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

Abstract

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.

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.…”

“…HL may be easier to achieve surgically and has been advocated by Girard et al [ 3 ]. Because HL will increase urogenital and defecation disorders, others have recently suggested that LL be preferred[ 4 , 5 ]. Some studies, however, showed no significance between LL and HL in terms of surgical or oncological outcomes[ 6 , 7 ].…”

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.…”