Arman Draginov, MD, MSc1, Humzah Quereshy, BA2, Tyler Chesney, MD1, Ahmed Sami Chadi, MD, MSc1, Fayez Quereshy, MD, MBA1. 1University Health Network, 2Case Western Reserve University Medical School
Introduction: In the treatment of distal sigmoid and rectal cancer, the appropriate level for ligation of the inferior mesenteric artery (IMA) remains unresolved. High-tie ligates the IMA proximally, and low-tie ligates the IMA distally, preserving the left colic artery and nearby neurovascular structures with a potential for improved anastomotic complications and genitourinary function. We compare anastomotic leaks between laparoscopic “high-tie” and “low-tie” as our primary outcome, and as secondary outcomes we compare 30-day complications and mortality. Furthermore, we explore alternative factors that may contribute to 30-day morbidity and mortality in this patient population.
Methods: In this retrospective cohort study, we identified all patients with primary sigmoid, rectosigmoid, and rectal cancer treated with elective laparoscopic resection and primary anastomosis between January 2002 and June 2018 through administrative data collection. Patients with incomplete outcomes data due to lost-to-follow-up status were excluded from the analysis. Anastomotic leaks, postoperative complications organized by Clavien-Dindo classification, and mortality at 30 days were compared across “high-tie” and “low-tie” cohorts using Chi-square tests. Factors associated with 30-day morbidity and mortality were assessed using univariable and multivariable logistic regression.
Results: In our cohort, 159 patients were treated with a high-tie approach and 123 with low-tie. Groups did not differ in sex, comorbidities, and stage; those treated with high-tie were slightly older (median age 69 (IQR 59-75) vs 64 (IQR 54-72). Between groups, there was no statistically significant difference in anastomotic leaks (high=3.2% vs low=5.7%, p=0.30). Additionally, for patients that experienced anastomotic failure, there was no difference in rates of reoperation (high=40.0% vs low=28.6%, p=0.68). Further, there were no differences in major (high=5.1% vs low=10.6%, p=0.08) or minor complications (high=21.5% vs low=29.3%, p=0.14). There were no mortalities observed in either cohort. On multivariable analysis, only neoadjuvant chemoradiation was associated with 30-day complications (OR: 2.03, 95%CI: 1.13-3.67) and anastomotic leaks (OR: 4.27, 95%CI: 1.28-14.22) in laparoscopic resections of sigmoid, rectosigmoid, and rectal cancer resections. Furthermore, there was no observed association between tumor location and the rate of anastomotic leaks (p=0.18).
Conclusion: For patients treated with a high-tie compared with a low-tie approach during laparoscopic resection of sigmoid, rectosigmoid, and rectal cancers, there was no difference in anastomotic leaks, complications, or postoperative mortality. Furthermore, additional studies are necessary to identify differences in genitourinary function associated with preservation of the left colic artery and nearby hypogastric plexus in the low-tie technique.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91783
Program Number: S059
Presentation Session: Colorectal II – Neoplasia
Presentation Type: Podium