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.

BACKGROUND: What level of arterial ligation is best in left-sided colon cancer and rectal cancer remains controversial. This study aims to assess the necessity and risk of high ligation from an oncological and technical perspective. METHODS: The lymph nodes at the origin of the inferior mesenteric artery (IMA) were separated as apical nodes in all patients operated for distal colorectal cancer in our department. The number and status of the nodes were prospectively assessed, and demographic and tumor-related variables were evaluated as risk factors for apical tumor invasion. Anastomotic leaks were also evaluated. RESULTS: A hundred and three patients (52 [50.5%] males, 60.3+/-12.9 years old) were included. The number of non-apical lymph nodes harvested was 14.5+/-7.1 with an additional 4.4+/-3.2 apical nodes at the high ligation site. Tumor invasion of apical nodes was observed in 6 (5.8%) patients. Two of these (1.9%) had no other positive nodes (skip metastases). Although none of the variables evaluated was found significant for predicting apical node positivity, tumor invasion was detected in 8.5 and 22.2% of patients with pT3 and pN2 cancers, respectively. Among patients, who had an anastomosis (n = 84, 81.6%), anastomotic leak was observed in 7(8.3%) and 1 (1.2%) of these patients required emergency relaparotomy. There was no mortality related to high ligation. CONCLUSIONS: High ligation of IMA may be routinely performed in patients with distal colorectal cancer, since tumor invasion of apical lymph nodes is neither rare (>5%) nor predictable, and skip metastases may also occur. This is especially true in case of an advanced disease for which apical node positivity peaks. The anastomotic leak rate is less than 10%, and mortality is low after high ligation of IMA.

Effects of seprafilm and heparin in combination on intra-abdominal adhesions.

AIM: Postoperative intra-abdominal adhesion formation is a significant cause of morbidity. The aim of this study was to assess the effects of heparin and Seprafilm, which is considered the gold standard, on the prevention of intra-abdominal adhesions. METHOD: Four groups consisting of 25 rats each were formed. Cecal abrasion was performed in all animals. Group 1 was the control group with no treatment; in group 2, heparin was applied intraperitoneally; in group 3, Seprafilm was used underneath the abdominal wall, and group 4 animals were treated with both heparin and Seprafilm. Two weeks after the surgical procedure, animals were sacrificed and specimens were removed for the measurement of the grade of adhesions, according to the Mazuji classification. RESULTS: Formation of adhesions was prevented in the three study groups treated with heparin only, Seprafilm only and both heparin and Seprafilm (p < 0.001) compared with the control group. There was no statistical difference between the treatment groups. Autopsy results of the animals that died within the first week after the surgical procedure revealed intra-abdominal abscess formation and infections, which were considered as possible causes of death. CONCLUSION: Seprafilm seems to be more effective in the prevention of adhesions. In the combined application of Seprafilm and heparin, heparin showed no additive impact. Future studies are needed to detect the suitable dose and side effects of heparin for humans.