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Efetov SK, Tomasicchio G, Kayaalp C, Rychkova A, Vincenti L, Dezi A, Picciariello A. Short-term outcomes of vessel-oriented D2 and D3 lymph node dissection for sigmoid colon cancer. Tech Coloproctol 2024; 29:36. [PMID: 39738697 DOI: 10.1007/s10151-024-03077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 11/24/2024] [Indexed: 01/02/2025]
Abstract
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.
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Affiliation(s)
- S K Efetov
- Department of Faculty Surgery No. 2, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
| | - G Tomasicchio
- General Surgery Unit "M. Rubino", Department of Precision and Regenerative Medicine and Jonic Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - C Kayaalp
- Private Gastrointestinal Surgery Clinic, Nisantasi, Istanbul, Turkey
| | - A Rychkova
- Department of Faculty Surgery No. 2, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - L Vincenti
- Surgical Unit, IRCCS de Bellis, 70013, Castellana Grotte, Bari, Italy
| | - A Dezi
- General Surgery Unit "M. Rubino", Department of Precision and Regenerative Medicine and Jonic Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - A Picciariello
- Department of Experimental Medicine, University of Salento, Lecce, Italy
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Jiang M, Ji J, Zhang Q, Sun L, Ji Y, Wang J, Ali M, Sun Q, Wang Y, Liu B, Ren J, Wang L, Wang W, Tang D, Wang D. Comparison of robotic assisted and laparoscopic radical resection for rectal cancer with or without left colic artery preservation. Sci Rep 2024; 14:28113. [PMID: 39548252 PMCID: PMC11568222 DOI: 10.1038/s41598-024-79713-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 11/12/2024] [Indexed: 11/17/2024] Open
Abstract
The preservation of the left colic artery (LCA) during rectal cancer resection remains a topic of controversy, and there is a notable absence of robust evidence regarding the outcomes associated with LCA preservation. And the advantages of robotic-assisted laparoscopy (RAL) surgery in rectal resection remain uncertain. The objective of this study was to assess the influence of LCA preservation surgery and RAL surgery on intraoperative and postoperative complications of rectal cancer resection. Patients who underwent laparoscopic (LSC) or RAL with or without LCA preservation resection for rectal cancer between April 2020 and May 2023 were retrospectively assessed. The patients were categorized into two groups: low ligation (LL) which with preservation of LCA and high ligation (HL) which without preservation of LCA. A one-to-one propensity score-matched analysis was performed to decrease confounding. The primary outcome was operative findings, operative morbidity, and postoperative genitourinary function. A total of 612 patients were eligible for this study, and propensity score matching yielded 139 patients in each group. The blood loss of the LL group was significantly less than that of the HL group (54.42 ± 12.99 mL vs. 65.71 ± 7.37 mL, p<0.001). The urinary catheter withdrawal time in the LL group was significantly shorter than that in the HL group (4.87 ± 2.04 d vs. 6.06 ± 2.43d, p<0.001). Anastomotic leakage in the LL group was significantly lower than that in HL group (1.44% vs. 7.91%, p = 0.011). The rate of urinary dysfunction and sexual dysfunction in LL group is both significantly lower than HL group. Blood loss and number of harvested lymph nodes (LNs) of both RAL subgroups in LL and HL groups were significantly more than that in LSC subgroups. The anastomotic leakage in the RAL subgroup of HL group was significantly lower than that in LSC subgroup (0% vs. 14.89%, p = 0.018). LCA preservation surgery for rectal cancer may help reduce the blood loss, urinary catheter withdrawal time, the rate of anastomotic leakage and ileus, and postoperative genitourinary function outcomes. RAL can reduce the probability of blood loss and improve harvest LNs in patients with rectal cancer.
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Affiliation(s)
- Mingrui Jiang
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Jin Ji
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Qi Zhang
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Longhe Sun
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Yong Ji
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Jie Wang
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Muhammad Ali
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Qiannan Sun
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Yong Wang
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Bin Liu
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jun Ren
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Liuhua Wang
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Wei Wang
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Dong Tang
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Daorong Wang
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China.
- Northern Jiangsu People's Hospital, Yangzhou, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China.
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Calleja R, Medina-Fernández FJ, Bergillos-Giménez M, Durán M, Torres-Tordera E, Díaz-López C, Briceño J. A comprehensive evaluation of 80 consecutive robotic low anterior resections: impact of not mobilizing the splenic flexure alongside low-tie vascular ligation as a standardized technique. J Robot Surg 2024; 18:156. [PMID: 38565813 DOI: 10.1007/s11701-024-01917-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
Rectal cancer surgery represents challenges due to its location. To overcome them and minimize the risk of anastomosis-related complications, some technical maneuvers or even a diverting ileostomy may be required. One of these technical steps is the mobilization of the splenic flexure (SFM), especially in medium/low rectal cancer. High-tie vascular ligation may be another one. However, the need of these maneuvers may be controversial, as especially SFM may be time-consuming and increase the risk of iatrogenic. The objective is to present the short- and long-term outcomes of a low-tie ligation combined with no SFM in robotic low anterior resection (LAR) for mid- and low rectal cancer as a standardized technique. A retrospective observational single-cohort study was carried out at Reina Sofia University Hospital, Cordoba, Spain. 221 robotic rectal resections between Jul-18th-2018 and Jan-12th-2023 were initially considered. After case selection, 80 consecutive robotic LAR performed by a single surgeon were included. STROBE checklist assessed the methodological quality. Histopathological, morbidity and oncological outcomes were assessed. Anastomotic stricture occurrence and distance to anal verge were evaluated after LAR by rectosigmoidoscopy. Variables related to the ileostomy closure such as time to closure, post-operative complications or hospital stay were also considered. The majority of patients (81.2%) presented a mid-rectal cancer and the rest, lower location (18.8%). All patients had adequate perfusion of the anastomotic stump assessed by indocyanine green. Complete total mesorectal excision was performed in 98.8% of the patients with a lymph node ratio < 0.2 in 91.3%. The anastomotic leakage rate was 5%. One patient (1.5%) presented local recurrence. Anastomosis stricture occurred in 7.5% of the patients. The limitations were small cohort and retrospective design. The non-mobilization of the splenic flexure with a low-tie ligation in robotic LAR is a feasible and safe procedure that does not affect oncological outcomes.
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Affiliation(s)
- Rafael Calleja
- Liver Transplantation and Hepatobiliary Surgery Unit, Reina Sofía University Hospital, Avenida Menéndez Pidal s/n, 14004, Córdoba, Spain
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain
| | - Francisco Javier Medina-Fernández
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain.
- Unit of Coloproctology General and Digestive Surgery Department, Reina Sofia University Hospital, Cordoba, Spain.
| | - Manuel Bergillos-Giménez
- Unit of Coloproctology General and Digestive Surgery Department, Reina Sofia University Hospital, Cordoba, Spain
| | - Manuel Durán
- Liver Transplantation and Hepatobiliary Surgery Unit, Reina Sofía University Hospital, Avenida Menéndez Pidal s/n, 14004, Córdoba, Spain
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain
| | - Eva Torres-Tordera
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain
- Unit of Coloproctology General and Digestive Surgery Department, Reina Sofia University Hospital, Cordoba, Spain
| | - César Díaz-López
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain
- Unit of Coloproctology General and Digestive Surgery Department, Reina Sofia University Hospital, Cordoba, Spain
| | - Javier Briceño
- Liver Transplantation and Hepatobiliary Surgery Unit, Reina Sofía University Hospital, Avenida Menéndez Pidal s/n, 14004, Córdoba, Spain
- Maimonides Biomedical Research Institute (IMIBIC), Avenida Menéndez Pidal s/n 14004, Córdoba, Spain
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Lee MW, Park SS, You K, Lee DE, Lee DW, Park SC, Han KS, Sohn DK, Hong CW, Kim B, Kim BC, Chang HJ, Kim DY, Oh JH. Long-term clinical outcomes after high and low ligations with lymph node dissection around the root of the inferior mesenteric artery in patients with rectal cancer. Ann Coloproctol 2024; 40:62-73. [PMID: 38414122 PMCID: PMC10915527 DOI: 10.3393/ac.2023.00094.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE This study aimed to evaluate the long-term clinical outcomes based on the ligation level of the inferior mesenteric artery (IMA) in patients with rectal cancer. METHODS This was a retrospective analysis of a prospectively collected database that included all patients who underwent elective low anterior resection for rectal cancer between January 2013 and December 2019. The clinical outcomes included oncological outcomes, postoperative complications, and functional outcomes. The oncological outcomes included overall survival (OS) and relapse-free survival (RFS). The functional outcomes, including defecatory and urogenital functions, were analyzed using the Fecal Incontinence Severity Index, International Prostate Symptom Score, and International Index of Erectile Function questionnaires. RESULTS In total, 545 patients were included in the analysis. Of these, 244 patients underwent high ligation (HL), whereas 301 underwent low ligation (LL). The tumor size was larger in the HL group than in the LL group. The number of harvested lymph nodes (LNs) was higher in the HL group than in the LL group. There were no significant differences in complication rates and recurrence patterns between the groups. There were no significant differences in 5-year RFS and OS between the groups. Cox regression analysis revealed that the ligation level (HL vs. LL) was not a significant risk factor for oncological outcomes. Regarding functional outcomes, the LL group showed a significant recovery in defecatory function 1 year postoperatively compared with the HL group. CONCLUSION LL with LNs dissection around the root of the IMA might not affect the oncologic outcomes comparing to HL; however, it has minimal benefit for defecatory function.
