Defecatory Dysfunction After Colon Cancer Resection: The Role of Inferior Mesenteric Artery Tie

Abstract

Background: Although oncological results for resection of colon cancer with inferior mesenteric artery (IMA) ligation at its origin (high tie) or immediately below the left colic artery (low tie) are similar, injury of the superior hypogastric plexus may be caused when the IMA is tied at its origin, thus impairing defecatory functions.

Aim: The importance of IMA tie location on defecatory dysfunction in patients undergoing laparoscopic sigmoidal resection without preoperative radiation therapy was studied.

Patients and methods: From February 2013 to December 2018, 56 consecutive patients submitted to curative laparoscopic resection for stage II and III, M0, sigmoidal cancer were randomized to a high or low tie of the IMA. All demographic data and information on symptoms and comorbidity, intra- and post-operative outcomes and defecatory function before and after surgery [according to the following scales: Fecal Incontinence Quality of Life (FIQL) scale, Jorge-Wexner incontinence and Agachan-Wexner constipation scores] were collected into a computerized database.

Results: All patients completed the questionnaires. The educational and social status, and lifestyle habits (defined as active or sedentary) of our groups were similar. A significant difference in total score of FIQL scale was observed between the high and low tie groups at 1 month [88±6 and 93±7, p=0.005, confidence interval for the difference between mean values (CI_Δ)=1.706-9.065] and 6 months (93±7 and 97±6, p=0.030, CI_Δ=0.390-7.547). The Jorge-Wexner incontinence scores showed a significant decrease in patients of the high group (1 month: 0.59±0.76 and 6 months: 0.62±0.79, respectively) when compared to those of the low tie group (1 month 0.17±0.38 and 6 months 0.17±0.38, respectively) (p=0.008 and p=0.006 at 1 and 6 months, respectively). At 1, 6 and 12 months, the overall Agachan-Wexner constipation scores were significantly higher in patients of the high tie group when compared to those of the low tie group (1 month: 5.1±1.1 and 4.3±0.86, p=0.002, CI_Δ=-1.350--0.316; 6 months: 7.4±1.4 and 6.2±1.4, p=0.003, CI_Δ=-1.959--0.436; and 12 months: 7.2±1.3 and 6±1.1, p=0.001, CI_Δ=-1.840--0.576, respectively).

Conclusion: Patients affected with stage II and III sigmoidal cancer had a better fecal continence at the short- to medium-term and less abdominal pain in the medium- to long-term when a low tie technique was utilized.

Keywords: Defecatory dysfunction; high inferior mesenteric artery tie; low inferior mesenteric artery tie; sigmoidal cancer.