Low IMA Ligation Did Not Significantly Reduce Leaks

A randomized trial found similar short-term morbidity and 12-month functional outcomes with both approaches, while highlighting the need to balance perfusion with a tension-free anastomosis.

By
Andrea Surnit
July 15, 2026
5 min

Conexiant

Objective:

To compare the rates of symptomatic anastomotic leakage and patient-reported outcomes between low and high inferior mesenteric artery ligation in minimally invasive rectal cancer surgery.

Approach:

Study Design: A multicenter, prospective, randomized clinical trial conducted at 7 tertiary hospitals in South Korea from July 2019 to August 2024.
Participants: 314 randomized patients aged 18 to 80 years with histologically confirmed clinical stage I to III primary rectal adenocarcinoma scheduled for minimally invasive anterior resection.
Intervention: Patients were assigned to either low ligation (inferior mesenteric artery divided distal to the left colic artery) or high ligation (within 2 cm of the artery’s origin).
Endpoints: Primary endpoint was symptomatic grade B or C anastomotic leakage within 30 days post-surgery.

Key Findings:

Symptomatic anastomotic leakage occurred in 5% of low ligation patients and 6% of high ligation patients, with no statistically significant difference.
No significant differences in overall 30-day morbidity or most patient-reported outcomes at 12 months.
The trial was underpowered to detect smaller differences due to lower than expected leakage rates.

Interpretation:

Limitations:

The study may have been underpowered due to lower observed leakage rates than anticipated.
Long-term cancer recurrence and survival were not assessed.
The proportion of patients receiving neoadjuvant chemoradiotherapy was lower than typical in Western practice.