High versus low ligation of inferior mesenteric artery during laparoscopic radical resection of rectal cancer

Abstract

Laparoscopic radical resection is standard treatment for resectable rectal cancer. However, whether high or low inferior mesenteric artery (IMA) ligation should be performed remains controversial. This retrospective cohort study compared the advantages and disadvantages of low vs high IMA ligation in patients undergoing laparoscopic total mesorectal excision for rectal cancer. Rectal cancer patients (n = 322) undergoing total mesorectal excision at our institution in 2010 to 17 were enrolled; 174 underwent high IMA ligation group and 148 low IMA ligation (LIMAL group). Baseline data on patients, operative indices, economic indices, pathology findings, perioperative complications, and survival in the 2 groups were analyzed retrospectively. The low IMA ligation group had significantly higher anus retention ratio (P = .022), shorter hospital stay (P = .025), lower medical expenses (P = .032), fewer cases of anastomotic leakage (P = .023) and anastomotic stricture (P < .001), and lower incidence of postoperative genitourinary dysfunction (P = .003). Cox regression analysis indicated that local recurrence, distant metastasis, tumor differentiation, and tumor-node-metastasis stage were independently associated with survival. Low ligation of the IMA during laparoscopic radical resection of rectal cancer appears to be associated with a lower risks for anastomotic leakage, anastomotic stricture, and genitourinary dysfunction, a shorter hospital stay, and lower costs. In contrast, the rate of lymph node harvest, tumor recurrence rate, metastasis, or mortality was not found to be related with the level of IMA ligation.

Genitourinary function and defecation after colorectal cancer surgery with low- and high-ligation of the inferior mesenteric artery: A meta-analysis

“…These studies involved a total of 4750 patients, with 1984 patients in the LL group and 2766 patients in the HL group. The baseline characteristics of the 14 eligible studies[ 4 , 5 , 7 , 13 - 23 ] are shown in Table 1 . Quality assessments of the included studies are shown in Table 2 and Figure 2 , and all endpoints are listed in Table 3 .…”

“…No significant differences in urinary dysfunction (OR = 1.23, 95%CI: 0.95 to 1.59, P = 0.12; Figure 3A )[ 4 , 7 , 16 - 18 , 20 , 21 ] or urinary retention (OR = 1.51, 95%CI: 0.85 to 2.68, P = 0.16; Figure 3B )[ 5 , 14 , 22 , 23 ] were found between the LL and HL groups. The LL group did, however, have a lower risk of urinary infection (OR = 0.29, 95%CI: 0.16 to 0.54, P < 0.0001; 3C )[ 7 , 15 , 21 ] and a decreased risk of genitourinary dysfunction (OR = 0.32, 95%CI: 0.17 to 0.61, P = 0.0006; Figure 3D ), compared with the HL group[ 13 , 19 ].…”

“…Although the LL group had a lower incidence of anastomotic stenosis than the HL group (OR = 0.31, 95%CI: 0.16 to 0.62, P = 0.0009; Figure 3H )[ 13 , 19 , 22 , 23 ], there were no significant differences in the anastomotic leakage rate (OR = 0.69, 95%CI: 0.45 to 1.07, P = 0.10; Figure 3I )[ 4 , 7 , 13 - 23 ], postoperative complication rate (OR = 1.07, 95%CI: 0.66 to 1.72, P = 0.79; Figure 3J )[ 7 , 14 , 15 , 18 , 21 ], or mortality (OR = 2.70, 95%CI: 0.64 to 11.40, P = 0.18; Figure 3K )[ 5 , 7 , 16 , 18 , 22 , 23 ] between the two groups. There were no differences in operative time (WMD, 4.42, 95%CI: −2.05 to 10.89, P = 0.18; Figure 3L )[ 4 , 13 , 15 - 19 ] or blood loss (WMD, −0.63, 95%CI: −4.01 to 2.76, P = 0.72; Figure 4A )[ 4 , 13 , 15 , 16 , 18 , 19 ] between the two groups.…”

Technical Feasibility and Oncological Safety of Low and High Ligation of the Inferior Mesenteric Artery in Colorectal Cancer Surgery for Asian Populations: a Systematic Review and Meta-analysis

“…Among them, 8 studies failed to provide su cient data and 11 studies published by non-Asian countries. Finally, 21 studies including 8 RCTs and 13 non-RCTs published between 2010 and 2020 were included in this systematic review and meta-analysis [4,7,9,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. A total of 5947 patients (2519 patients in LL group and 3428 patients in HL group) were involved in the study.…”

Preservation of inferior mesenteric vessels. Laparoscopic sigmoidectomy for cancer – a video vignette

“…Recently, left colic artery preservation with lymph node dissection of the IMA root during laparoscopic surgery for early rectosigmoid cancer has been proposed to avoid leaks ensuring an adequate lymph node harvest [1]. According to the literature, in advanced cancers high tie of the IMA should be considered mandatory [2,3]; conversely, in the case of early sigmoid cancers, its preservation with lymphadenectomy of the arterial root could be performed with good oncological outcomes and low risk of recurrence and anastomotic leaks. An adequate lymphadenectomy is feasible, as stated by many authors since the 1960s [4].…”