Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study

Impact of Low Ligation on Bowel Perfusion and Anastomotic Leakage in Minimally Invasive Rectal Cancer Surgery: A Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Whether the level of the inferior mesenteric artery ligation affects the incidence of anastomotic leakage remains unclear.

OBJECTIVE

To assess the impact of the level of inferior mesenteric artery ligation on blood flow to the anastomotic site and the incidence of anastomotic leakage using indocyanine green fluorescence imaging.

DESIGN

A post hoc analysis of the EssentiAL trial.

SETTINGS

This study was conducted at 41 tertiary referral centers in Japan.

PATIENTS

A total of 839 patients with rectal cancer (<12 cm from the anal verge) were included.

MAIN OUTCOME MEASURES

The incidence of anastomotic leakage and perfusion status were compared between the high and low ligation groups.

RESULTS

The median fluorescence time was similar at 25 seconds in both groups (p = 0.74). Although no statistical difference was noted, the high ligation group was more likely to have greater outliers in fluorescence time compared to the low ligation group. The high ligation group demonstrated higher poor perfusion rates than the low ligation group (2.8% vs 1.5%). In the high ligation group, anastomotic leakage occurred in 1 case of poor perfusion where additional resection was not performed by the surgeon's intraoperative judgment. In addition, the additional resection rate nearly doubled with the use of indocyanine green fluorescence imaging. After propensity score matching (129 patients per group), the overall anastomotic leakage rate was 13.2% in the high ligation group and 10.9% in the low ligation group ( p = 0.57).

LIMITATIONS

This study was a post hoc analysis, the sample size was small, and the anastomosis methods varied.

CONCLUSIONS

The level of inferior mesenteric artery ligation did not affect blood flow at the anastomotic site or the incidence of anastomotic leakage statistically, but assessing bowel perfusion using indocyanine green fluorescence imaging can offer clinical benefits, optimizing patient outcomes. See Video Abstract .

TRIAL REGISTRATION

The Japan Registry of Clinical Trials (jRCTs-CRB3180007), the Japanese Clinical Trials Registry (UMIN-CTR000030240).

IMPACTO DE LA LIGADURA BAJA EN LA PERFUSIN INTESTINAL Y LA FUGA ANASTOMTICA EN LA CIRUGA MNIMAMENTE INVASIVA DEL CNCER RECTAL UN ANLISIS POST HOC DE UN ENSAYO CONTROLADO ALEATORIZADO

ANTECEDENTES:No está claro si el nivel de la ligadura de la arteria mesentérica inferior afecta la incidencia de fuga anastomótica.OBJETIVO:Evaluar el impacto del nivel de ligadura de la arteria mesentérica inferior en el flujo sanguíneo al sitio de la anastomosis y la incidencia de fuga anastomótica mediante imágenes de fluorescencia con verde de indocianina.DISEÑO:Análisis post hoc del ensayo EssentiAL.ESCENARIO:Este estudio se realizó en 41 centros de referencia terciarios en Japón.PACIENTES:839 pacientes con cáncer rectal (<12 cm desde el márgen anal).PRINCIPALES MEDIDAS DE RESULTADOS:Se compararon la incidencia de fuga anastomótica y el estado de perfusión entre los grupos de ligadura alta y baja.RESULTADOS:El tiempo de fluorescencia medio fue similar a 25 segundos en ambos grupos (p = 0.74). Aunque no se observó ninguna diferencia estadística, el grupo de ligadura alta tuvo más probabilidades de tener mayores valores atípicos en el tiempo de fluorescencia en comparación con el grupo de ligadura baja. El grupo de ligadura alta demostró tasas de perfusión deficiente más altas que el grupo de ligadura baja (2.8 % frente a 1.5 %). En el grupo de ligadura alta, se produjo una fuga anastomótica en un caso de perfusión deficiente en el que no se realizó una resección adicional según el criterio intraoperatorio del cirujano. Además, la tasa de resección adicional casi se duplicó con el uso de imágenes de fluorescencia con verde de indocianina. Después de la comparación por puntaje de propensión (129 pacientes por grupo), la tasa general de fuga anastomótica fue del 13.2 % en el grupo de ligadura alta y del 10.9 % en el grupo de ligadura baja ( p = 0.57).LIMITACIONES:Este estudio fue un análisis post hoc, el tamaño de la muestra fue pequeño y los métodos de anastomosis variaron.CONCLUSIONES:El nivel de ligadura de la arteria mesentérica inferior no afectó estadísticamente el flujo sanguíneo en el sitio de la anastomosis ni la incidencia de fuga anastomótica, pero la evaluación de la perfusión intestinal mediante imágenes de fluorescencia con verde de indocianina puede ofrecer beneficios clínicos, optimizando los resultados del paciente. (Traducción-Dr. Jorge Silva Velazco)REGISTRO DEL ENSAYO:Registro japonés de ensayos clínicos (jRCTs-CRB3180007), Registro japonés de ensayos clínicos (UMIN-CTR000030240).

Short-term outcomes of vessel-oriented D2 and D3 lymph node dissection for sigmoid colon cancer

BACKGROUND

Level of lymph nodes dissection (LND) and inferior mesenteric artery (IMA) ligation is still matter of debate of radical resection of colorectal cancer. This study aims to compare the short-term outcome of three different surgical techniques to treat sigmoid cancer: low ligation (LL) of the IMA with D3-LND, low IMA ligation with D2-LND, and high ligation (HL) of the IMA with D3-LND.

METHODS

Patients affected by sigmoid colon cancer, who underwent radical resection with three different techniques (LL and D3-LND Group A, HL and D3-LND Group B, and LL with D2 LND- Group C), were included. Operative time (min), blood loss (ml), early postoperative complications, and number of harvested lymph nodes were compared.

RESULTS

Thirty patients per group were enrolled. The median operation time was shorter in group C (130 min, interquartile range [IQR] 120-140), compared with the 245 min (IQR 193.8-295.5) of group A and 257 min (IQR 183-345) of group B, p < 0.005. No significant differences between A and B group were observed in the median intraoperative blood loss, while group C had higher intraoperative blood loss (200 ml, IQR 200-260, p = 0.002). Anastomotic leak occurred in three patients belonging to group B. A reduced number of harvested lymph nodes was registered in Group C (14 lymph nodes, IQR 10-17), p < 0.005.

CONCLUSIONS

Both high and low tie ligation with D3-LND for sigmoid cancer can be considered safe and feasible with low rate of postoperative complications, allowing a higher number of harvested lymph nodes compared to low tie ligation with D2 lymphadenectomy.

Construction of a nomogram based on clinicopathologic features to predict the likelihood of No. 253 lymph node metastasis in rectal cancer patients

PURPOSE

To explore the high-risk factors for rectal cancer No.253 lymph node metastasis (LNM) and to construct a risk nomogram for the individualized prediction of No.253 LNM.

METHODS

This was a retrospective analysis of 425 patients with rectal cancer who underwent laparoscopic-assisted radical surgery. Independent risk factors for rectal cancer No.253 LNM was identified using multivariate logistic regression analysis, and a risk prediction nomogram was constructed based on the independent risk factors. In addition, the performance of the model was evaluated by discrimination, calibration, and clinical benefit.

