Does high ligation of the inferior mesenteric artery affect the results of surgery for rectal cancer? (a systematic review and meta-analysis)

AIM: to compare methods of high and low ligation of the inferior mesenteric artery (IMA) in relation to early and late outcomes in surgery for rectal and sigmoid cancer.

MATERIALS AND METHODS: the systematic review performed in accordance with PRISMA practice and guidelines.

RESULTS: eighteen studies (5 randomized clinical trials and 13 retrospective studies) are included in the study. The meta-analysis demonstrated that left colic artery (LCA) preservation significantly reduced the incidence of anasto- motic leaks compared with high ligation of IMA (OR = 1.60; CI 1.23–2.10; p = 0.0006). There were no differences in operation time, blood loss, frequency of splenic flexure mobilization, number of harvested lymph nodes, incidence of urinary dysfunction, postoperative hospital stay and 5-year disease-free survival.

CONCLUSION: low ligation of the IMA improves the blood supply to the anastomosis and reduces the risk of anasto- motic leakage.

1. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery — the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–616.

2. Charan I, Kapoor A, Singhal MK, Jagawat N, et al. High Ligation of Inferior Mesenteric Artery in Left Colonic and Rectal Cancers: Lymph Node Yield and Survival Benefit. Indian J Surg. 2015 Dec;77 (Suppl 3):1103-8. DOI: 10.1007/s12262-014-1179-2 Epub 2014 Sep 30.

3. Seike K, Koda K, Saito N, Oda 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 Jun;22(6):689–97. DOI: 10.1007/s00384-006-0221-7 Epub 2006 Nov 3.

4. Clinical recommendations. Rectal cancer. ICD 10: C20. Year of approval: 2020. ID: KR554/1. (in Russ.).

5. Moher D. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009 Jul;6(7):e1000097.

6. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010 Sep;25(9):603–5. DOI: 10.1007/s10654-010-9491-z Epub 2010 Jul 22.

7. Al Suhaimi MA, Yang SY, Kang JH, AlSabilah JF, et al. Operative safety and oncologic outcomes in rectal cancer based on the level of inferior mesenteric artery ligation: a stratified analysis of a large Korean cohort. Ann Surg Treat Res. 2019 Nov;97(5):254–260. DOI: 10.4174/astr.2019.97.5.254 Epub 2019 Nov 1.

8. Chen JN, Liu Z, Wang ZJ, Zhao FQ, et al. Low ligation has a lower anastomotic leakage rate after rectal cancer surgery. World J Gastrointest Oncol. 2020 Jun 15;12(6):632–641. DOI: 10.4251/wjgo.v12.i6.632

9. Dimitriou N, Felekouras E, Karavokyros I, Pikoulis E, et al. High versus low ligation of inferior mesenteric vessels in rectal cancer surgery: A retrospective cohort study. J BUON. 2018 Sep-Oct;23(5):1350–1361.

10. Draginov A, Chesney TR, Quereshy HA, Chadi SA, et al. Association of high ligation versus low ligation of the inferior mesenteric artery on anastomotic leak, postoperative complications, and mortality after minimally invasive surgery for distal sigmoid and rectal cancer. Surg Endosc. 2020 Oct;34(10):4593–4600. DOI: 10.1007/s00464-019-07203-0 Epub 2019 Oct 22.

11. Feng W, Zong Y, Zhao J, Li W, et al. High versus low ligation of the inferior mesenteric artery during laparoscopic rectal cancer surgery: A prospective study of surgical and oncological outcomes. J Surg Oncol. 2021 May;123 Suppl 1:S76-S80. DOI: 10.1002/jso.26362 Epub 2021 Mar 2.

12. Fujii S, Ishibe A, Ota M, Watanabe K, et al. Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. BJS Open. 2018 Jun 8;2(4):195– 202. DOI: 10.1002/bjs5.71

13. Guo Y, Wang D, He L, Zhang Y, et al. Marginal artery stump pressure in left colic artery-preserving rectal cancer surgery: a clinical trial. ANZ J Surg. 2017 Jul;87(7–8):576–581. DOI: 10.1111/ans.13032 Epub 2015 Feb 23.

14. Kim CS, Kim S. Oncologic and Anastomotic Safety of Low Ligation of the Inferior Mesenteric Artery With Additional Lymph Node Retrieval: A Case-Control Study. Ann Coloproctol. 2019 Aug;35(4):167–173. DOI: 10.3393/ac.2018.10.09 Epub 2019 Aug 31. PMID: 31487763;

15. Lee KH, Kim JS, Kim JY. Feasibility and oncologic safety of low ligation of inferior mesenteric artery with D3 dissection in cT3N0M0 sigmoid colon cancer. Ann Surg Treat Res. 2018 Apr;94(4):209–215. DOI: 10.4174/astr.2018.94.4.209 Epub 2018 Mar 26.

16. Luo Yang, Yu MH, Huang YZ, Jing R, et al. Lymphadenectomy Around Inferior Mesenteric Artery in Low-Tie vs High-Tie Laparoscopic Anterior Resection: Short- and Long-Term Outcome of a Cohort of 614 Rectal Cancers. Cancer Manag Res. 2021 May 14;13:3963–3971. DOI: 10.2147/CMAR.S282986

17. Luo Yuwen, Li R, Wu D, Zeng J, et al. Long-term oncological outcomes of low anterior resection for rectal cancer with and without preservation of the left colic artery: a retrospective cohort study. BMC Cancer. 2021 Feb 17;21(1):171. DOI: 10.1186/s12885-021-07848-y

18. Mari GM, Crippa J, Cocozza E, Berselli M, et al. Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection for Rectal Cancer Reduces Genitourinary Dysfunction: Results From a Randomized Controlled Trial (HIGHLOW Trial). Ann Surg. 2019 Jun;269(6):1018–1024. DOI: 10.1097/SLA.0000000000002947

19. Matsuda K, Yokoyama S, Hotta T, Takifuji K, et al. Oncological Outcomes following Rectal Cancer Surgery with High or Low Ligation of the Inferior Mesenteric Artery. Gastrointest Tumors. 2017 Sep;4(1– 2):45–52. DOI: 10.1159/000477805 Epub 2017 Jul 5.

