High Tie of the Inferior Mesenteric Artery in Curative Surgery for Left Colonic and Rectal Cancers: A Systematic Review

Abstract

Background: During surgery for left colonic and rectal cancers, the inferior mesenteric artery (IMA) can be ligated either at its aortic origin (high tie) or below the origin of the left colic artery (low tie). There is no consensus as to which method should be employed. Methods: We searched Medline, EMBASE, Cochrane collaboration, and National Guidelines Clearinghouse databases and undertook a systematic review on the use of IMA high tie during curative resections for left colonic and rectal cancers and its impact on patient survival, peri-operative morbidity and mortality, and lymph node retrieval rates. Results: Sixteen studies were eligible for systematic review, including one randomized controlled study, 7 quasi-experimental studies, and 8 retrospective cohort studies. Data on 7,649 patients were analyzed, of whom 4,847 underwent high ligation of the IMA. Despite a trend for improved survival in patients in whom high tie was employed, there is no conclusive evidence to support this. Mortality and morbidity, including anastomotic leak and autonomic nerve injury rates, are similar, while lymph node retrieval is improved. Conclusions: Although there is no undisputable evidence of improved survival, the use of IMA high tie contributes to improved lymph node retrieval rates and accuracy of tumour staging.

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

“…Based on the oncological, technical and anatomical considerations, the position of ligation of the IMA has been debated on performing "high ligation" and "low ligation" in surgeries for the tumor of left colon and rectum (Lange et al, 2008;Titu et al, 2008;Cirocchi et al, 2012). 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 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).…”

A Review of Controversies in the Management of Colorectal Cancers

“…In a recent review by Titu L V et al [21] concluded high ligation of the IMA can be performed safely and does not represent a source of increased morbidity in surgery for rectal and left colonic cancers. High tie leads to improved lymph node harvest, thus facilitating accurate tumour staging.…”