RESULTS

Multivariate logistic regression analysis showed that No.253 lymphadenectasis on CT (OR 10.697, P < 0.001), preoperative T4-stage (OR 4.431, P = 0.001), undifferentiation (OR 3.753, P = 0.004), and preoperative Ca199 level > 27 U/ml (OR 2.628, P = 0.037) were independent risk factors for No.253 LNM. A nomogram was constructed based on the above four factors. The calibration curve of the nomogram was closer to the ideal diagonal, indicating that the nomogram had a better fitting ability. The area under the ROC curve (AUC) was 0.865, which indicated that the nomogram had high discriminative ability. In addition, decision curve analysis (DCA) showed that the model could show better clinical benefit when the threshold probability was between 1% and 50%.

CONCLUSION

Preoperative No.253 lymphadenectasis on CT, preoperative T4-stage, undifferentiation, and elevated preoperative Ca199 level were found to be independent risk factors for the No.253 LNM. A predictive model based on these risk factors can help surgeons make rational clinical decisions.

A nomogram for predicting lymph nodes metastasis at the inferior mesenteric artery in rectal cancer: a retrospective case-control study

According to past and current literature, metastasis of the lymph nodes at the inferior mesenteric artery (IMA-LN), also known as 253LN of colorectal cancer has been seldom investigated. To date, there are still controversies on whether the 253LN need to be routinely cleaned. Using specific criteria, 347 patients who underwent radical resection for rectal cancer between April 2019 and July 2022 were selected for the study. Logistic regression was used to determine the likelihood that a patient may suffer 253LN metastasis, and a nomogram for 253LN metastasis subsequently developed. The c-index and calibration curve were used to evaluate precision and discrimination in the nomogram, and the appropriateness of the final nomogram for the clinical setting determined using decision curve analysis (DCA). 253LN metastases appeared in the pathological specimens of 29 (8.4%) of the selected patients. Logistic regression showed that preoperative parameters including serum carcinoembryonic antigen (CEA) value ( > 5 ng / ml, OR = 2.894, P = 0.023), distance from anal margin (> 9 cm, OR = 2.406, P = 0.045) and degree of differentiation (poor, OR = 9.712, P < 0.001) were significantly associated with 253LN metastasis. A nomogram to predict 253LN metastasis in rectal cancer was developed and showed considerable discrimination and good precision (c-index = 0.750). Furthermore, DCA confirmed that the nomogram has some feasibility for the clinical environment. Clinicopathological and radiological patient data can be pivotal for making surgical decisions relating to 253LN metastasis. A nomogram was developed using this data, providing an objective method that can significantly improve prognoses in colorectal cancer.

The Atlas of the Inferior Mesenteric Artery and Vein under Maximum-Intensity Projection and Three-Dimensional Reconstruction View

(1) Background: Understanding vascular patterns is crucial for minimizing bleeding and operating time in colorectal surgeries. This study aimed to develop an anatomical atlas of the inferior mesenteric artery (IMA) and vein (IMV). (2) Methods: A total of 521 patients with left-sided colorectal cancer were included. IMA and IMV patterns were identified using maximum-intensity projection (MIP) and three-dimensional (3D) reconstruction techniques. The accuracy of these techniques was assessed by comparing them with surgical videos. We compared the amount of bleeding and operating time for IMA ligation across different IMA types. (3) Results: Most patients (45.7%) were classified as type I IMA, followed by type II (20.7%), type III (22.6%), and type IV (3.5%). Newly identified type V and type VI patterns were found in 6.5% and 1% of patients, respectively. Of the IMVs, 49.9% drained into the superior mesenteric vein (SMV), 38.4% drained into the splenic vein (SPV), 9.4% drained into the SMV-SPV junction, and only 2.3% drained into the first jejunal vein (J1V). Above the root of the left colic artery (LCA), 13.1% of IMVs had no branches, 50.1% had one, 30.1% had two, and 6.7% had three or more branches. Two patients had two main IMV branches, and ten had IMVs at the edge of the mesocolon with small branches. At the IMA root, 37.2% of LCAs overlapped with the IMV, with 34.0% being lateral, 16.9% distal, 8.7% medial, and both the marginal type of IMV and the persistent descending mesocolon (PDM) type represented 1.4%. MIP had an accuracy of 98.43%, and 3D reconstruction had an accuracy of 100%. Blood loss and operating time were significantly higher in the complex group compared to the simple group for IMA ligation (p < 0.001). (4) Conclusions: A comprehensive anatomical atlas of the IMA and IMV was provided. Complex IMA patterns were associated with increased bleeding and operating time.

Complete mesocolic excision for right colon cancer: Is D3 lymphadenectomy necessary?

AIM

Although complete mesocolic excision (CME) for colon cancer is oncologically sound, to date, there has been no consensus on the extent of lymphadenectomy in radical right colectomy. This study essentially compared the perioperative and survival outcomes of CME with two templates of lymphadenectomy for right colon cancer.

METHOD

This was a propensity matched, retrospective analysis of a single centre, prospectively maintained database of all patients undergoing elective right colectomy for nonmetastatic, biopsy-proven adenocarcinoma from November 2013 to October 2018. CME + D3 was adopted selectively, documented prospectively, and compared with patients undergoing CME + central vascular ligation (CVL). The only technical difference between the groups was the excision of the surgical trunk of Gillot in the CME + D3 group. Postoperative, long-term outcomes and patterns of recurrence were compared between the groups.

RESULTS

Of the 244 eligible patients, 88 (36.1%) and 156 (63.9%) underwent CME + D3 and CME + CVL, respectively. Matched groups (72 [CME + D3] vs. 108 [CME + CVL]) showed no difference in histology, tumour grade, postoperative complications, mortality, and hospital stay. CME + D3 was preferentially performed laparoscopically (35.2% vs. 9%), was associated with lower blood loss (215 mL vs. 297 mL, p = 0.001), higher nodal yield (31 vs. 25 nodes, p = 0.003) and a higher incidence of chyle leak (4 vs. 0, p = 0.013). At a median follow-up of more than 57 months, there was no significant difference in local recurrence, disease-free or overall survival.

CONCLUSION

In this retrospective study, lymphadenectomy along the superior mesenteric vein, as a component of CME for right colon cancer, offered a higher nodal yield with no improvement in oncological outcome. Dissection of the SMV, over and above a D2 dissection, could therefore be restricted to specialized colorectal units until further studies establish the incremental oncological benefit of this extended lymphadenectomy or define a patient group in whom it is beneficial.

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

Within the intricate field of rectal cancer surgery, the contentious debate over the optimal level of ligation of the inferior mesenteric artery (IMA) persists as an ongoing discussion, influencing surgical approaches and patient outcomes. This narrative review incorporates historical perspectives, technical considerations, and functional as well as oncological outcomes, addressing key questions related to anastomotic leakage risks, genitourinary function, and oncological concerns, providing a more critical understanding of the well-known inconclusive evidence. Beyond the dichotomy of high versus low tie, it navigates the complexities of colorectal cancer surgery with a fresh perspective, posing a transformative question: "Is low tie ligation truly reproducible?" Considering a multidimensional approach that enhances patient outcomes by integrating the surgeon, patient, technique, and technology, instead of a rigid and categorical statement, we argued that a balanced response to this challenging question may require compromise.

