{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T16:11:03Z","timestamp":1783613463438,"version":"3.55.0"},"reference-count":57,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2022,8,23]],"date-time":"2022-08-23T00:00:00Z","timestamp":1661212800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: This study aimed to compare the effects of high ligation (HL) versus low ligation (LL) in colorectal cancer surgery. Materials and Methods: We performed a comprehensive search using multiple databases (trial registries and ClinicalTrials.gov), other sources of grey literature, and conference proceedings, with no restrictions on the language or publication status, up until 10 March 2021. We included all parallel-group randomized controlled trials (RCTs) and considered cluster RCTs for inclusion. The risk of bias domains were \u201clow risk,\u201d \u201chigh risk,\u201d or \u201cunclear risk.\u201d We performed statistical analyses using a random-effects model and interpreted the results according to the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE guidelines to rate the certainty of evidence (CoE) of the randomized controlled trials. Results: We found 12 studies (24 articles) from our search. We were very uncertain about the effects of HL on overall mortality, disease recurrence, cancer-specific mortality, postoperative mortality, and anastomotic leakage (very low CoE). There may be little to no difference between HL and LL in postoperative complications (low CoE). For short-term follow-up (within 6 months), HL may reduce defecatory function (constipation; low CoE). While HL and LL may have similar effects on sexual function in men, HL may reduce female sexual function compared with LL (low CoE). For long-term follow-up (beyond 6 months), HL may reduce defecatory function (constipation; low CoE). There were discrepancies in the effects regarding urinary dysfunction according to which questionnaire was used in the studies. HL may reduce male and female sexual function (low CoE). Conclusions: We are very uncertain about the effects of HL on survival outcomes, and there is no difference in the incidence of postoperative complications between HL and LL. More rigorous RCTs are necessary to evaluate the effect of HL and LL on functional outcomes.<\/jats:p>","DOI":"10.3390\/medicina58091143","type":"journal-article","created":{"date-parts":[[2022,8,24]],"date-time":"2022-08-24T00:22:48Z","timestamp":1661300568000},"page":"1143","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["High Versus Low Ligation of the Inferior Mesenteric Artery in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"58","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0496-1303","authenticated-orcid":false,"given":"Kwangmin","family":"Kim","sequence":"first","affiliation":[{"name":"Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"},{"name":"Trauma Center, Wonju Severance Christian Hospital, Wonju 26426, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanghyun","family":"An","sequence":"additional","affiliation":[{"name":"Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"},{"name":"Division of Colorectal Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Myung Ha","family":"Kim","sequence":"additional","affiliation":[{"name":"Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jae Hung","family":"Jung","sequence":"additional","affiliation":[{"name":"Department of Urology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"},{"name":"Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul 03722, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Youngwan","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"},{"name":"Division of Colorectal Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,8,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"394","DOI":"10.3322\/caac.21492","article-title":"Global cancer statistics 2018: Globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries","volume":"68","author":"Bray","year":"2018","journal-title":"CA Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1016\/j.ejso.2014.11.001","article-title":"Is right-sided colon cancer different to left-sided colorectal cancer?\u2014A systematic review","volume":"41","author":"Lee","year":"2015","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1186\/s12957-018-1458-7","article-title":"High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: A meta-analysis","volume":"16","author":"Zeng","year":"2018","journal-title":"World J. Surg. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1111\/codi.15419","article-title":"High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: A systematic review and meta-analysis of randomized controlled trial studies","volume":"23","author":"Kong","year":"2021","journal-title":"Colorectal Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10151-009-0547-6","article-title":"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","volume":"14","author":"Alici","year":"2010","journal-title":"Tech. Coloproctol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1789","DOI":"10.1007\/s00268-013-2130-6","article-title":"Extended lymphadenectomy in colon cancer is crucial","volume":"37","author":"Kessler","year":"2013","journal-title":"World J. