Colonic ischemia following surgery for sigmoid colon and rectal cancer: a study of 10 cases and a review of the literature

High Ligation of the Inferior Mesenteric Artery in Left-Sided Colon and Rectal Cancer Resection: Rates of Success and Outcomes

BACKGROUND

High ligation of the inferior mesenteric artery, defined as ligation before the takeoff of the left colic artery, is often described as the gold standard in low left-sided colon and rectal cancer surgery. The aim of this study is to quantify the rate of ligation at the described level at a single academic center. Additionally, we examined the relationship between level of ligation and cancer-related outcomes.

METHODS

This retrospective cohort study included patients ages 18 and over with low left-sided colon, rectal, and anal cancers undergoing surgical resection. Radiographic evidence of high ligation was defined as ligation of the inferior mesenteric artery before the takeoff of the left colic artery. Patients with and without radiographic evidence of high ligation on CT were compared. Secondary outcomes include lymph node yield and positivity, need for adjuvant therapy, and time from surgery to adjuvant therapy.

RESULTS

169 patients (54% male) were included in the study. 61.5% of operative reports described high ligation of the IMA. There was radiographic evidence of high ligation in 55.6% of total patients and in 70.2% of patients where high ligation was intended. There was no significant difference in surgeon experience, surgical procedure, or surgical approach. There was no difference in lymph node yield, time to adjuvant chemotherapy, or recurrence rates.

CONCLUSION

This study demonstrates good technical success rate of high ligation of the inferior mesenteric artery but shows no difference in short-term patient-measured outcomes between high and low ligation (or successful and unsuccessful high ligation).

Assessing anatomical variations of the inferior mesenteric artery via three-dimensional CT angiography and laparoscopic colorectal surgery: a retrospective observational study

To assess the anatomy of the inferior mesenteric artery (IMA) and its branches by reviewing laparoscopic left-sided colorectal cancer surgery videos and comparing them with preoperative three-dimensional computed tomography (3D-CT) angiography, to verify the accuracy of 3D-CT vascular reconstruction techniques. High-definition surgical videos and preoperative imaging data of 200 patients who underwent laparoscopic left-sided colorectal cancer surgery were analysed, and the alignment of the IMA and its branches in relation to the inferior mesenteric vein (IMV) was observed and summarized. The above two methods were used to measure the length of the IMA and its branches. Of 200 patients, 47.0% had the sigmoid arteries (SAs) arise from the common trunk with the superior rectal artery (SRA), and 30.5% had the SAs arise from the common trunk with the left colic artery (LCA). In 3.5% of patients, the SAs arising from both the LCA and SRA. The LCA, SA, and SRA emanated from the same point in 13.5% of patients, and the LCA was absent in 5.5% of patients. The range of D cm (IMA length measured by intraoperative silk thread) and d cm (IMA length measured by 3D-CT vascular reconstruction) in all cases was 1.84-6.62 cm and 1.85-6.52 cm, respectively, and there was a significant difference between them. (p < 0.001). The lengths between the intersection of the LCA and IMV measured intraoperatively were 0.64-4.29 cm, 0.87-4.35 cm, 1.32-4.28 cm and 1.65-3.69 cm in types 1A, 1B, 1C, and 2, respectively, and there was no significant difference between the groups (p = 0.994). There was only a significant difference in the length of the IMA between the 3D-CT vascular reconstruction and intraoperative observation data, which can provide guidance to surgeons in preoperative preparation.

Venous Congestive Ischemic Colitis After Sigmoid Colectomy: A Case Report

Venous congestion is a possible cause of ischemic colitis following colorectal surgery. As such, congestive ischemic colitis should be considered in such cases where the mesenteric artery is preserved. Herein, we describe the case of a 73-year-old man who presented to the hospital with a two-week history of difficult defecation and frequent mucous stools and was subsequently diagnosed with refractory ischemic enterocolitis due to venous congestion. The patient had undergone resection of the sigmoid colon cancer with preservation of the inferior mesenteric artery 11 months before presentation. Contrast-enhanced abdominal computed tomography revealed edematous wall thickening on the anal side of the anastomosis. A colonoscopy revealed a normal mucosa extending from the anastomosis to the descending colon; however, mucosal swelling, erythema, and erosion were observed on the rectal side of the anastomosis. Based on these findings, he was diagnosed with ischemic colitis. After two months of ineffective conservative treatment, the patient underwent surgery. Ischemic colitis was diagnosed as venous congestion based on the histopathological examination. Preservation of the mesenteric artery may result in ischemic colitis due to an imbalance between the arterial and venous blood flow. Chronic ischemic colitis due to venous congestion should be considered in cases of mesenteric artery preservation to reduce anastomotic leakage.

Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR

OBJECTIVES

To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications.

BACKGROUND

DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA).

METHODS

All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included.

RESULTS

Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up.

CONCLUSIONS

DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.

Discontinuity of marginal artery at splenic flexure and rectosigmoid junction: A systematic review and meta-analysis

AIM

The aim of this study was to provide comprehensive evidence-based assessment of the discontinuity of the marginal artery at the splenic flexure (SF) and the rectosigmoid junction (RSJ).

METHOD

A systematic review was conducted of literature published to 26 December 2022 in the electronic databases PubMed, SCOPUS and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes were the pooled PPEs of the marginal artery at the SF and the RSJ. The secondary outcome was the size of vascular anastomoses.

RESULTS

A total of 21 studies (n = 2,864 patients) were included. The marginal artery was present at the splenic flexure in 82% (95% CI: 62-95) of patients. Approximately 81% (95% CI: 63-94%) of patients had a large macroscopic anastomosis, while the remainder (19%) had small bridging ramifications forming the vessel. The marginal artery was present at the RSJ in 82% (95% CI: 70-91%) of patients.

CONCLUSION

The marginal artery may be absent at the SF and the RSJ in up to 18% of individuals, which may confer a higher risk of ischaemic colitis. As a result of high interstudy heterogeneity noted in our analysis, further well-powered studies to clarify the prevalence of the marginal artery at the SF and the RSJ, as well as its relationship with other complementary colonic collaterals (intermediate and central mesenteric), are warranted.

Long-term Oncological Results After Laparoscopic Sigmoidectomy for Adenocarcinoma

Purpose: Sigmoidectomy is performed in most cases for benign pathologies and mainly in cases of diverticulitis. Few studies in the literature report oncological results after sigmoidectomy for adenocarcinoma. The aim of this study was to report the long-term oncological outcomes after elective laparoscopic sigmoidectomy (LS) for adenocarcinoma. Methods: This study is a retrospective analysis of prospectively collected data. From January 2003 to February 2021, 173 patients underwent elective LS for adenocarcinoma. Twenty-four patients with a diagnosis of preoperative distant metastases were excluded (13.9%). Results: Seven postoperative complications were observed (7.1%). Of these, 2 (2%) anastomotic leakages were treated surgically by the Hartmann procedure (Clavien-Dindo grade III-b). The mean number of harvested lymph nodes with the specimen was 14.2 ± 7.1. At a median follow-up of 115 months (interquartile range 133.8), 2 (2%) and 9 patients (9.2%) had developed recurrence and metastases, respectively. During follow-up, 6 patients (6.1%) with metastases died due to disease progression and 6 other patients (6.1%) died due to causes other than cancer related. At the 5- and 10-year follow-ups, the overall survival rates were 90.5% ± 3.4% and 83.8% ± 4.5%, respectively, while the disease-free survival rates were 87.1% ± 4.1% and 83.5% ± 4.7%, respectively. Conclusion: LS is a safe and feasible technique both in terms of the number of harvested lymph nodes and oncological results. The possibility of sparing the colon without mobilizing the splenic flexure and dividing the left colic artery could reduce intra- and postoperative complications. Further studies with larger samples of patients are required to confirm these data.

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

Backgroud

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

Methods

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

Results

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

Conclusion

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

Nomogram for benign anastomotic stricture after surgery for rectal cancer

BACKGROUND

Benign anastomotic stricture remains among the most prevalent complications following surgery for rectal cancer.

OBJECTIVE

This study is aimed at identifying risk factors of anastomotic stricture as well as generating an effective nomogram for the stricture.

METHODS

Design: This is a retrospective study.

SETTING

This study was conducted from January 2015 to December 2019 in a single tertiary center for rectal cancer.

PATIENTS

A total of 117 rectal cancer patients after surgery without recurrence were enrolled in this study, of which 39 with anastomotic stricture and 78 without stricture.

MAIN OUTCOME MEASURES

Their clinical and pathological data were collected. Multiple logistic regression analysis was conducted to identify risk factors for anastomotic stricture and to generate the nomogram prediction model.

