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Table of Contents
JOURNAL SCAN
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 94-96

High versus low ligation of inferior mesenteric artery in the radical resection of rectal cancer


Department of Surgery, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, Delhi, India

Date of Web Publication22-Sep-2020

Correspondence Address:
Dr. Rajiv Nandan Sahai
Department of Surgery, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_25_20

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  Abstract 

Background: Despite ongoing debates, there is still no consensus regarding where to divide the inferior mesenteric artery for oncological reasons in rectal cancer: at its origin from the aorta (high ligation) or distal to the origin of the left colic artery (low ligation). Objectives: The purpose of this study was to compare the outcomes of high and low ligation of the inferior mesenteric artery in rectal cancer surgery. Data Sources: Medline, embase, cinahl, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN Register were searched. Study Selection: Randomized controlled trials investigating outcomes of curative anterior resection in patients with cancer of the rectum were included. Interventions: High ligation of the inferior mesenteric artery was compared with low ligation technique. Main Outcome Measures: We measured the total number of lymph nodes harvested, anastomotic leak, postoperative complications, postoperative mortality, operative time, intraoperative blood loss, conversion to open surgery, overall survival, and disease-free survival. Results: Analysis of 1102 patients from 8 trials suggested no difference between high and low ligation of the inferior mesenteric artery in terms of total number of lymph nodes harvested (mean difference = –0.87; p = 0.26), anastomotic leak (OR = 1.39; p = 0.15), postoperative complications (OR = 1.39; p = 0.78), postoperative mortality (risk difference = –0.00; p = 0.48), operative time (mean difference = –1.99; p = 0.79), intraoperative blood loss (mean difference = –2.28; p = 0.77), conversion to open surgery (risk difference = 0.01; p = 0.48), 5-year overall survival (OR = 0.76; p = 0.32), 5-year disease-free survival (OR = 0.88; p = 0.58), overall survival at maximum follow up (OR = 0.80; p = 0.43), and disease-free survival at maximum follow-up (OR = 0.83; p = 0.35). Limitations: Limited data were available on functional and long-term survival outcomes. Conclusions: There is no difference between high and low ligation of the inferior mesenteric artery in terms of oncological outcomes or postoperative morbidity and mortality. The available evidence is subject to potential confounding by the use of neoadjuvant therapy, adjuvant therapy, disease stage, location of tumor, and use of protective stoma. Functional outcomes including postoperative bowel, urinary and sexual function, and long-term survival outcomes should be the outcome of study in future trials.

Keywords: Anastomotic leakage, high ligation, inferior mesenteric artery, low ligation, rectal cancer, sigmoid colon cancer


How to cite this article:
Sahai RN. High versus low ligation of inferior mesenteric artery in the radical resection of rectal cancer. Indian J Colo-Rectal Surg 2019;2:94-6

How to cite this URL:
Sahai RN. High versus low ligation of inferior mesenteric artery in the radical resection of rectal cancer. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2022 May 20];2:94-6. Available from: https://www.ijcrsonweb.org/text.asp?2019/2/3/94/295857

Shahab Hajibandeh, Shahin Hajibandeh, Andrew Maw. Meta-analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing High and Low Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery. Dis Colon Rectum 2020;63:988-99.

(Doi: 10.1097/dcr.0000000000001693© the Ascrs 2020).


  Summary Top


Radical resection for rectal cancer has a few requirements which are unique.

As in any malignancy, lymph node metastasis and its removal is crucial and affects the outcome. However, even more important than lymph node excision are postoperative complications.

Anastomotic leak is the most common and the most important complication affecting the outcome of surgery and mortality.[1] Anastomotic ischemia and increased anastomosis tension are the most important reasons for anastomotic leak.[2]

It is presumed that while attempting curative resection of carcinoma of the sigmoid and rectum, high ligation of inferior mesenteric artery (IMA) facilitates removal of lymph nodes and hence leads to better staging and probably outcomes.[3]

High ligation also allows complete mobilization of the proximal colonic limb reducing anastomotic tension.[4]

On the other hand, high ligation leads to decreased blood flow to the anastomosis and hence an increased chance of leakage.[5] High ligation is also associated with a higher risk of hypogastric plexus injury and injury to preaortic nerves.[6] This leads to a decreased peristaltic proximal segment with its accompanying problems.

With low ligation, retrieval of lymph nodes may be inadequate, but blood flow to anastomosis is maintained and the risk of injury to nerves is low.[7]

There has always been a controversy about high or low ligation of IMA in cases of rectal malignancies. This debate is again relevant now as more and more surgeons doing this procedure laparoscopically.

In 1908, Moynihan proposed ligation of IMA at its origin (high ligation), thus sacrificing the superior rectal artery (SRA), the left colic artery (LCA), the ascending and descending limbs of the LCA, and the sigmoid arteries. This helped include the apical group of lymph nodes within the resection. During subsequent years, the high-tie principle was further advocated by several authors.

In the same year, Miles developed the abdominoperineal procedure. He believed that the route of lymphatic drainage of the rectum would follow its arterial supply; he recommended division of the SRA just distally to the origin of the LCA, with subsequent en bloc excision of nodes and bowel below.[8]

To come to some conclusion about this controversy, the authors compared the outcomes of high and low ligation of the IMA in rectal cancer surgery by doing a meta-analysis and trial sequential analysis of randomized controlled trials using data bases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN.