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1002\/bjs.1800790730","article-title":"Flush aortic tie versus selective preservation of the ascending left colic artery in low anterior resection for rectal carcinoma","volume":"79","author":"Corder","year":"1992","journal-title":"Br. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1159\/000107779","article-title":"Impact of upward lymph node dissection on survival rates in advanced lower rectal carcinoma","volume":"24","author":"Uehara","year":"2007","journal-title":"Dig. Surg."},{"key":"ref_9","first-page":"ED000142","article-title":"Updated guidance for trusted systematic reviews: A new edition of the cochrane handbook for systematic reviews of interventions","volume":"10","author":"Cumpston","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_10","unstructured":"Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., and Welch, V. (2021, March 10). Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (Updated February 2021). Available online: www.training.cochrane.org\/handbook."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/1745-6215-8-16","article-title":"Practical methods for incorporating summary time-to-event data into meta-analysis","volume":"8","author":"Tierney","year":"2007","journal-title":"Trials"},{"key":"ref_12","unstructured":"Sch\u00fcnemann, H., Bro\u017cek, J., Guyatt, G., and Oxman, A. (2022, March 10). Grade Handbook. Available online: https:\/\/gdt.gradepro.org\/app\/handbook\/handbook.html#h.m9385o5z3li7."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"988","DOI":"10.1097\/DCR.0000000000001693","article-title":"Meta-analysis and trial sequential analysis of randomized controlled trials comparing high and low ligation of the inferior mesenteric artery in rectal cancer surgery","volume":"63","author":"Hajibandeh","year":"2020","journal-title":"Dis. Colon Rectum"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2575","DOI":"10.1111\/codi.15798","article-title":"Level of inferior mesenteric artery ligation does not affect rectal cancer treatment outcomes despite better cancer-specific survival after low ligation-randomized trial results","volume":"23","author":"Kruszewski","year":"2021","journal-title":"Colorectal Dis."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1002\/ags3.12318","article-title":"Clinical impact of d3 lymph node dissection with left colic artery (lca) preservation compared to d3 without lca preservation: Exploratory subgroup analysis of data from jcog0404","volume":"4","author":"Akagi","year":"2020","journal-title":"Ann. Gastroenterol. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1075","DOI":"10.1007\/s00384-011-1188-6","article-title":"High tie versus low tie in rectal surgery: Comparison of anastomotic perfusion","volume":"26","author":"Komen","year":"2011","journal-title":"Int. J. Colorectal Dis."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1007\/s10353-018-0542-0","article-title":"High vascular ligation in left-sided colon cancer surgery issafe and adequate","volume":"50","author":"Samalavicius","year":"2018","journal-title":"Eur. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1200\/JCO.2019.37.4_suppl.653","article-title":"Clinical impact of d3 lymph node dissection preserving left colic artery (lca) compared to d3 without preserving lca: Exploratory subgroup analysis of data from randomized controlled trial of laparoscopic versus open surgery for colon cancer from japan clinical oncology group study jcog0404","volume":"37","author":"Akagi","year":"2019","journal-title":"J. Clin. Oncol."},{"key":"ref_19","unstructured":"Planelles-Soler, P., Mora-Lopez, L., Hannaoui, N., Serra-Pla, S., Dominguez-Garcia, A., Mu\u00f1oz-Rodriguez, J., Prats-Lopez, J., Navarro-Soto, S., and Serra-Aracil, X. (2021, October 01). Prospecitve Controlled and Randomized Study of the Genitourinary Function after Rectal Cancer Surgery in Relation to the Dissection of the Inferior Mesenteric Vessels, Available online: https:\/\/clinicaltrials.gov\/ct2\/show\/NCT03520088."},{"key":"ref_20","unstructured":"(2021, October 01). A Prospective Clinical Study for Laparoscopic d3 Dissection with Preservation of Left Colic Artery in Rectal Cancer, Available online: https:\/\/clinicaltrials.gov\/ct2\/show\/NCT02753465."},{"key":"ref_21","unstructured":"Park, J.S. (2021, October 01). Anastomotic Leakage after Laparoscopic Anterior Resection for Rectal Cancer with High Versus Low Ligation of Inferior Mesenteric Artery: A Randomized Multicenter Trial. Available online: https:\/\/trialsearch.who.int\/?TrialID=KCT0003523."},{"key":"ref_22","first-page":"3582","article-title":"Clinical effect of preservation of the left colonic artery in laparoscopic anterior resection for rectal cancer","volume":"96","author":"Niu","year":"2016","journal-title":"Zhonghua Yi Xue Za Zhi"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2969","DOI":"10.21873\/anticanres.14276","article-title":"Defecatory dysfunction after colon cancer resection: The role of inferior mesenteric artery tie","volume":"40","author":"Fiori","year":"2020","journal-title":"Anticancer Res."