Comparison of the short-term and long-term outcomes of three different types of inferior mesenteric artery ligation in left colonic and rectal cancers: a network meta-analysis

To perform a network meta-analysis of the literature to assess the short-term and long-term outcomes of three operations for left colon and rectal cancer. Electronic literature searches were performed in the PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials databases up to August 2022. A Bayesian network meta-analysis using R software, ADDIS, and Review Manager 5.4 was conducted to compare outcomes of high ligation of the inferior mesenteric artery(IMA),low ligation of the IMA with D2 dissection (LLD2), and low ligation of the IMA with D3 dissection (LLD3). Sensitivity analysis was applied to investigate the influence of each primary study on the final result of the meta-analysis. Asymmetry of data was estimated by using Egger's tests. Publication bias corrected by trimming and filling method. A total of 44 studies, 5 randomized clinical trials (RCTs) and 39 non-RCTs, were included in this meta-analysis. HL was associated with a higher risk of anastomotic leakage (HL vs. LLD2, OR = 1.35, 95% CI 1.13-3.25, P = 0.001; HL vs. LLD3, OR = 1.65, 95% CI 1.35-2.01, P < 0.001), and required a longer postoperative hospital stay (HL vs. LLD3, SMD = 0.28, 95%CI 0.09-0.48, P = 0.01).However HL showed an advantage in terms of operation time(HL vs. LLD3, SMD = - 0.13, 95%CI - 0.26 to 0.01, P = 0.04). LLD3 is most likely to rank best in terms of short-term and long-term outcomes after surgery for left colon and rectal cancer. Caution should be taken in the risk of anastomotic leakage when treating colorectal cancer with LLD2. HL, LLD2 and LLD3 provide similar overall survival rates for left colon and rectal cancer.

Efficacy of left colic artery preservation with D3 lymph node dissection in laparoscopic surgery for advanced sigmoid and rectal cancer

PURPOSE

For advanced left colon cancer, lymph node dissection at the root of the inferior mesenteric artery is recommended. Whether the left colic artery (LCA) should be preserved or resected remains contentious.

METHODS

The 367 patients who underwent laparoscopic sigmoidectomy or anterior resection and who were pathologically node-positive were reviewed. Patients were divided into LCA-preserving group (LCA-P, n = 60) and LCA-non-preserving group (LCA-NP, n = 307). Propensity score matching was applied to minimize selection bias and 59 patients were matched.

RESULTS

Before matching, the rates of poor performance status and cardiovascular disease were higher in the LCA-P group (p < 0.001). After matching, operation time was longer (276 vs. 240 min, p = 0.001), the frequency of splenic flexure mobilization (62.7% vs. 33.9%, p = 0.003) and lymphovascular invasion (84.7% vs. 55.9%, p = 0.001) was higher in the LCA-P group. Severe postoperative complications (CD ≥ 3) occurred only in the LCA-NP group (0% vs. 8.4%, p = 0.028). The median follow-up period was 38.5 months (range 2.0-70.0 months). The 5-year RFS rates (67.8% vs. 66.0%, p = 0.871) and OS rates (80.4% vs. 74.9%, p = 0.308) were comparable between the groups.

CONCLUSIONS

Laparoscopic LCA-sparing surgery for left-sided colorectal cancer reduces the risk of severe complications and offers a favorable long-term prognosis.

Level of Inferior Mesenteric Artery Ligation in Sigmoid Colon and Rectal Cancer Surgery: Analysis of Apical Lymph Node Metastasis and Recurrence

INTRODUCTION

Whether high or low ligation of the inferior mesenteric artery (IMA) is optimal for treating sigmoid colon and rectal cancers is controversial. The present study aimed to compare outcomes of high and low ligation of the IMA and determine the adequate extent of IMA lymph node dissection.

METHODS

Subjects were 455 consecutive stage I-III colorectal cancer patients who underwent curative surgery between 2011 and 2019. We assessed the association between the level of IMA ligation and overall survival and recurrence-free survival (RFS) by propensity score matching analysis. Clinicopathological features of IMA lymph node metastasis and recurrence patterns were analyzed.

RESULTS

After propensity score matching, the low ligation group had a significantly worse prognosis than that of the high ligation group for RFS (p = 0.039). Positive IMA lymph nodes were associated with pathological T3 or T4 stage and N2 stage. IMA lymph node recurrences in the high ligation group occurred at the superior left side of the IMA root. In contrast, all recurrences in the low ligation group occurred at the left colic artery bifurcation.

CONCLUSION

High ligation of IMA is oncologically safe. However, even with high ligation, care must be taken to ensure adequate lymph node dissection.

Impact on defecatory, urinary and sexual function after high-tie sigmoidectomy: a post-hoc analysis of a multicenter randomized controlled trial comparing extended versus standard complete mesocolon excision

OBJECTIVE

To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported.

METHODS

This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction.

RESULTS

Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, β =  - 0.54, p = 0.002; men β =  - 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046).

CONCLUSIONS

A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes.

TRIAL REGISTRATION

Clinical trials NCT03083951 HIGHLIGHTS: • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Inferior mesenteric artery ligation level in rectal cancer surgery: still no answer-a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis is to summarize the current scientific evidence regarding the impact of the level of inferior mesenteric artery (IMA) ligation on post-operative and oncological outcomes in rectal cancer surgery.

METHODS

We conducted a systematic review of the literature up to 06 September 2022. Included were RCTs that compared patients who underwent high (HL) vs. anterior (LL) IMA ligation for resection of rectal cancer. The literature search was performed on Medline/PubMed, Scopus, and the Web of Science without any language restrictions. The primary endpoint was overall anastomotic leakage (AL). Secondary endpoints were oncological outcomes, intraoperative complications, urogenital functional outcomes, and length of hospital stay.

RESULTS

Eleven RCTs (1331 patients) were included. The overall rate of AL was lower in the LL group, but the difference was not statistically significant (RR 1.43, 95% CI 0.95 to 2.96). The overall number of harvested lymph nodes was higher in the LL group, but the difference was not statistically significant (MD 0.93, 95% CI - 2.21 to 0.34). The number of lymph nodes harvested was assessed in 256 patients, and all had a laparoscopic procedure. The number of lymph nodes was higher when LL was associated with lymphadenectomy of the vascular root than when IMA was ligated at its origin, but there the difference was not statistically significant (MD - 0.37, 95% CI - 1.00 to 0.26). Overall survival at 5 years was slightly better in the LL group, but the difference was not statistically significant (RR 0.98, 95% CI 0.93 to 1.05). Disease-free survival at 5 years was higher in the LL group, but the difference was not statistically significant (RR 0.97, 95% CI 0.89 to 1.04).

CONCLUSIONS

There is no evidence to support HL or LL according to results in terms of AL or oncologic outcome. Moreover, there is not enough evidence to determine the impact of the level of IMA ligation on functional outcomes. The level of IMA ligation should be chosen case by case based on expected functional and oncological outcomes.

5 year oncological outcomes of the HIGHLOW randomized clinical trial

INTRODUCTION

The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled.

RESULTS

Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years.

