High ligation of the inferior mesenteric artery in rectal cancer surgery

Abstract

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.

Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer

“…Several reviews18, 19, 20, 21 found no significant difference between high and low tie with regard to short‐ and long‐term results, with different authors recommending different methods. All emphasized the need for RCTs18 20, 21. In the present study, patients with rectal cancer were randomized between high‐ and low‐tie ligation.…”

New Insights into Autonomic Nerve Preservation in High Ligation of the Inferior Mesenteric Artery in Laparoscopic Surgery for Colorectal Cancer

“…Though there is still no consistent evidences of the survival benefits (Hida and Okuno, 2013), it is proved that high ligation of the IMA may improve lymph node removal rates (Adachi et al, 1998), accuracy of tumor staging (Titu et al, 2008). Though high ligation of the IMA causes a reduction of blood supply to distal colon (Seike et al, 2007;Tsujinaka et al, 2012), it simultaneously contributes to low anastomosis with no tension in low anterior resection of rectal cancer Hida and Okuno, 2013).…”

Inferior Mesenteric Artery Lymph Node Metastasis Is an Independent Prognostic Factor for Stage III Sigmoid Colon and Rectal Cancer

“…Taken together, there is no conclusive evidence to support a survival benefit among patients who undergo removal of IMA lymph node by high ligation. [24][25][26] However, our results suggest that pathological evaluation after dissection of the IMA lymph node is necessary for appropriate tumor staging and accurate estimation of patient prognosis.…”