Effect of IMA Ligation Technique on Bleeding Complications in Rectal Cancer Patients Undergoing Total Mesorectal Excision

Effect of IMA Ligation Technique on Bleeding Complications in Rectal Cancer Patients Undergoing Total Mesorectal Excision | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of IMA Ligation Technique on Bleeding Complications in Rectal Cancer Patients Undergoing Total Mesorectal Excision Ama J. Winland, Reena S. Suresh, Miloslawa Stem, Jay R. Maturi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4605730/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Inferior mesenteric artery ligation techniques for left colon and rectal resections include stapling, using an energy device, or suture ligation based on surgeon preference. To our knowledge, no studies have demonstrated superiority of one technique over the other. Methods This retrospective study utilized an institutional database for adult rectal cancer patients undergoing total mesorectal excision (2006–2021). The association between IMA ligation technique (stapled, energy, or suture ligation) and primary outcomes of intra- and 30-day post-operative bleeding complications necessitating transfusion were assessed. Primary and secondary outcomes were analyzed using ANOVA, Pearson's Chi-squared or Fisher's exact test when appropriate. Results Among the 769 rectal cancer patients included, 69 (8.97%) underwent stapled ligation, 281 (36.54%) underwent energy ligation, and 419 (54.59%) underwent suture ligation. Patients in the suture ligation group more frequently underwent open procedures (17.39% vs 19.22% vs 92.84%; p < 0.001) compared to the stapled and energy groups, respectively. There were no differences in intra- (5.80%, 3.20%, 7.16%; p = 0.082) or post-operative bleeding necessitating transfusion (7.25%, 7.47%, 5.73%; p = 0.634). However, there was significantly more bleeding post-operatively for patients in the energy cohort compared to the suture ligation cohort when receiving an open approach (14.81% vs 5.91%: p = 0.016). There were no differences in 30-day overall morbidity, readmission, reoperation, or length of stay between groups. Conclusions Energy and stapling of the IMA is as safe as traditional IMA suture ligation, with potential benefit of suture ligation over bipolar energy in decreasing post-operative bleeding when undergoing an open approach. mesenteric artery inferior ligation rectal neoplasms colorectal neoplasms total mesorectal excision (TME) Figures Figure 1 INTRODUCTION Perioperative bleeding complications for total mesorectal excision (TME) can lead to catastrophic outcomes, ranging from blood product transfusion, reoperation, additional interventions, to even patient death. The incidence of intra-operative bleeding complications during TME is reported to be between 1.1–2.9% with a 2–5% risk of post-operative bleeding requiring transfusion [ 1 ]. Though bleeding complications are rare, the importance of reliable ligation of the inferior mesenteric artery (IMA) is paramount. The gold standard of ligation of any vessel for many decades has been suture ligation [ 2 , 3 ]. Advancements in minimally invasive surgery (MIS) and new hemostasis technologies have expanded the options for ligating larger vessels (up to 7mm). Given that the IMA diameter most commonly ranges from 2-4mm [ 4 ], the IMA is well-suited for ligation with newer devices. In addition to suture ligation, options now include stapling, clipping, as well as bipolar or ultrasonic energy. Especially for MIS approaches, several of these options are thought to be more appealing in terms of operative time and ease of use. The different hemostatic techniques can be separated into two different mechanisms of action: mechanical compression versus thermal energy. Suture ligation, stapling, and clipping provide mechanical hemostasis via manual compression and occlusion of the vessel. Though mechanical methods are thought to be more secure, there are also disadvantages. MIS suture ligation can be cumbersome and time consuming [ 5 ]. Clips and suture can dislodge. Additionally, clip and stapling devices are often limited by their size and articulating capability [ 3 ]. There is also concern that permanent material such as suture, clips, or staples can be adhesiogenic [ 2 , 6 ]. Meanwhile, bipolar energy devices deliver electrically converted thermal energy in addition to manual compression. This results in a chemical change in the tissues that also helps provide hemostasis [ 7 ]. Thermal spread is a concern, but there have been studies showing that thermal spread from these devices is minimal [ 6 , 8 ]. Oncologic outcomes are also important to consider. We know anastomotic leak after TME has a negative impact on overall and disease-free survival in rectal cancer patients [ 9 ], but data also suggest an association between perioperative blood transfusions and increased colorectal cancer recurrence [ 10 ]. The working hypothesis is that perioperative transfusions decrease the mechanisms associated with cancer immune surveillance. This further highlights the importance of vascular control in oncologic colectomies, as there is not only innate morbidity associated with bleeding complications but also potential oncologic consequences. An updated comprehensive understanding of options for vessel ligation and their efficacy is needed to further inform surgeons’ choice of hemostatic device. As techniques other than suture ligation gain more traction, choice of ligation technique should be informed by evidence in addition to surgeon preference or experience. This study aims to identify a superior IMA ligation technique among suture ligation, bipolar energy, and stapling. We evaluated peri-operative bleeding and associated complications across open, laparoscopic, and robotic approaches. METHODS Study Design and Setting This was a retrospective study involving a high-volume, tertiary healthcare system, using an institutional database for adult rectal cancer patients undergoing TME from January 2006- December 2021. All patients were followed for 30 days post-operatively. This study was approved by the Institutional Review Board of the Johns Hopkins University School of Medicine. Participants Initially, 945 patients were identified from the database. The following patients were excluded: patients who had undergone previous TME (n = 34), patients whose operative approach was unknown (n = 2), instances where the IMA was clipped (n = 8), the IMA was not ligated (n = 30) or the ligation technique was unknown (n = 81). No patients underwent IMA ligation via ultrasonic coagulating shears. Patients whose IMA was clipped were excluded as there were too few patients (n = 8) for meaningful statistical analysis. Patients with post-operative venous thromboembolism (VTE) were excluded as they required therapeutic anticoagulation shortly after surgery. Patients remaining were undergoing first-time TME with a known operative approach, no known post-operative VTE, and IMA ligation technique of either stapling, bipolar energy, or suture ligation. The final number of eligible patients was 769 (Fig. 1 ). Prior to analysis, patients were stratified by IMA technique: suture ligation, bipolar energy, and stapled. Demographic, Clinical and Operative Characteristics The demographic characteristics of age, sex, and race were analyzed for all patients. Clinical characteristics including American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking history, as well as history of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, history of myocardial infarction, congestive heart failure, preoperative steroid use, and neoadjuvant therapy were collected. The extracted operative data included operative approach, operation performed, and IMA division location. Neoadjuvant therapy included pre-operative chemotherapy, radiation, or chemoradiation. MIS patients included those who underwent a robotic, laparoscopic, or hand-assisted approach. Operations defined as other included pelvic exenteration, total proctocolectomy or were undefined. IMA ligation technique was determined from operative reports. If the technique for IMA ligation was not clearly stated, the technique was defined as unknown, and those patients were therefore excluded. Primary and Secondary Outcomes The association between IMA ligation technique (stapled, energy, or suture ligation) and the primary outcomes of intra- and post-operative bleeding requiring packed red blood cell (pRBC) transfusion was assessed. Secondary outcomes included 30-day overall morbidity, readmission, reoperation, operative time, and length of stay (LOS). Overall morbidity included the following complications: wound infection, pneumonia, urinary tract infection, VTE, cardiac complication, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, remained on the ventilator for > 48 hours, organ space surgical site infection (SSI), or anastomotic leak. Cardiac complication was defined as an arrythmia requiring intervention, myocardial infarction, or cardiac arrest. LOS was defined as days in the hospital from the time of the patient’s operation until discharge. Anastomotic leak was defined as CT or endoscopic evidence of anastomotic staple line dehiscence. Statistical Analysis Continuous variables were analyzed using ANOVA and Mann-Whitney U test. Categorical variables were analyzed using Pearson's Chi-squared or Fisher's exact tests, when appropriate. Pairwise comparison was performed between the energy and suture ligation groups for all primary and secondary outcomes. Statistical significance was defined as P < 0.05. All statistical analyses were performed using Stata, version 18.0 (StataCorp, College Station, Texas, USA). RESULTS Study Population The 769 included patients were predominantly white (81.66% vs 10.53% black vs 7.8% other), with a median age of 56 (Interquartile Range [IQR 47–67]), and with American Society of Anesthesiologists (ASA) classification I-II being the most common (54.10%) (Table 1 ). Of the tracked comorbidities, smoking history (40.96%), hypertension (37.19%) and diabetes (10.53%) were most common. Patients underwent neoadjuvant therapy prior to TME 80.23% of the time. Patients more frequently underwent an open approach (59.17%) versus MIS (40.83%) with low anterior resection (LAR) being more common (71.13%) than abdominoperineal