Advertisement

Techniques in Coloproctology

, Volume 14, Issue 1, pp 1–8 | Cite as

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

  • A. Alici
  • M. Kement
  • C. Gezen
  • T. Akın
  • S. Vural
  • N. Okkabaz
  • E. Basturk
  • A. Yegenoglu
  • M. OncelEmail author
Original Article

Abstract

Background

What level of arterial ligation is best in left-sided colon cancer and rectal cancer remains controversial. This study aims to assess the necessity and risk of high ligation from an oncological and technical perspective.

Methods

The lymph nodes at the origin of the inferior mesenteric artery (IMA) were separated as apical nodes in all patients operated for distal colorectal cancer in our department. The number and status of the nodes were prospectively assessed, and demographic and tumor-related variables were evaluated as risk factors for apical tumor invasion. Anastomotic leaks were also evaluated.

Results

A hundred and three patients (52 [50.5%] males, 60.3 ± 12.9 years old) were included. The number of non-apical lymph nodes harvested was 14.5 ± 7.1 with an additional 4.4 ± 3.2 apical nodes at the high ligation site. Tumor invasion of apical nodes was observed in 6 (5.8%) patients. Two of these (1.9%) had no other positive nodes (skip metastases). Although none of the variables evaluated was found significant for predicting apical node positivity, tumor invasion was detected in 8.5 and 22.2% of patients with pT3 and pN2 cancers, respectively. Among patients, who had an anastomosis (n = 84, 81.6%), anastomotic leak was observed in 7(8.3%) and 1 (1.2%) of these patients required emergency relaparotomy. There was no mortality related to high ligation.

Conclusions

High ligation of IMA may be routinely performed in patients with distal colorectal cancer, since tumor invasion of apical lymph nodes is neither rare (>5%) nor predictable, and skip metastases may also occur. This is especially true in case of an advanced disease for which apical node positivity peaks. The anastomotic leak rate is less than 10%, and mortality is low after high ligation of IMA.