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Affiliation(s)
- Min Wan Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kiho You
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Eun Lee
- Biostatistics Collaboration Team, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Wang X, Li J, Chen W, Yang Q. Preserving the left colonic artery in radical sigmoid and rectal cancer surgery is feasible: A meta-analysis. Medicine (Baltimore) 2024; 103:e37026. [PMID: 38277569 PMCID: PMC10817117 DOI: 10.1097/md.0000000000037026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 01/02/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND This study aims to investigate the safety and feasibility of preserving left colonic artery (LCA) in radical sigmoid and rectal cancer surgery. METHODS Relevant articles were systematically searched on the PubMed, Embase, and Cochrane Library. The quality of included studies was evaluated using the Cochrane Handbook. A meta-analysis was conducted to assess the surgical outcomes and oncological outcomes by RevMan 5.4 software. RESULTS Fifteen studies with a total of 5054 patients, including 2432 patients with LCA preservation and 2622 patients without LCA preservation, were included and analyzed in this study. The meta-analysis revealed that preserving LCA in radical surgery of sigmoid and rectal cancer has lower anastomotic leakage incidence (OR = 1.03, 95% confidence interval = 0.83-1.27, P < .0001). There were no significant differences in the operative time, intraoperative blood loss, number of dissected lymph nodes, postoperative complications as well as the oncological outcomes including systemic recurrence, local recurrence, 5-year overall survival rate, and 5-year disease-free survival rate. CONCLUSION SUBSECTIONS This pooled analysis showed that preserving the LCA is safe and feasible in radical sigmoid and rectal cancer surgery.
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Affiliation(s)
- Xin Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Jianxin Li
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Wangsheng Chen
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Qingqiang Yang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
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Brillantino A, Skokowski J, Ciarleglio FA, Vashist Y, Grillo M, Antropoli C, Herrera Kok JH, Mosca V, De Luca R, Polom K, Talento P, Marano L. Inferior Mesenteric Artery Ligation Level in Rectal Cancer Surgery beyond Conventions: A Review. Cancers (Basel) 2023; 16:72. [PMID: 38201499 PMCID: PMC10777981 DOI: 10.3390/cancers16010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
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.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, “A. Cardarelli” Hospital, Via A. Cardarelli 9, 80131 Naples, Italy; (A.B.); (M.G.); (C.A.)
| | - Jaroslaw Skokowski
- Department of Medicine, Academy of Applied Medical and Social Sciences—AMiSNS: Akademia Medycznych I Spolecznych Nauk Stosowanych—2 Lotnicza Street, 82-300 Elbląg, Poland; (J.S.); (K.P.)
- Department of General Surgery and Surgical Oncology, “Saint Wojciech” Hospital, “Nicolaus Copernicus” Health Center, Jana Pawła II 50, 80-462 Gdańsk, Poland
| | - Francesco A. Ciarleglio
- Department of General Surgery and Hepato-Pancreato-Biliary (HPB) Unit—APSS, 38121 Trento, Italy;
| | - Yogesh Vashist
- Department Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Maurizio Grillo
- Department of Surgery, “A. Cardarelli” Hospital, Via A. Cardarelli 9, 80131 Naples, Italy; (A.B.); (M.G.); (C.A.)
| | - Carmine Antropoli
- Department of Surgery, “A. Cardarelli” Hospital, Via A. Cardarelli 9, 80131 Naples, Italy; (A.B.); (M.G.); (C.A.)
| | - Johnn Henry Herrera Kok
- Department of General and Digestive Surgery—Upper GI Unit, University Hospital of León, 24008 León, Spain;
| | - Vinicio Mosca
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Napoli, Italy;
| | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
| | - Karol Polom
- Department of Medicine, Academy of Applied Medical and Social Sciences—AMiSNS: Akademia Medycznych I Spolecznych Nauk Stosowanych—2 Lotnicza Street, 82-300 Elbląg, Poland; (J.S.); (K.P.)
- Department of Gastrointestinal Surgical Oncology, Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
| | - Pasquale Talento
- Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Luigi Marano
- Department of Medicine, Academy of Applied Medical and Social Sciences—AMiSNS: Akademia Medycznych I Spolecznych Nauk Stosowanych—2 Lotnicza Street, 82-300 Elbląg, Poland; (J.S.); (K.P.)
- Department of General Surgery and Surgical Oncology, “Saint Wojciech” Hospital, “Nicolaus Copernicus” Health Center, Jana Pawła II 50, 80-462 Gdańsk, Poland
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Zeng H, Lan Q, Li F, Xu D, Lin S. 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. Updates Surg 2023; 75:2085-2102. [PMID: 37715053 DOI: 10.1007/s13304-023-01631-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/12/2023] [Indexed: 09/17/2023]
Abstract
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.
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Affiliation(s)
- Hao Zeng
- Fujian Medical University, Fuzhou, People's Republic of China
| | - Qilong Lan
- Department of Gastroenterology and Anorectal Surgery, Longyan First Hospital, Fujian Medical University, 105, Jiuyi North Road, Longyan, Fujian, 364000, People's Republic of China
| | - Fudi Li
- Department of Gastroenterology and Anorectal Surgery, Longyan First Hospital, Fujian Medical University, 105, Jiuyi North Road, Longyan, Fujian, 364000, People's Republic of China
| | - Dongbo Xu
- Department of Gastroenterology and Anorectal Surgery, Longyan First Hospital, Fujian Medical University, 105, Jiuyi North Road, Longyan, Fujian, 364000, People's Republic of China
| | - Shuangming Lin
- Department of Gastroenterology and Anorectal Surgery, Longyan First Hospital, Fujian Medical University, 105, Jiuyi North Road, Longyan, Fujian, 364000, People's Republic of China.
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Maruta H, Tominaga T, Nonaka T, Hisanaga M, Takeshita H, Fukuoka H, To K, Tanaka K, Sawai T, Nagayasu T. Efficacy of left colic artery preservation with D3 lymph node dissection in laparoscopic surgery for advanced sigmoid and rectal cancer. Surg Today 2023; 53:1335-1342. [PMID: 37072524 DOI: 10.1007/s00595-023-02689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023]
Abstract
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.
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Affiliation(s)
- Hiroshi Maruta
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Makoto Hisanaga
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | - Hiroaki Takeshita
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | | | - Kazuo To
- Department of Surgery, Ureshino Medical Center, Ureshino, Japan
| | - Kenji Tanaka
- Department of Surgery, Saiseikai Nagasaki Hospital, Saiseikai, Japan
| | - Terumitsu Sawai
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Silvestri V, Pontecorvi E, Sciuto A, Pacella D, Peltrini R, D'Ambra M, Lionetti R, Filotico M, Lauria F, Sarnelli G, Pirozzi F, Ruotolo F, Bracale U, Corcione F. Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial. Updates Surg 2023; 75:1569-1578. [PMID: 37505437 DOI: 10.1007/s13304-023-01593-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023]
Abstract
Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.