resection (APR) (22.11%) or other (6.76%). Table 1 Demographic, Clinical, and Operative Characteristics Characteristic, n (%) Total n = 769 Stapled n = 69 (8.97) Energy n = 281 (36.54) Suture Ligation n = 419 (54.49) p Age group, years <45 45–54 55–64 ≥ 65 140 (18.21) 207 (26.92) 186 (24.19) 236 (30.69) 10 (14.49) 10 (14.49) 21 (30.43) 28 (40.58) 47 (16.73) 83 (29.54) 69 (24.56) 82 (29.18) 83 (19.81) 114 (27.21) 96 (22.91) 126 (30.07) 0.124 Age, median (IQR) 56 (47,67) 60 (53,70) 56 (48,67) 56 (47,66) 0.022 Sex Male Female 445 (57.87) 324 (42.13) 39 (56.52) 30 (43.48) 161 (57.30) 120 (42.70) 245 (58.47) 174 (41.53) 0.927 Race White Black Other 628 (81.66) 81 (10.53) 60 (7.80) 58 (84.06) 8 (11.59) 3 (4.35) 223 (79.36) 32 (11.39) 26 (9.25) 347 (82.82) 41 (9.79) 31 (7.40) 0.611 ASA classification I-II III-IV Unknown 416 (54.10) 345 (44.86) 8 (1.04) 36 (52.17) 31 (44.93) 2 (2.9) 146 (51.96) 134 (47.69) 1 (0.36) 234 (55.85) 180 (42.96) 5 (1.19) 0.286 BMI ≥ 30 160 (20.81) 13 (18.84) 51 (18.15) 96 (22.91) < 0.001 Smoking History No Yes Unknown 416 (54.10) 315 (40.96) 38 (4.94) 45 (65.22) 21 (30.43) 3 (4.35) 160 (56.94) 113 (40.21) 8 (2.85) 211 (50.36) 181 (43.20) 27 (6.44) 0.041 DM 81 (10.53) 6 (8.70) 29 (10.32) 46 (10.98) 0.840 HTN 286 (37.19) 34 (49.28) 102 (36.30) 150 (35.80) 0.093 COPD 23 (2.99) 2 (2.90) 11 (3.91) 10 (2.39) 0.508 History of MI 43 (5.59) 3 (4.35) 18 (6.41) 22 (5.25) 0.724 CHF 14 (1.82) 2 (2.90) 5 (1.78) 7 (1.67) 0.940 Preop Steroid Use 28 (3.64) 1 (1.45) 12 (4.27) 15 (3.58) 0.531 Neoadjuvant Therapy 617 (80.23) 47 (68.12) 224 (79.72) 346 (82.58) 0.019 Operative Approach Open MIS 455 (59.17) 314 (40.83) 12 (17.39) 57 (82.61) 54 (19.22) 227 (80.78) 389 (92.84) 30 (7.16) < 0.001 Operation LAR APR Other 547 (71.13) 170 (22.11) 52 (6.76) 44 (63.77) 17 (24.64) 8 (11.59) 206 (73.31) 52 (18.51) 23 (8.19) 297 (70.88) 101 (24.11) 21 (5.01) 0.077 Abbreviations : IQR; Interquartile Range; ASA, American Society of Anesthesiologists; BMI, Body Mass Index; DM, Diabetes Mellitus; HTN, Hypertension; COPD, Chronic Obstructive Pulmonary Disease; MI, Myocardial Infarction; CHF, Congestive Heart Failure; LAR, Low Anterior Resection; APR, Abdominoperineal Resection Patients were stratified by IMA ligation technique: 69 (8.97%) underwent stapled ligation, 281 (36.54%) underwent energy ligation, and 419 (54.59%) underwent suture ligation of the IMA. The stapled group was older and underwent neoadjuvant therapy less frequently. Patients in the suture ligation group tended to be obese, smoke, and undergo an open operative approach. There were no differences between the proportion of LARs, APRs and other procedures performed between groups. Primary and Secondary Outcomes There were no differences in intra-operative bleeding (stapled: 5.80%, energy: 3.20%, suture: 7.16%; p = 0.082) or post-operative bleeding requiring transfusion (stapled: 7.25%, energy: 7.47%, suture: 5.73%; p = 0.634) among the three IMA ligation techniques (Table 2 ). In terms of secondary outcomes, the stapled group had longer operative times (median of 400 minutes; Interquartile Range [IQR] 306,469), followed by the energy group (330 minutes; IQR 244,453) and suture ligation group (272 minutes; IQR 213,370; p < 0.001). There were no differences in the rates of overall morbidity, readmission, reoperation, or LOS between the three groups. Table 2 30-Day Post-Operative Outcomes Outcome (%) Total n = 769 Stapled n = 69 (8.97) Energy n = 281 (36.54) Suture Ligation n = 419 (54.49) p Intraoperative bleeding 43 (5.59) 4 (5.80) 9 (3.20) 30 (7.16) 0.082 Bleeding requiring transfusion 50 (6.50) 5 (7.25) 21 (7.47) 24 (5.73) 0.634 Overall morbidity a 169 (21.98) 16 (23.19) 54 (19.22) 99 (23.63) 0.373 Anastomotic leak 13 (1.69) 4 (5.80) 3 (1.07) 6 (1.43) 0.040 Wound complication 45 (5.85) 2 (2.90) 10 (3.56) 33 (7.88) 0.032 Pneumonia 16 (2.08) 2 (2.90) 3 (1.07) 11 (2.63) 0.227 UTI 30 (3.90) 2 (2.90) 9 (3.20) 19 (4.53) 0.607 Shock/sepsis 14 (1.82) 0 (0) 5 (1.78) 9 (2.15) 0.465 Organ space SSI 31 (4.03) 2 (2.90) 11 (3.91) 18 (4.30) 0.854 Unplanned intubation 17 (2.21) 1 (1.45) 7 (2.49) 9 (2.15) 0.863 Bleeding requiring transfusion 50 (6.50) 5 (7.25) 21 (7.47) 24 (5.73) 0.634 Renal complications 38 (4.94) 3 (4.35) 19 (6.76) 16 (3.82) 0.206 On ventilator > 48hrs 9 (1.17) 0 (0) 3 (1.07) 6 (1.43) 0.892 Readmission 140 (18.21) 15 (21.74) 53 (18.86) 72 (17.18) 0.621 Reoperation 38 (4.94) 5 (7.25) 17 (6.05) 16 (3.82) 0.267 Operative time, median (IQR) 302 (229,416) 400 (306,469) 330 (244,453) 272 (213,370) < 0.001 LOS, median (IQR) 6 (5,10) 6 (4,9) 6 (4,10) 7 (5,10) 0.810 a Overall morbidity: Wound complication (deep incisional SSI + wound disruption), pneumonia, urinary tract infection, VTE, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, on ventilator > 48 hours, organ space SSI, and anastomotic leak. Abbreviations: SSI, Surgical Site Infection; UTI, Urinary Tract Infection; VTE, Venous Thromboembolism; IQR, Interquartile Range; LOS, length of stay. Primary and Secondary Outcomes Stratified by Operative Approach Open Approach There were no differences in intra-operative bleeding necessitating transfusion between the three IMA ligation techniques (25.0% stapled, 7.4% energy, 7.2% suture ligation; p = 0.104) (Table 3 ). Similarly, there were no differences in post-operative bleeding necessitating transfusion (8.3%, 14.8%, 5.9%; p = 0.058). When looking at secondary outcomes, the stapled cohort had longer operative times (357.5 minutes [IQR 320.5, 516]) followed by 281 minutes (IQR 180, 403) for energy and 271 minutes (IQR 213,365) for suture ligation (p = 0.026). Table 3 30-Day Post-Operative Outcomes Stratified by Operative Approach Open (n = 455) MIS (n = 314) Stapled (n = 12) Energy (n = 54) Suture (n = 389) p Stapled (n = 57) Energy (n = 227) Suture (n = 30) p Intraoperative bleeding 3 (25.0) 4 (7.4) 28 (7.2) 0.104 1 (1.8) 5 (2.2) 2 (6.7) 0.253 Bleeding requiring transfusion 1 (8.33) 8 (14.8) 23 (5.9) 0.058* 4 (7.0) 13 (5.7) 1 (3.3) 0.850 Overall morbidity a 3 (25.0) 18 (33.3) 90 (23.1) 0.262 13 (22.8) 36 (15.9) 9 (30.0) 0.111 Anastomotic leak 2 (16.7) 1 (1.9) 6 (1.5) 0.016 2 (3.51) 2 (0.88) 0 (0) 0.197 Wound complication 0 (0) 4 (7.4) 31 (8.0) 0.916 2 (3.5) 6 (2.6) 2 (6.7) 0.346 Pneumonia 0 (0) 2 (3.7) 11 (2.8) 0.764 2 (3.5) 1 (0.4) 0 (0) 0.111 UTI 0 (0) 4 (7.4) 18 (4.6) 0.540 2 (3.5) 5 (2.2) 1 (3.3) 0.576 Shock/sepsis 0 (0) 4 (7.4) 8 (2.1) 0.103* 0 (0) 1 (0.4) 1 (3.3) 0.215 Organ space SSI 0 (0) 4 (7.4) 17 (4.4) 0.516 2 (3.5) 7 (3.1) 1 (3.3) 0.999 Unplanned intubation 1 (8.33) 4 (7.4) 9 (2.3) 0.062 0 (0) 3 (1.3) 0 (0) 0.999 Renal complications 1 (8.3) 5 (9.3) 13 (3.3) 0.058 2 (3.5) 14 (6.7) 3 (10) 0.491 On ventilator > 48hrs 0 (0) 2 (3.7) 6 (1.5) 0.398 0 (0) 1 (0.4) 0 (0) 0.999 Readmission 2 (16.7) 14 (26.0) 63 (16.2) 0.200 13 (22.8) 39 (17.2) 9 (30.0) 0.193 Reoperation 1 (8.3) 2 (3.7) 15 (3.9) 0.545 4 (7.0) 15 (6.6) 1 (3.3) 0.865 Operative time, median (IQR) 357.5 (320.5,516) 281 (180,403) 271 (213,365) 0.026 412 (306,465) 334 (249,474) 293 (224,378) 0.005* LOS, median (IQR) 6.5 (5.5,10.5) 9 (5,12) 7 (5,10) 0.103* 6 (4,9) 5 (4,9) 8 (6,13) 0.012* a Overall morbidity: Wound complication (deep incisional SSI + wound disruption), pneumonia, urinary tract infection, VTE, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, on ventilator > 48 hours, organ space SSI, and anastomotic leak. *Statistically significant p-value < 0.05 for pairwise comparison between energy and suture ligation groups (for Open: p = 0.016 for bleeding requiring transfusion, p = 0.046 for shock/sepsis, p = 0.032 for LOS; for MIS: p = 0.004 for LOS, p = 0.037 for operative time) MIS Approach There were no differences in intra-operative bleeding necessitating transfusion between the three IMA ligation techniques (1.8% stapled, 2.2% energy, 6.7% suture ligation; p = 0.253) (Table 3 ). Likewise, there were no differences in post-operative bleeding necessitating transfusion (7.0%, 5.7%, 3.3%; p = 0.850). When looking at secondary outcomes, the stapled group had longer operative times (412 minutes [IQR 306,465]) compared to energy (334 minutes [IQR 249,474]) and suture ligation (293 minutes [IQR 224,378]: p = 0.005), but the suture ligation cohort had longer lengths of stay (8 days [IQR 6,13]) versus stapled (6 days [ 4 , 9 ]) and energy (5 days [IQR 4, 9]: p = 0.012). Pairwise Comparison of Energy Versus Suture Ligation Stratified by Operative Approach Open There was significantly more bleeding requiring transfusion post-operatively in the energy cohort compared to the suture ligation cohort (14.81% vs 5.91%: p = 0.016). When looking at secondary outcomes, the bipolar energy cohort had longer LOS (9 days [IQR 5, 12] vs 7 days [IQR 5, 10]: p = 0.032). MIS The energy group had longer operative times but shorter LOS (5 days [IQR 4, 9] versus 8 days [IQR 6, 13]: p = 0.004). DISCUSSION This was a multi-center single institution study including patients undergoing first-time TME for rectal cancer. We initially found no differences in intra-or post-operative bleeding between suture ligation, bipolar energy, and stapling. The groups were then stratified by operative approach in addition to IMA ligation technique to control for operative approach as a potential confounder. While no differences in intra or post-operative bleeding between the three IMA ligation techniques were found for either an open or MIS approach, pairwise comparison of bipolar energy and suture ligation patients receiving an open approach found that there was significantly more post-operative bleeding in the energy group. The stapled group had longer operative times, followed by the energy group and suture ligation group, which persisted with operative approach stratification. LOS varied depending on how the groups were stratified with a longer LOS in the suture ligation group, except for in the open cohort where the energy group had a significantly longer length of stay in pairwise comparison to suture ligation. There were no differences in the rates of overall morbidity, readmission, or reoperation between the three groups, which persisted in pairwise comparison and operative approach stratification. These findings suggest energy and stapling of the IMA is as safe as IMA suture ligation, with a potential benefit of suture ligation over energy in direct pairwise comparison when utilizing an open approach in decreasing