Mesenteric occlusive disease of the inferior mesenteric artery is associated with anastomotic leak after left-sided colon and rectal cancer surgery: a retrospective cohort study

Purpose Anastomotic leak (AL) is a serious complication following colorectal surgery. Atherosclerosis causes inadequate anastomotic perfusion and is suggested to be a risk factor for AL. The aim of this study was to investigate the association of mesenteric occlusive disease on preoperative computed tomography (CT) scan with AL after left-sided colon or rectal cancer surgery. Methods This was a retrospective, multicenter cohort study including 1273 patients that underwent left-sided or rectal cancer resection between 2009 and 2018 from three hospitals in the Netherlands. AL patients were 1:1 matched with non-leak patients and preoperative contrast-enhanced CT-scans were retrospectively analyzed for mesenteric atherosclerotic lesions. The main outcome measure was the presence of mesenteric occlusive disease on the preoperative CT-scan. Results Anastomotic leak developed in 6% of 1273 patients (N = 76). Low anterior resection and stage I–III disease were statistically significant associated with AL (p = 0.01, p = 0.04). No other statistically significant differences in patient characteristics between AL and non-leak patients were found. A clinically significant stenosis (≥ 70–100%) of the inferior mesenteric artery was statistically significant more frequent present in AL patients, compared to non-leak patients (p < 0.01). No statistically significant differences in the presence of mesenteric occlusive disease of the celiac artery and superior mesenteric artery between AL patients and non-leak patients were found. Conclusion Mesenteric occlusive disease of the IMA on preoperative CT-scan is associated with AL after left-sided colon or rectal resection for cancer. Preoperative identification of high-risk patients with a preoperative CT-scan of the mesenteric vasculature might be useful to reduce the risk of AL.

Surgical Excision of a Contained Rupture of an Inferior Mesenteric Aneurysm

Inferior mesenteric artery (IMA) aneurysms represent the minority of visceral aneurysm presentations. A 57-year-old female was admitted with a symptomatic IMA aneurysm secondary to atherosclerotic disease. She was treated with open excision which revealed a contained ruptured of a true aneurysm. This case highlights the challenges of an accurate preoperative diagnosis of IMA aneurysm and the correct position of the recent guidelines on visceral aneurysms issued by the Society of Vascular Surgery (SVS).

Exploring Central Vascular Anatomy With Axial Computed Tomography During Surgery for Sigmoid Colon and Rectal Cancer: New Insights Into the Anatomical Relationship Between the Inferior Mesenteric Artery and the Duodenum

Background: In some individuals, the inferior mesenteric artery (IMA) originates from the aorta above the lower edge of the duodenum. This anatomical feature has rarely been reported but may be important in guiding central vascular ligation and lymph node dissection in colorectal surgery. This retrospective study aimed to explore the anatomical relationship between the IMA and the duodenum and evaluate its potential impact on the efficacy of D3 lymph node dissection.Methods: A total of 439 patients undergoing laparoscopic colorectal surgery at the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively enrolled. Clinical data from axial computed tomography (CT) scans were collected and analysed.Results: In 27.69% of patients, the IMA originated at or above the lower edge of the duodenum (median distance: −8 mm). These patients were characterised by a shorter superior mesenteric artery to aortic bifurcation distance, a superiorly located IMA origin, and a greater distance between the IMA and both the left colic artery and the inferior mesenteric vein. The number of harvested lymph nodes was not significantly associated with the distance between the IMA and the duodenum (P = 0.858).Conclusions: Preoperative axial CT scans can provide a great deal of information regarding central vascular anatomy in the context of sigmoid colon and rectal cancer surgery. Nearly one-third of patients have the IMA originating at or above the duodenum. Whether this anatomical feature affects D3 lymph node dissection warrants further investigation.

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR).Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis.Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation.Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Low Ligation Plus High Dissection Versus High Ligation of the Inferior Mesenteric Artery in Sigmoid Colon and Rectal Cancer Surgery: A Meta-Analysis

BackgroundWhether high or low ligation of the inferior mesenteric artery (IMA) is superior in surgery for rectal and sigmoid colon cancers remains controversial. Although several meta-analyses have been conducted, the level of lymph node clearance was poorly defined. We performed a meta-analysis comparing high and low ligation of the IMA for sigmoid colon and rectal cancers, with emphasis on high dissection of the lymph node at the IMA root in all the included studies.MethodsPubMed, MEDLINE, and EMBASE databases were searched to identify relevant articles published until 2020. The patient’s perioperative and oncologic outcomes were analyzed. Statistical analysis was performed using the statistical software RevMan version 5.4.ResultsA total of 17 studies, including four randomized controlled trials, published between 2011 and 2020 were selected. In total, 1,846 patients received low ligation of the IMA plus high dissection of lymph nodes (LL+HD), and 2,648 patients received high ligation of the IMA (HL). LL+HD was associated with low incidence of anastomotic leakage (p &lt; 0.001), borderline long operative time (p = 0.06), and less yields of total lymph nodes (p = 0.03) but equivalent IMA root lymph nodes (p = 0.07); moreover, LL+HD exhibited non-inferior long-term oncological outcomes.ConclusionIn comparison with HL, LL+HD was an effective and safe oncological procedure for sigmoid colon and rectal cancers. Therefore, to ligate the IMA below the level of the left colic artery with D3 high dissection for sigmoid colon and rectal cancers might be suggested once the surgeons are familiar with this technique.Systematic Review RegistrationINPLASY.com, identifier 202190029.