RESULTS

Multivariate analysis of the primary cohort led to the identification of LCA (left colic artery) preservation (OR, 0.074; P = 0.0015), protective stoma (OR, 5.353; P = 0.012), anastomotic leakage (OR, 12.027; P = 0.005), and anastomotic distance (OR, 7.578; P = 0.012) as independent risk factors for anastomotic stricture. The following predictive model was derived: Logit (anastomotic stricture) = 0.074∗ LCA + 5.353∗ Protective stoma +12.027∗ Anastomotic leakage + 7.578∗ Anastomotic distance. Assessment of the predictive model revealed that the area under the curve (AUC) was 0.871, while the cutoff value was 15.444 with a sensitivity of 64.1% and a specificity of 94.8%.

LIMITATIONS

The main limitation is the research design of a retrospective and case-controlled study with a small sample size from a single center.

CONCLUSIONS

LCA preservation, protective stoma, anastomotic leakage, and anastomotic distance may affect the occurrence of anastomotic stricture following surgery for rectal cancer. The nomogram model generated in the present study can be valuable in the prediction of anastomotic stricture. This study has been registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/, ChiCTR 2100043775).

Comparison of high or modified low tie of the inferior mesenteric artery in laparoscopic rectal cancer surgery: A meta-analysis

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.

Clinical impact of inferior mesenteric vein preservation during left hemicolectomy with low ligation of the inferior mesenteric artery for distal transverse and descending colon cancers: A comparative study based on computed tomography

Purpose

Presence of a long remnant sigmoid colon after left hemicolectomy with inferior mesenteric vein (IMV) ligation for distal transverse and descending colon cancers may be a risk factor for venous ischemia. This study aimed to evaluate the clinical impact of IMV preservation in patients who underwent left hemicolectomy with inferior mesenteric artery (IMA) preservation.

Methods

We included 155 patients who underwent left hemicolectomy with IMA preservation for distal transverse and descending colon cancers from 2003 to 2020. Technical success of IMV preservation was determined by assessing pre- and post-operative patency of the IMV on computed tomography (CT) by an abdominal radiologist. Intestinal complications comprising ulceration, stricture, venous engorgement, and colitis in remnant colon were compared between the IMV preservation and ligation groups.

Results

IMV was preserved in 22 (14.2%) and ligated in 133 (85.8%) patients. Surgical time, postoperative recovery outcomes, and number of harvested lymph nodes were similar in both groups. The technical success of IMV preservation was 81.8%. Intestinal complications were less common in the preservation group than in the IMV ligation group (4.5% vs. 23.3%, P=0.048). The complications in the IMV ligation group were anastomotic ulcer (n=2), anastomotic stricture (n=4), venous engorgement of the remnant distal colon (n=4), and colitis in the distal colon (n=21).

Conclusions

IMV preservation may be beneficial after left hemicolectomy with IMA preservation for distal transverse and descending colon cancers. We suggest that IMV preservation might be considered when long remnant sigmoid colon is expected during left hemicolectomy with low ligation of IMA.

Preservation of the left colic artery in modified laparoscopic anterior rectal resections without auxiliary abdominal incisions for transanal specimen retrieval

Background

Laparoscopic low anterior rectal resection is the most widely used surgical procedure for middle and low rectal cancer. The aim of this study was to investigate the feasibility and safety of the extracorporeal placement of the anvil in preserving the left colic artery in laparoscopic low anterior rectal resection without auxiliary incisions for transanal specimen retrieval in this research.

Methods

Clinical data and follow-up data of patients undergoing laparoscopic low anterior rectal resection from January 2017 to October 2020 were collected. The resections were modified such that the resisting nail holder was extracorporeally placed for the transanal exenteration of the specimen without using auxiliary abdominal incisions while preserving the left colic artery. By analyzing the data of anastomotic stenosis, anastomotic bleeding and anastomotic fistulas after surgery, the advantages and disadvantages of this surgical method for patients were clarified.

Results

A total of 22 patients were enrolled. Five of 22 patients simultaneously underwent double-barrel terminal ileostomy. The postoperative exhaust time was 2–7 (median, 3) days. Postoperative anastomotic bleeding occurred in one patient, postoperative anastomotic fistula occurred in four patients, and postoperative anastomotic stenosis occurred in six patients. There were four patients with postoperative distant metastasis, of which three had concomitant local recurrence. Seventeen patients had no obvious symptoms or signs of recurrent metastases during follow-up appointments, and one died of liver failure.

Conclusions

Modified laparoscopic low anterior rectal resection, which resects the specimen through anus eversion by inserting the anvil extracorporeally while preserving the left colic artery, is safe and feasible for patients with low rectal cancer.