CONCLUSION

We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis

BACKGROUND

Whether to ligate the inferior mesenteric artery at its root during anterior resection for sigmoid colon or rectal cancer is still under debate. This study compared the surgical outcomes, postoperative recovery, and anastomotic leakage between high and low ligation of the inferior mesenteric artery through a subgroup analysis.

METHODS

This was a retrospective analysis of prospectively collected data. All patients who underwent colorectal resection for rectosigmoid cancer between December 2016 and December 2019 were enrolled. According to the surgical ligation level of the inferior mesenteric artery, the patients were categorized into either the high or low ligation group. The investigated population was matched using the propensity score method.

RESULTS

Overall, 894 patients with sigmoid or rectal cancer underwent elective anterior resection with high (577 patients) or low (317 patients) ligation of the inferior mesenteric artery. After the propensity score matching, 245 patients in each group were compared. High ligation of the inferior mesenteric artery was associated with higher incidence of anastomotic leakage (14.9% vs. 5.6%, P = 0.041) for mid- to low-rectum tumors and a higher incidence of complications (8.6% vs. 3.3%, P = 0.013) of grades 1-2 according to the Clavien-Dindo classification system.

CONCLUSION

Compared with high ligation, low ligation of the inferior mesenteric artery resulted in lower likelihood of morbidity and mortality in rectal and sigmoid cancers. Moreover, low ligation was less likely to result in anastomosis leakage in mid- to low-rectal cancers.

High and low inferior mesenteric artery ligation in laparoscopic low anterior rectal resections: A retrospective study

Backgroud

The high or low inferior mesenteric artery (IMA) ligation in rectal cancer remains a great debate. This study retrospectively discussed the outcomes of the perioperative period, defecation and urinary function and long-term prognosis in rectal cancer patients with high or low IMA ligation.

Methods

This study enrolled 220 consecutive rectal cancer cases, including 134 with high IMA ligation and 86 with low ligation. A comparison between the two groups was made for anastomotic leakage, low anterior resection syndrome (LARS), international prostate symptom score (IPSS), 5-year disease-free survival (DFS) and 5-year overall survival (OS).

Results

Low-ligation group had a longer operative time, and larger intraoperative blood loss. No significant difference was noted in anastomotic leakage incidence. In multivariable analysis, the male gender and tumor located at the lower rectum were identified as risk factors for anastomotic leakage. No significant differences were observed between groups in their LARS and IPSS questionnaire responses. The high-ligation vs. the low-ligation 5-year OS and DFS were 78.3% vs. 82.4% and 72.4% vs. 76.6%, respectively, which were not statistically different.

Conclusion

The ligation level of the IMA had no significant effect on the anastomotic leakage incidence, defecation, urinary function, and long-term prognosis.

Short- and long-term outcomes of preservation versus ligation of the inferior mesenteric artery in laparoscopic D3 lymph node dissection for descending colon cancer: a propensity score-matched analysis

PURPOSE

This study aimed to compare the short- and long-term outcomes of laparoscopic D3 lymph node (LN) dissection between ligation of the inferior mesenteric artery (IMA) (LIMA) and preservation of the IMA (PIMA) for descending colon cancer using propensity score-matched analysis.

METHODS

This retrospective study included 101 patients with stage I-III descending colon cancer who underwent laparoscopic D3 LN dissection with LIMA (n = 60) or PIMA (n = 41) at a single center between January 2005 and March 2022. After propensity score matching, 64 patients (LIMA, n = 32; PIMA, n = 32) were included in the analysis. The primary endpoint was the long-term outcomes, and the secondary endpoint was the surgical outcomes.

RESULTS

In the matched cohort, no significant difference was noted in the surgical outcomes, including the operative time, estimated blood loss, number of harvested LNs, number of harvested LN 253, and complication rate. The long-term outcomes were also not significantly different between the LIMA and PIMA groups (3-year recurrence-free survival, 72.2% vs. 75.6%, P = 0.862; 5-year overall survival, 69.8% vs. 63.4%, P = 0.888; 5-year cancer-specific survival, 84.2% vs. 82.8%, P = 0.607). No recurrence of LN metastasis was observed around the IMA root.

CONCLUSION

Laparoscopic D3 dissection in PIMA was comparable to that in LIMA regarding both short- and long-term outcomes. The optimal LN dissection for descending colon cancer should be investigated in future large-scale studies.

D3 lymph node dissection with versus without left colic artery preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer: A propensity score-matched analysis

PURPOSE

In surgery for colorectal cancer, dissection of the lymph nodes and fatty tissue around the root of the inferior mesenteric artery is important from an oncologic point of view. However, it is debatable whether it is better to preserve or remove the left colic artery (LCA). This study aimed to compare D3 lymphadenectomy with versus without LCA preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer.

METHODS

A total of 1138 patients underwent surgery for colorectal cancer between April 2011 and December 2018 at Fukui Prefectural Hospital. This propensity score-matched retrospective study analyzed the data of 163 patients: 42 patients with LCA preservation (group A) and 129 without LCA preservation (group B). Clinical and oncological outcomes were compared between the two groups.

RESULTS

There were no significant differences between groups A and B in patient characteristics, surgical outcomes, including the 5-year overall survival rate (75% vs. 64.2%, hazard ratio [HR] 1.34, 95% confidence interval [CI] 0.37-4.30), 5-year disease-free survival rate (85.7% vs. 85.7%, HR 0.99, 95% CI 0.24-4.22), and 5-year cancer-specific survival rate (92.8% vs. 89.3%, HR 1.50, 95% CI 0.25-11.4).

CONCLUSION

There were no significant differences in the short- and long-term outcomes of patients who underwent single-incision laparoscopic surgery with D3 lymphadenectomy with versus without LCA preservation. This suggests that LCA preservation is safe and feasible in single-incision laparoscopic surgery for sigmoid and rectosigmoid colon cancer.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer

INTRODUCTION

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

METHODS

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

RESULTS

Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework.

CONCLUSION

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Does the level of inferior mesenteric artery ligation affect short-term and long-term outcomes of patients with sigmoid colon cancer or rectal cancer? A single-center retrospective study

Background

For sigmoid colon or rectal cancer, a definite consensus regarding the optimal level ligating the inferior mesenteric artery (IMA) has not been reached. We performed this study to determine whether the ligation level significantly affected short-term and long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.

Methods

Medical records of patients with sigmoid colon or rectal cancer who had undergone curative laparoscopic surgery between January 2008 and December 2014 at the Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine were reviewed. Then, the high tie group (HTG) was compared with the low tie group (LTG) in terms of short-term and long-term outcomes.

Results

Five-hundred ninety patients were included. No significant differences between two groups regarding baseline characteristics existed. HTG had a significantly higher risk of anastomotic fistula than LTG (21/283 vs 11/307, P = 0.040). Additionally, high ligation was proven by multivariate logistic regression analysis to be an independent factor for anastomotic fistula (P = 0.038, OR = 2.232, 95% CI: 1.047–4.758). Furthermore, LT resulted in better preserved urinary function. However, LTG was not significantly different from HTG regarding operative time (P = 0.075), blood transfusion (P = 1.000), estimated blood loss (P = 0.239), 30-day mortality (P = 1.000), ICU stay (P = 0.674), postoperative hospital stay (days) (P = 0.636), bowel obstruction (P = 0.659), ileus (P = 0.637), surgical site infection (SSI) (P = 0.121), number of retrieved lymph nodes (P = 0.501), and number of metastatic lymph nodes (P = 0.131). Subsequently, it was revealed that level of IMA ligation did not significantly influence overall survival (OS) (P = 0.474) and relapse-free survival (RFS) (P = 0.722). Additionally, it was revealed that ligation level did not significantly affect OS (P = 0.460) and RFS (P = 0.979) of patients with stage 1 cancer, which was also observed among patients with stage 2 or stage 3 cancer. Ultimately, ligation level was not an independent predictive factor for either OS or RFS.

