title: Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery.
abstract: OBJECTIVE
  High ligation of the inferior mesenteric artery may jeopardize blood supply to the proximal bowel. We undertook this study to review the clinical features and outcomes of patients who developed proximal bowel necrosis after high ligation of the inferior mesenteric artery, and to assess the incidence and the risk factors for this complication.
  
  
  METHODS
  A retrospective analysis of patients undergoing high or low ligation for sigmoid colon and rectal cancer with a primary anastomosis between April 2004 and March 2009 was performed. Patient and tumor characteristics and the incidence of bowel necrosis were reviewed.
  
  
  RESULTS
  Four hundred and nine patients were included to the analysis. Six out of 302 patients (2.0%) with high ligation developed proximal bowel necrosis, while the remaining 107 patients with low ligation did not suffer from this complication. All patients who developed proximal bowel necrosis underwent secondary surgery with resection of necrotic bowel. The pathological examination of the resected specimen revealed mucosal to transmural ischemic necrosis without the evidence of vascular thrombosis or embolic occlusion. Univariate analysis revealed that advanced age, cerebrovascular disease, and hypertension were significantly associated with proximal bowel necrosis. Multivariate analysis demonstrated that cerebrovascular disease was an independent predictor of this complication. Of these six patients, two died from associated complications.
  
  
  CONCLUSIONS
  Proximal bowel necrosis after high ligation is potentially fatal, and this report provides a warning in clinical settings where high ligation is indicated. Further studies are warranted to evaluate its distinct relationship with high ligation and to clarify whether low ligation would be a safeguard.
authors.affiliation: Department of Surgery, Jichi Medical University, Saitama Medical Center, Saitama, Japan. tsujinakas@omiya.jichi.ac.jp
authors.forename: S
authors.initials: S
authors.lastname: Tsujinaka
authors.forename: Y J
authors.initials: YJ
authors.lastname: Kawamura
authors.forename: K-Y
authors.initials: KY
authors.lastname: Tan
authors.forename: K
authors.initials: K
authors.lastname: Mizokami
authors.forename: J
authors.initials: J
authors.lastname: Sasaki
authors.forename: T
authors.initials: T
authors.lastname: Maeda
authors.forename: Y
authors.initials: Y
authors.lastname: Kuwahara
authors.forename: F
authors.initials: F
authors.lastname: Konishi
authors.forename: A
authors.initials: A
authors.lastname: Lefor
mesh_terms: D000368:Aged; D003106:Colon / Q000098:blood supply / Q000473:pathology* / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000601:surgery*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D007511:Ischemia / Q000473:pathology* / Q000601:surgery; D008026:Ligation / Q000379:methods; D008297:Male; D017537:Mesenteric Artery, Inferior / Q000601:surgery*; D008875:Middle Aged; D015999:Multivariate Analysis; D009336:Necrosis; D011183:Postoperative Complications / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D012307:Risk Factors