Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer

Preliminary surgical outcomes of laparoscopic right hemicolectomy with transrectal specimen extraction: a propensity score matching study of 120 cases (with video)

Background

Compared with conventional laparoscopic surgery, natural orifice specimen extraction surgery (NOSES) has many advantages. Laparoscopic right colectomy with transvaginal specimen extraction has been reported, but the safety and feasibility of transrectal specimen extraction in male patients with ascending colon cancer remain to be verified. This study aimed to preliminarily evaluate the feasibility and safety of laparoscopic right hemicolectomy with transrectal specimen extraction.

Methods

The study was conducted at a single tertiary medical center in China. A total of 494 consecutive patients who underwent laparoscopic right colectomy between September 2018 and September 2020 were included. Transrectal specimen extraction was performed in 40 male patients (the NOSES group). Patients in the NOSES group were matched to the conventional laparoscopic group using propensity score matching at a 1:2 ratio. Short-term and long-term outcomes between the two groups were compared and evaluated.

Results

Forty patients in the NOSES group and 80 patients in the conventional laparoscopic group were matched for analysis. Baseline characteristics were balanced after propensity matching. The operative features, including operating time, intraoperative bleeding, and the number of harvested lymph nodes, were statistically comparable in both groups. In terms of post-operative recovery, patients in the NOSES group showed preferable outcomes, as evidenced by less post-operative pain and faster return to flatus, defecation, and discharge. The post-operative complications rate, according to the Clavien-Dindo classification system, was similar in both groups. No differences in overall survival or disease-free survival were observed between the two groups.

Conclusions

Laparoscopic right colectomy with transrectal specimen extraction is oncologically safe. Compared with conventional laparoscopic right colectomy, it can reduce post-operative pain, accelerate post-operative recovery, shorten the hospital stay, and achieve better cosmetic effect.

Is natural orifice specimen extraction surgery the future direction of minimally invasive colorectal surgery?

As science and technology have advanced, surgical techniques have become increasingly sophisticated. A revolution was triggered by the appearance of new electrical and optical instruments, shifting the field of surgery in the direction of "minimally invasive" and "noninvasive" procedures. Natural orifice specimen extraction surgery has emerged as a rising star in the field of minimally invasive surgery. It has increased rapidly, and it has become a hot topic in recent years. Natural orifice specimen extraction surgery has shown advantages in alleviating postoperative pain, improving bowel movements, providing a cosmetic effect, and improving psychological state without adversely affecting cancer outcomes. Different approaches have been classified and summarized for natural orifice specimen extraction surgery based on the procedure for specimen extraction and the location of the tumor, and natural orifice specimen extraction surgery can be used in resection all parts of the colorectum. The international natural orifice specimen extraction surgery consensus and monograph have also been published to improve the standardization of the application of this technique. Additional steps need to be taken to standardize natural orifice specimen extraction surgery, such as conducting large-scale randomized controlled trials, establishing a training system, and developing specific tools. Still, the natural orifice specimen extraction surgery procedure continues to follow the development of minimally invasive surgery and may be one of the future treatment options.

Natural orifice versus transabdominal specimen extraction in laparoscopic surgery for colorectal cancer: meta-analysis

BACKGROUND

Natural orifice specimen extraction (NOSE) is a technique that involves collecting a specimen for extraction through a natural opening avoiding a mini-laparotomy incision. The aim of this study was to compare NOSE and transabdominal specimen extraction in laparoscopic (LAP) colorectal cancer surgery for postoperative outcomes and oncological safety.

METHOD

A systematic search was conducted in five electronic databases from inception till October 2020. Articles were selected based on the inclusion criteria (studies comparing LAP and NOSE colorectal surgeries reporting at least one of the outcomes) and analysed. Primary outcomes included postoperative complications, pathological results (resection margins and lymph node collection), and oncological outcomes. Secondary outcomes included operating time, blood losses, use of analgesics, functional recovery, duration of hospital stay, and cosmetic results. Fixed and random-effect models were used to measure the pooled estimates.

RESULTS

Nineteen studies involving a total of 3432 participants were analysed (3 randomized clinical trials (RCTs) and 16 retrospective non-randomized studies). Pooled results showed significantly reduced postoperative complications (OR 0.54; 95 per cent c.i. 0.44 to 0.67; P < 0.00001). Pathological outcomes of NOSE were comparable to LAP with no significant difference noted in terms of resection margins (P > 0.05) and lymph node collection (weighted mean difference (WMD) -0.47; 95 per cent c.i. -0.94 to 0; P = 0.05). Pooled analysis demonstrated comparable long-term outcomes in terms of cancer recurrence (OR 0.94; 95 per cent c.i. 0.63 to 1.39; P = 0.75), 5-year disease-free survival (HR 0.97; 95 per cent c.i. 0.73 to 1.29; P = 0.83), and overall survival (HR 0.93, 95 per cent c.i. 0.58 to -1.51; P = 0.78). Finally, the NOSE group had decreased use of additional analgesia after surgery and earlier resumption of oral intake when compared with LAP (respectively OR 0.28; 95 per cent c.i. 0.20 to 0.37; P < 0.00001 and WMD -0.35; 95 per cent c.i. -0.54 to -0.15; P = 0.0005).