Conclusions

HT resulted in a significantly higher incidence of anastomotic fistula and worse preservation of urinary function. Level of IMA ligation did not significantly affect long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.

Laparoscopic Sigmoidectomy for Sigmoid Cancer With Persistent Descending Mesocolon: Anatomical Characteristics and Technical Tips

Although rare, persistent descending mesocolon (PDM) is an anatomical anomaly that carries potential risks for laparoscopic colorectal surgery. Impaired blood circulation of the reconstructed colon is especially risky during surgery. We report a case of sigmoid cancer with PDM, in which the patient underwent laparoscopic sigmoidectomy.

A 52-year-old man diagnosed with sigmoid cancer was referred to our hospital. PDM was identified with preoperative enhanced-contrast computed tomography, which revealed the sigmoid colon located in the right lower quadrant and a bear-claw inferior mesenteric artery (IMA). Preoperative examination showed cT1N0M0 stage I (Union for International Cancer Control {UICC} eighth). We were not able to identify the branches of IMA after the medial-to-lateral approach. We divided the mesentery and marginal artery and the main branches from IMA extracorporeally prior to lymphadenectomy. Each oral and anal side was dissected without touching the tumor. Then, we marked the line for lymphadenectomy using the dissected line of mesentery as an intracorporeal landmark. Pathological findings showed pT1N0M0 stage I (UICC eighth edition). The patient was discharged without complications.

Using this approach and the preoperative recognition of PDM, we performed laparoscopic sigmoidectomy with lymphadenectomy for early-stage PDM case successfully and safely. Our mesocolon dissection-first approach could be a feasible and safer approach for early-stage sigmoid cancer.

Usefulness of Computed Tomography Angiography in the Preoperative Workup of Patients With Colorectal Cancer

OBJECTIVES

The objective of this study is to analyze the main patterns of branching of the inferior mesenteric artery (IMA) and to determine if your knowledge changes the surgical strategy in the colorectal cancer.

METHODS

This retrospective study included 63 patients with cancer of the sigmoid or rectum. We assessed the patterns of IMA in 3 subtypes: type A (independent left colic artery [LCA]), type B (LCA and sigmoid artery arising in a common trunk) and type C (LCA, sigmoid artery, and superior rectal artery with a common origin). Colorectal surgeons evaluated how the vascular map changed the type of IMA ligation.

RESULTS

Inferior mesenteric artery branching was classified as type A in 55.6% patients, type B in 23.8%, and type C in 20.6%. Knowledge of the vascular map changed the type of ligation from high to low in 20 of the 50 patients who were candidates for surgery. The change was possible in tumors located in the sigmoid colon and the rectosigmoid junction with the type A or B branching.

CONCLUSIONS

Preoperative Multidetector Computed Tomography angiography can define the pattern of IMA branching. Based on this information, a low ligation can be performed in tumors located in sigmoid colon and rectosigmoid junction with IMA branching types A and B.

A study on spinal level, length, and branch type of the inferior mesenteric artery and the position relationship between the inferior mesenteric artery, left colic artery, and inferior mesenteric vein

Background

This study was aimed to explore the clinical application of dual-energy computed tomography (DECT) monoenergetic plus (mono+) imaging to evaluate anatomical variations in the inferior mesenteric artery (IMA).

Methods

The clinical and imaging data of 212 patients who had undergone total abdominal DECT were retrospectively analyzed. The post-processing mono+ technique was used to obtain 40-keV single-level images in the arterial phase. Three-dimensional reconstruction was performed to evaluate the relationship between the IMA root position and the spinal level, IMA length, and IMA branch type, as well as the position of the left colic artery (LCA) and inferior mesenteric vein (IMV) at the IMA root level.

Results

The IMA root was located at the L3 level in 78.3% of cases and at the L2/L3 level in 3.3%. The highest vertebral level of IMA origin was L2 (4.2%), and the lowest was L4 (7.1%). The distance from the IMA root to the level of the sacral promontory was 99.58 ± 13.07 mm, which increased with the elevation of the IMA root at the spinal level. Of the patients, 53.8% demonstrated Type I IMA, 23.1% Type II, 20.7% Type III, and 2.4% Type IV. The length of the IMA varied from 13.6 to 66.0 mm. 77.3% of the IMAs belonged to Type A, the adjacent type, and 22.7% to Type B, the distant type.

Conclusion

DECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA and the positional relationship between the LCA and IMV at the IMA root level, which would help clinicians plan individualized surgery for patients.

DECT mono+ optimal energy level can preoperatively determine the position of the IMA root.

DECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA.

DECT mono+ can preoperatively determine the positional relationship between the LCA and IMV at the IMA root level.

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR). Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis. Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation. Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Level of inferior mesenteric artery ligation does not affect rectal cancer treatment outcomes despite better cancer-specific survival after low ligation-randomized trial results

AIM

In rectal cancer surgery, the problem about which of the mesenteric artery ligation variants (high or low) is more beneficial to the patient remains unsolved. Recent meta-analyses suggest that the risk of surgical complications is similar for both ligation variants. The main objective was to compare the survival time in both groups with a minimum 48 months' follow-up. Secondary objectives were comparison of the number of harvested lymph nodes, the complication rate and other selected data related to the surgery.

METHOD

This was a randomized, single-centre, unblinded clinical trial of adult patients (n = 130) with cT1-3M0/ycT0-3M0 rectal and rectosigmoid junction adenocarcinoma undergoing radical open surgery. The intervention level was inferior mesenteric artery ligation.

RESULTS

The mean and median survival in the whole group was 45 months, while in the survivor group it was 83 and 82 months. The survival for 1-5 years, overall survival and disease-free survival were similar in both groups. The cancer-specific survival time was longer in the low inferior mesenteric artery ligation group (P = 0.005 for all and P = 0.02 for pTNM Stage III patients) There were no differences in the incidence of anastomotic leakage and overall morbidity. The median number of lymph nodes located at the root of the inferior mesenteric artery was 1; the mean was 1.7. They were not metastatic in any case. The median total number of harvested nodes was similar in both groups.

