Oncological Impact of High Vascular Tie After Surgery for Rectal Cancer

Boström, Petrus; Hultberg, Daniel Kverneng; Häggström, Jenny; Haapamäki, Markku M; Matthiessen, Peter; Rutegård, Jörgen; Rutegård, Martin

doi:10.1097/sla.0000000000003663

Cited by 16 publications

(33 citation statements)

References 39 publications

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“…Several other studies have also shown that the incidence of metastatic apical lymph nodes ranges from 0.3% to 8.6%[ 22 - 25 ]. Boström et al[ 7 ] recently published a nationwide cohort study and showed that the level of ligation did not influence the oncological outcome or overall survival. Sakamoto et al[ 26 ] investigated the potential impact of the lymph-vascular microanatomy of the IMA, and their findings partially support the surgical concept of LCA preserving lymph node dissection around the IMA due to potential metastasis in the lymphatic ducts within the IMA sheath.…”

Section: Discussionmentioning

confidence: 99%

“…Nowadays, some scholars believe that LL can reduce the incidence of postoperative complications, especially the anastomotic leakage (AL) rate; however, other studies suggest that HL can obtain a higher lymph node yield, and shorten the operation time, without having any effect on the AL[ 4 - 6 ]. A recent nationwide cohort study in Sweden showed that the ligation level did not influence patients’ overall survival and oncological outcomes[ 7 ].…”

Section: Introductionmentioning

confidence: 99%

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Low ligation has a lower anastomotic leakage rate after rectal cancer surgery

Chen

Liu

Wang

et al. 2020

WJGO

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BACKGROUND For laparoscopic rectal cancer surgery, the inferior mesenteric artery (IMA) can be ligated at its origin from the aorta [high ligation (HL)] or distally to the origin of the left colic artery [low ligation (LL)]. Whether different ligation levels are related to different postoperative complications, operation time, and lymph node yield remains controversial. Therefore, we designed this study to determine the effects of different ligation levels in rectal cancer surgery. AIM To investigate the operative results following HL and LL of the IMA in rectal cancer patients. METHODS From January 2017 to July 2019, this retrospective cohort study collected information from 462 consecutive rectal cancer patients. According to the ligation level, 235 patients were assigned to the HL group while 227 patients were assigned to the LL group. Data regarding the clinical characteristics, surgical characteristics and complications, pathological outcomes and postoperative recovery were obtained and compared between the two groups. A multivariate logistic regression analysis was performed to evaluate the possible risk factors for anastomotic leakage (AL). RESULTS Compared to the HL group, the LL group had a significantly lower AL rate, with 6 (2.8%) cases in the LL group and 24 (11.0%) cases in the HL group ( P = 0.001). The HL group also had a higher diverting stoma rate (16.5% vs 7.5%, P = 0.003). A multivariate logistic regression analysis was subsequently performed to adjust for the confounding factors and confirmed that HL (OR = 3.599; 95%CI: 1.374-9.425; P = 0.009), tumor located below the peritoneal reflection (OR = 2.751; 95%CI: 0.772-3.985; P = 0.031) and age (≥ 65 years) (OR = 2.494; 95%CI: 1.080-5.760; P = 0.032) were risk factors for AL. There were no differences in terms of patient demographics, pathological outcomes, lymph nodes harvested, blood loss, hospital stay and urinary function ( P > 0.05). CONCLUSION In rectal cancer surgery, LL should be the preferred method, as it has a lower AL and diverting stoma rate.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Low ligation has a lower anastomotic leakage rate after rectal cancer surgery

Chen

Liu

Wang

et al. 2020

WJGO

View full text Add to dashboard Cite

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“…Additionally, a retrospective analysis [67] including 890 patients showed that LL of the IMA with ALN dissection was not inferior to HL in terms of oncological prognosis. Besides, a large, nationwide cohort study [68], which was reported by Boström et al and included 8287 rectal cancer patients, showed an increased lymph node yield with HL, but failed to reveal an association between the level of ligation and long‐term survival outcomes. Furthermore, no significant difference in the 5‐year overall survival rate was found between the HL group and the LL group with ANL dissection in one included RCT [24] in which the 5‐year overall survival rate was the secondary outcome.…”