CONCLUSION

This meta-analysis showed that in comparison with LAP, NOSE decreases severe postoperative morbidity while improving postoperative recovery without compromising oncological safety, but it is limited by the small number of RCTs performed in this field.

Technical feasibility and perioperative outcome of laparoscopic resection rectopexy with natural orifice specimen extraction (NOSE) and intracorporeal anastomosis (ICA)

Purpose

Laparoscopic rectosigmoid resection rectopexy (LRR) is the most effective treatment of obstructive defecation syndrome but is associated with a higher postoperative morbidity compared to transanal approaches. Natural orifice specimen extraction (NOSE) has been described as a promising technique to lower morbidity in colorectal cancer surgery. In this study, we analyze the technical challenges of adapting this technique to LRR and compare the perioperative results to the conventional laparoscopic technique with specimen extraction via minilaparotomy and extracorporeal anastomosis.

Methods

We retrospectively analyzed 45 patients who underwent laparoscopic rectosigmoid resection rectopexy due to obstructive defecation syndrome at our institutions. From September 2020 to July 2021, we treated 17 consecutive patients with NOSE-LRR and compared the results to a historic cohort of 28 consecutive patients treated with conventional laparoscopic rectosigmoid resection rectopexy plus minilaparotomy (LAP-LRR) for specimen extraction between January 2019 and July 2020. Assessed were patient- and disease-specific parameters, operative time, hospital and postoperative complications and subjective patient satisfaction after 6 months of follow-up.

Results

Both groups were comparable in terms of gender distribution, age, and comorbidities. The median operating time was similar and the perioperative morbidity was comparable in both groups. The length of stay in hospital was significantly shorter in the NOSE-LRR group (median 6 vs 8 days).

Conclusion

NOSE-LRR can be implemented safely, performed in a comparable operating time, and is associated with a comparable rate of postoperative complications. The technique offers the a potentially fast postoperative recovery compared to the conventional laparoscopic technique.

Safety and oncological outcomes of natural orifice specimen extraction surgery compared with conventional laparoscopic surgery for right hemicolectomy: a systematic review and meta-analysis

Natural orifice specimen extraction surgery (NOSES) is a new technique and uses natural orifice as the delivery route for specimen extraction to avoid supererogatory incision, and the safety and oncological outcomes of NOSES for right hemicolectomy are still inconclusive, so a meta-analysis was performed to compare these to conventional laparoscopic surgery (CLS). Related literature comparing NOSES with CLS for right hemicolectomy, whether randomized controlled trials (RCTs) or retrospective studies, were systematically searched. A random-effect model or fixed-effect model was used based on the I² value. A total of six studies (all retrospective trials) involving 609 participants were included. Compared with CLS, NOSES was more preponderant than CLS in terms of surgical morbidity [odds ratio (OR) = 0.31; P = 0.0002], length of hospital stay [weighted mean difference (WMD) =  - 1.52; P = 0.006], time to first flatus (WMD =  - 0.82; P = 0.0008) and liquid intake (WMD =  - 1.40; P < 0.00001), pain score of POD1 (WMD =  - 1.99; P < 0.00001) and POD3 (WMD =  - 1.15; P = 0.02), and cosmetic result (WMD = 1.84; P < 0.00001), while operative time of NOSES was prolonged (WMD = 18.29; P = 0.04). The number of dissected lymph nodes, recurrence, and 3-year overall survival (3-year OS) in NOSES group were comparable to the CLS group. Despite the lack of enough evidence, NOSES for right hemicolectomy has demonstrated comparable safety and oncological outcomes as CLS with less postoperative morbidity and pain, better cosmetic effect, and rapider recovery.

Propensity score-matched comparison between totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction and conventional laparoscopic surgery with mini-laparotomy in the treatment of ascending colon cancer (with video)

BACKGROUND AND AIMS

Now that the debate about the safety and effectiveness of laparoscopic versus open surgery is over, attention has turned to innovations that can verify whether minimizing the impact of laparoscopy on the abdominal wall can further reduce pain, improve patient comfort, lead to superior cosmesis, and reduce morbidity. The aim of this study was to further explore the application value of totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction (NOSE) and to evaluate the short-term efficacy of transcolonic NOSE surgery for resecting specimens of ascending colon cancer.

METHODS

From January 2016 to May 2017, a retrospective study was conducted in Guangxi. Propensity score matching was used to minimize the bias from nonrandomized treatment assignment. Patients were followed up through May 2020.

RESULTS

Forty-nine patients underwent totally laparoscopic right hemicolectomy with transcolonic NOSE and 116 patients laparoscopic right hemicolectomy with mini-laparotomy (ML) procedures at our institution. After propensity score matching, each group included 45 patients, and all covariate imbalances were alleviated. The transcolonic NOSE group and the ML group did not differ significantly in terms of baseline clinical characteristics. The transcolonic NOSE group was associated with a shorter time to first flatus (NOSE vs ML: 1.8 ± .5 vs 3.2 ± .8, P = .032), a shorter length of hospital stay (11.3 ± 2.5 days vs 13.0 ± 3.1 days, P = .034), a shorter time to first liquid intake (2.6 ± .8 vs 3.8 ± .9, P = .068), less pain (1.8 ± .8 vs 4.2 ± .7, P = .013), less analgesia requirement (6 [13.3%] vs 21 [46.7%], P = .001), and lower C-reactive protein levels on postoperative day 1 (3.6 ± 1.7 vs 8.2 ± 2.2, P = .001) and postoperative day 3 (NOSE 2.4 ± 1.4 vs M: 4.6 ± 1.7 [P = .013]) than the ML group. The median follow-up was 28.4 months (interquartile range, 18.0-36.0). The 3-year overall survival rates were similar between the transcolonic NOSE group and the ML group.