Keywords

Apical lymph nodes Colorectal cancer Inferior mesenteric artery Anastomotic leak 

References

  1. 1.
    Tjandra JJ, Kilkenny JW, Buie WD et al (2005) Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 48:411–423CrossRefPubMedGoogle Scholar
  2. 2.
    Rouffet F, Hay JM, Vacher B et al (1994) Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective, controlled multicenter trial. French Association for Surgical Research. Dis Colon Rectum 37:651–659CrossRefPubMedGoogle Scholar
  3. 3.
    Kawamura YJ, Umetani N, Sunami E, Watanabe T, Masaki T, Muto T (2000) Effect of high ligation on the long-term of patients with operable colon cancer, particularly those with limited nodal involvement. Eur J Surg 166:803–807CrossRefPubMedGoogle Scholar
  4. 4.
    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 51:1139–1145CrossRefPubMedGoogle Scholar
  5. 5.
    Nelson H, Petrelli N, Carlin A et al (2001) Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93:583–596CrossRefPubMedGoogle Scholar
  6. 6.
    Slanetz CA, Grimson R (1997) Effect of high and intermediate ligation of survival and recurrence rates following curative resection of colorectal cancer. Dis Colon Rectum 40:1205–1219CrossRefPubMedGoogle Scholar
  7. 7.
    Hida J, Okuno K, Yasutomi M et al (2005) Optimal ligation level of the primary feeding artery and bowel resection margin in colon cancer surgery: the influence of the site of the primary feeding artery. Dis Colon Rectum 48:2232–2237CrossRefPubMedGoogle Scholar
  8. 8.
    Leggeri A, Roseano M, Balani A, Turaldo A (1994) Lumboaortic and iliac lymphadenectomy: what is the role today? Dis Colon Rectum 37:S54–S61CrossRefPubMedGoogle Scholar
  9. 9.
    Nano M, Dal Corso H, Ferronato M, Solej M, Hormung IP, Dei Poli M (2004) Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations. Dig Surg 21:123–126CrossRefPubMedGoogle Scholar
  10. 10.
    Bruch HP, Schwandner O, Schiedeck TH, Roblick UJ (1999) Actual standards and controversies on operative technique and lymph node dissection in colorectal cancer. Langenbecks Arch Surg 384:167–175CrossRefPubMedGoogle Scholar
  11. 11.
    Washington MK, Berlin J, Branton PA, Cancer Committee, College of American Pathologists et al (2008) Protocol for examination of specimens from patients with primary carcinomas of the colon and rectum. Arch Pathol Lab Med 132:1182–1193PubMedGoogle Scholar
  12. 12.
    Haboubi NY, Clark P, Kaftan SM, Schofield PF (1992) The importance of cobining xylene clearance and immunohistochemistry in the accurate staging of colorectal carcinoma. J R Soc Med 85:386–388PubMedGoogle Scholar
  13. 13.
    Pezim ME, Nichols RJ (1984) Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann Surg 200:729–733CrossRefPubMedGoogle Scholar
  14. 14.
    Surtees P, Ritchie JK, Philips RK (1990) High versus low ligation of inferior mesenteric artery in rectal cancer. Br J Surg 77:618–621CrossRefPubMedGoogle Scholar
  15. 15.
    Corder AP, Karanjia ND, Williams JD, Heald RJ (1992) Flush aortic tie versus selective preservation of ascending left colic artery in low resection for rectal carcinoma. Br J Surg 79:680–682CrossRefPubMedGoogle Scholar
  16. 16.
    Fazio S, Ciferri E, Giacchino P et al (2004) Cancer of the rectum: comparison of two different surgical approaches. Chir Ital 56:23–30PubMedGoogle Scholar
  17. 17.
    Uehara K, Yamamoto S, Fujita S, Akasu T, Moriya Y (2007) Impact of upward lymph node dissection on survival in advanced lower rectal carcinoma. Dig Surg 24:375–381CrossRefPubMedGoogle Scholar
  18. 18.
    Kanemitsu Y, Hirai T, Komori K, Kato T (2006) Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery. Br J Surg 93:609–615CrossRefPubMedGoogle Scholar
  19. 19.
    Palma RT, Waisberg J, Bromberg S, Simão AB, Godoy AC (2003) Micrometastasis in regional lymph nodes of extirpated colorectal carcinoma: immunohistochemical study using anti-cytokeratin antibodies AE1/AE3. Colorectal Dis 5:164–168CrossRefPubMedGoogle Scholar
  20. 20.
    Messerini L, Cianchi F, Cortesini C, Comin CE (2006) Incidence and prognostic significance of occult tumor cells in lymph nodes from patients with stage IIA colorectal carcinoma. Hum Pathol 37:1259–1267CrossRefPubMedGoogle Scholar
  21. 21.
    Seike K, Koda K, Saito N et al (2007) Laser Doppler assessment of the influence of division at the root of inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery. Int J Colorectal Dis 22:689–697CrossRefPubMedGoogle Scholar
  22. 22.
    Oncel M, Remzi FH (2003) Perioperative complications in colorectal surgery. Clin Colon Rectal Surg 16:143–152CrossRefGoogle Scholar
  23. 23.
    Alberts JC, Parvaiz A, Moran BJ (2003) Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection. Colorectal Dis 5:478–482CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • A. Alici
    • 1
  • M. Kement
    • 1
  • C. Gezen
    • 1
  • T. Akın
    • 1
  • S. Vural
    • 1
  • N. Okkabaz
    • 1
  • E. Basturk
    • 1
  • A. Yegenoglu
    • 1
  • M. Oncel
    • 1
    • 2
    • 3
    Email author
  1. 1.Department of General SurgeryKartal Education and Research HospitalIstanbulTurkey
  2. 2.Kartal Eğitim ve Arastirma HastanesiCevizliTurkey
  3. 3.Medical College of Gumushane UniversityGumushaneTurkey

Personalised recommendations