Background: In rectal cancer surgery, the approach towards the Inferior Mesenteric artery (IMA) has always been debated among the performers of “high tie” and “low tie” technique. The debate is centred on three factors; a) Oncologic outcomes, b) Vascular factor (evidenced by leak rate) and c) Injury to hypogastric nerves.
Objectives: This study aims to assess the oncologic adequacy with regard to 3-year Disease Free Survival (DFS) following low tie in rectal cancer surgery with Lymph Node (LN) yield and anastomotic leak rates as secondary outcomes.
Materials and Methods: This is a retro-prospective study of all consecutive patients with histologically proven rectum and recto-sigmoid adenocarcinoma who underwent low tie resections with curative intent with curative intent over a period from 01/01/2009 to 31/12/2016. Those patients with familial syndromes or history of other malignancies in the past were excluded from the study.
Results: There were 254 patients during the study period, of which 53 patients lost to follow up and 29 patients expired while on follow up due to others causes. The remaining 172 patients were included for analysis. Median follow-up was 61 months (8-117 months). The mean DFS was 81.6 months [standard error (SE): 3.2; 95% Confidence Interval (CI): 75.35-87.91]. The mean Overall Survival (OS) was 90.7months (SE:2.78, 95% CI 85.2 – 96.1). The 3-year DFS and the 3-year OS was 76.9% and 83.5% respectively. The stage of the tumor and LN positivity was found to have significant impact on DFS (p=0.006) and OS (p<0.001). There was no statistically significant impact of the number of positive LNs on DFS (0.931) and OS (p=0.783). Loco-Regional Recurrence (LRR) was seen in 11(6.3%) patients. Liver was the most common site of distant metastasis. Median LN yield in patients who underwent upfront surgery and those with NACRT was 14 (8-24) and 5(0-20) respectively. Anastomotic leak was seen in 6/121 (4.9%) patients.
Conclusion: Low tie in rectal cancer surgery provides comparable 3-year and 5-year DFS and OS with that of high tie reported in literature. Adequate LN yield can be achieved in low tie rectal cancer surgery with a low clinical anastomotic leak rate compared to that of other studies reported.