Guided Preservation of Ascending Left Colic Artery during Left Colectomy in Left Cancer Colon

Background: Left colectomy requires adequate anastomotic blood supply to prevent leakage. The ascending branch of the left colic artery (ALCA), often ligated during high inferior mesenteric artery (IMA) ligation, is critical for enhancing perfusion. Guided ALCA preservation optimizes blood flow to the colonic stump, potentially reducing complications without compromising oncological radicality. Aim: To assess the technical feasibility and safety of guided ALCA preservation during elective left colectomy for adenocarcinoma. It aimed to objectively assess its impact on anastomotic perfusion using indocyanine green (ICG) angiography and correlate this with short-term clinical outcomes. Patients and Methods: One hundred consecutive patients undergoing elective left colectomy for left-sided colon adenocarcinoma at Al-Azhar University Hospitals (January 2023 – December 2024) were included. ICG fluorescence angiography assessed proximal stump perfusion with and without ALCA preservation. A standardized algorithm guided preservation decisions. Primary endpoints were ALCA preservation rates and ICG perfusion scores; secondary endpoints included anastomotic leak, hospital stay, and oncological parameters. Results: Guided ALCA preservation was feasible in 92% of cases. ICG scores were significantly superior in the preservation group (4.5 ± 0.3 vs. 3.1 ± 0.5, p<0.001). The overall anastomotic leak rate was 4%, but only 1% in the ALCA preservation group versus 37.5% in the ligation group (p=0.002). Hospital stay was shorter with preservation (5.8 ± 1.2 days vs. 8.1 ± 2.5 days, p=0.01). Lymph node yield and margin status were comparable. Conclusion: Guided ALCA preservation is feasible and safe, significantly enhancing anastomotic perfusion and reducing leak rates without compromising oncology. ICG angiography is valuable for optimizing outcomes.