They measured the total number of lymph nodes harvested, anastomotic leak, postoperative complications, postoperative mortality, operative time, intraoperative blood loss, conversion to open surgery, overall survival, and disease-free survival.

Analysis of 1102 patients from eight trials suggested no difference between high and low ligation of the IMA in terms of total number of lymph nodes harvested (mean difference = −0.87; P = 0.26), anastomotic leak (odds ratio [OR] = 1.39; P = 0.15), postoperative complications (OR = 1.39; P = 0.78), postoperative mortality (risk difference = −0.00; P = 0.48), operative time (mean difference = −1.99; P = 0.79), intraoperative blood loss (mean difference = −2.28; P = 0.77), conversion to open surgery (risk difference = 0.01; P = 0.48), 5-year overall survival (OR = 0.76; P = 0.32), 5-year disease-free survival (OR = 0.88; P = 0.58), overall survival at maximum follow-up (OR = 0.80; P = 0.43), and disease-free survival at maximum follow-up (OR = 0.83; P = 0.35). The only shortcoming was that limited data were available on functional and long-term survival outcomes.

The authors concluded that there was no difference between high and low ligation of the IMA in terms of oncological outcomes or postoperative morbidity and mortality. The available evidence was subject to potential confounding by the use of neoadjuvant therapy, adjuvant therapy, disease stage, location of tumor, and use of protective stoma. They also suggested that functional outcomes including postoperative bowel, urinary and sexual function, and long-term survival outcomes should be the outcomes of study in future trials.


  Commentary Top


Colorectal cancer is already the third leading cause of cancer death in the world, and its incidence is steadily rising in developing nations with nearly 2 million new cases and about 1 million deaths are expected in 2018.[9]

With laparoscopic surgery taking giant strides, it is now almost the procedure of choice for most surgeons. It has been seen that low-tie group has a longer IMA-tie time. This probably reflects the technical complexity involved in the preservation of the LCA as IMA branching pattern with a large distance between the origins of the IMA and LCA causes technical difficulty.[10],[11]

Although low tie is a bit technically more difficult, low ligation of IMA during laparoscopic radical resection for rectal cancer appears to be associated with lower risks of anastomotic leakage, anastomotic stricture, and genitourinary dysfunction. Duration of hospital stay and medical costs were also significantly lower in patients undergoing low IMA ligation. However, lymph nodes harvested, recurrence rate, metastasis rate, and mortality were not associated with the level of IMA ligation.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nano M, Dal Corso H, Ferronato M, Solej M, Hornung JP, Dei Poli M. Ligation of the inferior mesenteric artery in the surgery of rectal cancer: Anatomical considerations. Dig Surg 2004;21:123-6.  Back to cited text no. 1
    
2.
Bruch HP, Schwandner O, Schiedeck TH, Roblick UJ. Actual standards and controversies on operative technique and lymph-node dissection in colorectal cancer. Langenbecks Arch Surg 1999;384:167-75.  Back to cited text no. 2
    
3.
Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: A systematic review. Dig Surg 2008;25:148-57.  Back to cited text no. 3
    
4.
Hida J, Yasutomi M, Maruyama T, Fujimoto K, Nakajima A, Uchida T, et al. Indication for using high ligation of the inferior mesenteric artery in rectal cancer surgery. Examination of nodal metastases by the clearing method. Dis Colon Rectum 1998;41:984-7.  Back to cited text no. 4
    
5.
Seike K, Koda K, Saito N, Oda K, Kosugi C, Shimizu K, et al. Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery. Int J Colorectal Dis 2007;22:689-97.  Back to cited text no. 5
    
6.
Matsuda K, Yokoyama S, Hotta T, Takifuji K, Watanabe T, Tamura K, et al. Oncological outcomes following rectal cancer surgery with high or low ligation of the inferior mesenteric artery. Gastrointest Tumors 2017;4:45-52.  Back to cited text no. 6
    
7.
Lange MM, Buunen M, van de Velde CJ, Lange JF. Level of arterial ligation in rectal cancer surgery: Low tie preferred over high tie. A review. Dis Colon Rectum 2008;51:1139-45.  Back to cited text no. 7
    
8.
Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908). CA Cancer J Clin 1971;21:361-4.  Back to cited text no. 8
    
9.
Rawla P, Sunkara T, Barsouk A. Epidemiology of colorectal cancer: Incidence, mortality, survival, and risk factors. Prz Gastroenterol 2019;14:89-103.  Back to cited text no. 9
    
10.
Bertrand MM, Delmond L, Mazars R, Ripoche J, Macri F, Prudhomme M. Is low tie ligation truly reproducible in colorectal cancer surgery? Anatomical study of the inferior mesenteric artery division branches. Surg Radiol Anat 2014;36:1057-62.  Back to cited text no. 10
    
11.
Patroni A, Bonnet S, Bourillon C, Bruzzi M, Zinzindohoué F, Chevallier JM, et al. Technical difficulties of left colic artery preservation during left colectomy for colon cancer. Surg Radiol Anat 2016;38:477-84.  Back to cited text no. 11
    
12.
Xiaolan Y, Qinghong L, Jian W, Yuanjie W, Jiawen HC, Dehu C, et al. High versus low ligation of inferior mesenteric artery during laparoscopic radical resection of rectal cancer – A retrospective cohort study. Medicine 2020;99:e119437.  Back to cited text no. 12
    




 

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