CONCLUSIONS

In total, laparoscopic right hemicolectomy with transcolonic specimen extraction appears to be safe for selected patients with ascending colon cancer as a minimally invasive surgery.

Nomogram for predicting the feasibility of natural orifice specimen extraction after laparoscopic rectal resection

BACKGROUND AND AIM

The goal of this study was to develop a preoperative nomogram for predicting the feasibility of trans-anal natural orifice specimen extraction (NOSE) for rectal cancer.

METHODS

The analysis included 201 patients who underwent trans-anal NOSE and 457 patients who failed to undergo trans-anal NOSE in Shanghai East Hospital. The data collected included age, gender, body mass index, presence of tumor obstruction, distance from anal verge; maximum tumor diameter and anteroposterior thickness of mesorectum (AP) measured by magnetic resonance imaging; interspinous diameter, intertuberous diameter (IT), anteroposterior diameter of the inlet (API), anteroposterior diameter of the midplane, anteroposterior diameter of the outlet (APO), sacral length and pelvic depth (PD) measured by computed tomography.

RESULTS

The multivariate analysis suggested that a lower body mass index (P < 0.001), no tumor obstruction (P = 0.005), a shorter distance from anal verge (P < 0.001), a smaller tumor size (P < 0.001), a thinner AP (P < 0.001), a wider and shallower bony pelvis (API/PD, P < 0.001), and a wider and shorter pelvic outlet (IT/APO, P < 0.001) were significantly associated with an increased probability of trans-anal NOSE. Successful NOSE patients had a decreased time to liquid intake (P < 0.001), a shorter postoperative hospital stay (P < 0.001), and fewer wound infections (P = 0.045). No significant difference in the rate of mortality or recurrence was observed. The nomogram model presented an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.78 to 0.85) and good calibration.

CONCLUSION

We developed a nomogram model that has some predicative value for the feasibility of laparoscopic rectal resection with trans-anal NOSE, utilizing clinical and radiologic parameters, available in most institutions.

A Case Series of Laparoscopic Colorectal Resections with Natural Orifice Specimen Extraction and Systematic Literature Review

Background  Minimal access surgery is associated with improved cosmetic and other short-term outcomes. Conventionally, an abdominal incision is made for specimen extraction. We assessed the feasibility of specimen extraction through one of the natural orifices and analyzed its impact on short-term outcomes. Methods  A prospectively collected data were reviewed on consecutive patients who underwent natural orifice specimen extraction (NOSE) after laparoscopic colorectal surgery. The results were compared with a matched group who had transabdominal extraction (TAE) of the specimens. A systematic literature review was performed to compare our results. Results  The combined median operating time for right and left colectomies was significantly higher in the NOSE group as compared with TAE group (260 vs. 150). There was no mortality in either group and no conversions to TAE in the NOSE group. No local metastasis or major iatrogenic injuries were reported at the time of retrieval. The results were comparable to those of a meta-analysis of randomized controlled trials. Conclusion  The results of NOSE are comparable to those of TAEs. The absence of a minilaparotomy for specimen extraction may lead to a speedy recovery and better cosmesis.

Natural orifice specimen extraction for colorectal surgery: Early adoption in a Western population

AIM

Natural orifice specimen extraction (NOSE) challenges the limits of minimally invasive colorectal surgery by exploiting a natural opening for specimen delivery. Technically challenging, it is less painful, requires smaller wounds and abolishes the possibility of incisional hernia. These advantages of NOSE are seen in the obese (body mass index [BMI] >30 kg/m² ). This audit aims to demonstrate the feasibility of NOSE colectomy in an Australian population.

METHOD

Prospective data collected from 2007 to the present were retrospectively analysed. Only patients with mucosally benign colorectal conditions were included: complex diverticulosis, post-malignant polypectomy and volvulus. Left sided mucosal malignancies were excluded. Study end-points included postoperative length of stay, anastomotic leak rate and wound complications.

RESULTS

In total, 159 patients underwent NOSE, mean age 59 years (19-88), mean BMI 28.2 kg/m² (17-45). Ten (6.2%) patients developed retroperitoneal small bowel herniation; seven required further surgery. There were five (3.1%) anastomotic leaks, seven (4.4%) postoperative ileus and three (1.9%) anastomotic bleeds. One (0.6%) patient had a superficial wound infection. There were no port site hernias. Patients with BMI <30 kg/m² (98 patients) and BMI >30 kg/m² (59 patients) were compared; there was no difference in anastomotic leak rate (P = 0.60), complication rate (P = 0.71) and length of stay (P = 0.63). However, duration of operation increased with BMI (P = 0.000).