intra-operative bleeding. When looking at previous work, there have been multiple prior ex vivo studies looking at the efficacy of the different hemostatic techniques with contradictory results, particularly when looking at the energy devices [ 2 – 3 , 6 , 8 ]. However, there have been no previous studies that suggest a potential benefit of suture ligation over bipolar energy when undergoing an open operative approach, such as in our pairwise comparison of rates of post-operative bleeding. A limitation of these studies is the static pressure used in these ex vivo animal models may create a different environment than the physiologic pulsatile pressure that is seen in human blood vessels [ 2 – 3 , 6 , 8 ]. There was an additional study that looked at the angle at which vessels are sealed in an ex vivo porcine model and found that burst pressures were 51% greater for those with a perpendicular seal on the artery [ 11 ]. The angle of vessel seal was not captured by our dataset but highlights the importance of good operative technique and could potentially be one of many variables that account for the wide variability across studies. Additionally, there have been multiple studies looking at mesenteric vessel ligation technique in colectomies specifically. While several studies have looked at safety of a single energy device [ 12 – 14 ] or pooled comparisons of like techniques [ 15 – 17 ], there are currently no studies, to our knowledge, comparing multiple techniques across multiple approaches. Nor are there studies looking at the efficacy of newer energy devices while utilizing an open approach. Our study looks at suture ligation, bipolar energy, and stapling independently as IMA ligation techniques, while also including both open and MIS approaches. Looking at efficacy of bipolar energy devices alone in an MIS approach, Pai et al demonstrated an intraoperative bleeding rate of 1.5% and postoperative pRBC transfusion rate of 0.25% when using the Enseal device [ 12 ]. Safety of the Ligasure device for mesenteric artery ligation in colectomy was demonstrated by Grieco et al who had no instances of intra- or postoperative bleeding in a 759 patient case series [ 13 ] and Martin et al. who demonstrated 99.8% immediate effective vessel sealing in a retrospective review of over 800 cancer patients undergoing colectomy [ 14 ]. These data are all in the context of our study that showed a comparatively increased rate of intra-operative bleeding rate at 3.20% and post-operative bleeding rate at 7.16% for our bipolar energy cohort. A randomized controlled trial (RCT) of IMA ligation techniques in laparoscopic colorectal resection for benign and malignant disease compared bipolar to a mechanical ligation (either vascular stapler or double clipping) group with the primary outcomes of operation duration, time to control individual vascular pedicles and cost [ 16 ]. When looking at our primary outcomes, though they were not directly comparable, their findings were similar with no significant difference in estimated blood loss (EBL), number of transfusions, or hematocrit (HCT) loss. Time taken for vascular control and time to control the IMA pedicle was significantly faster with bipolar energy for left colectomy, however, on multivariate analysis of operative time, type of vascular control did not contribute significantly to operative time. This is contradictory to our findings of a longer operative time with bipolar energy compared to suture ligation even for MIS approaches, challenging prior assumptions of MIS suture ligation being too cumbersome and time consuming. Similar to our findings, an additional prospective study of 200 patients looking at pooled mechanical (double clipping or suture ligation) versus vessel sealing devices (ultrasonic or bipolar energy) for elective sigmoidectomy in diverticulitis patients found no difference in mean hemoglobin levels, units of pRBCs transfused or hemorrhagic events between groups [ 15 ]. However, in contrast to our study, operative times and length of stay for the vessel sealing group were significantly shorter. One Cochrane review exists looking at energy source instruments for laparoscopic colectomy [ 17 ]. Their outcome measurements differed from ours, but they showed better overall hemostatic control in the bipolar energy group versus the mechanical ligation group but no significant difference in intraoperative EBL. Contrary to our findings, the study demonstrated shorter operative times for the bipolar energy group versus the mechanical ligation group. An important limitation is while some of the papers included look at vessel ligation technique specifically in reference to hemostasis, others looked at overall hemostatic control with variation in the techniques allowed within each case. Other limitations include, as detailed by the authors, the heterogeneity of the trials included, primary outcomes investigated, and involved pathology and procedure types. Furthermore, the authors concluded that it was not possible to demonstrate the best instrument for a laparoscopic colectomy based on their findings. This study attempted to overcome limitations from previous works to include broadening our patient population to include patients who received an open approach. Additionally, we looked at IMA ligation techniques individually, whereas most other studies looked at pooled groups of mechanical and energy techniques [ 15 – 17 ]. There are still multiple limitations to our study, however. This was a retrospective analysis of a heterogenous cohort where we looked at global perioperative bleeding complications. As with many retrospective studies, granular detail was not available. For example, operative time dedicated to control of the vascular pedicle, bleeding complications specifically associated with the IMA (our complications are global perioperative bleeding complications), as well as specific settings of the bipolar energy devices or types/loads of staplers were not available. Additionally, there was no standard method for ligating the pedicles between surgeons; they ligated per their preference. We have no data on each surgeon’s preference or whether a particular surgery dictated a deviation from their typical approach. For example, Martin et al. suggest caution when using the Ligasure in patients with significant atherosclerotic disease and calcification of vessels [ 14 ]. This could explain the longer operative times that we saw in the stapled cohort, with surgeons potentially electing to staple the IMA in cases where control of bleeding was difficult or anticipated to be so. While we were able to look at each group individually (stapled versus bipolar energy versus suture ligation), our patient population either did not include or included insufficient numbers of those who underwent IMA ligation via clipping or ultrasonic energy devices. While some ultrasonic devices are now approved for vascular pedicle ligation up to 7mm, at the beginning of our retrospective study, ultrasonic shears were not designed or approved by the FDA for successful ligation of larger vascular pedicles such as the IMA [ 18 ]. Additionally, we did not differentiate between open, laparoscopic, and robotic bipolar vessel sealing devices (Ligasure vs Vessel Sealer), which also contributes to the heterogeneity of our cohort. CONCLUSION There are a variety of options for IMA ligation for rectal cancer patients undergoing TME. Additional prospective, case-matched studies are needed to address the limitations of heterogeneity and more detailed intraoperative data; however, these findings show safety of the above IMA ligation methods in both open and MIS approaches, with evidence of less post-operative bleeding in patients who received an open approach and suture ligation of the IMA compared to ligation via bipolar energy. Declarations Funding/Support Information: Mr. Edwin Lewis and The Nicholl Family Foundation provided generous support of the Johns Hopkins Division of Colorectal Surgery Research Fund. Financial Disclosures: AJW, RSS, MS, JRM, SLG, AGK, JEE have no financial disclosures. VJO is currentlty or was previously a consultant for Medtronic, Inc., Asensus Surgical, Inc., Intuitive Surgical, Inc., and Potrero Medical, Inc. Presentations : Accepted for an e-poster presentation at the 2024 Annual ASCRS Scientific Meeting, Baltimore, MD. References Thinggaard B, Perdawood SK (2017) Complications of minimal invasive surgery for rectal cancer - a systematic review. https://doi.org/10.5281/zenodo.1041310 Lim C-S, Jang J-Y, Lee SE, et al (2013) Comparison of various methods of vessel ligation: what is the safest method? Surg Endosc 27:3129–3138. https://doi.org/10.1007/s00464-013-2866-y Tharakan SJ, Hiller D, Shapiro RM, et al (2016) Vessel sealing comparison: old school is still hip. Surg Endosc 30:4653–4658. https://doi.org/10.1007/s00464-016-4778-0 Kondov S, Dimov A, Beyersdorf F, et al (2022) Inferior mesenteric artery diameter and number of patent lumbar arteries as factors associated with significant type 2 endoleak after infrarenal endovascular aneurysm repair. Interact Cardiovasc Thorac Surg 35:016. https://doi.org/10.1093/icvts/ivac016 A M, F D, J S, et al (2008) Operative time and other outcomes of the electrothermal bipolar vessel sealing system (LigaSure) versus other methods for surgical hemostasis: a meta-analysis. Surgical innovation 15:284–291. https://doi.org/10.1177/1553350608324933 Harold KL, Pollinger H, Matthews BD, et al (2003) Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc 17:1228–1230. https://doi.org/10.1007/s00464-002-8833-7 Campbell PA, Cresswell AB, Frank TG, Cuschieri A (2003) Real-time thermography during energized vessel sealing and dissection. Surg Endosc 17:1640–1645. https://doi.org/10.1007/s00464-002-8781-2 Carbonell AM, Joels CS, Kercher KW, et al (2003) A Comparison of Laparoscopic Bipolar Vessel Sealing Devices in the Hemostasis of Small-, Medium-, and Large-Sized Arteries. Journal of Laparoendoscopic & Advanced Surgical Techniques 13:377–380. https://doi.org/10.1089/109264203322656441 Engel RM, Oliva K, Centauri S, et al (2023) Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study. Dis Colon Rectum 66:923–933. https://doi.org/10.1097/DCR.0000000000002454 Amato A, Pescatori M (2006) Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 