OUP accepted manuscript

Cases of delayed colo-anal anastomosis (DCAA) are currently reported instead of the colo-anal anastomosis with a protective loop ileostomy for rectal cancer. Post-operative colonic ischemia is considered as one of the serious complications of colorectal resection. Although indication of DCAA should be carefully selected, we experienced a case of post-operative stenosis caused by colonic ischemia after low anterior resection for rectal cancer, followed by this procedure.

Surgical anatomy of the accessory middle colic artery: a meta-analysis with implications for splenic flexure cancer surgery

AIM

Surgical resection of splenic flexure cancers (SFCs) is technically demanding due to the complex regional anatomy, characterized by the presence of embryological adhesions, close proximity to the pancreas and spleen, and a highly heterogeneous arterial supply and lymphatic drainage. The accessory middle colic artery (AMCA) is increasingly being recognized as an important source of blood supply to the splenic flexure. The aim of this study is to determine the prevalence and anatomical features of the AMCA.

METHOD

A systematic search of the scientific literature was conducted on PubMed and Embase from inception to November 2020 to identify potentially eligible studies. Data were extracted and prevalence was pooled into a meta-analysis using MetaXL and Meta-Analyst software.

RESULTS

A total of 16 studies (n = 2203 patients) were included. The pooled prevalence (PP) of the AMCA was 25.4% (95% CI 18.1-33.4). Its prevalence was higher in patients without a left colic artery (LCA) (PP = 83.2%; 95% CI 70.4-93.1). The commonest origin for the AMCA was the superior mesenteric artery (PP = 87.9%; 95% CI 86.4-90.7). The AMCA shared a common trunk/gave rise to pancreatic branches in 23.1% of cases (95% CI 15.3-31.9).

CONCLUSION

The AMCA contributes to the vascularization of the splenic flexure in approximately 25% of individuals, and may be an important feeder artery to SFCs, especially in the absence of a LCA. Preoperative identification of this artery is important to ensure optimal surgery for SFC and minimize complications.

Lymphadenectomy Around Inferior Mesenteric Artery in Low-Tie vs High-Tie Laparoscopic Anterior Resection: Short- and Long-Term Outcome of a Cohort of 614 Rectal Cancers

Background

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

Methods

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

Results

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

Conclusion

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

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

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.

Short- and long-term outcomes of rectal cancer patients with high or improved low ligation of the inferior mesenteric artery

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.

The sigmoidea ima artery: A player in colonic ischemia?

INTRODUCTION

The sigmoidea ima artery is defined as the lowest sigmoid artery, which forms the distal end of the marginal artery by linking with the superior rectal artery. It supplies the rectosigmoid junction, which is a critical area for ischemia. The aim of the present study was to delineate the area supplied by the inferior mesenteric artery with special consideration of the sigmoidea ima artery.

MATERIALS AND METHODS

The inferior mesenteric artery was dissected from its origin to the bifurcation of the superior rectal artery in 30 cadavers (15 male, 15 female). Vessel length and distance to the promontory were measured for each branch.

RESULTS

There were two manifestations of the sigmoidea ima artery, irrespective of the branching pattern of the inferior mesenteric artery. It originated below the promontory in 25 cases (83.3%) and above it in three (10%). It did not derive from the superior rectal artery in two cases (6.7%). In these 16.7%, the marginal artery was absent near the rectosigmoid junction.

CONCLUSIONS

We suggest the terms "arteria sigmoidea ima pelvina" and "arteria sigmoidea ima abdominalis" for the two variants. The terms "arteria marginalis pelvina" and "arteria marginalis abdominalis" could be applied in clinical practice. An abdominal marginal artery could be considered a risk factor for colonic ischemia in colorectal resections and abdominal aortic aneurysm repair. Both variants should be considered when pre- and intra-operative perfusion measurements are interpreted.

Congestive ischemic colitis occurring after resection of left colon cancer: 4 case series

BACKGROUND

Ischemic colitis can occur after colectomy and is sometimes difficult to treat. We report 4 cases of refractory, delayed onset, regional congestive colitis occurring on the anal side of the anastomosis after laparoscopic left hemicolectomy.

CASE PRESENTATION

A total of 191 patients underwent surgery for left colon cancer (transverse, descending, and sigmoid colon cancer) at our hospital from January 2012 to December 2017. During the procedures, the left colic artery (LCA) or sigmoid colic artery (SA) was dissected, the superior rectal artery (SRA) was preserved, and the inferior mesenteric vein (IMV) was dissected at the inferior margin of the pancreas. Congestive ischemic colitis due to venous return dysfunction occurred in 4 cases (2.1%), 5 to 34 months postoperatively. The patients had diarrhea and blood in the stool. On computed tomography (CT), the patients exhibited continuous intestinal edema and high-density adipose tissue from the anastomosis site to the rectum. Contrast enhancement showed dilation of the vasa recti and arteries from the inferior mesenteric artery (IMA) to the SRA. Three patients improved with long-term intestinal rest; in 1 case, the stenosis did not improve and required colorectal resection.