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Affiliation(s)
- Vania Silvestri
- Department of General Surgery, SS Annunziata Hospital, 67039, Sulmona, L'Aquila, Italy.
| | - Emanuele Pontecorvi
- Department of General Surgery, SS Annunziata Hospital, 67039, Sulmona, L'Aquila, Italy
| | - Antonio Sciuto
- Department of General Surgery, Santa Maria Delle Grazie Hospital, Pozzuoli, 80078, Naples, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Michele D'Ambra
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131, Naples, Italy
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria Delle Grazie Hospital, Pozzuoli, 80078, Naples, Italy
| | | | - Umberto Bracale
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084, Salerno, Italy
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
- Department of General Surgery, Clinica Mediterranea, 80122, Naples, Italy
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Cirocchi R, Marchetti F, Mari G, Bagolini F, Cavaliere D, Avenia S, Anania G, Tebala G, Donini A, Davies RJ, Fingerhut A. Inferior mesenteric artery ligation level in rectal cancer surgery: still no answer-a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:286. [PMID: 37493853 PMCID: PMC10371924 DOI: 10.1007/s00423-023-03022-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
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.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
| | | | - Giulio Mari
- Department of Colorectal Surgery ASST Brianza, Desio Hospital, Desio, Italy
| | | | - Davide Cavaliere
- Department of Colorectal Surgery and General Surgery, Ospedale Per Gli Infermi, Faenza, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Gabriele Anania
- Department of Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, Hospital of Santa Maria of Terni, Terni, Italy
| | - Annibale Donini
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Richard Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
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Feng W, Miao Y, Li W, Xu Z, Chen F, Lv Z, Liu W, Zheng M, Zhao J, Zong Y, Lu A. High ligation versus low ligation of the inferior mesenteric artery in laparoscopic rectal cancer surgery: a retrospective study on surgical and long-term outcome. Langenbecks Arch Surg 2023; 408:249. [PMID: 37380790 DOI: 10.1007/s00423-023-02980-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND In laparoscopic low anterior resection for rectal cancer surgery, there has been controversy to whether the inferior mesenteric artery (IMA) should be ligated at the origin of its aorta (high ligation (HL)) or below the branches of the left colonic artery (LCA) (low ligation (LL)). This study was intended to clarify oncological outcome and long-term prognosis of retrospective analysis. METHODS Analyzed the cases who underwent laparoscopic low anterior resection (LAR) in Shanghai Ruijin Hospital from January 2015 to December 2016, 357patients scheduled into 2 groups according to the level of IMA ligation: HL (n = 247) versus LL (n = 110). RESULTS The primary endpoint is long-term outcomes, and the secondary endpoint is the incidence rate of major postoperative complications. There were no significant differences in 5-year overall survival (P = 0.92) and 5-year disease-free survival (P = 0.41). There were no differences between the clinical baseline levels in each group. The incidence of low anterior resection syndrome (LARS) in the two groups was statistically significant (P = 0.037). No significant differences were observed in operative time (P = 0.092) and intraoperative blood loss (P = 0.118). In the HL group, 6 cases (2.4%) had additional colonic excision due to poor anastomotic blood supply; none of the colonic anastomosis in the low ligation group had ischemic manifestations, and length from the proximal margin (P = 0.076), length from the distal margin (P = 0.184), the total number of lymph nodes excised (P = 0.065), and anastomotic leakage incidence (P = 0.33). CONCLUSION Low ligation of the IMA which reserved LCA with vascular root lymph node dissection in laparoscopic low anterior resection for rectal cancer surgery may help protect the blood supply of the anastomosis, and will not increase postoperative complications while enhance recovery, without compromising radical excision and long-term prognosis.
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Affiliation(s)
- Wenqing Feng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yiming Miao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wenchang Li
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zifeng Xu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Fangqian Chen
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zeping Lv
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wangyi Liu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Minhua Zheng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Jingkun Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yaping Zong
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Aiguo Lu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China.
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12
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Reyaz I, Reyaz N, Salah QM, Nagi TK, Mian AR, Bhatti AH, Obeidat K, Hirani S. Comparison of High Ligation Versus Low Ligation of the Inferior Mesenteric Artery (IMA) on Short-Term and Long-Term Outcomes in Sigmoid Colon and Rectal Cancer Surgery: A Meta-analysis. Cureus 2023; 15:e39406. [PMID: 37362536 PMCID: PMC10287114 DOI: 10.7759/cureus.39406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
This study was done to compare the perioperative outcomes and long-term outcomes between low ligation and high ligation of the inferior mesentric artery (IMA) in sigmoid colon and rectal cancer surgery. This study was conducted following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A literature search was performed in electronic databases including PubMed, CINAHIL, EMBASE, and Web of Science to identify studies published between January 1, 2015, and April 30, 2023. The outcomes assessed in this meta-analysis included postoperative complications (anastomotic leakage, surgical site infection, and postoperative ileus), intraoperative outcomes (duration of surgery in minutes, total intraoperative blood loss in milliliters, total lymph nodes harvested, and total number of metastatic lymph nodes), recovery outcomes (time to first flatus and length of hospital stay), and long-term outcomes (five-year mortality rate and disease-free survival rate). A total of 17 studies were included in this meta-analysis. Of these, six were randomized control trials (RCTs) and 11 were retrospective cohort studies. This meta-analysis suggests that lower ligation may be associated with a lower risk of anastomotic leakage compared to higher ligation in patients undergoing colon cancer surgery. However, there was no significant difference between the two techniques in terms of surgical site infection, postoperative ileus, total lymph nodes harvested, number of metastatic lymph nodes, duration of surgery, intraoperative blood loss, and length of hospital stay. Time to first flatus was significantly shorter in patients who underwent lower ligation. Additionally, there were no significant differences in the five-year mortality rate and disease-free survival rate between the two techniques. The results of this study indicate that both techniques are comparable in most aspects and suggest that the choice of technique should be based on individual patient factors and surgeon preference.
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Affiliation(s)
- Ibrahim Reyaz
- Internal Medicine, Christian Medical College and Hospital, Ludhiana, IND
| | - Nafisa Reyaz
- Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh, IND
| | - Qais M Salah
- Internal Medicine, Faculty of Medicine, Al Quds University, Jerusalem, PSE
| | - Talwinder K Nagi
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | | | - Ali Hanif Bhatti
- Internal Medicine, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Kinan Obeidat
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
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13
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Ren H, Liu Y, Zhang M, An L. Feasibility of preservation of superior rectal artery plus dissection of lymph nodes around inferior mesenteric artery in laparoscopic resection for sigmoid colon cancer. Front Surg 2023; 10:1086868. [PMID: 36865630 PMCID: PMC9971221 DOI: 10.3389/fsurg.2023.1086868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023] Open
Abstract
Background Limited data are available about superior rectal artery (SRA) preservation in laparoscopic resection for sigmoid colon cancer (SCC). This study aimed to evaluate the short-term and long-term efficacies of SRA preservation in laparoscopic radical resection for SCC. Methods We retrospectively analyzed 207 patients with SCC who underwent laparoscopic radical resection for SCC from January 2017 to June 2021. A total of 84 patients received lymph node clearance around the inferior mesenteric artery (IMA) root (D3 lymph node dissection) with preservation of SRA (SRA preservation group), and 123 patients received high ligation of the IMA (control group). The clinicopathological data of the two groups were compared, and Kaplan-Meier method was performed to estimate patient survival. Results Compared with the control group, the operation time of the SRA preservation group was longer (p < 0.001), but the postoperative exhaust and defecation times were significantly shorter (p = 0.003, p < 0.001). Two cases of postoperative ileus and four cases of anastomotic leakage were observed in the control group, whereas the SRA preservation group had none. However, no statistical difference was observed between the groups (p = 0.652, p = 0.248). The overall survival also showed no significant difference in (p = 0.436). Conclusion Preservation of SRA plus dissection of lymph nodes around IMA did not increase postoperative morbidity and mortality nor affect the prognosis of patients but increased the bowel blood supply, which may have a significant positive effect on the recovery of postoperative intestinal function and reduction of anastomotic leakage.
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Affiliation(s)
| | - Yong Liu
- Correspondence: Haoyuan Ren Yong Liu
| | - Mingran Zhang
- Department of Gastrointestinal Surgery, The People's Hospital of Deyang, Deyang, China
| | - Liang An
- Department of Gastrointestinal Surgery, The People's Hospital of Deyang, Deyang, China
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14
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Hsu CC, Hsu YJ, Chern YJ, Jong BK, Liao CK, Hsieh PS, Tsai WS, You JF. Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis. BMC Surg 2023; 23:33. [PMID: 36755252 PMCID: PMC9909897 DOI: 10.1186/s12893-023-01932-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
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.