2006:CD005033. https://doi.org/10.1002/14651858.CD005033.pub2 Voegele AC, Korvick DL, Gutierrez M, et al (2013) Perpendicular Blood Vessel Seals Are Stronger Than Those Made at an Angle. Journal of Laparoendoscopic & Advanced Surgical Techniques 23:669–672. https://doi.org/10.1089/lap.2013.0028 Pai A, Sugrue J, Bibi S, et al (2016) Safety and efficacy of an electrothermal bipolar vessel sealing device in sealing and division of the inferior mesenteric vessels in minimally invasive colorectal surgery. Tech Coloproctol 20:505–506. https://doi.org/10.1007/s10151-016-1488-5 Grieco M, Apa D, Spoletini D, et al (2018) Major vessel sealing in laparoscopic surgery for colorectal cancer: a single-center experience with 759 patients. World J Surg Onc 16:101. https://doi.org/10.1186/s12957-018-1402-x Martin ST, Heeney A, Pierce C, et al (2011) Use of an electrothermal bipolar sealing device in ligation of major mesenteric vessels during laparoscopic colorectal resection. Tech Coloproctol 15:285–289. https://doi.org/10.1007/s10151-011-0707-3 Trilling B, Riboud R, Abba J, et al (2016) Energy vessel sealing systems versus mechanical ligature of the inferior mesenteric artery in laparoscopic sigmoidectomy. Int J Colorectal Dis 31:903–908. https://doi.org/10.1007/s00384-016-2508-7 Adamina M, Champagne BJ, Hoffman L, et al (2011) Randomized clinical trial comparing the cost and effectiveness of bipolar vessel sealers versus clips and vascular staplers for laparoscopic colorectal resection. Br J Surg 98:1703–1712. https://doi.org/10.1002/bjs.7679 Tou S, Malik AI, Wexner SD, Nelson RL (2011) Energy source instruments for laparoscopic colectomy. Cochrane Database Syst Rev CD007886. https://doi.org/10.1002/14651858.CD007886.pub2 Marcello PW, Roberts PL, Rusin LC, et al (2006) Vascular pedicle ligation techniques during laparoscopic colectomy: A prospective randomized trial. Surg Endosc 20:263–269. https://doi.org/10.1007/s00464-005-0258-7 Additional Declarations Competing interest reported. Funding: No funding was received to assist with the preparation of this manuscript. Generally, Mr. Edwin Lewis and The Nicholl Family Foundation provided generous support of the Johns Hopkins Division of Colorectal Surgery Research Fund though not to any particular study. Conflicts of interest/Competing interests: Financial interests: Author V.O. is or previously was in the last 3 years a consultant for Medtronic, Inc., Asensus Surgical, Inc., Intuitive Surgical, Inc., Potrero Medical, Inc. Author V.O. received payment/honoraria for lectures/presentations from Medtronic, Inc., and Intuitive Surgical, Inc. Author V.O. received support for attending meetings and/or travel from Intuitive Surgical, Inc. and Medtronic, Inc. Non-financial interests: none. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4605730","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316778526,"identity":"1ad89535-80c3-4c88-999e-fa8d4d94ab08","order_by":0,"name":"Ama J. Winland","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYLACCQYGHgZ2IIOnAkgwMzcQqYUZpOUMSAsjEVrAAKSFtw3EIqCFf9rhBwwWDIdlzJmZnz14O682mr8dqOVHxTbcbrqdZgB02GEey2Y2c8O5247nzjjM2MDYc+Y2bmtuJ4C03OYxOMxgJs277VhuA1ALM2Mbbi3yt9M/QLWwf5PmnXMsdz4hLQa3c2C28ABtaajJ3UBIi+HtnIIDEgb/QVrKJOccO5C7EajlID6/yN1O3/hYoiLN3uB4+zaJNzV1ufPOHz744EcFHu8DwWEJAwQbTB7Aqx4IGD8g2HWEFI+CUTAKRsEIBACMilT2uFVkTwAAAABJRU5ErkJggg==","orcid":"","institution":"Walter Reed National Military Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Ama","middleName":"J.","lastName":"Winland","suffix":""},{"id":316778527,"identity":"73eac6a6-525d-4ff7-b4f1-9c300d9977eb","order_by":1,"name":"Reena S. Suresh","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Reena","middleName":"S.","lastName":"Suresh","suffix":""},{"id":316778528,"identity":"0ed5cb65-56d8-489e-b830-5706c41cab1b","order_by":2,"name":"Miloslawa Stem","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Miloslawa","middleName":"","lastName":"Stem","suffix":""},{"id":316778529,"identity":"737964bd-107c-4016-b877-45361bfef607","order_by":3,"name":"Jay R. Maturi","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jay","middleName":"R.","lastName":"Maturi","suffix":""},{"id":316778533,"identity":"546c5246-4551-490c-bb84-36e0b0e131e4","order_by":4,"name":"Susan L. Gearhart","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"L.","lastName":"Gearhart","suffix":""},{"id":316778535,"identity":"3c3e5c26-06a3-4762-95da-3e869abb82d2","order_by":5,"name":"Alodia Gabre-Kidan","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Alodia","middleName":"","lastName":"Gabre-Kidan","suffix":""},{"id":316778536,"identity":"8f6433cb-cfba-4025-8aef-4a4fdc6d295f","order_by":6,"name":"Jonathan E. Efron","email":"","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"E.","lastName":"Efron","suffix":""},{"id":316778539,"identity":"e0c46152-c5cf-443e-9f52-b5af9f3480b4","order_by":7,"name":"Vincent J. Obias","email":"","orcid":"","institution":"Johns Hopkins Medicine National Capital Region","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"J.","lastName":"Obias","suffix":""}],"badges":[],"createdAt":"2024-06-19 11:53:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4605730/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4605730/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60605104,"identity":"469d9a53-42ff-4c15-a57b-0b84b1fd5e34","added_by":"auto","created_at":"2024-07-18 16:40:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":544344,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Selection Criteria: A total of 769 patients were found to be eligible based on our inclusion criteria for the study\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4605730/v1/963b8a3677a634c1f85a44c3.png"},{"id":64976554,"identity":"3ff3f842-6111-482a-a85a-61885f1ca948","added_by":"auto","created_at":"2024-09-21 08:11:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1370962,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4605730/v1/11d2f0aa-a8bf-48c3-abec-eb9d0dee2af0.pdf"}],"financialInterests":"Competing interest reported. Funding:\nNo funding was received to assist with the preparation of this manuscript. Generally, Mr. Edwin Lewis and The Nicholl Family Foundation provided generous support of the Johns Hopkins Division of Colorectal Surgery Research Fund though not to any particular study.\n\nConflicts of interest/Competing interests:\nFinancial interests: Author V.O. is or previously was in the last 3 years a consultant for Medtronic, Inc., Asensus Surgical, Inc., Intuitive Surgical, Inc., Potrero Medical, Inc. Author V.O. received payment/honoraria for lectures/presentations from Medtronic, Inc., and Intuitive Surgical, Inc. Author V.O. received support for attending meetings and/or travel from Intuitive Surgical, Inc. and Medtronic, Inc. \n\nNon-financial interests: none.","formattedTitle":"Effect of IMA Ligation Technique on Bleeding Complications in Rectal Cancer Patients Undergoing Total Mesorectal Excision","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePerioperative bleeding complications for total mesorectal excision (TME) can lead to catastrophic outcomes, ranging from blood product transfusion, reoperation, additional interventions, to even patient death. The incidence of intra-operative bleeding complications during TME is reported to be between 1.1\u0026ndash;2.9% with a 2\u0026ndash;5% risk of post-operative bleeding requiring transfusion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Though bleeding complications are rare, the importance of reliable ligation of the inferior mesenteric artery (IMA) is paramount. The gold standard of ligation of any vessel for many decades has been suture ligation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Advancements in minimally invasive surgery (MIS) and new hemostasis technologies have expanded the options for ligating larger vessels (up to 7mm). Given that the IMA diameter most commonly ranges from 2-4mm [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], the IMA is well-suited for ligation with newer devices. In addition to suture ligation, options now include stapling, clipping, as well as bipolar or ultrasonic energy. Especially for MIS approaches, several of these options are thought to be more appealing in terms of operative time and ease of use.\u003c/p\u003e \u003cp\u003eThe different hemostatic techniques can be separated into two different mechanisms of action: mechanical compression versus thermal energy. Suture ligation, stapling, and clipping provide mechanical hemostasis via manual compression and occlusion of the vessel. Though mechanical methods are thought to be more secure, there are also disadvantages. MIS suture ligation can be cumbersome and time consuming [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Clips and suture can dislodge. Additionally, clip and stapling devices are often limited by their size and articulating capability [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There is also concern that permanent material such as suture, clips, or staples can be adhesiogenic [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Meanwhile, bipolar energy devices deliver electrically converted thermal energy in addition to manual compression. This results in a chemical change in the tissues that also helps provide hemostasis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Thermal spread is a concern, but there have been studies showing that thermal spread from these devices is minimal [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOncologic outcomes are also important to consider. We know anastomotic leak after TME has a negative impact on overall and disease-free survival in rectal cancer patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], but data also suggest an association between perioperative blood transfusions and increased colorectal cancer recurrence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The working hypothesis is that perioperative transfusions decrease the mechanisms associated with cancer immune surveillance. This further highlights the importance of vascular control in oncologic colectomies, as there is not only innate morbidity associated with bleeding complications but also potential oncologic consequences.