CONCLUSION

Diagnoses were easy in these cases, but treatment was prolonged and surgery was necessary in 1 case. While this condition is rare, caution is warranted as it is difficult to treat.

Surgical complications in colorectal cancer patients

BACKGROUND

Advancements in diagnostic and therapeutic sciences have allowed early diagnosis and treatment of cancer. Colorectal cancer is one of the most commonly reported cancers, particularly in elderly patients.

METHODS

Open and laparoscopic surgeries are used for the removal of the tumor, along with chemotherapy, depending on the stage of cancer. However, colorectal cancer surgery is associated with a great number of complications, that affect the efficacy of the surgery and overall health and survival of the patient.

RESULTS

Prevalence of these complications have shown discrepancies depending on the condition of the patient and disease and surgical skills of the surgeon. Preoperative evaluation, intraoperative care and postoperative measures can reduce the incidence of these complications.

CONCLUSION

This review highlights some frequently reported complications associated with colorectal cancer surgery, their risk factors and subsequent therapeutic measures to treat them.

Evaluation of characteristics of left-sided colorectal perfusion in elderly patients by angiography

BACKGROUND

Handling of the inferior mesenteric artery (IMA) and maintaining anastomotic perfusion are important in radical resection of left-sided colorectal cancer. However, the branching of this artery and the drainage patterns of this vein vary among individuals, and the characteristics and perfusion region of this artery in elderly patients remain unclear.

AIM

To evaluate the characteristics and perfusion region of the IMA in elderly patients using angiography.

METHODS

We enrolled 154 patients (> 65 years old) who underwent digital subtraction angiography of the IMA. The characteristics, bifurcation, and distribution of the IMA and termination of the anastomotic perfusion of the left colon and rectum were examined using digital subtraction angiography. Collateral arterial arches and the IMA hemoperfusion region were also recorded. Perfusion regions were cross-referenced with clinical and anatomical features by the univariate analysis.

RESULTS

Of 154 patients, 25 (16.2%) had IMA lesions. The left colic artery arose independently from the IMA in 44.2% of patients, shared a trunk with the sigmoid artery in 35.1%, shared an opening with the sigmoid and superior rectal arteries in 16.9%, and was absent in 5.1%. The IMA perfusion region stopped at the splenic flexure in 50 (32.5%) patients. The collateral circulation existed in the colonic perfusion region, including the marginal artery (Drummond’s artery), the ascending branch of the left colonic artery to supply the transverse colon, and the arc of Riolan with a frequency of 100%, 22.7%, and 1.9%, respectively. The IMA perfusion region was independently associated with the comorbidity of atherosclerosis, IMA atherosclerotic lesion, branching pattern, collateral circulation, and marginal artery integrity.

CONCLUSION

The IMA and its branches are prone to arteriosclerosis, and IMA perfusion may be interrupted at the splenic flexure in elderly patients. The applicability and precision of preoperative angiography for evaluating the IMA branching and perfusion patterns could facilitate geriatric laparoscopic left-sided colorectal cancer surgery with suspicion of poor IMA perfusion.

Anatomical study of the left colic artery in laparoscopic-assisted colorectal surgery

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.

Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer

BACKGROUND

The optimal level for inferior mesenteric artery ligation during anterior resection for rectal cancer is controversial. The aim of this randomized trial was to clarify whether the inferior mesenteric artery should be tied at the origin (high tie) or distal to the left colic artery (low tie).

METHODS

Patients were allocated randomly to undergo either high- or low-tie ligation and were stratified by surgical approach (open or laparoscopic). The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were duration of surgery, blood loss and 5-year overall survival.

RESULTS

Some 331 patients entered the trial between June 2006 and September 2012. The trial was stopped prematurely as recruitment was slow. Seven patients were excluded after randomization but before operation because of procedural changes. High tie and low tie were performed in 164 and 160 patients respectively. The incidence of anastomotic leakage was not significantly different (17·7 versus 16·3 per cent respectively; P = 0·731). The incidence of severe complications requiring intervention was 2·4 versus 5·0 per cent for high and low tie respectively (P = 0·222). In multivariable analysis, risk factors for anastomotic leakage included male sex (odds ratio 4·36, 95 per cent c.i. 1·56 to 12·18) and distance of the tumour from the anal verge (odds ratio 0·99, 0·98 to 1·00). At 5 years there were no significant differences in overall (87·2 versus 89·4 per cent respectively; P = 0·386) and disease-free (76·3 versus 77·6 per cent; P = 0·765) survival.