CONCLUSIONS

In radically treated adenocarcinoma of the rectum and the rectosigmoid junction, the level of inferior mesenteric artery ligation below the left colic artery branch provides similar treatment results to inferior mesenteric artery ligation just below its branching from the aorta in relation to overall and disease-free survival, and the risk of complications. Low inferior mesenteric artery ligation results in better cancer-specific survival. The risk of metastases at the mesenteric nodes is negligible.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Clinical effect and standardization of indocyanine green angiography in the laparoscopic colorectal surgery

Anastomotic complications occur after 5% to 20% of operations for rectosigmoid colon cancer. The intestinal perfusion status at the anastomotic site is an important modifiable risk factor, and surgeons should carefully evaluate and optimize the perfusion at the intended site of anastomosis. Indocyanine green (ICG) angiography is a simple noninvasive perfusion assessment modality. The use of ICG angiography is rapidly spreading in the field of colorectal surgery. However, there is debate on its contribution to reducing anastomotic complications. In this review, we discuss the clinical utility and the standardization of ICG angiography. ICG angiography can unequivocally reveal unfavorable perfusion zones and provide quantitative parameters to predict the risk of hypoperfusion-related anastomotic complications. Many studies have demonstrated the clinical utility of ICG angiography for reducing anastomotic complications. Recently, two multicenter randomized clinical trials reported that ICG angiography did not significantly reduce the incidence of anastomotic leakage. Most previous studies have been small-scale single-center studies, and there is no standardized ICG angiography protocol to date. Additionally, ICG angiography evaluations have mostly relied on surgeons’ subjective judgment. For these reasons, it is necessary to establish a standardized ICG angiography protocol and develop a quantitative analysis protocol for the objective assessment. In conclusion, ICG angiography could be useful for detecting poorly perfused colorectal segments to prevent anastomotic leakage after colorectal surgery. An optimized and standardized ICG angiography protocol should be established to improve the reliability of perfusion assessments. In the future, artificial intelligence-based quantitative analyses could be used to easily assess colonic perfusion status.

Genitourinary function and defecation after colorectal cancer surgery with low- and high-ligation of the inferior mesenteric artery: A meta-analysis

BACKGROUND

The effect of low ligation (LL) vs high ligation (HL) of the inferior mesenteric artery (IMA) on functional outcomes during sigmoid colon and rectal cancer surgery, including urinary, sexual, and bowel function, is still controversial.

AIM

To assess the effect of LL of the IMA on genitourinary function and defecation after colorectal cancer (CRC) surgery.

METHODS

EMBASE, PubMed, Web of Science, and the Cochrane Library were systematically searched to retrieve studies describing sigmoid colon and rectal cancer surgery in order to compare outcomes following LL and HL. A total of 14 articles, including 4750 patients, were analyzed using Review Manager 5.3 software. Dichotomous results are expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and continuous outcomes are expressed as weighted mean differences (WMDs) with 95%CIs.

RESULTS

LL resulted in a significantly lower incidence of nocturnal bowel movement (OR = 0.73, 95%CI: 0.55 to 0.97, P = 0.03) and anastomotic stenosis (OR = 0.31, 95%CI: 0.16 to 0.62, P = 0.0009) compared with HL. The risk of postoperative urinary dysfunction, however, did not differ significantly between the two techniques. The meta-analysis also showed no significant differences between LL and HL in terms of anastomotic leakage, postoperative complications, total lymph nodes harvested, blood loss, operation time, tumor recurrence, mortality, 5-year overall survival rate, or 5-year disease-free survival rate.

CONCLUSION

Since LL may result in better bowel function and a reduced rate of anastomotic stenosis following CRC surgeries, we suggest that LL be preferred over HL.

Quantitative evaluation of colon perfusion after high versus low ligation in rectal surgery by indocyanine green: a pilot study

BACKGROUND

In the field of rectal cancer surgery, there remains ongoing debate on the merits of high ligation (HL) and low ligation (LL) of the inferior mesenteric artery (IMA) in terms of perfusion and anastomosis leakage. Recently, infrared fluorescence of indocyanine green (ICG) imaging has been used to evaluate perfusion status during colorectal surgery.

OBJECTIVE

The purpose of this study is to compare the changes in perfusion status between HL and LL through quantitative evaluation of ICG.

METHODS

Patients with rectosigmoid or rectal cancer were randomized into a high or LL group. ICG was injected before and after IMA ligation, and region of interest (ROI) values were measured by an image analysis program (HSL video©).

RESULTS

From February to July 2020, 22 patients were enrolled, and 11 patients were assigned to each group. Basic demographics were similar between the two groups, except for albumin level and cardiac ejection fraction. There were no significant differences in F_max between the two groups, but T_max was significantly higher and Slope_max was significantly lower in the HL group than in the LL group. Anastomosis leakage was significantly associated with neoadjuvant chemoradiation and F_max.

CONCLUSION

After IMA ligation, T_max increased and Slope_max decreased significantly in the HL group. However, the intensity of perfusion status (F_max) did not change according to the level of IMA ligation.

Analysis of risk factors and prognosis of 253 lymph node metastasis in colorectal cancer patients

Background

This study aimed to explore potential risk factors for 253 lymph node metastasis, and to identify the prognostic impact of 253 lymph node metastasis in colorectal cancer patients.

Methods

A retrospective study was conducted of 391 colorectal cancer patients who underwent surgical treatments that included 253 lymph node dissection. Clinicopathological features, molecular indexes and 1-year overall survival rates were analyzed.

Results

Univariate analyses revealed the following risk factors for 253 lymph node metastasis: high preoperative levels of CEA, large tumour max diameters, and numbers of harvested lymph nodes, presence of vessel carcinoma emboli, low level of MSH6 and MLH1 immunohistochemical staining intensity. Multivariate analysis showed that elevated MLH1 immunohistochemical staining intensity was an independent protective factor for 253 lymph node metastasis (OR: 0.969, 95% CI 0.945, 0.994, P = 0.015). A significant difference was found in 1-year overall survival rate between 253 lymph node-positive and lymph node-negative colorectal cancer patients (88.9% vs.75.0%, P < 0.001).

Conclusions

253 lymph node-positive colorectal cancer patients had a worse prognosis than the 253 lymph node-negative patients. 253 lymph node dissection may improve the prognosis of colorectal cancer patients with high risk factors for 253 lymph node metastasis.

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

Background

Preservation of the left colic artery in low-tie (LT) of inferior mesenteric artery remains controversial compared to high-tie (HT) in the colon and rectal cancers, for lymph node dissection, anastomotic leakage, and oncological outcome. This cohort study aims to analyze short- and long-term outcomes of laparoscopic anterior resections in LT vs HT for rectal cancers.

Methods

We analyzed a cohort of laparoscopic AR for RC from 2013 to 2016 at Renji Hospital, Shanghai, China. Short- and long-term outcome in LT vs HT group were compared for clinico-demographic characteristics, operative-time, lymph node dissection, short-term 30-day outcome, and long-term 3- and 5-year overall survival as well as disease-free survival. The x², t-test, and logistic regressions analysis were used and p<0.05 was considered significant.

Results

The cohort consisted of 614 laparoscopic AR with LT (236) and HT (378). The clinicodemographic characteristics were comparable among the groups. The surgery took longer in LT. The yield of LND was similar. Leakage occurred in 12.21% (n=75). Leakage was fewer in LT than HT, 8.89% vs 14.28%, p=0.047. The postoperative severe complications were higher in HT. The 30-day mortality was nil. The long-term 3- and 5-year overall survival and disease-free survival were similar in LT and HT.

Conclusion

The LT with preservation of left colic artery had similar lymph node yield, but lower leakage and complications than HT in laparoscopic anterior resections for rectal cancers. The long-term 3- and 5-year overall and disease-free survival were similar in the two groups.

