Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study
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In rectal anterior resection, a clear consensus regarding the optimal level of inferior mesenteric artery (IMA) ligation does not exist because of a lack of randomized trials. We conducted a randomized trial to determine if the IMA should be tied at the origin (high tie, HT) or distal to the left colic artery (low tie, LT) (HTLT study). This study is a subanalysis of HTLT study for laparoscopic surgery.
All candidates were randomly divided into the HT or LT groups. The lymph node dissection around the origin of the IMA was performed in the LT group. The stratified factor was the approach (open or laparoscopy). Evaluation parameters were operative factors, short-term and long-term results. In the present study, laparoscopic surgeries were examined as subgroup analysis.
From June 2006 to September 2012, 331 patients were registered. Two hundred and fifteen patients (107 for HT: 108 for LT) underwent laparoscopic surgeries. There was no difference between the groups in background. The incidence of anastomotic leakage (HT: LT %) showed no significant differences for grade 2 or higher (11.2:9.3), and grade 3 or higher (2.8:4.6). There were no differences in operative time (200:205 min), blood loss (15:15 ml), number of dissected lymph nodes (22:20), and postoperative hospital stay (10:10 days). The incidence of bowel obstruction in HT was significant (3.7 vs. 0%, p = 0.043). There were no significant differences in overall survival (5-year: 91.3 vs. 90.2%, p = 0.850) and disease-free survival (5-year: 83.2 vs. 78.0%, p = 0.525). There were no differences in the first recurrent site and death reason between both groups. The risk factors for leakage were being male and an anastomotic level in a multivariate analysis by logistic regression.
The IMA ligation level was unrelated to anastomotic leakage. No significant difference was detected in long-term results between HT and LT.
KeywordsLaparoscopic Rectal anterior resection Inferior mesenteric artery High tie Low tie Randomized study
The authors thank Mari S. Oba for the statistical contributions.
Compliance with ethical standards
Shoichi Fujii, Atsushi Ishibe, Mitsuyoshi Ota, Hirokazu Suwa, Jun Watanabe, Chikara Kunisaki, and Itaru Endo have no conflict of interest to disclose.
- 2.Moynihan BG (1908) The surgical treatment of cancer of the sigmoid flexure and rectum. Surg Gynecol Obstet 6:463Google Scholar
- 7.Alici A, Kement M, Gezen C, Akin T, Vural S, Okkabaz N, Basturk E, Yegenoglu A, Oncel M (2010) Apical lymph nodes at the root of the inferior mesenteric artery in distal colorectal cancer: an analysis of the risk of tumor involvement and the impact of high ligation on anastomotic integrity. Tech Coloproctol 14:1–8CrossRefPubMedGoogle Scholar
- 9.West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 30:1763–1769CrossRefPubMedGoogle Scholar
- 13.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 14:99CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Dworkin MJ, Allen-Mersh TG (1996) Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon. J Am Coll Surg 183:357–360Google Scholar
- 16.Komen N, Slieker J, de Kort P, de Wilt JH, van der Harst E, Coene PP, Gosselink MP, Tetteroo G, de Graaf E, van Beek T, den Toom R, van Bockel W, Verhoef C, Lange JF (2011) High tie versus low tie in rectal surgery: comparison of anastomotic perfusion. Int J Colorectal Dis 26:1075–1078CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Japanese Society for Cancer of the Colon and Rectum (2010) JSCCR Guidelines 2010 for the Treatment of Colorectal Cancer. Kanehira-Syuppan, Tokyo, pp 15–76Google Scholar
- 24.Japanese Society for Cancer of Colon and Rectum (2006) General rules for clinical and pathological studies on cancer of the colon, rectum and anus, 7th edn. Kanehira-Syuppan, Tokyo, pp 6–47Google Scholar
- 25.The Japan Society of Coloproctology (2009) Specialist system rule [The Japan Society of Coloproctology web site]. Available at: http://www.coloproctology.gr.jp/pdf/200912specialistrules.pdf. Accessed 25 May 2017
- 27.American Society of Anesthesiologists. ASA Physical Status Classification System Available at: http://www.asahq.org/Home/For-Members/Clinical-Information/ASA-Physical-Status-Classification-System. Accessed 25 May 2017
- 28.International Union Against Cancer. Colon and Rectum (2010) TNM classification of malignant tumours, 7th edn. New York: Wiley-Liss, pp 143–164Google Scholar
- 29.National Cancer Institute (2009) Common terminology criteria for adverse events version 4.0. Available at http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40. Accessed 25 May 2017
- 39.Bonnet S, Berger A, Hentati N, Abid B, Chevallier JM, Wind P, Delmas V, Douard R (2012) High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses. Dis Colon Rectum 55:515–521CrossRefGoogle Scholar
- 40.Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N (2015) Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg 220:186–194CrossRefGoogle Scholar