\u003c/p\u003e \u003cp\u003eAn updated comprehensive understanding of options for vessel ligation and their efficacy is needed to further inform surgeons\u0026rsquo; choice of hemostatic device. As techniques other than suture ligation gain more traction, choice of ligation technique should be informed by evidence in addition to surgeon preference or experience. This study aims to identify a superior IMA ligation technique among suture ligation, bipolar energy, and stapling. We evaluated peri-operative bleeding and associated complications across open, laparoscopic, and robotic approaches.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis was a retrospective study involving a high-volume, tertiary healthcare system, using an institutional database for adult rectal cancer patients undergoing TME from January 2006- December 2021. All patients were followed for 30 days post-operatively. This study was approved by the Institutional Review Board of the Johns Hopkins University School of Medicine.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eInitially, 945 patients were identified from the database. The following patients were excluded: patients who had undergone previous TME (n\u0026thinsp;=\u0026thinsp;34), patients whose operative approach was unknown (n\u0026thinsp;=\u0026thinsp;2), instances where the IMA was clipped (n\u0026thinsp;=\u0026thinsp;8), the IMA was not ligated (n\u0026thinsp;=\u0026thinsp;30) or the ligation technique was unknown (n\u0026thinsp;=\u0026thinsp;81). No patients underwent IMA ligation via ultrasonic coagulating shears. Patients whose IMA was clipped were excluded as there were too few patients (n\u0026thinsp;=\u0026thinsp;8) for meaningful statistical analysis. Patients with post-operative venous thromboembolism (VTE) were excluded as they required therapeutic anticoagulation shortly after surgery. Patients remaining were undergoing first-time TME with a known operative approach, no known post-operative VTE, and IMA ligation technique of either stapling, bipolar energy, or suture ligation. The final number of eligible patients was 769 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Prior to analysis, patients were stratified by IMA technique: suture ligation, bipolar energy, and stapled.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographic, Clinical and Operative Characteristics\u003c/h2\u003e \u003cp\u003eThe demographic characteristics of age, sex, and race were analyzed for all patients. Clinical characteristics including American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking history, as well as history of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, history of myocardial infarction, congestive heart failure, preoperative steroid use, and neoadjuvant therapy were collected. The extracted operative data included operative approach, operation performed, and IMA division location. Neoadjuvant therapy included pre-operative chemotherapy, radiation, or chemoradiation. MIS patients included those who underwent a robotic, laparoscopic, or hand-assisted approach. Operations defined as other included pelvic exenteration, total proctocolectomy or were undefined. IMA ligation technique was determined from operative reports. If the technique for IMA ligation was not clearly stated, the technique was defined as unknown, and those patients were therefore excluded.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003ePrimary and Secondary Outcomes\u003c/h2\u003e \u003cp\u003eThe association between IMA ligation technique (stapled, energy, or suture ligation) and the primary outcomes of intra- and post-operative bleeding requiring packed red blood cell (pRBC) transfusion was assessed. Secondary outcomes included 30-day overall morbidity, readmission, reoperation, operative time, and length of stay (LOS).\u003c/p\u003e \u003cp\u003eOverall morbidity included the following complications: wound infection, pneumonia, urinary tract infection, VTE, cardiac complication, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, remained on the ventilator for \u0026gt;\u0026thinsp;48 hours, organ space surgical site infection (SSI), or anastomotic leak. Cardiac complication was defined as an arrythmia requiring intervention, myocardial infarction, or cardiac arrest. LOS was defined as days in the hospital from the time of the patient\u0026rsquo;s operation until discharge. Anastomotic leak was defined as CT or endoscopic evidence of anastomotic staple line dehiscence.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were analyzed using ANOVA and Mann-Whitney U test. Categorical variables were analyzed using Pearson's Chi-squared or Fisher's exact tests, when appropriate. Pairwise comparison was performed between the energy and suture ligation groups for all primary and secondary outcomes. Statistical significance was defined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using Stata, version 18.0 (StataCorp, College Station, Texas, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eThe 769 included patients were predominantly white (81.66% vs 10.53% black vs 7.8% other), with a median age of 56 (Interquartile Range [IQR 47\u0026ndash;67]), and with American Society of Anesthesiologists (ASA) classification I-II being the most common (54.10%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the tracked comorbidities, smoking history (40.96%), hypertension (37.19%) and diabetes (10.53%) were most common. Patients underwent neoadjuvant therapy prior to TME 80.23% of the time. Patients more frequently underwent an open approach (59.17%) versus MIS (40.83%) with low anterior resection (LAR) being more common (71.13%) than abdominoperineal resection (APR) (22.11%) or other (6.76%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic, Clinical, and Operative Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;769\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStapled\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;69 (8.97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnergy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;281 (36.54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSuture Ligation\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;419 (54.49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group, years\u003c/p\u003e \u003cp\u003e\u0026lt;45\u003c/p\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003cp\u003e55\u0026ndash;64\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (18.21)\u003c/p\u003e \u003cp\u003e207 (26.92)\u003c/p\u003e \u003cp\u003e186 (24.19)\u003c/p\u003e \u003cp\u003e236 (30.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (14.49)\u003c/p\u003e \u003cp\u003e10 (14.49)\u003c/p\u003e \u003cp\u003e21 (30.43)\u003c/p\u003e \u003cp\u003e28 (40.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (16.73)\u003c/p\u003e \u003cp\u003e83 (29.54)\u003c/p\u003e \u003cp\u003e69 (24.56)\u003c/p\u003e \u003cp\u003e82 (29.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83 (19.81)\u003c/p\u003e \u003cp\u003e114 (27.21)\u003c/p\u003e \u003cp\u003e96 (22.91)\u003c/p\u003e \u003cp\u003e126 (30.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (47,67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (53,70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (48,67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56 (47,66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e445 (57.87)\u003c/p\u003e \u003cp\u003e324 (42.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (56.52)\u003c/p\u003e \u003cp\u003e30 (43.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e161 (57.30)\u003c/p\u003e \u003cp\u003e120 (42.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e245 (58.47)\u003c/p\u003e \u003cp\u003e174 (41.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003cp\u003eWhite\u003c/p\u003e \u003cp\u003eBlack\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e628 (81.66)\u003c/p\u003e \u003cp\u003e81 (10.53)\u003c/p\u003e \u003cp\u003e60 (7.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (84.06)\u003c/p\u003e \u003cp\u003e8 (11.59)\u003c/p\u003e \u003cp\u003e3 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e223 (79.36)\u003c/p\u003e \u003cp\u003e32 (11.39)\u003c/p\u003e \u003cp\u003e26 (9.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e347 (82.82)\u003c/p\u003e \u003cp\u003e41 (9.79)\u003c/p\u003e \u003cp\u003e31 (7.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA classification\u003c/p\u003e \u003cp\u003eI-II\u003c/p\u003e \u003cp\u003eIII-IV\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e416 (54.10)\u003c/p\u003e \u003cp\u003e345 (44.86)\u003c/p\u003e \u003cp\u003e8 (1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (52.17)\u003c/p\u003e \u003cp\u003e31 (44.93)\u003c/p\u003e \u003cp\u003e2 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e146 (51.96)\u003c/p\u003e \u003cp\u003e134 (47.69)\u003c/p\u003e \u003cp\u003e1 (0.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e234 (55.85)\u003c/p\u003e \u003cp\u003e180 (42.96)\u003c/p\u003e \u003cp\u003e5 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (20.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (18.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (18.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96 (22.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking History\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e416 (54.10)\u003c/p\u003e \u003cp\u003e315 (40.96)\u003c/p\u003e \u003cp\u003e38 (4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (65.22)\u003c/p\u003e \u003cp\u003e21 (30.43)\u003c/p\u003e \u003cp\u003e3 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160 (56.94)\u003c/p\u003e \u003cp\u003e113 (40.21)\u003c/p\u003e \u003cp\u003e8 (2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e211 (50.36)\u003c/p\u003e \u003cp\u003e181 (43.20)\u003c/p\u003e \u003cp\u003e27 (6.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (10.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (8.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (10.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46 (10.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e286 (37.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (49.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102 (36.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150 (35.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (2.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (2.