CONCLUSION

The level of ligation of the inferior mesenteric artery does not significantly influence the rate of anastomotic leakage. Registration number: NCT01861678 ( https://clinicaltrials.gov).

Resection of Colorectal Cancer With Versus Without Preservation of Inferior Mesenteric Artery

OBJECTIVE

To assess the clinical significance of preservation of the inferior mesenteric artery (IMA) in comparison with IMA ligation in surgery for sigmoid colon or rectal (colorectal) cancer.

METHODS

Consecutive patients (n=862) with colorectal cancer who underwent intended surgical resection of the main tumor between 1986 and 2011 were retrospectively analyzed. The patients were divided into 2 groups: IMA preserved (n=745) and IMA ligated (n=117).

RESULTS

No significant difference was observed in incidence of advanced stage III or IV disease between the 2 groups (P=0.56 and 0.51, respectively), whereas a longer operation time (287 [95 to 700] vs. 215 [60 to 900] min, respectively; P<0.001) and greater amount of intraoperative bleeding (595 [15 to 4530] vs. 235 [1 to 11565] mL, respectively; P<0.001) were observed in the IMA-ligated group. The overall incidence of surgery-related complications was higher in the IMA-ligated group than in the IMA-preserved group (53.0% vs. 38.5%, respectively; P=0.003). Urinary dysfunction and abdominal abscess were significantly more frequent in the IMA-ligated group (11.1% vs. 4.0%, P=0.001; and 6.8% vs. 2.6%, P=0.01, respectively), and postoperative hospitalization was longer (11 to 140, median 28 vs. 5 to 153, median 19 d, respectively; P<0.001). No significant difference was found in overall survival rate between the 2 groups.

CONCLUSIONS

For colorectal cancer resection, IMA preservation may be no change to IMA ligation as to patient' survival, with small risk of operative morbidity.

Colonic Necrosis Following Laparoscopic High Anterior Resection for Sigmoid Colon Cancer: Case Report and Review of the Literature

We report a patient who experienced colonic necrosis after laparoscopic high anterior resection for sigmoid colon cancer, and review the literature to evaluate the clinical features of colonic necrosis following surgery for sigmoid colon and rectal cancer. A 76-year-old man with sigmoid colon cancer underwent laparoscopic high anterior resection. The operation included high ligation of the inferior mesenteric artery and end-to-end anastomosis using circular staples. Pathology findings revealed a pT4N2M0 lesion. Beginning on postoperative day (POD) 1, the patient experienced a high, spiking fever, and gradually developed leukocytosis and high inflammatory condition. The patient complained of abdominal distention, but had no signs of peritonitis. Abdominal computed tomography on POD4 showed wall thickness of the proximal colon from the anastomosis site and ascites with free air. An anastomotic leakage was suspected. Emergency laparotomy revealed a disrupted anastomosis without feces in the abdomen and a gangrenous 15 cm segment of the colon proximal to the anastomosis. The affected area of the colon was excised and Hartmann's procedure was performed. His postoperative period was uneventful. Our review of the literature demonstrates that elderly male patients with cardiovascular and pulmonary complications undergoing laparoscopic sigmoid and rectal cancer surgery with high ligation have high risk of postoperative colonic necrosis. We experienced colonic necrosis following laparoscopic high anterior resection for sigmoid colon cancer and required immediate resection. Elderly male patients with cardiovascular and pulmonary complications undergoing laparoscopic sigmoid and rectal cancer surgery with high ligation should be carefully monitored for postoperative colonic necrosis.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease

AIM

Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA).

METHODS

This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors.

RESULTS

The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04).

CONCLUSION

Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

Marginal artery stump pressure in left colic artery-preserving rectal cancer surgery: a clinical trial

BACKGROUND

The aim of this clinical trial is to evaluate the influence of high and low ligation of the inferior mesenteric artery with apical lymph node dissection on the anastomotic blood supply, lymph node retrieval rate, operative time and anastomotic leakage rate in rectal cancer surgery.

