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

Roberto Cirocchi; Francesco Marchetti; Giulio Mari; Francesco Bagolini; Davide Cavaliere; Stefano Avenia; Gabriele Anania; Giovanni Tebala; Annibale Donini; Richard Justin Davies; Abe Fingerhut

doi:10.1007/s00423-023-03022-z

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

Langenbecks Arch Surg. 2023 Jul 26;408(1):286. doi: 10.1007/s00423-023-03022-z.

Authors

Affiliations

¹ Department of Medicine and Surgery, University of Perugia, Perugia, Italy. roberto.cirocchi@unipg.it.
² Department of Surgical Sciences, University of Ferrara, Ferrara, Italy.
³ Department of Colorectal Surgery ASST Brianza, Desio Hospital, Desio, Italy.
⁴ Department of Colorectal Surgery and General Surgery, Ospedale Per Gli Infermi, Faenza, Italy.
⁵ Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
⁶ Department of Digestive and Emergency Surgery, Hospital of Santa Maria of Terni, Terni, Italy.
⁷ Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
⁸ Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China.
⁹ Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.

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.

Keywords: IMA ligation; Laparoscopy; Rectal cancer; Rectum; Surgery.

Publication types

Meta-Analysis
Systematic Review
Review

MeSH terms

Anastomotic Leak / epidemiology
Anastomotic Leak / etiology
Humans
Laparoscopy* / methods
Ligation / methods
Lymph Node Excision / adverse effects
Lymph Nodes / pathology
Mesenteric Artery, Inferior / surgery
Rectal Neoplasms* / pathology
Rectal Neoplasms* / surgery
Rectum / surgery