Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

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

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Yang Y, Wang G, He J, Zhang J, Xi J, Wang F (2018) High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a meta-analysis. Int J Surg 52:20–24

    Article  Google Scholar 

  2. Yasuda K, Kawai K, Ishihara S, Murono K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Yamaguchi H, Aoki S, Mishima H, Maruyama T, Sako A, Watanabe T (2016) Level of arterial ligation in sigmoid colon and rectal cancer surgery. World J Surg Oncol 14:99

    Article  Google Scholar 

  3. Zhang C, Chen L, Cui M, Xing J, Yang H, Yao Z, Zhang N, Tan F, Liu M, Xu K, Su X (2020) Short- and long-term outcomes of rectal cancer patients with high or improved low ligation of the inferior mesenteric artery. Sci Rep 10:15339

    Article  CAS  Google Scholar 

  4. Bertrand MM, Delmond L, Mazars R, Ripoche J, Macri F, Prudhomme M (2014) Is low tie ligation truly reproducible in colorectal cancer surgery? Anatomical study of the inferior mesenteric artery division branches. Surg Radiol Anat 36:1057–1062

    Article  CAS  Google Scholar 

  5. Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ (2001) Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Rectal Cancer, Washington, D.C., May 1, 1999. Dis Colon Rectum 44:915–919

  6. Cirocchi R, Farinella E, Trastulli S, Desiderio J, Di Rocco G, Covarelli P, Santoro A, Giustozzi G, Redler A, Avenia N, Rulli A, Noya G, Boselli C (2011) High tie versus low tie of the inferior mesenteric artery: a protocol for a systematic review. World J Surg Oncol 9:147

    Article  Google Scholar 

  7. Lange MM, Buunen M, van de Velde CJ, Lange JF (2008) Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review Dis Colon Rectum 51:1139–1145

    Article  Google Scholar 

  8. Kong M, Chen H, Xin Y, Jiang Y, Han Y, Sheng H (2021) High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta-analysis of randomized controlled trial studies. Colorectal Dis 23:614–624

    Article  Google Scholar 

  9. Hajibandeh S, Hajibandeh S, Maw A (2020) Meta-analysis and trial sequential analysis of randomized controlled trials comparing high and low ligation of the inferior mesenteric artery in rectal cancer surgery. Dis Colon Rectum 63:988–999

    Article  Google Scholar 

  10. Moriya Y (2006) Function preservation in rectal cancer surgery. Int J Clin Oncol 11:339–343

    Article  Google Scholar 

  11. Celentano V, Cohen R, Warusavitarne J, Faiz O, Chand M (2017) Sexual dysfunction following rectal cancer surgery. Int J Colorectal Dis 32:1523–1530

    Article  CAS  Google Scholar 

  12. Zhang C, Li GX, Ding ZH, Wu T, Zhong SZ (2006) Preservation of the autonomic nerve in rectal cancer surgery: anatomical factors in ligation of the inferior mesenteric artery. Nan Fang Yi Ke Da Xue Xue Bao 26:49–52

    PubMed  Google Scholar 

  13. Nano M, Dal Corso H, Ferronato M, Solej M, Hornung JP, Dei Poli M (2004) Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations. Dig Surg 21:123–126; discussion 126–127

  14. Höer J, Roegels A, Prescher A, Klosterhalfen B, Töns C, Schumpelick V (2000) Preserving autonomic nerves in rectal surgery. Results of surgical preparation on human cadavers with fixed pelvic sections. Chirurg 71:1222–1229

    Article  Google Scholar 

  15. Campbell A, Macdonald A, Oliphant R, Russell D, Fogg QA (2018) Neurovasculature of high and low tie ligation of the inferior mesenteric artery. Surg Radiol Anat 40:1343–1348

    Article  Google Scholar 

  16. Liu J, Gong Y, He M, Zeng X, Liu Y (2020) Clinical effect of preservation or nonpreservation of left colic artery in total mesorectal excision under laparoscopy: a meta-analysis. Gastroenterol Res Pract 2020:1958573

    PubMed  PubMed Central  Google Scholar 

  17. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4:1

    Article  Google Scholar 

  18. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898

  19. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses BMJ 327:557–560

    PubMed  Google Scholar 

  20. Fiori E, Crocetti D, Lamazza A, F DEF, Sterpetti AV, Irace L, Mingoli A, Sapienza P, G DET, (2020) Is low inferior mesenteric artery ligation worthwhile to prevent urinary and sexual dysfunction after total mesorectal excision for rectal cancer? Anticancer Res 40:4223–4228