METHODS

A total of 57 Chinese patients were randomly distributed into group A and group B and underwent radical resection of rectal cancer. Patients in group A underwent high ligation of the inferior mesenteric artery, and patients in group B underwent apical lymph node resection around the root of the inferior mesenteric artery with preservation of the left colic artery. The marginal artery stump pressure was measured after colon and artery reconstruction. Systemic pressure, distal colon length, operative time and lymph node retrieval rate were measured and recorded. The results were analysed and related to patient characteristics and post-operative complications.

RESULTS

The anastomotic blood supply negatively and linearly correlated with age and distal colon length and showed a positive linear correlation with systemic pressure. Patients who received low ligation with apical lymph node dissection had a better anastomotic blood supply than those who received high ligation. No differences were found in lymph node retrieval rate, operative time and anastomotic leakage rate. Anastomotic leakage was associated with a worse anastomotic blood supply.

CONCLUSIONS

Low ligation with apical lymph node dissection in rectal cancer treatment provides better anastomotic blood supply but is not associated with differences in node retrieval rate or operation time.

Anatomy of the inferior mesenteric artery evaluated using 3-dimensional CT angiography

BACKGROUND

The branching of the inferior mesenteric artery and vein varies among individuals. Three-dimensional CT angiography is a less invasive modality than traditional angiographic examination to assess the artery and vein.

OBJECTIVE

We aimed to demonstrate the clinical applicability of CT angiography by evaluating bifurcations of the inferior mesenteric artery and the positional relationship between the inferior mesenteric artery and vein.

DESIGN

This was a prospective observational study of patients undergoing preoperative CT angiography.

SETTINGS

This study was conducted at a single tertiary care institution in Japan.

PATIENTS

A total of 471 consecutive patients who underwent preoperative CT angiography from April 2012 to December 2013 were prospectively enrolled.

MAIN OUTCOME MEASURES

The branching pattern of the inferior mesenteric artery, the positional relationship between the inferior mesenteric artery and vein, and the associations between inferior mesenteric artery length and clinical features were evaluated.

RESULTS

The length of the inferior mesenteric artery varied widely, from 10.1 to 82.2 mm. In 41.2% patients, the left colic artery arose independently from the sigmoid artery, and in 44.7% of the patients, the left colic artery and sigmoid artery had a common trunk, whereas the left colic artery did not exist in 5.1%. The left colic artery was located lateral to the inferior mesenteric vein at the level of the origin of the inferior mesenteric artery in 73.0% of the patients. The incidence of a short inferior mesenteric artery was significantly increased in men with high BMIs (75.0%).

LIMITATIONS

Three-dimensional reconstruction was performed by the use of a single software, and angiographic examination was not performed. Therefore, accuracy and reliability of the 3-dimensional reconstruction could not be established for each modality.

CONCLUSIONS

Using 3-dimensional CT angiography, preoperative understanding of the anatomic vascular variations can be easily obtained, which would help surgeons to safely perform laparoscopic surgery in the left-side colon and rectum.

New insights into autonomic nerve preservation in high ligation of the inferior mesenteric artery in laparoscopic surgery for colorectal cancer

AIM

To take a deeper insight into the relationship between the root of the inferior mesenteric artery (IMA) and the autonomic nerve plexuses around it by cadaveric anatomy and explore anatomical evidence of autonomic nerve preservation in high ligation of the IMA in laparoscopic surgery for colorectal cancer.

METHODS

Anatomical dissection was performed on 11 formalin-fixed cadavers and 12 fresh cadavers. Anatomical evidence-based autonomic nerve preservation in high ligation of the IMA was performed in 22 laparoscopic curative resections of colorectal cancer.

RESULTS

As the upward continuation of the presacral nerves, the bilateral trunks of SHP had close but different relationships with the root of the IMA. The right trunk of SHP ran relatively far away from the root of IMA. When the apical lymph nodes were dissected close to the root of the IMA along the fascia space in front of the anterior renal fascia, the right trunk of SHP could be kept in suit under the anterior renal fascia. The left descending branches to SHP constituted a natural and constant anatomical landmark of the relationship between the root of IMA and the left autonomic nerves. Proximal to this, the left autonomic nerves surrounded the root of the IMA. Distally, the left trunk of the SHP departed from the root of IMA under the anterior renal fascia. When high ligation of the IMA was performed distal to it, the left trunk of SHP could be preserved. The distance between the left descending branches to SHP and the origin of IMA varied widely from 1.3 cm to 2.3 cm.

CONCLUSIONS

The divergences of the bilateral autonomic nerve preservation around the root of the IMA may contribute to provide anatomical evidence for more precise evaluation of the optimal position of high ligation of the IMA in the future.

Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center

Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.

The relation between inferior mesenteric vein ligation and collateral vessels to splenic flexure: anatomical landmarks, technical precautions and clinical significance

PURPOSE

Our aim to assess clinical significance of the relation between inferior mesenteric vein ligation and collateral blood supply (meandering mesenteric artery) to the splenic flexure with elaboration more in anatomical landmarks and technical tips.

MATERIALS AND METHODS

We review the literature regarding the significance of the collateral vessels around inferior mesenteric vein (IMV) root and provide our prospective operative findings, anatomical landmarks and technical tips. We analyzed the incidence and pattern of anatomic variation of collateral vessels around the IMV.

RESULTS

A total of 30 consecutive patients have been prospectively observed in a period between June 25-2012 and September 7-2012. Nineteen males and eleven females with mean age of 63 years. Major colorectal procedures were included. There were three anatomical types proposed, based on the relation between IMV and the collateral vessel. Type A and B in which either the collateral vessel crosses or runs close to the IMV with incidence of 43.3% and 13.3%, respectively, whereas type C is present in 43.3%. There was no definitive relation between the artery and vein. No intra or postoperative ischemic events were reported.

CONCLUSION

During IMV ligation, inadvertent ligation of Arc of Riolan or meandering mesenteric artery around the IMV root "in type A&B" might result in compromised blood supply to the left colon, congestion, ischemia and different level of colitis or anastomotic dehiscence. Therefore, careful dissection and skeletonization at the IMV root "before ligation if necessary" is mandatory to preserve the collateral vessel for the watershed area and to avoid further injury.

Clinical characteristics of ischemic colitis after surgery for colorectal cancer

PURPOSE

This study was performed to clarify the clinical features of ischemic colitis (IC) after colorectal cancer surgery.

METHODS

This study retrospectively reviewed the medical records of 35 patients with IC. Patients were divided into two groups: those who had undergone colorectal cancer surgery (POIC group, n = 13) and those who had not undergone colorectal cancer surgery (NOIC group, n = 22). Gangrenous colitis was seen in one patient in the POIC group, and transient colitis was seen in the remaining 34 patients.

RESULTS

Among the patients with transient colitis, there were significantly more patients without underlying diseases or promoting factors in the POIC group than in the NOIC group (P = 0.01). Abdominal pain was more frequently reported in the NOIC group than in the POIC group as both the initial symptom (P = 0.02) and throughout the disease course (P = 0.02). Ischemic changes occupying more than half the circumference of the intestinal wall were more frequently found in the NOIC group than in the POIC group (P = 0.03).

CONCLUSIONS

Although transient POIC may occur without any underlying disease, severe symptoms rarely occur. However, if POIC occurs in a patient with severe underlying disease, then the occurrence of severe colitis should be considered.

Are there any surgical and radiological correlations to the level of ligation of the inferior mesenteric artery after sigmoidectomy for cancer?

INTRODUCTION

The Société Française de Chirurgie Digestive and the American Society of Colon and Rectal Surgeons recommend a ligation at the origin of the primary feeding vessel for sigmoid cancer to ensure optimal lymphadenectomy. We evaluated the correlation between the level of ligation defined by the surgeon and the real level of ligation visualized on postoperative CT scan.

PATIENTS AND METHODS

From December 2004 to August 2010, in a series of 146 patients undergoing colectomy for sigmoid cancer, 51 (19 women) CT measurements (visualization of the left colonic artery (LCA), length of the arterial stump) were performed by a radiologist blinded to operative data.

RESULTS

This series comprised 63% of men with a mean age of 69 years. A correlation was demonstrated between the level of ligation assessed by the surgeon and the real level of ligation demonstrated on postoperative CT scan in 41% of cases. No risk factors for absence of correlation were identified (laparoscopy, gender, BMI, emergency, and ASA score). In the "no correlation" group, the site of ligation was overestimated in 70% of cases. No significant difference was observed between the "correlation" and "no correlation" groups for lymphadenectomy (21.6 and 18 lymph nodes, p=0.5593) or 5-year overall survival (71.4 and 93.1 months, p=0.57).

CONCLUSION

In conclusion, the surgical and radiological correlations are low as the intraoperative estimation of the level of IMA ligation was correlated with CT findings in less than 50% of cases. No risk factors for non-correlation were identified, and there was no impact on lymphadenectomy. Overestimation of the level of ligation was the most frequent situation but did not appear to have any impact on tumor staging or on patient management in this group of patients.