Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Jun 15, 2020; 12(6): 632-641
Published online Jun 15, 2020. doi: 10.4251/wjgo.v12.i6.632
Low ligation has a lower anastomotic leakage rate after rectal cancer surgery
Jia-Nan Chen, Zheng Liu, Zhi-Jie Wang, Fu-Qiang Zhao, Fang-Ze Wei, Shi-Wen Mei, Hai-Yu Shen, Juan Li, Wei Pei, Zheng Wang, Jun Yu, Qian Liu
Jia-Nan Chen, Zheng Liu, Zhi-Jie Wang, Fu-Qiang Zhao, Fang-Ze Wei, Shi-Wen Mei, Hai-Yu Shen, Juan Li, Wei Pei, Zheng Wang, Qian Liu, Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
Jun Yu, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
Author contributions: Chen JN, Zhao FQ, and Wang ZJ designed the research; Mei SW, Shen HY, Wei FZ and Li J collected the data; Pei W, Wang Z, Liu Z analyzed the data; Chen JN drafted the article; Liu Q and Yu J revised the paper.
Supported by the Medicine and Health Technology Innovation Project of Chinese Academy of Medical Sciences, No. 2017-12M-1-006; and China Scholarship Council, No. CSC201906210471.
Institutional review board statement: Our investigation received approval from the ethics committee of the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College.
Informed consent statement: All patients signed informed consent forms.
Conflict-of-interest statement: The authors declare there is no conflict of interest in regard to this research.
Data sharing statement: No additional data are available.
STROBE statement: The authors have carefully read the STROBE statement checklist of items and prepared the manuscript based on the requirements of the STROBE statement checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Qian Liu, MD, Chief Doctor, Professor, Surgeon, Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China. fcwpumch@163.com
Received: January 11, 2020
Peer-review started: January 11, 2020
First decision: April 7, 2020
Revised: May 13, 2020
Accepted: May 14, 2020
Article in press: May 14, 2020
Published online: June 15, 2020
Abstract
BACKGROUND

For laparoscopic rectal cancer surgery, the inferior mesenteric artery (IMA) can be ligated at its origin from the aorta [high ligation (HL)] or distally to the origin of the left colic artery [low ligation (LL)]. Whether different ligation levels are related to different postoperative complications, operation time, and lymph node yield remains controversial. Therefore, we designed this study to determine the effects of different ligation levels in rectal cancer surgery.

AIM

To investigate the operative results following HL and LL of the IMA in rectal cancer patients.

METHODS

From January 2017 to July 2019, this retrospective cohort study collected information from 462 consecutive rectal cancer patients. According to the ligation level, 235 patients were assigned to the HL group while 227 patients were assigned to the LL group. Data regarding the clinical characteristics, surgical characteristics and complications, pathological outcomes and postoperative recovery were obtained and compared between the two groups. A multivariate logistic regression analysis was performed to evaluate the possible risk factors for anastomotic leakage (AL).

RESULTS

Compared to the HL group, the LL group had a significantly lower AL rate, with 6 (2.8%) cases in the LL group and 24 (11.0%) cases in the HL group (P = 0.001). The HL group also had a higher diverting stoma rate (16.5% vs 7.5%, P = 0.003). A multivariate logistic regression analysis was subsequently performed to adjust for the confounding factors and confirmed that HL (OR = 3.599; 95%CI: 1.374-9.425; P = 0.009), tumor located below the peritoneal reflection (OR = 2.751; 95%CI: 0.772-3.985; P = 0.031) and age (≥ 65 years) (OR = 2.494; 95%CI: 1.080-5.760; P = 0.032) were risk factors for AL. There were no differences in terms of patient demographics, pathological outcomes, lymph nodes harvested, blood loss, hospital stay and urinary function (P > 0.05).

CONCLUSION

In rectal cancer surgery, LL should be the preferred method, as it has a lower AL and diverting stoma rate.

Keywords: Rectal neoplasms, Inferior mesenteric artery, Anastomotic leakage, Laparoscopy, Ligation, Postoperative complications

Core tip: Anastomotic leakage (AL) is one of the most common and serious postoperative complications of colorectal surgery and is a major cause of postoperative mortality and morbidity. Our study shows that low ligation of the inferior mesenteric artery in rectal cancer patients has a lower AL rate and diverting stoma rate. Older age and tumor located below the peritoneal reflection are also risk factors for AL. In rectal cancer surgery, low ligation should be the preferred method.