Low versus high inferior mesenteric artery ligation and gastrointestinal quality of life following anterior resection for rectal cancer.

AIM: To assess whether the level of inferior mesenteric artery (IMA) ligation independently affects gastrointestinal-specific quality of life after anterior resection for rectal cancer. METHODS: A prospective cohort study including 125 patients with stage II-III mid- or upper- rectal adenocarcinoma who underwent open anterior resection with total mesorectal excision between 2020 and 2025 was conducted. Patients were classified according to the intraoperative level of IMA ligation as having either low ligation with preservation of the left colic artery (n = 75) or high ligation proximal to the origin of the left colic artery (n = 50). Gastrointestinal Quality of Life Index (GIQLI; range 0-144) was assessed 6-8 weeks after protective stoma closure. RESULTS: GIQLI scores were significantly higher after low IMA ligation compared with high ligation (127.3 ± 5.7 versus 121.6 ± 5.7; p < 0.001). In univariable analysis, high IMA ligation was associated with lower GIQLI scores (B = -5.733; p < 0.001). In multivariable regression analysis excluding the Low Anterior Resection Syndrome (LARS) score, high IMA ligation remained independently associated with lower GIQLI scores (B = -5.016; p < 0.001). In exploratory receiver operating characteristic (ROC) analysis, IMA ligation alone demonstrated moderate discriminatory ability (AUC = 0.689; 95% CI 0.595-0.783), while addition of IMA ligation to established predictors improved model discrimination (AUC=0.790; 95% CI 0.710-0.871). CONCLUSION: Low IMA ligation was associated with better postoperative gastrointestinal quality of life following anterior resection for rectal cancer. When oncologically appropriate, preservation of the left colic artery may optimise patient-reported outcomes.