The effect of different inferior mesenteric artery ligation levels and different lymph node dissection areas on the short- and long-term outcomes of rectal cancer

Background

Surgery is the most effective treatment for rectal cancer patients, but its key steps, including selection of the level of inferior mesenteric artery ligation and removal of 253 lymph nodes, are still inconclusive. This study aimed to analyze the effects of different surgical methods, including levels of ligation (low vs. high) and lymph node dissection areas (D2 vs. D3) on the short-term and long-term outcomes.

Methods

Between March 2014 and August 2018, 253 rectal cancer patients were retrospectively analyzed; 113 patients underwent low ligation D2 lymph node dissection (LLD2), 75 patients underwent low ligation D3 lymph node dissection (LLD3), and 65 patients underwent high ligation (HL). We compared the short-term and long-term outcomes among the different groups.

Results

There were no significant differences among the groups in terms of the intraoperative variables, including operative time, blood transfusion, and conversion from laparoscopic to open surgery. The median blood loss was significantly lower in LLD3 (50 mL) than in LLD2 (100 mL) and HL (100 mL), but it was not significantly different between LLD2 and HL. There were no significant differences among the LLD2, LLD3, and HL groups in the incidence of postoperative complications (9.7% vs. 12.0% vs. 10.8%, respectively) and hospital stay (14 vs. 15 vs. 14, respectively). The anastomotic leakage Clavien-Dindo grade was significantly lower with LLD2 and LLD3 than with HL, but it was the same between LLD2 and LLD3. The total number of lymph nodes harvested in the LLD3 group (n=14) was higher than that in the LLD2 group (n=12), but it was not significantly different than that in the HL group (n=13). There were no significant differences among the groups in terms of 3-year overall survival rate and disease-free survival rate.

Conclusions

Low ligation was similar to HL in terms of major intraoperative and postoperative parameters, but it can reduce the severity of anastomotic leakage to a certain extent. D3 lymph node dissection can increase the total number of lymph nodes harvested, but it did not improve long-term prognosis.

Long-term oncological outcomes of low anterior resection for rectal cancer with and without preservation of the left colic artery: a retrospective cohort study

Background

There is uncertainty in the literature about preserving the left colic artery (LCA) during low anterior resection for rectal cancer. We analyzed the effect of preserving the LCA on long-term oncological outcomes.

Methods

We retrospectively collected clinicopathological and follow-up details of patients who underwent low anterior resection for rectal cancer in the General Surgery Department of Guangdong Provincial People’s Hospital, from January 2014 to December 2015. Cases were divided into low ligation (LL), LCA preserved, or high ligation (HL), LCA not preserved, of the inferior mesenteric artery. The 5-year overall survival (OS) and disease-free survival (DFS) rates were compared between the two groups.

Results

Altogether, there were 221 and 295 cases in the LL group and HL groups, respectively. Operating time in the LL group was significantly longer than in the HL group (224.7 vs. 211.7 min, p = 0.039). Postoperative 30-day mortality, early complications including anastomotic leakage showed no significant differences between the LL and HL groups (postoperative 30-day mortality, 0.9% LL, 1.4% HL, p = 0.884; early complications, 41.2% LL, 38.3% HL, p = 0.509; anastomotic leakage 8.6% LL, 13.2% HL, p = 0.100). The median follow-up periods were 51.4 (7–61) months in the LL group and 51.2 (8–61) months in the HL group. During follow-up, the percentages of patients who died, had local recurrence, or had metastases were 39.8, 7.7, and 38.5%, respectively, in the LL group and 39, 8.5, and 40%, respectively, in the HL group; these differences were not significant (all p > 0.05). The 5-year OS and DFS were 69.6 and 59.6% in the LL group, respectively, and 69.1 and 56.2% in the HL group, respectively; these differences were not significant (all p > 0.05). After stratification by tumor-node-metastasis stage, the difference between the 5-year OS and DFS for stages I, II, and III cancer were not significant (all p > 0.05).

Conclusions

The long-term oncological outcomes of LL group are comparable with HL group. LL cannot be supported due to the absence of lower complication rates and the longer operating times.

Minimally invasive surgery for colorectal cancer with persistent descending mesocolon: radiological findings and short-term outcomes

BACKGROUND

Persistent descending mesocolon (PDM) is typically asymptomatic. However, features such as adhesion and variations in vessel anatomy could affect the surgical techniques for colorectal cancer (CRC). This study aimed to investigate the frequency and radiological features of PDM. Short-term outcomes after conventional laparoscopic surgery (CLS) for CRC with PDM were also investigated to assess the feasibility of CLS and identify strategies for minimally invasive surgery (MIS) in CRC with PDM.

METHODS

Patients who underwent MIS, including CLS and robot-assisted laparoscopic surgery (RALS), for left-sided CRC between April 2016 and June 2019, were investigated. PDM was defined as the existence of the right border of the descending colon inside the right border of the left kidney based on preoperative computed tomography findings.

RESULTS

Radiological findings of 837 patients were examined, and PDM was found in 19 (2.3%) patients. Radiality of the inferior mesenteric artery (IMA) was found in 5 of 19 (26.3%) PDM cases, which was significantly higher than that in non-PDM cases. The median lengths between the IMA and inferior mesenteric vein (IMV) and between the IMV and descending colon in PDM cases were 14.8 mm and 17.2 mm, respectively, which were significantly shorter than those in non-PDM cases. Short-term outcomes were evaluated only in CLS cases since the rate of hybrid surgery among RALS cases differed between non-PDM and PDM cases (0% vs. 44.4%), which would affect the surgical outcomes. The short-term outcomes in 447 CLS cases were similar between PDM and non-PDM cases. The frequency of extracorporeal division of the left colic artery (LCA) and IMV was significantly higher in PDM than in non-PDM cases (70.0% vs. 5.7%).

CONCLUSIONS

This radiological definition of PDM was feasible. CLS for left-sided CRC with PDM was feasible, and dividing the LCA and IMV extracorporeally would be vital for safe surgery.

Value of intra-operative Doppler sonographic measurements in predicting post-operative anastomotic leakage in rectal cancer: a prospective pilot study

BACKGROUND

Anastomotic leakage is a serious surgical complication in rectal cancer; however, effective evaluation methods for predicting anastomotic leakage individual risk in patients are not currently available. This study aimed to develop a method to evaluate the risk of leakage during surgery.

METHODS

The 163 patients with rectal cancer, who had undergone anterior resection and low-ligation procedures for Doppler sonographic hemodynamic measurement from April 2011 to January 2015 in Peking University Cancer Hospital, were prospectively recruited. A predictive model was constructed based on the associations between anastomotic leakage and alterations in the anastomotic blood supply in the patients, using both univariate and multivariate statistical analyses, as well as diagnostic methodology evaluation, including Chi-square test, logistic regression model, and receiver operating characteristic curve.