    Article  Google Scholar 

  21. Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Watanabe T, Mitani Y, Ieda J, Mizumoto Y, Yamaue H (2015) Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery. Br J Surg 102:501–508

    Article  CAS  Google Scholar 

  22. Mari GM, Crippa J, Cocozza E, Berselli M, Livraghi L, Carzaniga P, Valenti F, Roscio F, Ferrari G, Mazzola M, Magistro C, Origi M, Forgione A, Zuliani W, Scandroglio I, Pugliese R, Costanzi ATM, Maggioni D (2019) Low ligation of inferior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary dysfunction: results from a randomized controlled trial (HIGHLOW Trial). Ann Surg 269:1018–1024

    Article  Google Scholar 

  23. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43:9–16; discussion 16–17

  24. Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97

    Article  CAS  Google Scholar 

  25. Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD (1996) A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 39:681–685

    Article  CAS  Google Scholar 

  26. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM (1999) Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 11:319–326

    Article  CAS  Google Scholar 

  27. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P (2004) ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 23:322–330

    Article  Google Scholar 

  28. Jones LR (2002) The use of validated questionnaires to assess female sexual dysfunction. World J Urol 20:89–92

    Article  Google Scholar 

  29. Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, Troidl H (1995) Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. Br J Surg 82:216–222

    Article  CAS  Google Scholar 

  30. Masoni L, Mari FS, Nigri G, Favi F, Gasparrini M, Dall’Oglio A, Pindozzi F, Pancaldi A, Brescia A (2013) Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial. Surg Endosc 27:199–206

    Article  Google Scholar 

  31. Fiori E, Crocetti D, Lamazza A, F DEF, Scotti GB, Sterpetti AV, Mingoli A, Sapienza P, G DET, (2020) Defecatory dysfunction after colon cancer resection: the role of inferior mesenteric artery tie. Anticancer Res 40:2969–2974

    Article  Google Scholar 

  32. McNair AG, Whistance RN, Forsythe RO, Macefield R, Rees J, Pullyblank AM, Avery KN, Brookes ST, Thomas MG, Sylvester PA, Russell A, Oliver A, Morton D, Kennedy R, Jayne DG, Huxtable R, Hackett R, Dutton SJ, Coleman MG, Card M, Brown J, Blazeby JM (2016) Core outcomes for colorectal cancer surgery: a consensus study. PLoS Med 13:e1002071

  33. Nocera F, Angehrn F, von Flüe M, Steinemann DC (2021) Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 406:233–250

    Article  Google Scholar 

  34. Maeda Y, Shinohara T, Futakawa N, Minagawa N, Sunahara M, Koyama R, Nagatsu A, Hamada T (2018) The oncologic outcomes of inferior mesenteric artery-preserving laparoscopic lymph node dissection for upper-rectal or sigmoid colon cancer. J Laparoendosc Adv Surg Tech A 28:1352–1358

    Article  Google Scholar 

  35. Crocetti D, Cavallaro G, Tarallo MR, Chiappini A, Polistena A, Sapienza P, Fiori E, De Toma G (2019) Preservation of left colic artery with lymph node dissection of IMA root during laparoscopic surgery for rectosigmoid cancer. Results of a retrospective analysis. Clin Ter 170:e124–e128

    CAS  PubMed  Google Scholar 

  36. Pallisera-Lloveras A, Planelles-Soler P, Hannaoui N, Mora-López L, Muñoz-Rodriguez J, Serra-Pla S, Dominguez-Garcia A, Prats-López J, Navarro-Soto S, Serra-Aracil X (2019) Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial. BMC Urol 19:75

    Article  Google Scholar 

  37. Morita T, Murata A, Koyama M, Totsuka E, Sasaki M (2003) Current status of autonomic nerve-preserving surgery for mid and lower rectal cancers: Japanese experience with lateral node dissection. Dis Colon Rectum 46:S78–87; discussion S87–78

  38. Maeda K, Maruta M, Utsumi T, Sato H, Toyama K, Matsuoka H (2003) Bladder and male sexual functions after autonomic nerve-sparing TME with or without lateral node dissection for rectal cancer. Tech Coloproctol 7:29–33

