Sigmoid resection for diverticular disease – to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta‐analysis

Abstract

Aim In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta‐analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage. Method A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta‐analysis software Review Manager 5.3. Results Eight studies met the inclusion criteria and were included in the meta‐analysis: two randomized controlled trials (RCTs) and six non‐RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26–1.33, I2 = 55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14–2.65, I2 = 0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed. Conclusion This meta‐analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA‐preserving technique as mandatory in resection for left‐sided colonic diverticular disease.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

“…More recent evidence, from both retrospective and prospective cohort studies, was either in favour of IMA preservation or inconclusive on its effect compared to IMA ligation [213][214][215][216][217]. A recent review and meta-analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate comparing IMA preservation with IMA ligation [218]. The authors conclude that, to date, there is insufficient evidence to recommend the IMA-preserving technique as mandatory in resection for left-sided colonic diverticular disease and the decision remains at the discretion of the operating surgeon.…”

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis

“…The line of dissection is straightforward, and it yields a less bulky specimen which is beneficial for transrectal extraction. This approach also preserves the inferior and superior mesenteric artery and protect against inadvertent damage of the underlying autonomic nerves and ureter and is associated with less sexual, urinary and bladder dysfunction [ 21 , 22 ]. However, this technique requires more advanced minimally invasive skills to dissect through thick, bulky and chalky mesentery which often bleeds [ 21 , 22 ].…”

“…This approach also preserves the inferior and superior mesenteric artery and protect against inadvertent damage of the underlying autonomic nerves and ureter and is associated with less sexual, urinary and bladder dysfunction [ 21 , 22 ]. However, this technique requires more advanced minimally invasive skills to dissect through thick, bulky and chalky mesentery which often bleeds [ 21 , 22 ]. Therefore, a third critical factor is the coordinated use of the vessel sealer in concert with the fenestrated bipolar to divide the tissue and control cumbersome mesentery bleeding.…”

Colonic Diverticular Disease

“…Another study reported a lower radiological and clinical leak rate [148]. Both systematic reviews and cohort studies have reported that leak rates are either lower or the same with vessel preserving surgery [149][150][151][152][153][154]. High pedicle ligation seems therefore warranted in cases where cancer cannot be excluded, whereas IMA preservation may otherwise be beneficial.…”