Section: Discussionmentioning

confidence: 99%

“…The pooled analysis also showed that LL of the IMA with ALN dissection did not compromise the number of harvested lymph nodes compared with HL, although the quality of evidence was very low. Additionally, a retrospective analysis [67] including 890 patients showed that LL of the IMA with ALN dissection was not inferior to HL in terms of oncological prognosis. Besides, a large, nationwide cohort study [68], which was reported by Boström et al and included 8287 rectal cancer patients, showed an increased lymph node yield with HL, but failed to reveal an association between the level of ligation and long-term survival outcomes.…”

Section: Ta B L E 1 Study Characteristics For the Included Trialsmentioning

confidence: 97%

High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta‐analysis of randomized controlled trial studies

et al. 2020

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Aim Surgeons have concerns whether high ligation (HL) of the inferior mesenteric artery (IMA) increases the incidence of anastomotic leakage (AL). This meta‐analysis aimed to evaluate the influence of HL of the IMA on AL compared with low ligation (LL). Methods PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched. Randomized controlled trial studies that compared HL with LL of the IMA in anterior resection for rectal cancer and reported AL outcomes were eligible for inclusion. The odds ratios and mean differences were analysed by a random‐effects model. Trial sequential analysis was performed to minimize the risk of random errors. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence for outcomes. Results Of the 531 records screened, five randomized controlled trials with 779 patients were selected for analysis. The pooled incidence of AL was 12.1% (95% Cl 7.77–18.26) in the HL group and 9.7% (95% Cl 5.79–15.82) in the LL group (OR 1.20, 95% CI 0.77–1.87, P = 0.42). In trial sequential analysis, the cumulative Z‐score curve exceeded the futility boundary, although the required information size of 1060 had not been reached. The quality of evidence was judged to be high according to the GRADE approach. Conclusions This meta‐analysis shows that HL of the IMA does not increase the incidence of AL in anterior resection for rectal cancer.

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“…On the one hand, the impact of preserving the LCA on the development of AL in rectal cancer patients following anterior resection remains controversial [ 12 – 14 ]. Another point of debate is whether LCA preservation affects lymph node (LN) dissection and oncological outcomes [ 15 , 16 ]. Since the benefits of LCA preservation are debatable, robust evidence of the outcomes of LCA preservation plus apical LN dissection is lacking.…”

Section: Introductionmentioning

confidence: 99%

Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis

Zheng

Xie

et al. 2022

BMC Surg

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Background Preserving the left colic artery (LCA) during anterior resection for rectal cancer is controversial, and robust evidence of the outcomes of LCA preservation plus apical lymph node dissection is lacking. The purpose of this study was to investigate the impact of LCA preservation plus apical lymph node dissection surgery on anastomotic leakage and number of harvested lymph nodes. Methods Patients who underwent laparoscopic or robotic anterior resection for rectal cancer between September 2017 and May 2020 were retrospectively assessed. The patients were categorized into two groups: preservation of LCA and nonpreservation of LCA. A one-to-one propensity score-matched analysis was performed to decrease confounding. The primary outcome was anastomotic leakage within 30 days after surgery. The secondary outcomes were number of harvested lymph nodes, 3-year overall survival, and 3-year disease-free survival. Results A total of 216 patients were eligible for this study, and propensity score matching yielded 60 patients in each group. Anastomotic leakage in the LCA preservation group was significantly lower than that in the LCA nonpreservation group (3.3% vs. 13.3%, P = 0.048). No significant differences were observed in blood loss, operation time, intraoperative complications, splenic flexure mobilization, total number of harvested lymph nodes, number of positive lymph nodes, time to first flatus, or postoperative hospital stay. Kaplan–Meier survival analysis showed a 3-year disease-free survival of 85.7% vs. 80.5% (P = 0.738) and overall survival of 92.4% vs. 93.7% (P = 0.323) for the preservation and nonpreservation groups, respectively. Conclusion LCA preservation plus apical lymph node dissection surgery for rectal cancer may help reduce the incidence of anastomotic leakage without impairing the number of harvested lymph nodes. Preliminary results suggest that 3-year disease-free survival and overall survival rates may not differ between the two types of surgery, but studies with larger sample sizes are needed to confirm these conclusions. Trial registration ClinicalTrials.gov, NCT03776370. Registered 14 December 2018—Retrospectively registered, https://clinicaltrials.gov.

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Oncological Impact of High Vascular Tie After Surgery for Rectal Cancer

Abstract: Supplemental Digital Content is available in the text

Cited by 16 publications

References 39 publications

Low ligation has a lower anastomotic leakage rate after rectal cancer surgery

Low ligation has a lower anastomotic leakage rate after rectal cancer surgery

High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta‐analysis of randomized controlled trial studies

Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis

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