RESULTS

The overall anastomotic leakage incidence was 9.2% (15/163). Doppler hemodynamic parameters whose reduction was significantly associated with anastomotic leakage were peak systolic velocity, pulsatility index, and resistance index. The areas under the receiver operating characteristic curve of residual rates of peak systolic velocity, pulsatility index, and resistance index in predicting anastomotic leakage were 0.703 (95% confidence interval [CI]: 0.552-0.854), 0.729 (95% CI: 0.579-0.879), and 0.689 (95% CI: 0.522-0.856), respectively. The predictive model revealed that the patients with severely reduced blood-flow signal exhibited a significantly higher incidence rate of anastomotic leakage than those with sufficient blood supply (19.6% vs. 3.7%, P = 0.003), particularly the patients with low rectal cancer (25.9% vs. 3.9%, P = 0.007) and those receiving neoadjuvant chemoradiotherapy (32.1% vs. 3.7%, P = 0.001), independent of prophylactic ileostoma. Multivariate analysis revealed that insufficient blood supply of the anastomotic bowel was an independent risk factor for anastomotic leakage (odds ratio: 10.37, 95% CI: 2.703-42.735, P = 0.001).

CONCLUSION

Based on this explorative study, Doppler sonographic hemodynamic measurement of the anastomotic bowel presented potential value in predicting anastomotic leakage.

Oncologic and Anastomotic Safety of Low Ligation of the Inferior Mesenteric Artery With Additional Lymph Node Retrieval: A Case-Control Study

PURPOSE

We assessed the oncologic and anastomotic benefits of low ligation of the inferior mesenteric artery (IMA) with additional lymph node (LN) retrieval.

METHODS

We performed a retrospective case-control study between January 2011 and July 2015. All patients underwent curative resection of a primary sigmoid or rectal tumor. We excluded patients with distant metastases at the time of diagnosis. The case group included patients who underwent high ligation of the IMA (high group, HG). The control group included patients who underwent low ligation of the IMA with low group with additional LN retrieval (LGAL). Controls were identified by matching patients based on age (±5 years), sex, tumor location, and final histopathological stage. Finally, each group included 97 patients.

RESULTS

Clinical characteristics did not significantly differ between groups. The mean number of additional harvested LN was 2.19 (range, 0-11), and one patient in the LGAL had a metastatic LN among the additional harvested LN. The overall morbidity was 22.7% in the HG and 30% in the LGAL (P = 0.257). Anastomotic leakage occurred in 14 patients (14.4%) in the HG and 5 patients (5.2%) in the LGAL (P = 0.030). The mean disease-free survival time in the HG was longer than that in the LGAL (P = 0.008). The mean overall survival (OS) time was 70.4 ± 1.3 months. The mean OS was 63.7 ± 1.6 months in the HG and 69.1 ± 2.6 months in the LGAL (P = 0.386).

CONCLUSION

Low ligation of the IMA with additional LN retrieval is technically safe. However, the oncologic effect was better after high ligation of IMA.

Colonic hypoperfusion following ligation of the inferior mesenteric artery in rectosigmoid colon cancer patients

Purpose

Colon perfusion status is one of the most important factors for the determination of postoperative anastomotic complications. Colonic hypoperfusion can be induced by inferior mesenteric artery (IMA) ligation in some patients. This study aimed to evaluate atherosclerotic risk assessment and vascular parameters of CT angiography as predictors of colonic hypoperfusion.

Methods

This prospective study was conducted at a tertiary referral hospital and included 46 rectosigmoid colon cancer patients undergoing laparoscopic anterior resection between August 2013 to July 2014. Atherosclerotic risk scores were assessed using the Framingham cardiovascular risk score system. The IMA length, branching pattern, atherosclerotic calcification, and intermesenteric artery and mesenteric vascular diameters were evaluated using CT angiography. Mesenteric marginal artery pressures were measured before and after IMA clamping. The mean arterial pressure (MAP) index was calculated by dividing the mesenteric marginal MAP into the systemic MAP to determine the mesenteric hypoperfusion status after IMA clamping. A critically low MAP index was defined as <0.4.

Results

Critically low MAP index (<0.4) was observed in 6 cases (13.0%) after IMA clamping. Atherosclerotic calcification of the IMA and superior mesenteric artery occurred in 11 (23.9%) and 5 patients (10.9%), respectively. Low MAP index was associated with high atherosclerotic risk score and short IMA length, rather than atherosclerotic calcification and other vascular parameters of the major mesenteric arteries. Multivariate analysis indicated that high atherosclerotic risk and short IMA length were independent predictors of critically low MAP index.

Conclusion

Atherosclerotic risk assessment and IMA length were useful predictors of the mesenteric hypoperfusion status following IMA ligation during laparoscopic rectosigmoid colon surgery.

Lymph node yield, survival benefit, and safety of high and low ligation of the inferior mesenteric artery in colorectal cancer surgery: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis was to compare high inferior mesenteric artery (IMA) ligation (HL) with low IMA ligation (LL) for the treatment of colorectal cancer and to evaluate the lymph node yield, survival benefit, and safety of these surgeries.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, and China Biomedical Literature Database (CBM) were systematically searched for relevant articles that compared HL and LL for sigmoid or rectal cancer. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes and the weighted mean difference (WMD) for continuous outcomes.

RESULTS

In total, 30 studies were included in this analysis. There were significantly higher odds of anastomotic leakage and urethral dysfunction in patients treated with HL compared to those treated with LL (OR = 1.29; 95% CI = 1.08 to 1.55; OR = 2.45; 95% CI = 1.39 to 4.33, respectively). There were no significant differences between the groups in terms of the total number of harvested lymph nodes, the number of harvested lymph nodes around root of the IMA, local recurrence rate, and operation time. Further, no statistically significant group differences in 5-year overall survival rates and 5-year disease-free survival rates were detected among all patients nor among subgroups of stage II patients and stage III patients, respectively.

CONCLUSIONS

LL can achieve equivalent lymph node yield to HL, and both procedures have similar survival benefits. However, LL is associated with a lower incidence of leakage and urethral dysfunction. Thus, LL is recommended for colorectal cancer surgery.

Biology-Based Surgery: The Extent of Lymphadenectomy in Cancer of the Colon

The progression of colon cancer (CC) involves hematogenous and lymphatic spread to locoregional lymph nodes (LN), distant LN, and metastatic sites including the liver. The biological mechanisms that govern CC progression remain elusive. The Halsted model assumes an orderly, stepwise progression from the primary tumor to nearby nodes, henceforth to anatomically more distant nodes, and ultimately to distant organs. The Fisher model, on the other hand, regards the release of metastatic cells as early and essentially random events. The underlying biology has important implications for the ideal extent of surgery: when the Fisher model is correct, efforts to remove apical (central), extramesenteric, or para-aortic LN are unlikely to affect the oncological outcome. Recent data from phylogenetic studies suggest that cancer cell populations differ genetically among different LN stations and from distant metastases. Circulating tumor cells and other liquid biomarkers can be detected in the circulation of patients with early-stage disease. Local recurrence in CC is uncommon, and it is associated with a high risk of systemic progression and poor survival. Clinical studies comparing standard colectomy with extensive surgery (high ligation of the inferior mesenteric artery, complete mesocolic excision, D3 dissection, and para-aortic or extramesenteric node dissection) show that these techniques increase the LN count, while any beneficial effect on the risk of local recurrence or disease-free survival is at present uncertain due to the lack of controlled trials. Ongoing randomized trials comparing extensive vs. standard surgery for CC will generate important answers.