CONCLUSION

This large series of NOSE colectomy from Australia suggests that NOSE is comparable to conventional laparoscopic colectomy in terms of postoperative outcome. Given that obesity has not featured in the NOSE literature, our study suggests that NOSE, for benign disease, is safe in obese patients, without added morbidity.

The safety and efficacy of laparoscopic surgery versus laparoscopic NOSE for sigmoid and rectal cancer

BACKGROUND

Laparoscopic surgery with natural orifice specimen extraction (La-NOSE) is being performed more frequently for the minimally invasive management of sigmoid and rectal cancer. The objective of this meta-analysis was to compare the clinical and oncological safety and efficacy of La-NOSE versus conventional laparoscopy (CL).

METHODS

A search of the PubMed, Web of Science, and Cochrane databases was performed for studies that compared clinical or oncological outcomes of conventional laparoscopic resection using NOSE with conventional laparoscopic resection for sigmoid and rectal cancer.

RESULTS

Compared with CL group, the length of hospital stay and the pain score on the first day were shorter in the La-Nose group. The La-NOSE group had a lower incidence of total perioperative complications (OR 0.46; 95% CI [0.32 to 0.66]; I² = 0%; P < 0.0001) and a lower incidence of surgical site infections (SSIs) (OR 0.11; 95% CI [0.04 to 0.29]; I² = 0%; P < 0.0001) than the CL group, while the anastomotic leakage showed no significant difference between the La-Nose group and the CL group (P = 0.19). 5-year disease-free survival (DFS) and 5-year overall survival (OS) were no significant difference between the La-Nose group and the CL group (P = 0.43, P = 0.40, respectively).

CONCLUSIONS

La-NOSE can achieve oncological and surgical safety comparable to that of CL for patients with sigmoid and rectal cancer. La-NOSE in patients was associated with a shorter hospital stay, shorter time to first flatus or defecation, less postoperative pain, and fewer surgical site infections (SSIs) and total perioperative complications. In general, the operative time in La-NOSE was longer than that in CL. The long-term oncological efficacy of La-NOSE seems to be equivalent to that of CL.

Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study

INTRODUCTION

In recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE.

CASE PRESENTATION

From May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 min. The median blood loss was 10 mL. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases.

CONCLUSION

Total laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.

Laparoscopic right hemicolectomy with intracorporeal anastomosis and natural orifice surgery extraction/minimal extraction site surgery in the obese

BACKGROUND

Despite advantages associated with laparoscopic colorectal surgery, there is significant morbidity associated with incisions required for specimen extraction and restoration of bowel continuity. In laparoscopic colorectal surgery, the length of the longest incision depends upon that required to facilitate extra-corporeal steps. The purpose of this study was to analyse obese patients (body mass index >30 kg/m² ) who have undergone laparoscopic small bowel or right-sided colonic resection with intracorporeal anastomosis (ICA) and natural orifice surgery extraction (NOSE)/minimal extraction site (MES) surgery.

METHODS

A retrospective review of 11 obese patients who have undergone laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES was conducted.

RESULTS

Mean body mass index was 40.4 kg/m² (range 32.7-56 kg/m² ) in 11 patients. Procedures performed were laparoscopic right hemicolectomy (7) - one with high anterior resection, pelvic peritonectomy, bilateral salpingo-oophorectomy and greater omentectomy, small bowel resection (2), transverse colotomy (1) and segmental transverse colectomy (1). All colonic specimens were extracted via NOSE (vaginal colpotomy or transcolonic), except two requiring a miniaturized extraction wound. Small bowel specimens were extracted via a 12-mm port hole, without extension. Mean operating time was 240 min (range 100-510 min). Mean time to discharge was 4 days (range 4-6 days). Complications included a superficial wound infection in a patient presenting with an obstructed tumour and a second patient developed a seroma following small bowel resection for an incarcerated hernia.

CONCLUSION

Obese patients can undergo laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES surgery and benefit from short length of stay and low morbidity.

Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique

BACKGROUND

In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer.

METHODS

Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented.

RESULTS

Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points.

CONCLUSIONS

PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.

Colorectal resection via natural orifice specimen extraction versus conventional laparoscopic extraction: a meta-analysis with meta-regression

BACKGROUND

Studies have shown differences in postoperative outcomes between two minimally invasive extraction methods for colorectal lesions-natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLS). The aim of this study was to discover the major differences in NOSES and CLS to refine current practice.

METHODS

Electronic databases were searched for articles comparing NOSES and CLS from inception till March 2020. Weighted mean differences (WMD) and odds ratio (OR) were estimated for continuous and dichotomous outcomes, respectively. Summary statistics were calculated using the DerSimonian and Laird random effects.

