Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis

Abstract

Background Preserving the left colic artery (LCA) during anterior resection for rectal cancer is controversial, and robust evidence of the outcomes of LCA preservation plus apical lymph node dissection is lacking. The purpose of this study was to investigate the impact of LCA preservation plus apical lymph node dissection surgery on anastomotic leakage and number of harvested lymph nodes. Methods Patients who underwent laparoscopic or robotic anterior resection for rectal cancer between September 2017 and May 2020 were retrospectively assessed. The patients were categorized into two groups: preservation of LCA and nonpreservation of LCA. A one-to-one propensity score-matched analysis was performed to decrease confounding. The primary outcome was anastomotic leakage within 30 days after surgery. The secondary outcomes were number of harvested lymph nodes, 3-year overall survival, and 3-year disease-free survival. Results A total of 216 patients were eligible for this study, and propensity score matching yielded 60 patients in each group. Anastomotic leakage in the LCA preservation group was significantly lower than that in the LCA nonpreservation group (3.3% vs. 13.3%, P = 0.048). No significant differences were observed in blood loss, operation time, intraoperative complications, splenic flexure mobilization, total number of harvested lymph nodes, number of positive lymph nodes, time to first flatus, or postoperative hospital stay. Kaplan–Meier survival analysis showed a 3-year disease-free survival of 85.7% vs. 80.5% (P = 0.738) and overall survival of 92.4% vs. 93.7% (P = 0.323) for the preservation and nonpreservation groups, respectively. Conclusion LCA preservation plus apical lymph node dissection surgery for rectal cancer may help reduce the incidence of anastomotic leakage without impairing the number of harvested lymph nodes. Preliminary results suggest that 3-year disease-free survival and overall survival rates may not differ between the two types of surgery, but studies with larger sample sizes are needed to confirm these conclusions. Trial registration ClinicalTrials.gov, NCT03776370. Registered 14 December 2018—Retrospectively registered, https://clinicaltrials.gov.

Surgical considerations for the “perfect” colorectal anastomosis

“…One RCT by Fujii et al comparing high versus low IMA ligation in 331 patients undergoing anterior resection did not demonstrate any difference in anastomotic leak rate ( 15 ). Given the paucity of well-designed studies investigating the differences in IMA ligation, together with the heterogeneity of data and selection bias, meta-analyses on this topic have arrived at conflicting conclusions ( 16 - 20 ).…”

“…Some authors have proposed a more tailored approach to IMA ligation, only performing a high ligation for patients at risk of IMA nodal involvement ( 20 , 21 ). This is necessarily flawed given the limited accuracy with which nodal involvement can be predicted preoperatively.…”

Inferior Mesenteric Artery Ligation Level in Rectal Cancer Surgery beyond Conventions: A Review

“…The imperative for an ad hoc randomized study, with a larger sample size tailored on the oncological outcomes, coupled with the need to address intersurgeon variabilities, is evident for achieving statistically significant results in this context. Other studies have explored this research question, and despite being summarized in various systematic reviews and meta-analyses, a conclusive answer is still elusive [ 4 , 35 , 36 , 37 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 ]. Moreover, primary research studies face various limiting factors, including missing data, a low sample size, and inadequate comparisons that combine rectosigmoid cancers with true rectal cancers.…”

Venous Congestive Ischemic Colitis After Sigmoid Colectomy: A Case Report

“…In colorectal cancer surgery, it is crucial to perform adequate lymph node dissection and prevent complications such as anastomotic leakage and ischemic colitis. Therefore, the optimal mechanisms of ligation and preservation of the mesenteric arteries remain controversial [ 1 ].…”