studies and the low rate of apical lymph node metastasis [ 11 , 21 – 25 ].…”