RESULTS

Twenty-one studies (15 on malignant disease, 4 on benign disease, 2 on both) were included in this meta-analysis, totalling 2378 patients (1079 NOSE, 1299 CLS). NOSE was associated with decreased: intraoperative bleeding (WMD: - 10.652 ml; 95% CI: - 18.818 ml to - 2.482 ml; p < 0.001), pain score (WMD: - 1.520; 95% CI - 1.965 to - 1.076; p < 0.001), time to flatus (WMD: - 0.306 days; 95% CI: - 0.526 to - 0.085 days; p < 0.001), length of hospital stay (WMD: - 1.048 days; 95% CI: - 1.488 to - 0.609 days; p < 0.001), and total morbidity (OR: 0.548; 95% CI: 0.387 to 0.777; p = 0.001). Subgroup analyses showed significant differences between malignant and benign lesions for intraoperative bleeding (p = 0.011) and pain score (p = 0.010). Meta-regression analyses showed an association between the American Society of Anaesthesiologists (ASA) physical status classification III with pain (p = 0.03) and ASA III with time to flatus (p = 0.04).

CONCLUSIONS

This meta-analysis and meta-regression demonstrated that NOSES had better postoperative outcomes compared to CLS. More comprehensive reviews should be conducted on the long-term outcomes specific to the extraction site to better inform clinical practice.

Meta-analysis of laparoscopic anterior resection with natural orifice specimen extraction (NOSE-LAR) versus abdominal incision specimen extraction (AISE-LAR) for sigmoid or rectal tumors

BACKGROUND

Natural orifice specimen extraction surgery is a novel technique of minimally invasive surgery. The purpose of this study was to compare the safety of laparoscopic anterior resection with natural orifice specimen extraction (NOSE-LAR) and abdominal incision specimen extraction (AISE-LAR) for sigmoid or rectum tumors.

METHODS

MEDLINE (PubMed), Embase, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus, and ClinicalTrials databases were systematically searched for related articles up to August 2019. The primary outcomes included postoperative complications (overall postoperative complication, incision-related complication, anastomotic fistula, and severe complication) and pathologic results (lymph nodes harvested, proximal resection margin, and distal resection edge). The statistical analysis was performed on STATA 12.0 software.

RESULTS

Ten studies comprising 1787 patients were used for meta-analysis. Compared with AISE-LAR, NOSE-LAR had more advantages in terms of overall postoperative complication (odds ratio (OR) = 0.65 (95% CI, 0.46 to 0.90; P = 0.01)), incision-related complication (OR = 0.13 (95% CI, 0.05 to 0.35; P < 0.01)), distal resection edge (weighted mean difference (WMD) = 0.17 cm (95% CI, 0.02 to 0.33 cm; P = 0.02)), recovery of gastrointestinal function (WMD = - 0.38 day (95% CI, - 0.70 to - 0.06 day; P = 0.02 )), pain scores in postoperative day 1 (WMD = - 1.64 (95% CI, - 2.31 to - 0.98; P < 0.01)), additional analgesics usage (OR = 0.21 (95% CI, 0.11 to 0.40; P < 0.01)) and hospital stay (WMD = - 0.71 day (95% CI, - 1.10 to - 0.32 day; P < 0.01)), while the operation time of NOSE-LAR was prolonged (WMD = 7.4 min (95% CI, 0.17 to 14.64 min; P = 0.04)). The anastomotic fistula, severe complication, lymph nodes harvested, proximal resection margin, intraoperative blood loss, and long-term outcomes in NOSE-LAR were comparable with AISE-LAR.

CONCLUSIONS

The safety of NOSE-LAR was demonstrated, and it could be an alternative to conventional surgery in laparoscopic anterior resection for sigmoid and rectal tumors. However, further randomized and multi-center trials are required.

Minimally invasive right colectomy with transrectal natural orifice extraction: could this be the next step forward?

Background

The transvaginal natural orifice specimen extraction (NOSE) approach for right-side colon surgery has been proven to exhibit favorable short-term outcomes. However, thus far, no study has reported the advantages of transrectal NOSE for right-side colon surgery. The aim of this study was to compare the technical feasibility, safety, and short-term outcomes of minimally invasive right hemicolectomy using the transrectal NOSE method and those of conventional mini-laparotomy specimen extraction.

Methods

A study was conducted on consecutive patients who had minimally invasive right hemicolectomy either for malignancy or benign disease at Chang Gung Memorial Hospital, Linkou, Taiwan, between January 2017 and December 2018. The patients were divided into two groups: conventional surgery with specimen extraction using mini-laparotomy and NOSE surgery. Surgical outcomes, including complications, postoperative short-term recovery, and pain intensity, were analyzed.

Results

We enrolled 297 patients (151 males, mean age 64.9 ± 12.8 years) who had minimally invasive right hemicolectomy. Of these 297 patients, 272 patients had conventional surgery with specimen extraction through mini-laparotomy and 25 patients had NOSE surgery (23 transrectal, 2 transvaginal). The diagnosis of colon disease did not differ significantly between the conventional and NOSE groups. Postoperative morbidity and mortality rates were comparable. The postoperative hospital stay was significantly (p = 0.004) shorter in the NOSE group (median 5 days, range 3–17 days) than in the conventional group (median 7 days, range 3–45 days). Postoperative pain was significantly (p = 0.026 on postoperative day 1 and p = 0.002 on postoperative day 2) greater in the conventional group than in the NOSE group.

Conclusions

NOSE was associated with acceptable short-term surgical outcomes that were comparable to those of conventional surgery. NOSE results in less postoperative wound pain and a shorter hospital stay than conventional surgery. Larger studies are needed

Can transanal natural orifice specimen extraction after laparoscopic anterior resection for colorectal cancer reduce the inflammatory response?