20. Nayeri M, Iskander O, Tabchouri N, Artus A, et al. Low Tie Compared to High Tie Vascular Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery Decreases Postoperative Complications Without Affecting Overall Survival. Anticancer Res. 2019 Aug;39(8):4363–4370. DOI: 10.21873/anticanres.13605

21. Park SS, Park B, Park EY, Park SC, et al. Outcomes of high versus low ligation of the inferior mesenteric artery with lymph node dissection for distal sigmoid colon or rectal cancer. Surg Today. 2020 Jun;50(6):560– 568. DOI: 10.1007/s00595-019-01942-2 Epub 2020 Jan 6.

22. Qi Z, Zheng W, Daorong W. Routine high ligation versus low ligation of inferior mesenteric artery with lymphadenectomy in laparoscopic rectal anterior resection: A single-center research. Asian J Surg. 2020 Aug;43(8):835–837. DOI: 10.1016/j.asjsur.2020.03.011 Epub 2020 Apr 3.

23. You X, Liu Q, Wu J, Wang Y, et al. High versus low ligation of inferior mesenteric artery during laparoscopic radical resection of rectal cancer: A retrospective cohort study. Medicine (Baltimore). 2020 Mar;99(12):e19437. DOI: 10.1097/MD.0000000000019437

24. Zhang C, Chen L, Cui M, Xing J, et al. Short- and long-term out-comes of rectal cancer patients with high or improved low ligation of the inferior mesenteric artery. Sci Rep. 2020 Sep 18;10(1):15339. DOI: 10.1038/s41598-020-72303-0

25. Lowry AC, Simmang CL, Boulos P, Farmer KC, et al. Consensus statement of definitions for anorectal physiology and rectal cancer. ANZ J Surg. 2001 Oct;71(10):603–5. DOI: 10.1046/j.1445-2197.2001.02204.x

26. 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 Nov-Dec;21(6):361–4. DOI: 10.3322/canjclin.21.6.361

27. Moynihan BGA., et al. The surgical treatment of cancer of the sigmoid flexure and rectum. Surg Gynecol Obstet. 1908;6:463–6.

28. Zeng J, Su G. High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis. World J Surg Oncol. 2018 Aug 2;16(1):157. DOI: 10.1186/s12957-018-1458-7

29. Rutegård M, Hemmingsson O, Matthiessen P, Rutegård J. High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage. Br J Surg. 2012 Jan;99(1):127–32. DOI: 10.1002/bjs.7712 Epub 2011 Oct 28.

30. Moriya Y. Function preservation in rectal cancer surgery. Int J Clin Oncol. 2006 Oct;11(5):339–43. DOI: 10.1007/s10147-006-0608-z

31. Nesbakken A, Nygaard K, Bull-Njaa T, Carlsen E, et al. Bladder and sexual dysfunction after mesorectal excision for rectal cancer. Br J Surg. 2000 Feb;87(2):206–10. DOI: 10.1046/j.1365-2168.2000.01357.x

32. Guraya SY. Optimum level of inferior mesenteric artery ligation for the left-sided colorectal cancer. Systematic review for high and low ligation continuum. Saudi Med J. 2016 Jul;37(7):731–6. DOI: 10.15537/smj.2016.7.14831

33. Cirocchi R, Trastulli S, Farinella E, Desiderio J, et al. High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed. Surg Oncol. 2012 Sep;21(3):e111–23. DOI: 10.1016/j.suronc.2012.04.004 Epub 2012 Jul 6.

34. Hida J, Okuno K. High ligation of the inferior mesenteric artery in rectal cancer surgery. Surg Today. 2013 Jan;43(1):8–19. DOI: 10.1007/s00595-012-0359-6 Epub 2012 Oct 7.

35. Fan YC, Ning FL, Zhang CD, Dai DQ. Preservation versus non-preservation of left colic artery in sigmoid and rectal cancer surgery: A meta-analysis. Int J Surg. 2018 Apr;52:269–277. DOI: 10.1016/j.ijsu.2018.02.054 Epub 2018 Mar 1.

36. Nano M, Dal Corso H, Ferronato M, Solej M, et al. Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations. Dig Surg. 2004;21(2):123–6; discussion 126-7. DOI: 10.1159/000077347 Epub 2004 Mar 16.

37. Meyers MA. Griffiths’ point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon. AJR Am J Roentgenol. 1976 Jan;126(1):77–94. DOI: 10.2214/ajr.126.1.77

38. Rondelli F, Pasculli A, De Rosa M, Avenia S, et al. Is routine splenic flexure mobilization always necessary in laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive meta-analysis. Updates Surg. 2021 Oct;73(5):1643–1661. DOI: 10.1007/s13304-021-01135-y Epub 2021 Jul 24.

39. Chand M, Miskovic D, Parvaiz AC. Is splenic flexure mobilization necessary in laparoscopic anterior resection? Dis Colon Rectum. 2012 Nov;55(11):1195–7. DOI: 10.1097/DCR.0b013e3182687f10