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Affiliation(s)
- Chia-Chen Hsu
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Yu-Jen Hsu
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Yih-Jong Chern
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Bor-Kang Jong
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Chun-Kai Liao
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Pao-Shiu Hsieh
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Wen-Sy Tsai
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
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15
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WANG C, HUANG T, WANG X. Ligation level of inferior mesenteric artery in rectal cancer: a meta-analysis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023. [DOI: 10.23736/s0393-3660.22.04868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Yu J, Chen Y, Li T, Sheng B, Zhen Z, Liu C, Zhang J, Yan Q, Zhu P. High and low inferior mesenteric artery ligation in laparoscopic low anterior rectal resections: A retrospective study. Front Surg 2023; 9:1027034. [PMID: 36713667 PMCID: PMC9881683 DOI: 10.3389/fsurg.2022.1027034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/18/2022] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Jun Yu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China,Correspondence: Yi Chen Peng Zhu
| | - Tong Li
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Sheng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuo Zhen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chang Liu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianbo Zhang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Yan
- Health Management Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Zhu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China,Correspondence: Yi Chen Peng Zhu
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Sato A, Imaizumi K, Kasajima H, Ichimura K, Sato K, Yamana D, Tsuruga Y, Umehara M, Kurushima M, Nakanishi K. 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. LANGENBECK'S ARCHIVES OF SURGERY 2023; 408:23. [PMID: 36637543 DOI: 10.1007/s00423-023-02771-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/09/2022] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Aya Sato
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Ken Imaizumi
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan.
| | - Hiroyuki Kasajima
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Kentaro Ichimura
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Kentaro Sato
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Daisuke Yamana
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Yosuke Tsuruga
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Minoru Umehara
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Michihiro Kurushima
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
| | - Kazuaki Nakanishi
- Department of Gastroenterological Surgery, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate, Hokkaido, 041-8680, Japan
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Zhong W, Liu C, Zhang L, Zhong J, He X, Fang C, Liu H, Xia L, Zuo Z, Zhang L. Comparison of high or modified low tie of the inferior mesenteric artery in laparoscopic rectal cancer surgery: A meta-analysis. Medicine (Baltimore) 2022; 101:e32065. [PMID: 36451442 PMCID: PMC9704925 DOI: 10.1097/md.0000000000032065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The purpose of this study was to perform a meta-analysis comparing the oncological, intraoperative and safety outcomes in laparoscopic rectal cancer surgery with and without preservation of the left colic artery (LCA). METHOD We searched several databases including PubMed, Web of Science, Cochrane Library, and Embase databases. This meta-analysis included randomized clinical trials, prospective, and retrospective comparative studies regarding high- or modified low-tie ligation of the inferior mesenteric artery in laparoscopic rectal cancer surgery. RESULTS Of 641 potentially eligible articles, 16 studies with 3050 participants met the eligibility criteria and were included in the meta-analysis. There was no significant difference in estimated blood loss (WMD -2.63, 95% CI -5.69 to 0.43; P = .09), the number of harvested lymph nodes (WMD -0.35, 95% CI -1.60 to 0.20; P = .50), the number of apical lymph node yield (WMD -0.19, 95% CI -0.52 to 0.13; P = .24), the number of apical lymph node metastasis (OR 0.76, 95% CI 0.40 to 1.45; P = .40), rate of conversion to open surgery (OR 0.74, 95% CI 0.50 to 1.09; P = .513), rate of urinary dysfunction (OR 1.39, 95% CI 0.71 to 2.74; P = .34), rate of recurrence and metastasis (OR 1.10, 95% CI 0.75 to 1.61; P = .64), 5-year survival rate (OR 0.89, 95% CI 0.67 to 1.18; P = .42). However, this meta-analysis demonstrated a statistically significant difference in operating time (WMD -9.92, 95% CI -15.49 to -5.84; P = .0005), rate of diverting stom (OR 1.42, 95% CI 1.06 to 1.92; P = .02), rate of anastomotic leakage (OR 2.673, 95% CI 1.91 to 3.62; P < .00001), time to first flatus (WMD 0.29, 95% CI 0.11 to 0.48; P = .002), time of hospitalization (WMD 0.64, 95% CI 0.14 to 1.15; P = .01) between the 2 surgical techniques. COCLUSION The available evidence suggests that preserving the left colic artery is a safe, effective technique for patients with laparoscopic rectal cancer. nique for patients with laparoscopic rectal cancer.
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Affiliation(s)
- Wu Zhong
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Chuanyuan Liu
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Lei Zhang
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Junqiao Zhong
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Xianping He
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Chuanfa Fang
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Hongquan Liu
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Laiyang Xia
- Department of Gastroenterological Surgery, the Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
| | - Zhengyun Zuo
- Department of Anorectal Surgery, Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, China
| | - Leichang Zhang
- Department of Anorectal Surgery, Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, China
- *Correspondence: Leichang Zhang, Department of Anorectal Surgery, Hospital of Jiangxi University of Traditional Chinese Medicine, No. 445 Bayi Avenue, Nanchang 330006, Jiangxi, China (e-mail: )
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Lee SY, Kim S, Son GM, Kim HJ, Park SY, Park JS, Kim CH, Ha GW, Lee KH, Kim JS, Bae KB, Bae SU, Kang SI. Anastomotic leak after minimally invasive anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery: a study protocol for a multicentre randomized clinical trial. Trials 2022; 23:920. [PMID: 36316694 PMCID: PMC9620593 DOI: 10.1186/s13063-022-06862-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although many efforts have been made to decrease the incidence of anastomotic leak (AL), it remains one of the most serious complications of rectal cancer surgery. Many previous studies have reported an association between the ligation level of the inferior mesenteric artery (IMA) (high or low) and the incidence of AL after rectal cancer surgery. However, we cannot draw a solid conclusion because of the low quality and heterogeneity of those studies. Therefore, this study aims to investigate the impact of the IMA ligation level on the occurrence of AL after minimally invasive anterior resection of rectal cancer. METHODS/DESIGN Patients with primary rectal cancer without distant metastases will be included after screening. They will be randomly assigned (1:1) to receive high or low ligation of the IMA. The primary endpoint is AL incidence; secondary endpoints are quality of life; urinary, sexual, and defecatory functions; and 3-year disease-free survival. We hypothesized that the incidence rate of AL would be 15% and 5% in the high- and low-ligation groups, respectively. With a two-sided α of 0.05 and a power of 0.8, the sample size is calculated to be 314 patients (157 per group), considering a 10% dropout rate. DISCUSSION Although many studies have compared the short- and long-term outcomes of high and low ligation of the IMA in rectal cancer surgery, it is still debatable. This trial aims to help draw a more solid conclusion regarding the association between the IMA ligation level and AL incidence after rectal cancer surgery. We also hope to contribute to standardizing the method of rectal cancer surgery in this trial. TRIAL REGISTRATION Clinical Research Information Service KCT0003523. Registered on February 18, 2019.
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Affiliation(s)
- Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Jeonnam, South Korea
| | - Sohyun Kim
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, 20 Geumo-ro Mulgeum-eup, Yangsan, 50612, South Korea.
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 40414, South Korea.
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 40414, South Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 40414, South Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Jeonnam, South Korea
| | - Gi Won Ha
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Jeonbuk, South Korea
| | - Kyung-Ha Lee
- Department of Surgery, Chungnam National University Hospital & College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Sejong Hospital & College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Ki Beom Bae
- Department of Surgery, Paik Institute for Clinical Research, Inje University, College of Medicine, Inje University, Busan Paik Hospital, Busan, South Korea
| | - Sung Uk Bae
- Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, South Korea
| | - Sung Il Kang
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, South Korea
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20
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Zheng H, Li F, Xie X, Zhao S, Huang B, Tong W. Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis. BMC Surg 2022; 22:164. [PMID: 35538516 PMCID: PMC9092824 DOI: 10.1186/s12893-022-01614-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/18/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Preserving the left colic artery (LCA) during anterior resection for rectal cancer is controversial, and robust evidence of the outcomes of LCA preservation plus apical lymph node dissection is lacking. The purpose of this study was to investigate the impact of LCA preservation plus apical lymph node dissection surgery on anastomotic leakage and number of harvested lymph nodes. METHODS Patients who underwent laparoscopic or robotic anterior resection for rectal cancer between September 2017 and May 2020 were retrospectively assessed. The patients were categorized into two groups: preservation of LCA and nonpreservation of LCA. A one-to-one propensity score-matched analysis was performed to decrease confounding. The primary outcome was anastomotic leakage within 30 days after surgery. The secondary outcomes were number of harvested lymph nodes, 3-year overall survival, and 3-year disease-free survival. RESULTS A total of 216 patients were eligible for this study, and propensity score matching yielded 60 patients in each group. Anastomotic leakage in the LCA preservation group was significantly lower than that in the LCA nonpreservation group (3.3% vs. 13.3%, P = 0.048). No significant differences were observed in blood loss, operation time, intraoperative complications, splenic flexure mobilization, total number of harvested lymph nodes, number of positive lymph nodes, time to first flatus, or postoperative hospital stay. Kaplan-Meier survival analysis showed a 3-year disease-free survival of 85.7% vs. 80.5% (P = 0.738) and overall survival of 92.4% vs. 93.7% (P = 0.323) for the preservation and nonpreservation groups, respectively. CONCLUSION LCA preservation plus apical lymph node dissection surgery for rectal cancer may help reduce the incidence of anastomotic leakage without impairing the number of harvested lymph nodes. Preliminary results suggest that 3-year disease-free survival and overall survival rates may not differ between the two types of surgery, but studies with larger sample sizes are needed to confirm these conclusions. Trial registration ClinicalTrials.gov, NCT03776370. Registered 14 December 2018-Retrospectively registered, https://clinicaltrials.gov .
