High and Low inferior mesenteric artery Ligation Show Similar Outcomes in Rectal Cancer Surgery: JAMA

A new study published in the Journal of American Medical Association showed that in patients having minimally invasive rectal cancer surgery, modest ligation of the inferior mesenteric artery (IMA) did not substantially lower the incidence of anastomotic leakage when compared to high ligation.

Due to possible trade-offs between anastomotic integrity and functional results, the ideal degree of inferior mesenteric artery occlusion following rectal cancer resection is still debatable. To ascertain if mild ligation of the IMA, as opposed to high ligation, lowers the risk of anastomotic leaking in patients having minimally invasive anterior resection for rectal cancer, this study was carried out.

Between July 2019 and August 2024, this clinical study included patients with rectal cancer in stages I through III. Patients planned for laparoscopic or robotic anterior resection were randomly assigned to either a high or low IMA ligation. The primary operation might be high ligation (at the root of the IMA) or low ligation (distal to the origin of the left colic artery). The main endpoint was the rate of anastomotic leaking. Secondary endpoints were surgical complications and functional outcomes (bowel, urine, and sexual function) examined 12 months after surgery.

The modified intention-to-treat analysis comprised 293 of the 314 randomized participants. There were 191 male patients (65.2%) and 102 female patients (34.8%) with a median (IQR) age of 64.0 (55.3-73.0). Nine out of 150 patients (6.0%) in the high-ligation group and 7 out of 143 patients (4.9%) in the low-ligation group experienced symptomatic anastomotic leakage.

30-day postoperative morbidity was 14.0% overall as opposed to 22.0%. Bowel function (mean [SD] Low Anterior Resection Syndrome [LARS] score, 15.8 [12.8] in the low-ligation group vs. 17.3 [11.8] in the high-ligation group; P =.32) and the percentage of patients with major LARS (24/121 [19.8%] in the low-ligation group vs. 25/130 in the high-ligation group [19.2%]; P >.99).

When compared to strong ligation, reduced ligation of the IMA did not considerably lower the rate of anastomotic leakage in this randomized clinical experiment. With similar rates of complications and long-term functional results, both methods seem to be safe and practical for minimally invasive rectal cancer surgery.

Reference:

Kim, C. H., Park, S. Y., Lee, S. Y., Son, G. M., Kim, H. J., Ha, G. W., Lee, K.-H., Kim, D.-W., Park, J. S., Bae, K. B., & Korean ColoRectal surgeOn Study Group of the Southern Province (K-CROSS). (2026). Inferior mesenteric artery ligation level and anastomotic leakage in low anterior resection: A randomized clinical trial. JAMA Surgery. https://doi.org/10.1001/jamasurg.2026.2248