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of MI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (5.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (6.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (5.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop Steroid Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (3.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e617 (80.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (68.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e224 (79.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e346 (82.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Approach\u003c/p\u003e \u003cp\u003eOpen\u003c/p\u003e \u003cp\u003eMIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e455 (59.17)\u003c/p\u003e \u003cp\u003e314 (40.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (17.39)\u003c/p\u003e \u003cp\u003e57 (82.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (19.22)\u003c/p\u003e \u003cp\u003e227 (80.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e389 (92.84)\u003c/p\u003e \u003cp\u003e30 (7.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003cp\u003eLAR\u003c/p\u003e \u003cp\u003eAPR\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e547 (71.13)\u003c/p\u003e \u003cp\u003e170 (22.11)\u003c/p\u003e \u003cp\u003e52 (6.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (63.77)\u003c/p\u003e \u003cp\u003e17 (24.64)\u003c/p\u003e \u003cp\u003e8 (11.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e206 (73.31)\u003c/p\u003e \u003cp\u003e52 (18.51)\u003c/p\u003e \u003cp\u003e23 (8.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e297 (70.88)\u003c/p\u003e \u003cp\u003e101 (24.11)\u003c/p\u003e \u003cp\u003e21 (5.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: IQR; Interquartile Range; ASA, American Society of Anesthesiologists; BMI, Body Mass Index; DM, Diabetes Mellitus; HTN, Hypertension; COPD, Chronic Obstructive Pulmonary Disease; MI, Myocardial Infarction; CHF, Congestive Heart Failure; LAR, Low Anterior Resection; APR, Abdominoperineal Resection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients were stratified by IMA ligation technique: 69 (8.97%) underwent stapled ligation, 281 (36.54%) underwent energy ligation, and 419 (54.59%) underwent suture ligation of the IMA. The stapled group was older and underwent neoadjuvant therapy less frequently. Patients in the suture ligation group tended to be obese, smoke, and undergo an open operative approach. There were no differences between the proportion of LARs, APRs and other procedures performed between groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePrimary and Secondary Outcomes\u003c/h2\u003e \u003cp\u003eThere were no differences in intra-operative bleeding (stapled: 5.80%, energy: 3.20%, suture: 7.16%; p\u0026thinsp;=\u0026thinsp;0.082) or post-operative bleeding requiring transfusion (stapled: 7.25%, energy: 7.47%, suture: 5.73%; p\u0026thinsp;=\u0026thinsp;0.634) among the three IMA ligation techniques (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In terms of secondary outcomes, the stapled group had longer operative times (median of 400 minutes; Interquartile Range [IQR] 306,469), followed by the energy group (330 minutes; IQR 244,453) and suture ligation group (272 minutes; IQR 213,370; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no differences in the rates of overall morbidity, readmission, reoperation, or LOS between the three groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e 30-Day Post-Operative Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;769\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStapled\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;69 (8.97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnergy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;281 (36.54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSuture Ligation\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;419 (54.49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (5.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (3.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (7.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (6.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (7.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (5.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.634\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall morbidity\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169 (21.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (23.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (19.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99 (23.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (1.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (5.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (3.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (7.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (3.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (4.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock/sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (2.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan space SSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (4.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (4.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (2.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (6.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (7.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (5.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.634\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (6.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (3.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn ventilator\u0026thinsp;\u0026gt;\u0026thinsp;48hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (18.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (21.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (18.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72 (17.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (6.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (3.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e302 (229,416)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400 (306,469)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e330 (244,453)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e272 (213,370)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (4,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (5,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eOverall morbidity: Wound complication (deep incisional SSI\u0026thinsp;+\u0026thinsp;wound disruption), pneumonia, urinary tract infection, VTE, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, on ventilator\u0026thinsp;\u0026gt;\u0026thinsp;48 hours, organ space SSI, and anastomotic leak.\u003c/p\u003e \u003cp\u003eAbbreviations: SSI, Surgical Site Infection; UTI, Urinary Tract Infection; VTE, Venous Thromboembolism; IQR, Interquartile Range; LOS, length of stay.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrimary and Secondary Outcomes Stratified by Operative Approach\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eOpen Approach\u003c/h2\u003e \u003cp\u003eThere were no differences in intra-operative bleeding necessitating transfusion between the three IMA ligation techniques (25.0% stapled, 7.4% energy, 7.2% suture ligation; p\u0026thinsp;=\u0026thinsp;0.104) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similarly, there were no differences in post-operative bleeding necessitating transfusion (8.3%, 14.8%, 5.9%; p\u0026thinsp;=\u0026thinsp;0.058). When looking at secondary outcomes, the stapled cohort had longer operative times (357.5 minutes [IQR 320.5, 516]) followed by 281 minutes (IQR 180, 403) for energy and 271 minutes (IQR 213,365) for suture ligation (p\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e 30-Day Post-Operative Outcomes Stratified by Operative Approach\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eOpen (n\u0026thinsp;=\u0026thinsp;455)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eMIS (n\u0026thinsp;=\u0026thinsp;314)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStapled (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEnergy (n\u0026thinsp;=\u0026thinsp;54)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eSuture (n\u0026thinsp;=\u0026thinsp;389)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eStapled (n\u0026thinsp;=\u0026thinsp;57)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eEnergy (n\u0026thinsp;=\u0026thinsp;227)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eSuture (n\u0026thinsp;=\u0026thinsp;30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.058*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall morbidity\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock/sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.103*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan space SSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn ventilator\u0026thinsp;\u0026gt;\u0026thinsp;48hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e357.5 (320.5,516)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e281 (180,403)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e271 (213,365)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e412 (306,465)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e334 (249,474)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e293 (224,378)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.005*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5 (5.5,10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5,12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.103*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (4,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (4,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8 (6,13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.012*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eOverall morbidity: Wound complication (deep incisional SSI\u0026thinsp;+\u0026thinsp;wound disruption), pneumonia, urinary tract infection, VTE, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, on ventilator\u0026thinsp;\u0026gt;\u0026thinsp;48 hours, organ space SSI, and anastomotic leak.