    Article  CAS  Google Scholar 

  39. Moszkowicz D, Alsaid B, Bessede T, Penna C, Nordlinger B, Benoît G, Peschaud F (2011) Where does pelvic nerve injury occur during rectal surgery for cancer? Colorectal Dis 13:1326–1334

    Article  CAS  Google Scholar 

  40. Liang JT, Lai HS, Lee PH (2007) Laparoscopic pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer after chemoradiation therapy. Ann Surg Oncol 14:1285–1287

    Article  Google Scholar 

  41. Shiraishi T, Ito M, Sasaki T, Nishizawa Y, Tsukada Y, Ikeda K (2021) Association between urinary function and resected pattern of the autonomic nerve system after transanal total mesorectal excision for rectal cancer. Colorectal Dis 23:405–414

    Article  CAS  Google Scholar 

  42. Kauff DW, Kronfeld K, Gorbulev S, Wachtlin D, Lang H, Kneist W (2016) Continuous intraoperative monitoring of pelvic autonomic nerves during TME to prevent urogenital and anorectal dysfunction in rectal cancer patients (NEUROS): a randomized controlled trial. BMC Cancer 16:323

    Article  CAS  Google Scholar 

  43. Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Diener MK, Ulrich A (2015) Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 102:735–745

    Article  Google Scholar 

  44. Kowalewski KF, Seifert L, Ali S, Schmidt MW, Seide S, Haney C, Tapking C, Shamiyeh A, Kulu Y, Hackert T, Müller-Stich BP, Nickel F (2021) Functional outcomes after laparoscopic versus robotic-assisted rectal resection: a systematic review and meta-analysis. Surg Endosc 35:81–95

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Severn PGME School of Surgery, Park House, 1200 Parkway, Bristol, BS34 8YU, UK

    Yegor Tryliskyy

  2. The University of Edinburgh, Edinburgh, UK

    Yegor Tryliskyy & Chee Siong Wong

  3. University of South Wales, Cardiff, UK

    Ivanna Demykhova

  4. P.L. Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine

    Volodymyr Tyselskyi & Andrii Kebkalo

  5. Northwestern Medical Group, Chicago, IL, USA

    Vitaliy Poylin

Authors
  1. Yegor Tryliskyy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chee Siong Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ivanna Demykhova
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Volodymyr Tyselskyi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andrii Kebkalo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vitaliy Poylin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yegor Tryliskyy.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix. Literature search algorithm

Appendix. Literature search algorithm

Stage 1: databases search

Database

Search strategy

Embase

#1 exp * “INFERIOR MESENTERIC ARTERY”/ OR exp * “MESENTERIC ARTERY”/

#2 exp * “RECTUM CANCER”/ OR exp * “RECTUM TUMOR”/

#3 exp * “RECTUM ANTERIOR RESECTION”/

#4 exp * “ARTERY LIGATION”/

#5 #1 AND #2

#6 #1 AND #3

#7 #2 AND #4

#8 #3 AND #4

#9 #5 OR #6 OR #7 OR #8

Medline

#1 exp *LIGATION/

#2 exp * “MESENTERIC ARTERY, INFERIOR”/

#3 exp * “RECTAL NEOPLASMS”/

#4 exp *PROCTECTOMY/

#5 #1 AND #3

#6 #1 AND #4

#7 #2 AND #3

#8 #2 AND #4

#9 #5 OR #6 OR #7 OR #8

PubMed

#1 (ligation).ti,ab

#2 (rectal cancer).ti,ab

#3 (anterior resection).ti,ab

#4 (inferior mesenteric artery).ti,ab

#5 #1 AND #2

#6 #1 AND #3

#7 #2 AND #3

#8 #2 AND #4

#9 #5 AND #6 AND #7 AND #8

CINAHL

#1 (anterior resection).ti,ab

#2 (inferior mesenteric artery).ti,ab

#3 (rectal cancer).ti,ab

#4 (ligation).ti,ab

#5 #1 AND #2

#6 #1 AND #4

#7 #2 AND #3

#8 #2 AND #4

#9 #5 OR #6 OR #7 OR #8

  1. Stage 2: manual search of reference lists of included articles

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tryliskyy, Y., Wong, C.S., Demykhova, I. et al. 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 37, 709–718 (2022). https://doi.org/10.1007/s00384-022-04101-1

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-022-04101-1

Keywords

Search

Navigation