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Affiliation(s)
- Huichao Zheng
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China
| | - Xingjie Xie
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China
| | - Song Zhao
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China
| | - Bin Huang
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China
| | - Weidong Tong
- Department of General Surgery, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Daping, Yuzhong District, Chongqing, 400042, China.
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21
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Usefulness of Computed Tomography Angiography in the Preoperative Workup of Patients With Colorectal Cancer. J Comput Assist Tomogr 2022; 46:349-354. [PMID: 35467565 DOI: 10.1097/rct.0000000000001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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22
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Tryliskyy Y, Wong CS, Demykhova I, Tyselskyi V, Kebkalo A, Poylin V. Systematic review and meta-analysis of randomized controlled trials evaluating the effect of the level of ligation of inferior mesenteric artery on functional outcomes in rectal cancer surgery. Int J Colorectal Dis 2022; 37:709-718. [PMID: 35152339 DOI: 10.1007/s00384-022-04101-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This systematic review and meta-analysis studied the role of high (HL) versus low (LL) inferior mesenteric artery (IMA) ligation on genitourinary and defecatory dysfunction in patients who had undergone resection for rectal cancer (RC). METHODS A systematic literature search of four major databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) comparing HL and LL of IMA in RC surgery were identified. Those studies that looked at genitourinary or defecatory dysfunction were included. Random-effects modeling to summarize statistics was performed. The risk of bias was assessed using Cochrane's Risk-of-Bias tool 2. RESULTS Three RCTs were included. There was clinical heterogeneity with regard to cancer stage and location as well as operative techniques and adjuvant treatments. Functional outcomes (FO) that were reported by at least two studies were International Consultation on Incontinence Questionnaire (ICIQ), International Index for Erectile Function (IIEF), Jorge-Wexner incontinence score (J-W). Difference was observed in ICIQ at 9 months after surgery favoring LL (standard mean difference: - 0.66; 95% confidence intervals (CI): - 0.92, - 0.40; P = 0.37; I 2 = 0%). Difference was also observed in IIEF at 9 months favoring LL (mean difference: 7.43; CI: 1.86, 13.00; P = 0.16; I 2 = 50%). CONCLUSIONS Although our study has demonstrated the superiority of LL in genitourinary function preservation, these results should be taken with consciousness due to significant heterogeneity between included studies, small sample size, and potential bias. More high-quality studies are needed. PROSPERO CRD4202121099 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021210998.
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Affiliation(s)
- Yegor Tryliskyy
- Severn PGME School of Surgery, Park House, 1200 Parkway, Bristol, BS34 8YU, UK. .,The University of Edinburgh, Edinburgh, UK.
| | | | | | - Volodymyr Tyselskyi
- P.L. Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Andrii Kebkalo
- P.L. Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
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23
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Yin TC, Chen YC, Su WC, Chen PJ, Chang TK, Huang CW, Tsai HL, Wang JY. Low Ligation Plus High Dissection Versus High Ligation of the Inferior Mesenteric Artery in Sigmoid Colon and Rectal Cancer Surgery: A Meta-Analysis. Front Oncol 2021; 11:774782. [PMID: 34858855 PMCID: PMC8632045 DOI: 10.3389/fonc.2021.774782] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
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 controlled 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), and less yields of total lymph nodes (p = 0.03) but equivalent IMA root lymph nodes (p = 0.07); moreover, LL+HD exhibited non-inferior 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 the IMA below the level of the left colic artery with D3 high dissection for sigmoid colon and rectal cancers might be suggested once the surgeons are familiar with this technique. SYSTEMATIC REVIEW REGISTRATION INPLASY.com, identifier 202190029.
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Affiliation(s)
- Tzu-Chieh Yin
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
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24
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Huang X. Laparoscopic D3 lymph node dissection with left colic artery and sigmoid artery preservation in rectal cancer - a video vignette. Colorectal Dis 2021; 23:3034-3035. [PMID: 34459090 DOI: 10.1111/codi.15889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/13/2021] [Accepted: 08/06/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Xing Huang
- The First Department of General Surgery (Department of Colorectal and Anal Surgery), Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University), Changsha, China
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Franceschilli M, Di Carlo S, Vinci D, Sensi B, Siragusa L, Bellato V, Caronna R, Rossi P, Cavallaro G, Guida A, Sibio S. Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery. World J Clin Cases 2021; 9:7297-7305. [PMID: 34616795 PMCID: PMC8464444 DOI: 10.12998/wjcc.v9.i25.7297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/14/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Since the 19th century, appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors. This approach can be applied to any surgery for gastrointestinal cancer. During surgery for colon and rectal cancer, an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease. The adequate number of lymph nodes to be removed is standardized and reported by several guidelines. It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients. Our review focuses on the concept of "complete mesenteric excision (CME) with central vascular ligation (CVL)," a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years. The aim of this study was to evaluate the evolution of this approach over the years, its potential oncologic benefits and potential risks, and the improvements offered by laparoscopic techniques. Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin (CVL) which guarantees removal of a larger number of lymph nodes. The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery, providing the same oncologic results as open surgery. This has been widely applied to colorectal cancer surgery; however, CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzes results of these procedures in terms of oncological outcomes, technical feasibility and complexity, especially within the context of minimally invasive surgery.
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Affiliation(s)
- Marzia Franceschilli
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Sara Di Carlo
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Danilo Vinci
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Bruno Sensi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Leandro Siragusa
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Vittoria Bellato
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Unit of Pancreatic and Biliary Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Piero Rossi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Giuseppe Cavallaro
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Andrea Guida
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Simone Sibio
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
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26
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Bai X, Zhang CD, Pei JP, Dai DQ. Genitourinary function and defecation after colorectal cancer surgery with low- and high-ligation of the inferior mesenteric artery: A meta-analysis. World J Gastrointest Surg 2021; 13:871-884. [PMID: 34512910 PMCID: PMC8394385 DOI: 10.4240/wjgs.v13.i8.871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/12/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao Bai
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Jun-Peng Pei
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Dong-Qiu Dai
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
- Cancer Center, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province , China
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27
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Franceschilli M, Vinci D, Di Carlo S, Sensi B, Siragusa L, Guida A, Rossi P, Bellato V, Caronna R, Sibio S. Central vascular ligation and mesentery based abdominal surgery. Discov Oncol 2021; 12:24. [PMID: 35201479 PMCID: PMC8777547 DOI: 10.1007/s12672-021-00419-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.
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Affiliation(s)
- M Franceschilli
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - D Vinci
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy.
| | - S Di Carlo
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - B Sensi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - L Siragusa
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - A Guida
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - P Rossi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - V Bellato
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - R Caronna
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| | - S Sibio
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
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28
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Jonnada PK, Karunakaran M, Rao D. Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: a systematic review and meta-analysis. Future Oncol 2021; 17:3645-3661. [PMID: 34259582 DOI: 10.2217/fon-2021-0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Dayakar Rao
- Yashoda Cancer Institute, Hyderabad, Telangana, 500036, India
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29
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Guidolin K, Covelli A, Chesney TR, Draginov A, Chadi SA, Quereshy FA. Apical lymphadenectomy during low ligation of the IMA during rectosigmoid resection for cancer. Surg Open Sci 2021; 5:1-5. [PMID: 34337371 PMCID: PMC8313841 DOI: 10.1016/j.sopen.2021.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/09/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023] Open
Abstract
Background Low ligation of the inferior mesenteric artery with preservation of the left colic artery may decrease the risk of colorectal anastomotic ischemia compared to high ligation at its origin. Low ligation leaves apical nodes in situ and is therefore paired with apical lymphadenectomy. We sought to compare relevant oncologic outcomes between high ligation and low ligation plus apical lymphadenectomy in rectosigmoid resection for colorectal cancer. Methods We conducted a retrospective cohort study. Patients receiving a rectosigmoid resection for cancer between January 2012 and July 2018 were included. Patients with metastatic disease and those who underwent low ligation without apical lymphadenectomy were excluded. Our primary outcome was nodal yield/metastasis. Secondary outcomes included perioperative complications, local recurrence, and overall survival. Results Eighty-four patients underwent high ligation and 89 low ligation plus apical lymphadenectomy (median follow-up 20 months). In the low-ligation group, a median of 2 (interquartile range = 1–3) apical nodes was resected; 4.1% were malignant, increasing pathologic stage in 25% of these patients. There were no differences in nodal yield, complications, anastomotic leak, local recurrence, or overall survival. Conclusion No differences were identified between high ligation and low ligation plus apical lymphadenectomy with respect to relevant clinical outcomes. Prospective trial data are needed to robustly establish the oncologic benefit and safety of the low ligation plus apical lymphadenectomy technique.