BACKGROUND AND AIM

Avoiding abdominal incisions is one of the unique features of natural orifice specimen extraction (NOSE) surgery. There has been no consensus on whether the avoidance of abdominal incisions can reduce the systemic inflammatory response after NOSE surgery. This study was designed to evaluate the safety and feasibility of transanal NOSE, especially the inflammatory response after transanal NOSE versus mini-laparotomy (LAP).

METHODS

A total of 172 colorectal cancer patients who underwent transanal NOSE were matched with 172 patients who underwent LAP for colorectal cancer. Clinical characteristics, pathological features, perioperative parameters, and indicators of the inflammatory response were collected and compared. The inflammatory response was assessed by measuring body temperature, neutrophil count, C-reactive protein levels, and procalcitonin levels.

RESULTS

Patients in the NOSE group had better short-term outcomes, such as lower incidence of wound infection, less postoperative pain, less need for anesthetic drugs, and faster recovery of intestinal function. Regarding the inflammatory response, the average body temperature of patients in the NOSE group was higher on postoperative day (POD) 2 than that in the LAP group. A higher median neutrophil count and C-reactive protein levels were observed in the NOSE group on POD3 and POD5 than was observed in the LAP group.

CONCLUSIONS

Transanal NOSE is safe and feasible for colorectal cancer, with better short-term outcomes. Although transanal NOSE produced a larger systemic inflammatory response than LAP in the early postoperative stages, this response did not appear to translate into infectious morbidity.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer

Background

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL).

Methods

A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire.

Results

A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups.

Conclusions

Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

Natural orifice specimen extraction with a modified reverse puncture device technique for total laparoscopic colorectal resection: feasibility and efficacy

Objective: To evaluate the feasibility and efficacy of the modified reverse puncture device (mRPD) technique for transanal anastomosis in total laparoscopic colorectal resection with natural orifice specimen extraction surgery (NOSES).Methods: From August 2015 to September 2017, 34 patients underwent laparoscopic colorectal resection using the mRPD technique to place the anvil in the abdominal cavity and complete transanal anastomosis.Results: All patients who underwent total laparoscopic colorectal resection with NOSES were analyzed. The anvil placement time was 5-14 min, with an average of 6.7 min. The postoperative pain visual analogue scale (VAS) score was 1-4 points, with an average of 2.2 points. The postoperative hospital stay was 7-13 days, with an average of 8.7 days. No complications, such as anastomotic bleeding or stenosis, occurred. During a 14- to 28-month follow-up period (average, 19.5 months), no cases of long-term complications were observed.Conclusion: Total laparoscopic colorectal resection using mRPD is a technically feasible and safe procedure with satisfactory short-term efficacy.

The Comparison of Laparoscopic Colorectal Resection with Natural Orifice Specimen Extraction versus Mini-Laparotomy Specimen Extraction for Colorectal Tumours: A Systematic Review and Meta-Analysis of Short-Term Outcomes

Aim

The aims of this study were to compare the short-term outcomes of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLAPS) for colorectal tumours and to evaluate the safety and feasibility of NOSES in colorectal resection.

Methods

A literature review was performed on the PubMed, Cochrane Library, and Embase databases up to March 2019. Papers conforming to the inclusion criteria were used for further analysis. The short-term outcomes included intraoperative outcomes and postoperative recovery results. The weighted mean difference (WMD) was calculated for continuous outcomes and odds ratio (OR) for dichotomous results. Study quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS) or the 6-item Jadad scale.

Results

Eight studies comprising 686 patients met the inclusion criteria. Compared with CLAPS, NOSES had more advantages in terms of postoperative complications, postoperative pain, recovery of gastrointestinal function, duration of hospital stay, and cosmetic results. The lymph nodes harvested and intraoperative blood loss in NOSES were comparable with CLAPS; however, a prolonged operative time was observed in NOSES.

Conclusions

NOSES was shown to be a safe and viable alternative to CLAPS in colorectal oncology in terms of short-term results. Further long-term and randomized trials are required.

Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis

Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.

Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.

Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.

Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.

Comparison of short-term and survival outcomes for transanal natural orifice specimen extraction with conventional mini-laparotomy after laparoscopic anterior resection for colorectal cancer

Background

Transanal natural orifice specimen extraction (NOSE) in colorectal surgery has been introduced as a less invasive surgery. However, its long-term survival effects remain controversial. The aim of this study was to compare the short-term and long-term survival outcomes of transanal NOSE with those of the conventional laparoscopic approach with mini-laparotomy (LAP) for anastomosis construction and specimen extraction in sigmoid colon cancer or rectal cancer.

Methods

From January 2007 to January 2018, a retrospective study was conducted at the China National Cancer Center. In total, 52 consecutive patients who underwent laparoscopic anterior resection with NOSE were matched with an additional 52 patients who underwent conventional LAP for colorectal cancer.

