A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go?

BACKGROUND The optimal level of pedicle ligation during proctectomy for rectal cancer, either at the origin of the inferior mesenteric artery or the superior rectal artery, is still debated. OBJECTIVE The objective was to determine whether superior rectal artery ligation portends equivalent technical or oncologic outcomes. DESIGN This was a retrospective analysis of a rectal cancer database (2007-2017). SETTINGS The study was conducted at 6 tertiary referral centers in the United States (Emory University, University of Michigan, University of Pittsburgh Medical Center, The Ohio State University Wexner Medical Center, Vanderbilt University Medical Center, and Washington University School of Medicine in St. Louis). PATIENTS Patients with primary, nonmetastatic rectal cancer who underwent low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES Anastomotic leak, lymph node harvest, locoregional recurrence-free survival, recurrence-free survival, and overall survival were measured. RESULTS Of 877 patients, 86% (n = 755) received an inferior mesenteric artery ligation, whereas 14% (n = 122) received a superior rectal artery ligation. A total of 12%, 33%, 24%, and 31% were pathologic stage 0, I, II, and III. Median follow-up was 31 months. Superior rectal artery ligation was associated with a similar anastomotic leak rate compared with inferior mesenteric artery ligation (9% vs 8%; p = 1.0). The median number of lymph nodes removed was identical (15 vs 15; p = 0.38). On multivariable analysis accounting for relevant clinicopathologic factors, superior rectal artery ligation was not associated with increased anastomotic leak rate, worse lymph node harvest, or worse locoregional recurrence-free survival, recurrence-free survival, or overall survival (all p values >0.1). LIMITATIONS This was a retrospective design. CONCLUSIONS Compared with inferior mesenteric artery ligation, superior rectal artery ligation is not associated with either worse technical or oncologic outcomes. Given the potential risks of inadequate blood flow to the proximal limb of the anastomosis and autonomic nerve injury, we advocate for increased use of superior rectal artery ligation. See Video Abstract at http://links.lww.com/DCR/B646. ESTUDIO DEL CONSORCIO DE CNCER DE RECTO DE ESTADOS UNIDOS DE LIGADURA BAJA DE LA ARTERIA MESENTRICA INFERIOR CONTRA LIGADURA ALTA DE LA ARTERIA MESENTRICA INFERIOR QU TAN ALTO DEBEMOS EXTENDERNOS ANTECEDENTES:el nivel optimo de la ligadura del pediculo en la proctectomia para el cancer de recto, ya sea en el origen de la arteria mesenterica inferior o en la arteria rectal superior aun no esta definido.OBJETIVO:El objetivo era determinar si la ligadura de la arteria rectal superior pronostica resultados tecnicos u oncologicos similares.DISENO:Analisis retrospectivo de una base de datos de cancer de recto (2007-2017).ESCENARIO:el estudio se realizo en seis centros de referencia de tercer nivel en los Estados Unidos (Universidad de Emory, Universidad de Michigan, Centro medico de la Universidad de Pittsburgh, Centro medico Wexner de la Universidad Estatal de Ohio, Centro medico de la Universidad de Vanderbilt y Escuela de Medicina de la Universidad de Washington en St. Louis).PACIENTES:Se incluyeron pacientes con cancer de recto primario no metastasico que se sometieron a reseccion anterior baja o reseccion abdominoperineal.PRINCIPALES VARIABLES ANALIZADAS:Se midio la fuga anastomotica, los ganglios linfaticos recuperados, la sobrevida sin recidiva locorregional, la sobrevida sin recidiva y la sobrevida global.RESULTADOS:De 877 pacientes, en el 86% (n = 755) se realizo una ligadura de la arteria mesenterica inferior, y en el 14% (n = 122) se realizo una ligadura de la arteria rectal superior. El 12%, 33%, 24% y 31% estaban en estadio patologico 0, I, II y III respectivamente. La mediana de seguimiento fue de 31 meses. La ligadura de la arteria rectal superior se asocio con una tasa de fuga anastomotica similar a la ligadura de la arteria mesenterica inferior (9 vs 8%, p = 1,0). La mediana del numero de ganglios linfaticos extirpados fue identica (15 contra 15, p = 0,38). En el analisis multivariado que tiene en cuenta los factores clinico-patologicos relevantes, la ligadura de la arteria rectal superior no se asocio con una mayor tasa de fuga anastomotica, una peor cosecha de ganglios linfaticos o una peor sobrevida libre de recurrencia locorregional, sobrevida libre de recurrencia o sobrevida global (todos p> 0,1).LIMITACIONES:Diseno retrospectivo.CONCLUSIONES:En comparacion con la ligadura de la arteria mesenterica inferior, la ligadura de la arteria rectal superior no se asocia a peores resultados tecnicos ni oncologicos. Debido a los riesgos potenciales de un flujo sanguineo inadecuado del munon proximal de la anastomosis y la lesion de los nervios autonomicos, proponemos una mayor realizacion de la ligadura de la arteria rectal superior. Consulte Video Resumen en http://links.lww.com/DCR/B646.