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Affiliation(s)
- Keegan Guidolin
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
| | - Andrea Covelli
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Department of Surgery, University Health Network, Toronto, Ontario
| | - Tyler R Chesney
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Department of Surgery, St. Michael's Hospital, Toronto, Ontario
| | - Arman Draginov
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
| | - Sami A Chadi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Department of Surgery, University Health Network, Toronto, Ontario
| | - Fayez A Quereshy
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Department of Surgery, University Health Network, Toronto, Ontario
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30
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Wang Y, Shu W, Ouyang A, Wang L, Sun Y, Liu G. The New Concept of Physiological "Riolan's Arch" and the Reconstruction Mechanism of Pathological Riolan's Arch After High Ligation of the Inferior Mesenteric Artery by CT Angiography-Based Small Vessel Imaging. Front Physiol 2021; 12:641290. [PMID: 34239446 PMCID: PMC8257958 DOI: 10.3389/fphys.2021.641290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background Due to the complexity of anatomical relationship between superior mesenteric artery (SMA) and left colic artery (LCA), there is no unified anatomical concept of "Riolan's arch." There is no consensus as to tie off the inferior mesenteric artery (IMA) at its origin or just below the origin of the left colic artery during radical surgery of sigmoid colon and rectal cancers. The aim of the study is to investigate the anatomy of shortcut anastomotic branches (adjacent branches) of SMA at splenic flexure and to explore how the shortcut pathway (Riolan's arch) was formed, as the compensation of anastomotic branches between MCA and LCA under pathological conditions and the reconstruction and the mechanism of pathological Riolan's arch after high ligation of the inferior mesenteric artery. Methods Between January 2018 and May 2020, patients with colorectal cancer who underwent CTA before surgery were enrolled in the study. The anatomy of shortcut anastomotic branch of SMA and LCA was investigated by volume rendering technique (VR) and maximum-intensity projection (MIP). GE's small vessel extraction technology (selected VR) was used to directly display these shortcut anastomotic branches on a map and to establish their three-dimensional anatomical classification. Then, we used the axonometric drawing to make the model more exact. Next, combining with some cases of pathological Riolan's arch and basing on hydrodynamic principle, we speculate the mechanism of collateral circulation. Finally, based on the retrospective study of high ligation cases and combined principles of fluid mechanics, we show how these shortcut anastomotic branches evolved into Riolan's arch. Results We report the classification of the ascending branch of LCA (which approaches the splenic flexure) and the left branch of MCA, display these shortcut anastomotic branches on a map, and establish their three-dimensional anatomical classification. We found that Riolan's arch is a shortcut pathway for the compensation of anastomotic branches, between MCA and LCA under pathological conditions, and that the formation mechanism of shortcut path accords with the principle of hydrodynamics. Conclusions Our results show the mechanism of pathological Riolan's arch formation and provide new anatomic thinking for the battle between high and low ligation of IMA in colorectal cancer surgery.
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Affiliation(s)
- Ying Wang
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Weibin Shu
- Tumor Research and Therapy Center, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Aimie Ouyang
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Lei Wang
- Department of Gastroenterology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yuping Sun
- Department of Oncology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guoqin Liu
- Department of Gastroenterology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
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31
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Short-Term Outcomes Following Hand-Assisted Laparoscopy for Left-Sided Colon and Rectal Malignancies: Single-Center Experience of 580 Cases. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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32
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Namba Y, Mukai S, Saito Y, Moriuchi T, Bekki T, Okimoto S, Oishi K, Fujisaki S, Takahashi M, Fukuda T, Egi H, Ohdan H. Risk Factors for Anastomotic Leakage after Colorectal Surgery with Double-staple Technique Anastomosis: Impact of the Agatston Score. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:181-187. [PMID: 33937559 PMCID: PMC8084537 DOI: 10.23922/jarc.2020-099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/03/2021] [Indexed: 01/23/2023]
Abstract
Objectives Anastomotic leakage is associated with severe morbidity, mortality, and functional defects. Its risk factors remain unclear. However, blood perfusion may be a potential major risk factor. It has been reported that the Agatston score is an index for blood flow perfusion evaluation. Therefore, we evaluated the clinical indicators associated with anastomotic leakage, including the Agatston score, in patients who underwent colorectal surgery. Methods We retrospectively analyzed 147 patients who underwent elective colorectal surgery with the double-staple technique anastomosis for colorectal cancer between April 2015 and March 2020. The primary outcome was the presence or absence of anastomotic leakage. Univariate and multivariate analyses were employed to identify pre- and intraoperative risk factors. Results Of the 147 patients analyzed, anastomotic leakage occurred in 12 (8.16%). Male gender, history of angina and myocardial infarction, preoperative white blood cell count, the Agatston score, extent of bleeding, operation time, and intraoperative fluid volume were significantly related to a higher incidence of anastomotic leakage in univariate analysis. Multivariate analysis demonstrated that the incidence of anastomotic leakage was high in patients with a high Agatston score. Conclusions The Agatston score can predict the incidence of anastomotic leakage in patients following colorectal surgery. Thus, perioperative measures to prevent anastomotic leakage are recommended when a high Agatston score is observed. A prospective trial is required to demonstrate, with a high level of evidence, that the Agatston score can be useful as a risk score for anastomotic leakage following colorectal surgery.
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Affiliation(s)
- Yosuke Namba
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Shoichiro Mukai
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Yasufumi Saito
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | | | - Tomoaki Bekki
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Sho Okimoto
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Koichi Oishi
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Seiji Fujisaki
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | | | | | - Hiroyuki Egi
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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33
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A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report. Int J Surg Case Rep 2021; 83:105906. [PMID: 34023548 PMCID: PMC8164025 DOI: 10.1016/j.ijscr.2021.105906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Patients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed. Case presentation A 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation. Discussion During surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications. Conclusions Controlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.
The patient with PAH complicated by MCTD underwent Hartman’s operation for sigmoid colon cancer. Control of PAH by epoprostenol preoperatively is important to prevent perioperative cardiac complications. The level of ligation of the IMA and the LCA is important to avoid severe edema of stoma.
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34
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Technical considerations depending on the level of vascular ligation in laparoscopic rectal resection. Surg Endosc 2021; 36:1961-1969. [PMID: 33876306 DOI: 10.1007/s00464-021-08479-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
AIM In addition to ischemia there is also anastomotic ends tension proven to be a risk factor for anastomotic leak. HT vascular ligation is accepted as a rule, in attempt to achieve tension-free anastomosis. LT is a preferred option, based on the more accurate preservation of proximal intestinal segment microperfusion and lower risk of damage to the hypogastric plexus. The aim of this study is evaluation of comparative indicators in high tie (HT) and low tie (LT) laparoscopic rectal resections. METHODS A prospective nonrandomized comparative cohort study of patients in our department with cancer of the rectum in clinical stage I-III, operated on in laparoscopic approach over a 6-years period. RESULTS For the period 2015-2020, a number of 208 laparoscopic surgeries have been done for rectal cancer. Patients were divided into three groups-group A with HT vascular ligation 116 pts. (69%), group B-53 pts. (25%), underwent low ligation-LT and group C-39pts. (19%) low tie plus lymph node dissection of the apical LN group (LT-appic LND). The distribution was made without randomization, based on the operators' expertise. Anastomotic leaks were 3.8% in group A, 3.0% in group B and 2.9% in group C (p > 0.05) with no significance difference. There is no significant difference in the number of lymph nodes obtained in group A and group B, while in group C the number of the harvested lymph nodes was higher (p < 0.05). The indicators for intestinal / defecation dysfunction, as well as for urinary/sexual dysfunction, according to our data, are significantly more favorable in patients with LT, in contrast to the other two groups. CONCLUSION HT vascular ligation attempts to achieve tension-free anastomosis and more harvested lymph nodes. However, LT could be a preferred option, based on the lack of significant evidence for a difference in specific oncological survival and due to more accurate preservation of proximal intestinal segment microperfusion to prevent anastomosis dehiscence, also for its lower risk of damage to the hypogastric plexus. Splenic flexure mobilization provides elongation of the proximal intestinal segment, but has no proven effect on anastomotic leakage incidence. It increases surgical duration and is in fact necessary in up to 30% of the cases. At the present moment there is no precise data whether LT has an advantage in terms of prevention of autonomic nervous and urogenital dysfunction. New prospective randomized and highly probative studies are needed to standardize the procedures in specific clinical situations.
