The ideal level of ligation of the inferior mesenteric artery (IMA) during curative resection of sigmoid colon and rectal cancer is still controversial. The aim of this meta-analysis was to examine the impact of high ligation and low ligation of the IMA on anastomotic leakage, overall morbidity, postoperative mortality, and oncological outcomes in patients undergoing surgery for sigmoid colon and rectal cancer. PubMed, EMBASE, Web of Science, and BioMed Central databases were searched to identify relevant articles published from May 1953 to March 2018. A total of 18 articles (14 non-randomized studies and 4 randomized clinical trials) were identified. Review Manager 5.3 software was used for analysis of data. The pooled odds ratio (OR) and weighted mean difference (WMD), with 95% CI, were calculated using either the fixed effects model or random effects model. Of the 5917 patients included in this meta-analysis, 3652 patients underwent low ligation of the IMA and 2265 patients underwent high ligation of the IMA. Anastomotic leakage rate was 9.8% in high ligation patients vs. 7.0% in low ligation patients; the risk of anastomotic leakage was significantly higher in high ligation patients (OR = 1.33; 95% CI 1.10–1.62; P = 0.004). What is more, overall morbidity was also significantly higher in high ligation patients (OR = 1.39; 95% CI, 1.05–1.68; P = 0.05). Postoperative mortality, number of harvested lymph nodes, overall recurrence rate, and 5-year survival rate did not differ significantly between the two groups. Low ligation of the IMA during curative resection of sigmoid colon and rectal cancer appears to be associated with lower risk of anastomotic leakage and overall morbidity. However, there was no significant advantage of low ligation over high ligation of IMA in terms of postoperative mortality, the number of harvested lymph nodes, overall recurrence rate, or 5-year survival rate.

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High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis

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 andomized 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. PROSPERO registration number: CRD42019148626.

Meta-analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing High and Low Ligation of the Inferior Mesenteric Artery in Rectal Cancer Surgery.

The aim of the present meta-analysis compared left colic artery (LCA) preservation with non-preservation in laparoscopic resection of rectal cancer in terms of feasibility, efficacy and safety The PubMed, Ovid, Embase, Web of Science, CBM, CNKI, VIP and WanFang Data databases were searched prior to June 2017 for studies comparing LCA preservation and non-preservation in laparoscopic resection for rectal cancer Two researchers screened the literature independently, extracted the data and evaluated the risk of bias The study was performed using RevMan 53 software for meta-analysis A total of 10 studies comparing LCA preservation and non-preservation in laparoscopic resection for rectal cancer were selected for this meta-analysis, with a combined study population of 1,471 patients The results of the meta-analysis demonstrated that, when comparing LCA preservation with non-preservation in laparoscopic resection for rectal cancer, there were significant differences between the two groups in terms of operative time (P<001), estimated blood loss (P<001), percentage of neostomy (P<001), the number of retrieved lymph nodes (P<001), time to first postoperative exhaust (P<001) and amount of anastomotic leakage (P<001) However, there were no significant differences in postoperative hospital stay (P=028), incidence of recurrence (P=073) and incidence of metastasis (P=052) Therefore, compared with LCA non-preservation, patients in whom the LCA was preserved during laparoscopic resection for rectal cancer had a better prognosis However, there was no difference in recurrence or metastasis between the two groups Although the operative time and estimated blood loss were increased with LCA preservation, these may be reduced with improving proficiency of the operating surgeons The conclusions of the present study require verification by larger samples and high-quality randomized controlled trials

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Evaluation of the clinical efficacy of preserving the left colic artery in laparoscopic resection for rectal cancer: A meta-analysis.

Background Whether high or low ligation of the inferior mesenteric artery (IMA) is superior in surgery for rectal and sigmoid colon cancers remains controversial. Although several meta-analyses have been conducted, the level of lymph node clearance was poorly defined. We performed a meta-analysis comparing high and low ligation of the IMA for sigmoid colon and rectal cancers, with emphasis on high dissection of the lymph node at the IMA root in all the included studies. Methods PubMed, MEDLINE, and EMBASE databases were searched to identify relevant articles published until 2020. The patient’s perioperative and oncologic outcomes were analyzed. Statistical analysis was performed using the statistical software RevMan version 5.4. Results A total of 17 studies, including four randomized control trials, published between 2011 and 2020 were selected. In total, 1,846 patients received low ligation of the IMA plus high dissection of lymph nodes (LL+HD) and 2,648 patients received high ligation of the IMA (HL). LL+HD was associated with low incidence of anastomotic leakage (P < 0.001), borderline long operative time (P = 0.06), less yields of total lymph nodes (P = 0.03) but equivalent IMA root lymph nodes (P = 0.07); moreover, LL+HD exhibited noninferior long-term oncological outcomes. Conclusion In comparison with HL, LL+HD was an effective and safe oncological procedure for sigmoid colon and rectal cancers. Therefore, to ligate IMA below the level of left colic artery with D3 high dissection for sigmoid colon and rectal cancers might be suggested once the surgeons are familiar with this technique. Protocol registration This meta-analysis was registered on INPLASY (registration number 202190029).

Low Ligation Plus High Dissection Versus High Ligation of the Inferior Mesenteric Artery in Sigmoid Colon and Rectal Cancer Surgery: A Meta-Analysis.

The level of ligation of the inferior mesenteric artery (IMA) is a critical factor that can influence outcomes. The aim of this meta-analysis was to compare outcomes following high or low ligation of IMA. A systematic search was performed for relevant articles published between 2000 and 2020. Meta-analysis was performed using fixed-effects or random-effects models; 31 studies were included. Results show significantly lower rates of anastomotic leak, postoperative morbidity and urinary dysfunction with low ligation compared with high ligation. Though recurrence rates were similar, 5-year overall survival was longer in the low ligation group. Low ligation of IMA decreases anastomotic leak rates and overall morbidity. Addition of IMA nodal clearance to low ligation appears to improve overall survival in colorectal cancer.

Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: a systematic review and meta-analysis.

Objective: To evaluate the value and feasibility of preservation of the left colonic artery (LCA) in laparoscopic anterior resection for rectal cancer. Methods: The clinical data of 97 patiens who received laparoscopic anterior resection of rectal cancer from 2009.3 to 2015.3 were randomly divided into two groups, including 52 cases with preservation of LCA and 45 cases without preservation of LCA. The operation time, quantity of bleeding, number of lymph nodes removed around the root of inferior mesenteric artery (IMA), the rate of lymph node metastasis around the root of IMA, the incidence of transverse colostomy and anastomotic leak were compared between the two groups. Results: All 97 operations were successfully completed by laparoscopic operation. There were significantly statistical differences in operation time, quantity of bleeding and transverse colon stoma between two groups(P<0.05), but no difference in the number of lymph nodes removed and the rate of lymph node metastasis. Conclusions: The preservation of the left colonic artery in laparoscopic anterior resection of rectal cancer can preserve more supplying vessels for anastomosis and prevent anastomotic leak.

D G Cai

Papers

Clinical effect of preservation of the left colonic artery in laparoscopic anterior resection for rectal cancer