},{"key":"ref_24","first-page":"1132","article-title":"Effect of ligation level of inferior mesenteric artery on postoperative defecation function in patients with rectal cancer","volume":"18","author":"Wang","year":"2015","journal-title":"Zhonghua Wei Chang Wai Ke Za Zhi"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"S76","DOI":"10.1002\/jso.26362","article-title":"High versus low ligation of the inferior mesenteric artery during laparoscopic rectal cancer surgery: A prospective study of surgical and oncological outcomes","volume":"123","author":"Feng","year":"2021","journal-title":"J. Surg. Oncol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"4223","DOI":"10.21873\/anticanres.14423","article-title":"Is low inferior mesenteric artery ligation worthwhile to prevent urinary and sexual dysfunction after total mesorectal excision for rectal cancer?","volume":"40","author":"Fiori","year":"2020","journal-title":"Anticancer Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1097\/SLA.0000000000002947","article-title":"Low ligation of inferior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary dysfunction: Results from a randomized controlled trial (highlow trial)","volume":"269","author":"Mari","year":"2019","journal-title":"Ann. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1111\/ans.13032","article-title":"Marginal artery stump pressure in left colic artery-preserving rectal cancer surgery: A clinical trial","volume":"87","author":"Guo","year":"2017","journal-title":"ANZ J. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1159\/000477805","article-title":"Oncological outcomes following rectal cancer surgery with high or low ligation of the inferior mesenteric artery","volume":"4","author":"Matsuda","year":"2017","journal-title":"Gastrointest. Tumors"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1002\/bjs.9739","article-title":"Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery","volume":"102","author":"Matsuda","year":"2015","journal-title":"Br. J. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1002\/bjs5.71","article-title":"Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer","volume":"2","author":"Fujii","year":"2018","journal-title":"BJS Open"},{"key":"ref_32","first-page":"46","article-title":"Accurate low ligation of inferior mesenteric artery and root lymph node dissection according to different vascular typing in laparoscopic radical resection of rectal cancer","volume":"21","author":"Zhou","year":"2018","journal-title":"Zhonghua Wei Chang Wai Ke Za Zhi"},{"key":"ref_33","first-page":"1313","article-title":"Clinical research of laparoscopic low anterior resection with preservation of the left colonic artery","volume":"20","author":"Wu","year":"2017","journal-title":"Zhonghua Wei Chang Wai Ke Za Zhi"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1007\/BF02237236","article-title":"Fecal incontinence quality of life scale: Quality of life instrument for patients with fecal incontinence","volume":"43","author":"Rockwood","year":"2000","journal-title":"Dis. Colon Rectum"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1016\/S0399-8320(04)95012-9","article-title":"Validation of the french version of the fecal incontinence quality-of-life (fiql) scale","volume":"28","author":"Rullier","year":"2004","journal-title":"Gastroenterol. Clin. Biol."},{"key":"ref_36","first-page":"153","article-title":"Italian translation and prospective validation of fecal incontinence quality of life (fiql) index","volume":"57","author":"Altomare","year":"2005","journal-title":"Chir. Ital."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2708","DOI":"10.1007\/s00464-009-0475-6","article-title":"The minimal clinically important difference in the gastrointestinal quality-of-life index after cholecystectomy","volume":"23","author":"Shi","year":"2009","journal-title":"Surg. Endosc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.urology.2019.08.004","article-title":"The minimum clinically important difference of the international consultation on incontinence questionnaires (iciq-ui sf and iciq-lutsqol)","volume":"133","author":"Lim","year":"2019","journal-title":"Urology"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1770","DOI":"10.1016\/S0022-5347(01)66780-6","article-title":"Benign prostatic hyperplasia specific health status measures in clinical research: How much change in the american urological association symptom index and the benign prostatic hyperplasia impact index is perceptible to patients?","volume":"154","author":"Barry","year":"1995","journal-title":"J. Urol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2051","DOI":"10.1089\/end.2010.0296","article-title":"Does greenlight hps() laser photoselective vaporization prostatectomy affect sexual function?","volume":"24","author":"Spaliviero","year":"2010","journal-title":"J. Endourol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1089\/jwh.2017.6335","article-title":"Effect of single-session, cryogen-cooled monopolar radiofrequency therapy on sexual function in women with vaginal laxity: The viveve i trial","volume":"27","author":"Krychman","year":"2018","journal-title":"J. Womens Health"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e13","DOI":"10.1111\/codi.12055","article-title":"Prognostic significance of apical lymph node metastasis in patients with node-positive rectal cancer","volume":"15","author":"Peng","year":"2013","journal-title":"Colorectal Dis."