\u003c/p\u003e \u003cp\u003e*Statistically significant p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for pairwise comparison between energy and suture ligation groups (for Open: p\u0026thinsp;=\u0026thinsp;0.016 for bleeding requiring transfusion, p\u0026thinsp;=\u0026thinsp;0.046 for shock/sepsis, p\u0026thinsp;=\u0026thinsp;0.032 for LOS; for MIS: p\u0026thinsp;=\u0026thinsp;0.004 for LOS, p\u0026thinsp;=\u0026thinsp;0.037 for operative time)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMIS Approach\u003c/h2\u003e \u003cp\u003eThere were no differences in intra-operative bleeding necessitating transfusion between the three IMA ligation techniques (1.8% stapled, 2.2% energy, 6.7% suture ligation; p\u0026thinsp;=\u0026thinsp;0.253) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Likewise, there were no differences in post-operative bleeding necessitating transfusion (7.0%, 5.7%, 3.3%; p\u0026thinsp;=\u0026thinsp;0.850). When looking at secondary outcomes, the stapled group had longer operative times (412 minutes [IQR 306,465]) compared to energy (334 minutes [IQR 249,474]) and suture ligation (293 minutes [IQR 224,378]: p\u0026thinsp;=\u0026thinsp;0.005), but the suture ligation cohort had longer lengths of stay (8 days [IQR 6,13]) versus stapled (6 days [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]) and energy (5 days [IQR 4, 9]: p\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePairwise Comparison of Energy Versus Suture Ligation Stratified by Operative Approach\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eOpen\u003c/h2\u003e \u003cp\u003eThere was significantly more bleeding requiring transfusion post-operatively in the energy cohort compared to the suture ligation cohort (14.81% vs 5.91%: p\u0026thinsp;=\u0026thinsp;0.016). When looking at secondary outcomes, the bipolar energy cohort had longer LOS (9 days [IQR 5, 12] vs 7 days [IQR 5, 10]: p\u0026thinsp;=\u0026thinsp;0.032).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMIS\u003c/h2\u003e \u003cp\u003eThe energy group had longer operative times but shorter LOS (5 days [IQR 4, 9] versus 8 days [IQR 6, 13]: p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis was a multi-center single institution study including patients undergoing first-time TME for rectal cancer. We initially found no differences in intra-or post-operative bleeding between suture ligation, bipolar energy, and stapling. The groups were then stratified by operative approach in addition to IMA ligation technique to control for operative approach as a potential confounder. While no differences in intra or post-operative bleeding between the three IMA ligation techniques were found for either an open or MIS approach, pairwise comparison of bipolar energy and suture ligation patients receiving an open approach found that there was significantly more post-operative bleeding in the energy group. The stapled group had longer operative times, followed by the energy group and suture ligation group, which persisted with operative approach stratification. LOS varied depending on how the groups were stratified with a longer LOS in the suture ligation group, except for in the open cohort where the energy group had a significantly longer length of stay in pairwise comparison to suture ligation. There were no differences in the rates of overall morbidity, readmission, or reoperation between the three groups, which persisted in pairwise comparison and operative approach stratification. These findings suggest energy and stapling of the IMA is as safe as IMA suture ligation, with a potential benefit of suture ligation over energy in direct pairwise comparison when utilizing an open approach in decreasing intra-operative bleeding.\u003c/p\u003e \u003cp\u003eWhen looking at previous work, there have been multiple prior \u003cem\u003eex vivo\u003c/em\u003e studies looking at the efficacy of the different hemostatic techniques with contradictory results, particularly when looking at the energy devices [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, there have been no previous studies that suggest a potential benefit of suture ligation over bipolar energy when undergoing an open operative approach, such as in our pairwise comparison of rates of post-operative bleeding. A limitation of these studies is the static pressure used in these ex vivo animal models may create a different environment than the physiologic pulsatile pressure that is seen in human blood vessels [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There was an additional study that looked at the angle at which vessels are sealed in an ex vivo porcine model and found that burst pressures were 51% greater for those with a perpendicular seal on the artery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The angle of vessel seal was not captured by our dataset but highlights the importance of good operative technique and could potentially be one of many variables that account for the wide variability across studies.\u003c/p\u003e \u003cp\u003eAdditionally, there have been multiple studies looking at mesenteric vessel ligation technique in colectomies specifically. While several studies have looked at safety of a single energy device [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] or pooled comparisons of like techniques [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], there are currently no studies, to our knowledge, comparing multiple techniques across multiple approaches. Nor are there studies looking at the efficacy of newer energy devices while utilizing an open approach. Our study looks at suture ligation, bipolar energy, and stapling independently as IMA ligation techniques, while also including both open and MIS approaches. Looking at efficacy of bipolar energy devices alone in an MIS approach, Pai et al demonstrated an intraoperative bleeding rate of 1.5% and postoperative pRBC transfusion rate of 0.25% when using the Enseal device [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Safety of the Ligasure device for mesenteric artery ligation in colectomy was demonstrated by Grieco et al who had no instances of intra- or postoperative bleeding in a 759 patient case series [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Martin et al. who demonstrated 99.8% immediate effective vessel sealing in a retrospective review of over 800 cancer patients undergoing colectomy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These data are all in the context of our study that showed a comparatively increased rate of intra-operative bleeding rate at 3.20% and post-operative bleeding rate at 7.16% for our bipolar energy cohort.\u003c/p\u003e \u003cp\u003eA randomized controlled trial (RCT) of IMA ligation techniques in laparoscopic colorectal resection for benign and malignant disease compared bipolar to a mechanical ligation (either vascular stapler or double clipping) group with the primary outcomes of operation duration, time to control individual vascular pedicles and cost [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. When looking at our primary outcomes, though they were not directly comparable, their findings were similar with no significant difference in estimated blood loss (EBL), number of transfusions, or hematocrit (HCT) loss. Time taken for vascular control and time to control the IMA pedicle was significantly faster with bipolar energy for left colectomy, however, on multivariate analysis of operative time, type of vascular control did not contribute significantly to operative time. This is contradictory to our findings of a longer operative time with bipolar energy compared to suture ligation even for MIS approaches, challenging prior assumptions of MIS suture ligation being too cumbersome and time consuming. Similar to our findings, an additional prospective study of 200 patients looking at pooled mechanical (double clipping or suture ligation) versus vessel sealing devices (ultrasonic or bipolar energy) for elective sigmoidectomy in diverticulitis patients found no difference in mean hemoglobin levels, units of pRBCs transfused or hemorrhagic events between groups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, in contrast to our study, operative times and length of stay for the vessel sealing group were significantly shorter.\u003c/p\u003e \u003cp\u003eOne Cochrane review exists looking at energy source instruments for laparoscopic colectomy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Their outcome measurements differed from ours, but they showed better overall hemostatic control in the bipolar energy group versus the mechanical ligation group but no significant difference in intraoperative EBL. Contrary to our findings, the study demonstrated shorter operative times for the bipolar energy group versus the mechanical ligation group. An important limitation is while some of the papers included look at vessel ligation technique specifically in reference to hemostasis, others looked at overall hemostatic control with variation in the techniques allowed within each case. Other limitations include, as detailed by the authors, the heterogeneity of the trials included, primary outcomes investigated, and involved pathology and procedure types. Furthermore, the authors concluded that it was not possible to demonstrate the best instrument for a laparoscopic colectomy based on their findings.\u003c/p\u003e \u003cp\u003eThis study attempted to overcome limitations from previous works to include broadening our patient population to include patients who received an open approach. Additionally, we looked at IMA ligation techniques individually, whereas most other studies looked at pooled groups of mechanical and energy techniques [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. There are still multiple limitations to our study, however. This was a retrospective analysis of a heterogenous cohort where we looked at global perioperative bleeding complications. As with many retrospective studies, granular detail was not available. For example, operative time dedicated to control of the vascular pedicle, bleeding complications specifically associated with the IMA (our complications are global perioperative bleeding complications), as well as specific settings of the bipolar energy devices or types/loads of staplers were not available. Additionally, there was no standard method for ligating the pedicles between surgeons; they ligated per their preference. We have no data on each surgeon\u0026rsquo;s preference or whether a particular surgery dictated a deviation from their typical approach. For example, Martin et al. suggest caution when using the Ligasure in patients with significant atherosclerotic disease and calcification of vessels [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This could explain the longer operative times that we saw in the stapled cohort, with surgeons potentially electing to staple the IMA in cases where control of bleeding was difficult or anticipated to be so.