Results

Patients in the NOSE group experienced shorter time to passage of flatus (2.8±0.8 vs 3.2±0.9 days; p=0.042), less pain (4.2±1.4 vs 5.4±1.7; p=0.003) and less analgesia required (7.7% vs 25.0%; p=0.032). After a median follow-up of 68.5 (range, 8–83) months, the two groups had similar 5-year overall survival rates (92.3% vs 94.2%; p=0.985) and disease-free survival rates (84.6% vs 86.5%; p=0.802).

Conclusion

Transanal NOSE for total laparoscopic anterior resection is safe and feasible with more advantages, including lower pain, lower tissue trauma and faster recovery of intestinal function. Moreover, with proper protection of the surgical route, transanal NOSE has the same long-term outcomes as conventional laparoscopic surgery.

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer

In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.

Natural orifice specimen extraction in colorectal surgery: patient selection and perspectives

Over the past 30 years, colorectal surgery has evolved to include minimally invasive surgical techniques. Minimally invasive surgery is associated with reduced postoperative pain, reduced wound complications, earlier return of bowel function, and possibly shorter length of hospital stay. These benefits have been attributed to a reduction in operative trauma compared to open surgery. The need to extract the specimen in colorectal operations through a “mini-laparotomy” can negate many of the advantages of minimally invasive surgery. Natural orifice specimen extraction (NOSE) is the opening of a hollow viscus that already communicates with the outside world, such as the vagina or distal gastrointestinal tract, in order to remove a specimen. The premise of this technique is to reduce the trauma required to remove the specimen with the expectation that this may improve outcomes. Reduction in postoperative analgesic use, quicker return of bowel function, and shorter length of hospital stay have been observed in colorectal operations with NOSE compared to conventional specimen extraction. While the feasibility of NOSE has been demonstrated in colorectal surgery, failures of this technique have also been described. Selection of patients who can successfully undergo NOSE needs further investigation. This review aims to guide surgeons in appropriately selecting patients for NOSE in colorectal surgery. Patient and specimen characteristics are reviewed in order to define patient populations in which NOSE is likely to be successful. Randomized trials comparing NOSE to conventional specimen extraction in colorectal surgery tend to enroll patients with favorable characteristics (body mass index <30, American Society of Anesthesiologists class ≤3, specimen diameter <6.5 cm) and demonstrate improved outcomes. Adopters of NOSE should restrict using this technique to the populations in which feasibility has been defined in the literature. Wider application to other populations, particularly patients with body mass index >30 and those with significant comorbidities, requires further study.

Left colon resection with transrectal specimen extraction: current status

BACKGROUND

Full laparoscopic left colectomy with transrectal specimen extraction is proposed as an improvement of the minimally invasive surgical technique. This paper reviews in detail the current status of left-sided colectomy and upper rectum resection with transrectal specimen extraction.

METHODS

A systematic review was performed of all types of publications on colorectal resection with natural orifice specimen extraction (NOSE). We only included studies reporting on left colectomy, sigmoidectomy, and high anterior resection with transrectal specimen extraction (TRSE), excluding transanal (TASE), transvaginal, or transcolonic specimen extraction. Surgical techniques, patient characteristics, and outcomes were reviewed in detail.

RESULTS

Thirty-five papers reported on TRSE (2 randomized clinical trials, 7 case-matched series, 19 case series, 5 case reports, and 2 articles on surgical technique). We found a wide variety of innovative anastomotic and specimen extraction techniques. After excluding duplicates and papers reporting mixed TRSE and TASE results, outcomes in patients undergoing TRSE from 23 publications showed a conversion rate to conventional laparoscopy of 3.7% (21/559), overall morbidity 9.5% (53/559) [major in 2.9% (16/559), intra-abdominal infection in 2.1% (12/559)]. No mortality was reported. Postoperative anal incontinence was rarely reported. Several studies showed a decrease in postoperative pain and some in length of hospital stay.

CONCLUSIONS

Colectomy with TRSE is feasible and seems safe in selected patients. Reported outcomes seem in general similar to conventional laparoscopic colectomy with a possible benefit in postoperative pain and length of hospital stay. Obvious selection bias and lack of high quality trials do not allow firm conclusions to be drawn.

Long-term outcomes after Natural Orifice Specimen Extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study

Purpose

The aim of this study was to compare the long-term outcomes of total laparoscopic surgery with Natural Orifice Specimen Extraction (NOSE) with those for conventional laparoscopy (CL)-assisted surgery for treating rectal cancers.

Methods

We reviewed the prospectively collected records of 844 patients (163 NOSE and 681 CL) who underwent curative surgery for mid- or upper rectal cancers from January 2006 to November 2012. We applied propensity score analyses and compared oncological outcomes for the NOSE and CL groups in a 1:1 matched cohort.

Results

After propensity score matching, each group included 138 patients; the NOSE and CL groups did not differ significantly in terms of baseline clinical characteristics. The median follow-up was 57.7 months (interquartile range, 42.4–82.5 months). The combined 5-year local recurrence rate for all tumor stages was 4.1% (95% confidence interval [CI], 0.9%–7.4%) in the NOSE group and 3.0% (95% CI, 0%–6.3%) in the CL group (P = 0.355). The combined 5-year disease-free survival rates for all stages were 89.3% (95% CI, 84.3%–94.3%) in the NOSE group and 87.3% (95% CI, 81.8%–92.9%) in the CL group (P = 0.639). The postoperative mean fecal incontinence scores at 6, 12, and 24 months were similar between the 2 groups.