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35
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Hu S, Li S, Huang X, Yan Y, Teng D, Lin H, He C, Gao Z, Wang Y, Du X. 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. J Gastrointest Oncol 2021; 12:580-591. [PMID: 34012651 DOI: 10.21037/jgo-20-327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
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.
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Affiliation(s)
- Shidong Hu
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Songyan Li
- Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiaohui Huang
- Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yang Yan
- Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Da Teng
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Haiguan Lin
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Changzheng He
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zihe Gao
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yufeng Wang
- Department of Hospital Management, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiaohui Du
- Medical School of Chinese PLA, Beijing, China.,Department of General Surgery, The First Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
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36
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Yin TC, Su WC, Chen PJ, Chang TK, Chen YC, Li CC, Hsieh YC, Tsai HL, Huang CW, Wang JY. Oncological Outcomes of Robotic-Assisted Surgery With High Dissection and Selective Ligation Technique for Sigmoid Colon and Rectal Cancer. Front Oncol 2020; 10:570376. [PMID: 33194663 PMCID: PMC7641631 DOI: 10.3389/fonc.2020.570376] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the complication rate. We present preliminary experiences of operative and oncologic outcomes of patients with rectal or sigmoid colon cancer who underwent robotic surgery employing the high dissection and selective ligation technique. Methods: Over May 2013 to April 2017, 113 stage I-III rectal or sigmoid colon cancer patients underwent robotic surgery with the single-docking technique at one institution. We performed D3 lymph node dissection and low-tie ligation of the IMA (i.e., high dissection and selective ligation technique). Clinicopathological features, perioperative parameters, and postoperative outcomes were retrospectively analyzed. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Results: Sphincter preservation rate was 96.3% in rectal cancer patients. Median number of harvested lymph nodes was 12. Apical nodes were pathologically harvested in 84 (82.4%) patients. R0 resection was performed in 108 (95.6%) patients. Overall complication rate was 17.7%; but most complications were mild and the patients recovered uneventfully. Estimated 5-year OS was 86.1% and 3-year DFS was 79.6% after median follow-up periods of 49.1 months (range, 5.3-85.3). Conclusions: High dissection of the IMA and selective ligation of the major feeding vessel to the sigmoid colon or rectum can be safely performed using da Vinci Surgical System,yielding favorable clinical, and oncologic outcomes in rectal or sigmoid colon cancer treatment.
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Affiliation(s)
- Tzu-Chieh Yin
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chien Hsieh
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
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37
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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; 34:4593-4600. [PMID: 31641914 DOI: 10.1007/s00464-019-07203-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the treatment of distal sigmoid and rectal cancer, the appropriate level for the ligation of the inferior mesenteric artery (IMA) remains unresolved. High ligation divides the IMA proximally at its origin, and low ligation ligates the IMA distal to the origin of left colic artery. We assessed the association of level of ligation in scheduled minimally invasive resection of sigmoid and rectal cancers on anastomotic leak, postoperative complications, and death within 30 days. METHODS We identified all patients with primary sigmoid and rectal cancer treated with scheduled minimally invasive resection and primary anastomosis between January 2002 and June 2018 using linked institutional and National Surgical Quality Improvement Program databases. We assessed the association of level of ligation with each outcome by fitting individual univariable and multivariable logistic regression models, adjusting for surgical approach, tumor location, neoadjuvant chemoradiotherapy, and Charlson comorbidity index. RESULTS We included 158 patients treated with high ligation and 123 patients treated with low ligation. Overall, 12 patients had an anastomotic leak requiring intervention within 30 days: 5 in the high ligation group (3.2%, 95% CI 1.4-7.2%) and 7 in the low ligation group (5.7%, 95% CI 2.8-11.3%). There was no association between the level of ligation and anastomotic leak (unadjusted OR 1.85, 95% CI 0.58-6.38; adjusted OR 0.63, 95% CI 0.16-2.55). Similarly, there was no association between the level of ligation and reoperation for anastomotic leak (OR 1.29, 95% CI 0.15-10.9), major complications (Clavien-Dindo III-V; OR 2.22, 95% CI 0.90-5.77), minor complications (Clavien-Dindo I-II; OR 1.51, 95% CI 0.88-2.60), and all complications (OR 1.58, 95% CI 0.94-2.67). No deaths occurred in either group. CONCLUSIONS There was no association of level of ligation of the IMA with anastomotic leak, postoperative complications as a composite, or death. The choice of high or low ligation of the IMA should be made based on technical factors such as length for the creation of a tension-free anastomosis.
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Zhang C, Chen L, Cui M, Xing J, Yang H, Yao Z, Zhang N, Tan F, Liu M, Xu K, Su X. Short- and long-term outcomes of rectal cancer patients with high or improved low ligation of the inferior mesenteric artery. Sci Rep 2020; 10:15339. [PMID: 32948817 PMCID: PMC7501289 DOI: 10.1038/s41598-020-72303-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/26/2020] [Indexed: 01/01/2023] Open
Abstract
The ligation site of the inferior mesenteric artery (IMA) during laparoscopic radical resection for rectal cancer has been controversial. Consecutive patients (n = 205) with rectal cancer who underwent laparoscopic-assisted low anterior resection from January 2009 to December 2015 were retrospectively analyzed. The patients were divided into high ligation (n = 126) and improved low ligation groups (n = 79). A total of 205 rectal cancer patients underwent laparoscopic assisted anterior resection: 126 patients in the high ligation group and 79 patients in the improved low ligation group. The improved low ligation group was better than the high ligation group in terms of postoperative flatus time and postoperative defecation time. There were no differences between the groups in terms of blood loss, operation time, total number of lymph nodes, anastomotic leakage, postoperative time to first liquid diet and postoperative hospital stay. There were also no differences in 5-year overall survival (OS). Compared to high ligation, the improved low ligation ensures the extent of lymph node dissection, and promotes the early recovery of postoperative gastrointestinal function, but does not increase the operation time, bleeding risk, or anastomotic leakage. A ligation site of the IMA in laparoscopic rectal cancer surgery may not influence oncological outcomes.
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Affiliation(s)
- Chenghai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Lei Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Zhendan Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Maoxing Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 211] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Du CZ, Fan ZH, Yang YF, Yuan P, Gu J. Value of intra-operative Doppler sonographic measurements in predicting post-operative anastomotic leakage in rectal cancer: a prospective pilot study. Chin Med J (Engl) 2020; 132:2168-2176. [PMID: 31461731 PMCID: PMC6797145 DOI: 10.1097/cm9.0000000000000410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Chang-Zheng Du
- Gastrointestinal Cancer Center, Peking University Cancer Hospital, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China.,Department of Pathology, Duke University Medical School, Durham, NC, USA
| | - Zhi-Hui Fan
- Department of Sonography, Peking University Cancer Hospital, Beijing 100142, China
| | - Yuan-Fan Yang
- Department of Pathology, Duke University Medical School, Durham, NC, USA
| | - Ping Yuan
- Peking University Shougang Hospital, Beijing 100144, China
| | - Jin Gu
- Gastrointestinal Cancer Center, Peking University Cancer Hospital, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China.,Peking University Shougang Hospital, Beijing 100144, China.,Peking-Tsinghua Joint Center for Life Sciences, Beijing 100871, China
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Akagi T, Inomata M, Hara T, Mizusawa J, Katayama H, Shida D, Ohue M, Ito M, Kinugasa Y, Saida Y, Masaki T, Yamamoto S, Hanai T, Yamaguchi S, Watanabe M, Sugihara K, Fukuda H, Kanemitsu Y, Kitano S. Clinical impact of D3 lymph node dissection with left colic artery (LCA) preservation compared to D3 without LCA preservation: Exploratory subgroup analysis of data from JCOG0404. Ann Gastroenterol Surg 2020; 4:163-169. [PMID: 32258982 PMCID: PMC7105844 DOI: 10.1002/ags3.12318] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/20/2020] [Accepted: 01/23/2020] [Indexed: 12/21/2022] Open
Abstract
AIM We investigated the clinical impact of D3 lymph node dissection preserving left colic artery (LCA) compared to D3 without LCA preservation using data from JCOG0404. LCA preservation is expected to maintain adequate blood supply, which is effective in preventing anastomotic leakage, intestinal paralysis, and bowel obstruction. Whether D3 with LCA preservation (Group A) improves clinical outcomes following resection of sigmoid colon cancer compared to D3 without LCA preservation (Group B) is unclear. METHODS Procedure type was identified from photographs of the surgical field collected for central surgical review in JCOG0404. Clinical outcomes were compared between each procedure. RESULTS Among the 1057 randomized patients in JCOG0404, 631 patients receiving sigmoid colectomy or anterior resection were included in the subgroup analysis. Group A comprised of 135 patients and Group B of 496 patients. Patient backgrounds did not differ between groups. Median operative time, blood loss, anastomotic leakage, and intestinal paralysis were not remarkably different (Group A vs Group B: 185 vs 186 minutes, 60 vs 50 mL, 3.0% vs 5.0%, and 2.2% vs 3.8%). More overall postoperative complications occurred in Group B than Group A (21.6% vs 9.6%, P = .022). Five-year relapse-free survival (RFS) and overall survival (OS) tended to be better in Group A than Group B (RFS: 83.7% and 80.5%, HR 0.80 [95% CI 0.51-1.26], OS: 96.3% and 91.1%, HR 0.41 [95% CI 0.19-0.89]). CONCLUSIONS Short- and long-term outcomes tend to be better in Group A than Group B, indicating that preservation of LCA could be an alternative treatment.
