An audit of outcomes in colorectal cancer in China

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.

Oncological impact of laparoscopic lymphadenectomy with preservation of the left colic artery for advanced sigmoid and rectosigmoid colon cancer

BACKGROUND

Laparoscopic lymphadenectomy around the inferior mesenteric artery (IMA) with preservation of the left colic artery (LCA) remains a controversial approach. The aim of the study was to investigate the clinical outcomes.

METHODS

This study analysed 211 patients who underwent laparoscopic resection of advanced (≥T3) sigmoid and rectosigmoid colon cancers with D3 lymphadenectomy including 91 high ligations of the IMA (HL) and 120 low ligations with preservation of the LCA (LL) from January 1998 to December 2009.

RESULTS

There were no significant differences in operative result between the groups. In stage II cancer, the overall survival rate (94.8% HL vs. 91.8% LL; 95% confidence interval (CI), -0.8 to 0.68, p = 0.920) and disease-free survival (93.0% HL vs. 87.6% LL; 95% CI, -0.8 to 0.40, p = 0.540) did not differ significantly between the two groups. A similar tendency in overall survival was observed in patients with stage III cancer (88.3% HL vs. 86.9% LL; 95% CI, -0.44 to 0.57, p = 0.989) and disease-free survival (71.4% HL vs. 69.8% LL; 95% CI, -0.38 to 0.40, p = 0.637).

CONCLUSIONS

Laparoscopic lymphadenectomy around the IMA with preservation of the LCA resulted in acceptable clinical outcomes in patients with advanced sigmoid and rectosigmoid colon cancer.

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed

Nowadays left colon and rectal cancer treatment has been well standardized in both open and laparoscopy. Nevertheless, the level of the ligation of the inferior mesenteric artery (IMA), at the origin from the aorta (high tie) or below the origin of the left colic artery (low tie), is still debated. The objective of the systematic review is to evaluate the current scientific evidence of high versus low tie of the IMA in colorectal cancer surgery. The outcomes considered were overall 30-days postoperative morbidity, overall 30-days postoperative mortality, anastomotic leakage, 5-years survival rate, and overall recurrence rate. A total of 8.666 patients were included in our analysis, 4.281 forming the group undergoing high tie versus 4.385 patients undergoing low tie. Neither the high tie nor the low tie strategy showed an evidence based success, as no statistically significant differences were identified for all outcomes measured. Future high powered and well designed randomized clinical trials are needed to draw definitive conclusion on this dilemma.