\u003c/p\u003e \u003cp\u003eWhile we were able to look at each group individually (stapled versus bipolar energy versus suture ligation), our patient population either did not include or included insufficient numbers of those who underwent IMA ligation via clipping or ultrasonic energy devices. While some ultrasonic devices are now approved for vascular pedicle ligation up to 7mm, at the beginning of our retrospective study, ultrasonic shears were not designed or approved by the FDA for successful ligation of larger vascular pedicles such as the IMA [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, we did not differentiate between open, laparoscopic, and robotic bipolar vessel sealing devices (Ligasure vs Vessel Sealer), which also contributes to the heterogeneity of our cohort.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThere are a variety of options for IMA ligation for rectal cancer patients undergoing TME. Additional prospective, case-matched studies are needed to address the limitations of heterogeneity and more detailed intraoperative data; however, these findings show safety of the above IMA ligation methods in both open and MIS approaches, with evidence of less post-operative bleeding in patients who received an open approach and suture ligation of the IMA compared to ligation via bipolar energy.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding/Support Information:\u0026nbsp;\u003c/strong\u003eMr. Edwin Lewis and The Nicholl Family Foundation provided generous support of the Johns Hopkins Division of Colorectal Surgery Research Fund.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFinancial Disclosures:\u003c/strong\u003e AJW, RSS, MS, JRM, SLG, AGK, JEE have no financial disclosures. VJO is currentlty or was previously a consultant for Medtronic, Inc., Asensus Surgical, Inc., Intuitive Surgical, Inc., and Potrero Medical, Inc.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003ePresentations\u003c/strong\u003e: Accepted for an e-poster presentation at the 2024 Annual ASCRS Scientific Meeting, Baltimore, MD.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThinggaard B, Perdawood SK (2017) Complications of minimal invasive surgery for rectal cancer - a systematic review. https://doi.org/10.5281/zenodo.1041310\u003c/li\u003e\n\u003cli\u003eLim C-S, Jang J-Y, Lee SE, et al (2013) Comparison of various methods of vessel ligation: what is the safest method? Surg Endosc 27:3129\u0026ndash;3138. https://doi.org/10.1007/s00464-013-2866-y\u003c/li\u003e\n\u003cli\u003eTharakan SJ, Hiller D, Shapiro RM, et al (2016) Vessel sealing comparison: old school is still hip. Surg Endosc 30:4653\u0026ndash;4658. https://doi.org/10.1007/s00464-016-4778-0\u003c/li\u003e\n\u003cli\u003eKondov S, Dimov A, Beyersdorf F, et al (2022) Inferior mesenteric artery diameter and number of patent lumbar arteries as factors associated with significant type 2 endoleak after infrarenal endovascular aneurysm repair. Interact Cardiovasc Thorac Surg 35:016. https://doi.org/10.1093/icvts/ivac016\u003c/li\u003e\n\u003cli\u003eA M, F D, J S, et al (2008) Operative time and other outcomes of the electrothermal bipolar vessel sealing system (LigaSure) versus other methods for surgical hemostasis: a meta-analysis. Surgical innovation 15:284\u0026ndash;291. https://doi.org/10.1177/1553350608324933\u003c/li\u003e\n\u003cli\u003eHarold KL, Pollinger H, Matthews BD, et al (2003) Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc 17:1228\u0026ndash;1230. https://doi.org/10.1007/s00464-002-8833-7\u003c/li\u003e\n\u003cli\u003eCampbell PA, Cresswell AB, Frank TG, Cuschieri A (2003) Real-time thermography during energized vessel sealing and dissection. Surg Endosc 17:1640\u0026ndash;1645. https://doi.org/10.1007/s00464-002-8781-2\u003c/li\u003e\n\u003cli\u003eCarbonell AM, Joels CS, Kercher KW, et al (2003) A Comparison of Laparoscopic Bipolar Vessel Sealing Devices in the Hemostasis of Small-, Medium-, and Large-Sized Arteries. Journal of Laparoendoscopic \u0026amp; Advanced Surgical Techniques 13:377\u0026ndash;380. https://doi.org/10.1089/109264203322656441\u003c/li\u003e\n\u003cli\u003eEngel RM, Oliva K, Centauri S, et al (2023) Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study. Dis Colon Rectum 66:923\u0026ndash;933. https://doi.org/10.1097/DCR.0000000000002454\u003c/li\u003e\n\u003cli\u003eAmato A, Pescatori M (2006) Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 2006:CD005033. https://doi.org/10.1002/14651858.CD005033.pub2\u003c/li\u003e\n\u003cli\u003eVoegele AC, Korvick DL, Gutierrez M, et al (2013) Perpendicular Blood Vessel Seals Are Stronger Than Those Made at an Angle. Journal of Laparoendoscopic \u0026amp; Advanced Surgical Techniques 23:669\u0026ndash;672. https://doi.org/10.1089/lap.2013.0028\u003c/li\u003e\n\u003cli\u003ePai A, Sugrue J, Bibi S, et al (2016) Safety and efficacy of an electrothermal bipolar vessel sealing device in sealing and division of the inferior mesenteric vessels in minimally invasive colorectal surgery. Tech Coloproctol 20:505\u0026ndash;506. https://doi.org/10.1007/s10151-016-1488-5\u003c/li\u003e\n\u003cli\u003eGrieco M, Apa D, Spoletini D, et al (2018) Major vessel sealing in laparoscopic surgery for colorectal cancer: a single-center experience with 759 patients. World J Surg Onc 16:101. https://doi.org/10.1186/s12957-018-1402-x\u003c/li\u003e\n\u003cli\u003eMartin ST, Heeney A, Pierce C, et al (2011) Use of an electrothermal bipolar sealing device in ligation of major mesenteric vessels during laparoscopic colorectal resection. Tech Coloproctol 15:285\u0026ndash;289. https://doi.org/10.1007/s10151-011-0707-3\u003c/li\u003e\n\u003cli\u003eTrilling B, Riboud R, Abba J, et al (2016) Energy vessel sealing systems versus mechanical ligature of the inferior mesenteric artery in laparoscopic sigmoidectomy. Int J Colorectal Dis 31:903\u0026ndash;908. https://doi.org/10.1007/s00384-016-2508-7\u003c/li\u003e\n\u003cli\u003eAdamina M, Champagne BJ, Hoffman L, et al (2011) Randomized clinical trial comparing the cost and effectiveness of bipolar vessel sealers versus clips and vascular staplers for laparoscopic colorectal resection. Br J Surg 98:1703\u0026ndash;1712. https://doi.org/10.1002/bjs.7679\u003c/li\u003e\n\u003cli\u003eTou S, Malik AI, Wexner SD, Nelson RL (2011) Energy source instruments for laparoscopic colectomy. Cochrane Database Syst Rev CD007886. https://doi.org/10.1002/14651858.CD007886.pub2\u003c/li\u003e\n\u003cli\u003eMarcello PW, Roberts PL, Rusin LC, et al (2006) Vascular pedicle ligation techniques during laparoscopic colectomy: A prospective randomized trial. Surg Endosc 20:263\u0026ndash;269. https://doi.org/10.1007/s00464-005-0258-7\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"mesenteric artery, inferior, ligation, rectal neoplasms, colorectal neoplasms, total mesorectal excision (TME)","lastPublishedDoi":"10.21203/rs.3.rs-4605730/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4605730/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInferior mesenteric artery ligation techniques for left colon and rectal resections include stapling, using an energy device, or suture ligation based on surgeon preference. To our knowledge, no studies have demonstrated superiority of one technique over the other.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study utilized an institutional database for adult rectal cancer patients undergoing total mesorectal excision (2006\u0026ndash;2021). The association between IMA ligation technique (stapled, energy, or suture ligation) and primary outcomes of intra- and 30-day post-operative bleeding complications necessitating transfusion were assessed. Primary and secondary outcomes were analyzed using ANOVA, Pearson's Chi-squared or Fisher's exact test when appropriate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 769 rectal cancer patients included, 69 (8.97%) underwent stapled ligation, 281 (36.54%) underwent energy ligation, and 419 (54.59%) underwent suture ligation. Patients in the suture ligation group more frequently underwent open procedures (17.39% vs 19.22% vs 92.84%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to the stapled and energy groups, respectively. There were no differences in intra- (5.80%, 3.20%, 7.16%; p\u0026thinsp;=\u0026thinsp;0.082) or post-operative bleeding necessitating transfusion (7.25%, 7.47%, 5.73%; p\u0026thinsp;=\u0026thinsp;0.634). However, there was significantly more bleeding post-operatively for patients in the energy cohort compared to the suture ligation cohort when receiving an open approach (14.81% vs 5.91%: p\u0026thinsp;=\u0026thinsp;0.016). There were no differences in 30-day overall morbidity, readmission, reoperation, or length of stay between groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEnergy and stapling of the IMA is as safe as traditional IMA suture ligation, with potential benefit of suture ligation over bipolar energy in decreasing post-operative bleeding when undergoing an open approach.\u003c/p\u003e","manuscriptTitle":"Effect of IMA Ligation Technique on Bleeding Complications in Rectal Cancer Patients Undergoing Total Mesorectal Excision","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:40:52","doi":"10.21203/rs.3.rs-4605730/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e939f7d7-bc13-478c-b1fb-87a7063c0896","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-21T08:03:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 16:40:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4605730","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4605730","identity":"rs-4605730","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}