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"2076","DOI":"10.1002\/1097-0142(19940415)73:8<2076::AID-CNCR2820730811>3.0.CO;2-6","article-title":"Pathologic determinants of survival associated with colorectal cancer with lymph node metastases: A multivariate analysis of 579 patients","volume":"73","author":"Newland","year":"1994","journal-title":"Cancer"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1097\/SLA.0b013e31823785f6","article-title":"Distribution of lymph node metastases is an independent predictor of survival for sigmoid colon and rectal cancer","volume":"255","author":"Huh","year":"2012","journal-title":"Ann. Surg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10147-019-01485-z","article-title":"Japanese society for cancer of the colon and rectum (jsccr) guidelines 2019 for the treatment of colorectal cancer","volume":"25","author":"Hashiguchi","year":"2020","journal-title":"Int. J. Clin. Oncol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"3645","DOI":"10.2217\/fon-2021-0149","article-title":"Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: A systematic review and meta-analysis","volume":"17","author":"Jonnada","year":"2021","journal-title":"Future Oncol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.1097\/DCR.0000000000002052","article-title":"A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go?","volume":"64","author":"Turgeon","year":"2021","journal-title":"Dis. Colon Rectum."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"3511","DOI":"10.1007\/s00464-021-08673-x","article-title":"Quantitative evaluation of colon perfusion after high versus low ligation in rectal surgery by indocyanine green: A pilot study","volume":"36","author":"Han","year":"2022","journal-title":"Surg. Endosc."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.ijsu.2016.05.042","article-title":"Lengthening of left colon after rectal resection: What all is adequate? A prospective cohort study","volume":"31","author":"Reddy","year":"2016","journal-title":"Int. J. Surg."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1007\/s10151-012-0930-6","article-title":"Lengthening of the colon for low rectal anastomosis in a cadaveric study: How much can we gain?","volume":"17","author":"Boonyapibal","year":"2013","journal-title":"Tech. Coloproctol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1002\/bjs.5327","article-title":"Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery","volume":"93","author":"Kanemitsu","year":"2006","journal-title":"Br. J. Surg."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1093\/gastro\/gow023","article-title":"Pelvic autonomic nerve preservation in radical rectal cancer surgery: Changes in the past 3 decades","volume":"4","author":"Chew","year":"2016","journal-title":"Gastroenterol. Rep."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1016\/j.jviscsurg.2016.10.002","article-title":"Genito-urinary sequelae after carcinological rectal resection: What to tell patients in 2017","volume":"154","author":"Abdelli","year":"2017","journal-title":"J. Visc. Surg."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"774","DOI":"10.3389\/fonc.2021.774782","article-title":"Low Ligation Plus High Dissection Versus High Ligation of the Inferior Mesenteric Artery in Sigmoid Colon and Rectal Cancer Surgery: A Meta-Analysis","volume":"11","author":"Yin","year":"2021","journal-title":"Front. Oncol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1007\/s00384-022-04101-1","article-title":"Systematic review and meta-analysis of randomized controlled trials evaluating the effect of the level of ligation of inferior mesenteric artery on functional outcomes in rectal cancer surgery","volume":"37","author":"Tryliskyy","year":"2022","journal-title":"Int. J. Colorectal Dis."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1002\/jrsm.46","article-title":"Pooling health-related quality of life outcomes in meta-analysis-a tutorial and review of methods for enhancing interpretability","volume":"2","author":"Thorlund","year":"2011","journal-title":"Res. Synth. Methods"},{"key":"ref_57","first-page":"n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2011","journal-title":"BMJ"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/9\/1143\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:14:01Z","timestamp":1760141641000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/9\/1143"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,23]]},"references-count":57,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2022,9]]}},"alternative-id":["medicina58091143"],"URL":"https:\/\/doi.org\/10.3390\/medicina58091143","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,23]]}}}