DOI: http://dx.doi.org/10.18203/2349-2902.isj20190389

Apical lymph node dissection of the inferior mesenteric artery with preservation of left colic artery in colorectal cancer

Ahmed Farag El Kased, Mohammed S. Amar, Ahmed S. Elgammal, Amira M. Elfeky

Abstract


Background: Nowadays, surgery for colorectal cancer has been standardized both ways in open and laparoscopic approaches but there are still debates regarding the level of ligation of the IMA at its origin from aorta (high ligation) or below the origin of left colic artery (low ligation). The technique of apical lymph node dissection with preservation of LCA has the advantage of both, better lymph node harvest and lower postoperative complications. It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. This study evaluates the nodal yield of ALMA and the short-term outcome of this technique.

Methods: Author retrospectively studied 40 patients with operable sigmoid and rectal cancer who admitted to general surgery department in Menoufia University Hospitals from May 2016 to May 2018. All patient underwent curative surgical resection with ALMA. The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated.

Results: Results ALMA was successful in 36 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 20min.

Conclusions: ALMA (lymph node dissection around the IMA preserving the root of the IMA and LCA) was feasible by this method without compromising operation time, blood loss or the number of harvested lymph nodes with accepted rate of postoperative complications.

Keywords


Apical lymph node, Inferior mesenteric artery, Left colic artery

Full Text:

PDF

References


Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: Cancer J Clin. 2011;61(2):69-90.

Arezzo A, Passera R, Scozzari G, Verra M, Morino M. Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic review and meta-analysis. Surg Endoscopy. 2013;27(5):1485-502.

Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Digestive Surg. 2008;25(2):148-57.

Kanemitsu Y, Hirai T, Komori K, Kato T. Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery. Brit J Surg: Incorporating Euro J Surg Swiss Surg. 2006;93(5):609-15.

Kang J, Hur H, Min BS, Kim NK, Lee KY. Prognostic impact of inferior mesenteric artery lymph node metastasis in colorectal cancer. Ann Surg Oncol. 2011;18:704–710.

Goh N, Fong SS, How KY, Wong KY, Loong TH, Tay GT. Apical lymph node dissection of the inferior mesenteric artery. Colorectal Dis. 2016;18(6):O206-9.

Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. 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. Inter J Impotence Res. 1999;11(6):319.

Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodynamics: Off J Inter Continence Soc. 2004;23(4):322-30.

Jones LA. The use of validated questionnaires to assess female sexual dysfunction. World J Urol. 2002;20(2):89-92.

Lange MM, Buunen M, Van de velde CJ, Lange JF. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie: a review. Dis Colon Rectum. 2008;51(7):1139-45.

Alici A, Kement M, Gezen C, Akın T, Vural S, Okkabaz N, et al. 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. 2010;14(1):1-8.

Pezim ME, Nicholls RJ. Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann Surg. 1984;200(6):729.

Chin CC, Yeh CY, Tang R, Changchien CR, Huang WS, Wang JY. The oncologic benefit of high ligation of the inferior mesenteric artery in the surgical treatment of rectal or sigmoid colon cancer. Inter J Colorectal Dis. 2008;23(8):783-8.

Hida JI, Okuno K. High ligation of the inferior mesenteric artery in rectal cancer surgery. Surg Today. 2013;43(1):8-19.

Palma RT, Waisberg J, Bromberg SH, Simao AB, Godoy AC. Micrometastasis in regional lymph nodes of extirpated colorectal carcinoma: immunohistochemical study using anti‐cytokeratin antibodies AE1/AE3. Colorectal Dis. 2003;5(2):164-8.

Seike K, Koda K, Saito N, Oda K, Kosugi C, Shimizu K, et al. Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery. Inter J Colorectal Dis. 2007;22(6):689-97.

Dworkin MJ, Allen-Mersh TG. Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon. J Am Coll Surg. 1996;183(4):357-60.

Nano M, Dal Corso H, Ferronato M, Solej M, Hornung JP, Dei Poli M. Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations. Digestive Surg. 2004;21(2):123-7.

Kim NK, Aahn TW, Park JK, Lee KY, Lee WH, Sohn SK, et al. Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum. 2002;45(9):1178-85.

Havenga K, De Ruiter MC, Enker WE, Welvaart K. Anatomical basis of autonomic nerve‐preserving total mesorectal excision for rectal cancer. Brit J Surg. 1996;83(3):384-8.