This multicenter RCT compared high IMA ligation (at the root) vs low IMA ligation (distal to the left colic artery origin) in 293 patients with clinical stage I–III rectal cancer undergoing minimally invasive (laparoscopic or robotic) anterior resection, enrolled July 2019–August 2024, with functional outcomes assessed at 12 months.
Symptomatic anastomotic leakage was 4.9% (7/143) with low ligation vs 6.0% (9/150) with high ligation — not significantly different (RR 0.82; 95% CI 0.31–2.13; P = .68). 30-day morbidity (14.0% vs 22.0%; P = .08) and 12-month LARS scores (15.8 vs 17.3; P = .32) were also similar.
- Trial may have been underpowered to detect a small but clinically meaningful difference in anastomotic leakage rates. - 21 of 314 randomized patients were excluded from the modified ITT analysis, risking selection bias. - Single-country trial (South Korea registry) limits generalizability to other practice settings.
Surgeons can choose either high or low IMA ligation in minimally invasive rectal cancer resection without meaningfully changing anastomotic leak risk or long-term bowel function. Low ligation does not need to be routinely favored over high ligation on the basis of leak prevention alone.