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Affiliation(s)
- Tomonori Akagi
- Gastroenterological and Pediatric SurgeryOita University of Faculty of MedicineYufuJapan
| | - Masafumi Inomata
- Gastroenterological and Pediatric SurgeryOita University of Faculty of MedicineYufuJapan
| | - Takao Hara
- Gastroenterological and Pediatric SurgeryOita University of Faculty of MedicineYufuJapan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | - Dai Shida
- Department of Colorectal SurgeryNational Cancer CenterTokyoJapan
| | - Masayuki Ohue
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masaaki Ito
- Department of Colorectal SurgeryNational Cancer Center Hospital EastKashiwaJapan
| | - Yusuke Kinugasa
- Department of Gastrointestinal SurgeryTokyo Medical and Dental UniversityTokyoJapan
| | | | | | | | | | - Shigeki Yamaguchi
- Department of Gastroenterological SurgerySaitama Medical University International Medical CenterSaitamaJapan
| | - Masahiko Watanabe
- Department of SurgeryKitasato University School of MedicineSagamiharaJapan
| | - Kenichi Sugihara
- Department of SurgeryTokyo Medical and Dental UniversityTokyoJapan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | | | - Seigo Kitano
- Gastroenterological and Pediatric SurgeryOita University of Faculty of MedicineYufuJapan
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Park SS, Park B, Park EY, Park SC, Kim MJ, Sohn DK, Oh JH. 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; 50:560-568. [DOI: 10.1007/s00595-019-01942-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023]
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Zhang W, Yuan WT, Wang GX, Song JM. Anatomical study of the left colic artery in laparoscopic-assisted colorectal surgery. Surg Endosc 2019; 34:5320-5326. [PMID: 31834513 DOI: 10.1007/s00464-019-07320-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/06/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND It is important for lymph node dissection around the inferior mesenteric artery (IMA) with preservation of the left colic artery (LCA) to be aware of the track and the length of the LCA. We aimed to investigate the branching pattern and trajectory of LCA and measure the distances from the root of the IMA to the origin of the LCA (D mm) and from the origin of LCA to intersection of LCA and IMV (d mm) during laparoscopic left-sided colorectal operations. METHODS We analyzed 106 patients who underwent laparoscope-assisted left-side colorectal surgery during laparoscopic surgery. The branching patterns among the IMA, LCA, and sigmoidal trunk were evaluated; the trajectory of LCA was examined; the D mm and d mm were measured using a length of silk in the surgical operation. RESULTS In 59.5% patients, the LCA arose independently from the sigmoidal trunk (type A); in 8.5% patients, the LCA and sigmoidal trunk arose from the IMA at the same point (type B); in 29.2% patients, the LCA and sigmoidal trunk had a common trunk (type C); the LCA did not exist in 2.8% (type D).The D mm and d mm for all cases ranged from 15.0 to 65.3 mm (median, 43.1 mm) and from 20.3 to 46.2 mm (median, 34.8 mm), respectively. 74.8% of the LCA went straight upper left and upward to proximal part of descending colon (type I), 25.2% went to the lower left at first, then turned to travel straight upward to proximal part of descending colon (type II). CONCLUSION This study showed the anatomic variations of LCA during laparoscopic left-sided colorectal operation, which would help surgeons safely perform laparoscopic surgery in the left-side colon and rectum.
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Affiliation(s)
- Wei Zhang
- The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 on Jian-She-East Road, Zhengzhou, Henan Province, China
| | - Wei-Tang Yuan
- The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 on Jian-She-East Road, Zhengzhou, Henan Province, China
| | - Gui-Xian Wang
- The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 on Jian-She-East Road, Zhengzhou, Henan Province, China
| | - Jun-Min Song
- The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 on Jian-She-East Road, Zhengzhou, Henan Province, China.
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Cui Y, Sun S, Li Z, Wang W. Safety, Survival, and Efficacy of Preserving Left Colonic Artery in Rectal Cancer Surgery: A Meta-Analysis and Review. J Laparoendosc Adv Surg Tech A 2019; 29:1405-1413. [PMID: 31436498 DOI: 10.1089/lap.2019.0406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- YongHe Cui
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - ShaoMing Sun
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Zhanwu Li
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - WenJun Wang
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
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Sakamoto W, Yamada L, Suzuki O, Kikuchi T, Okayama H, Endo H, Fujita S, Saito M, Momma T, Saze Z, Ohki S, Kono K. Microanatomy of inferior mesenteric artery sheath in colorectal cancer surgery. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:167-174. [PMID: 31768467 PMCID: PMC6845289 DOI: 10.23922/jarc.2019-016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
Abstract
Objectives: Left colic artery preserving lymph node dissection around the inferior mesenteric artery (IMA) is a standard procedure for rectal cancer surgery. Although the IMA sheath is a well-known structure, to our knowledge, there are no reports describing its microanatomy from an oncological point of view; therefore, there is no consensus on how to handle the sheath for accurate lymph node dissection around IMA. We aimed to investigate the components of the IMA sheath pathologically, focusing particularly on the presence of lymph nodes (LNs) and lymphatic ducts (LDs). Methods: We evaluated rectal and sigmoid cancer specimens resected with high-tie technique in our institute in April 2017-April 2018. The specimens were collected consecutively, without any selection. In the resected specimens, the entire anatomical structure of IMA was investigated. We defined the IMA sheath as the tissues located between the surface of the IMA adventitia and collagenous layers connecting the outermost nerve fibers. The microanatomy around the IMA was examined using H&E staining, and LDs were identified using D2-40 immunohistochemistry. Results: Twenty patients were enrolled. No LNs were observed within the sheath in any of the cases. However, there were a significant number of LDs (11.08 ± 3.35) within the sheath. Conclusions: Our anatomical definition of IMA sheath was feasible and objectively possible. These microanatomical results partially support the surgical concept of left colic artery preserving lymph node dissection around the IMA. It may be difficult to remove all lymphatic ducts without removing the IMA itself.
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Affiliation(s)
- Wataru Sakamoto
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Leo Yamada
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Osamu Suzuki
- Department of Diagnostic Pathology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tomohiro Kikuchi
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Hirokazu Okayama
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Hisahito Endo
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shotaro Fujita
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Motonobu Saito
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tomoyuki Momma
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Zenichiro Saze
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shinji Ohki
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Koji Kono
- Department of Gastrointestinal Tract Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
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Yin Z, Zheng B, Wei M, Zhai Y, Zhou S, Zhang B, Wu T, Qiao Q, Wang N, He X. b-Shaped Laparoscopic Dual Anastomosis for Mid-Low Rectal Cancer: A Safe and Feasible Technique. J Laparoendosc Adv Surg Tech A 2019; 29:1174-1179. [PMID: 31233371 DOI: 10.1089/lap.2019.0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Zhiyuan Yin
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Bobo Zheng
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingguang Wei
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Yulong Zhai
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Shuai Zhou
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Bo Zhang
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Tao Wu
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Qing Qiao
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Nan Wang
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Xianli He
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
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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; 35:167-173. [PMID: 31487763 PMCID: PMC6732324 DOI: 10.3393/ac.2018.10.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/09/2018] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Cho Shin Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sohyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Tiselius C, Kindler C, Rosenblad A, Smedh K. Localization of mesenteric lymph node metastases in relation to the level of arterial ligation in rectal cancer surgery. Eur J Surg Oncol 2019; 45:989-994. [DOI: 10.1016/j.ejso.2019.01.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/25/2019] [Indexed: 01/13/2023] Open
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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. Int J Colorectal Dis 2019; 34:947-962. [PMID: 30997603 DOI: 10.1007/s00384-019-03291-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
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.
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