Conclusion

In our experience, NOSE for mid- and upper rectal cancer had acceptable long-term oncologic outcomes comparable to those of conventional minimal invasive surgery and seems to be a safe alternative to reduce access trauma.

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Background

Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy.

Methods

A systematic literature search was performed to identify RCTs and non- RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals.

Results

Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (−0·75, 95 per cent c.i. −1·09 to −0·42; P = 0·001) and on POD 2–4 (−0·58, −0·91 to −0·26; P &lt; 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P &lt; 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P &lt; 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P &lt; 0·001).

Conclusion

Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

Success rate of natural orifice specimen extraction after laparoscopic colorectal resections

PURPOSE

To date, no data have been available to inform which cases are appropriate for natural orifice specimen extraction (NOSE) after laparoscopic colorectal resections (LCRRs). Our aim was to evaluate the success rate and the factors affecting the failure in patients who were scheduled for NOSE after LCRRs.

METHODS

Seventy-two consecutive cases that were intended for NOSE after LCRR were enrolled. The transanal route was always chosen as the first option, and when it failed, the transvaginal route was tried in female patients. If both failed, the specimen was judged as unsuitable for NOSE and removed through an abdominal wall incision. Demographic data, surgical indications, resection localization, implemented procedures, incision sites, specimen extraction methods, specimen sizes, and failures of NOSE were recorded.

RESULTS

A total of 349 colorectal resections (240 open and 109 laparoscopic) in a 3-year period were examined. The subset of 72 consecutive patients who met the criteria were analyzed. Five cases required a conversion to open surgery during resections. In the remaining 67 patients, NOSE after LCRR was successful in 49 cases (73.1%) but failed in 18 (26.9%). Specimens were extracted from transanal and transvaginal routes in 37 (75.5%) and 12 (24.5%) patients, respectively. The failure rate of NOSE after LCRR was higher in males, in colonic lesions, and in large-sized tumors. The mean sizes of transanal and transvaginal extracted specimens were 3.5 ± 3.1 and 5.4 ± 1.4 cm, respectively (p < 0.05). The mean size of the tumors in the failed cases was 6.5 ± 4.2 cm (p < 0.05).

CONCLUSIONS

Approximately 2/3 of the unselected LCRRs were suitable for NOSE. The success rate increased with female gender, small-sized tumors, and rectal resections.

Natural Orifice Specimen Extraction With Single Stapling Colorectal Anastomosis for Laparoscopic Anterior Resection: Feasibility, Outcomes, and Technical Considerations

BACKGROUND

Double and triple stapling techniques to close the rectal stump in laparoscopic anterior resection are fraught with technical drawbacks that could possibly be avoided with the use of the single stapling technique. However, little is known of its safety in laparoscopic surgery or outcomes when combined with natural orifice specimen extraction.

OBJECTIVE

This study aims to analyze the feasibility and the operative and immediate postoperative outcomes of single-stapled anastomosis and natural orifice specimen extraction with conventional techniques. It intends to evaluate technical variations related to colon, mesentery, and pelvic anatomy characteristics.

DESIGN AND PATIENTS

A consecutive series of 188 patients underwent elective surgery for benign or malignant lesions between 10 and 40 cm from the anal verge, 5 cm or less in diameter on radiological examination, stage T1 to T3, Nx, M0, with 2 different methods of rectal stump closure (pursestring vs linear-stapled closure) associated with single or double stapling and per anus vs conventional specimen extraction.

SETTING

This study was conducted at China Medical University Hospital, Taiwan, a tertiary referral center, between January 2012 and April 2015.

MAIN OUTCOME MEASURES

The main outcomes measured are feasibility and operative and immediate postoperative outcomes.

RESULTS

Single-stapled resection with natural orifice specimen extraction was feasible in 94% patients with an 11% perioperative morbidity rate. The patients required statistically significantly less analgesia, had earlier return of bowel movements, and shorter hospital stay, whereas there was no statistically significant difference in the overall readmission rate and overall morbidity, including anastomotic leakage.

LIMITATIONS

This was a single-center, retrospective case-matched study.

CONCLUSION

Anatomic variations (short colon and short mesentery) can be managed adequately with intracorporeal anvil head fixation. The single stapling technique is feasible and as safe as conventional double stapling techniques, although it is technically more demanding. The transanal endoscopic operation platform can be useful when the rectal stump is long.

Endoluminal Therapy in Colorectal Cancer

Appropriate endoscopic resection for colorectal polyps can present a challenge to endoscopists, as these lesions may harbor malignancy. With recent advances in endoscopy, however, we are now entering an exciting frontier of endoscopic therapy for gastrointestinal lesions. These techniques include endoluminal mucosal resection and endoscopic submucosal dissection, which may be utilized on several colonic lesions. This article will discuss these principle endoscopic techniques, their outcomes, and briefly highlight their influence on endoscopic interventions, including transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery.

Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis

PURPOSE

We wished to determine the effects of laparoscopic resection using natural orifice specimen extraction (NOSE) for patients with colorectal disease through a meta-analysis.

METHODS

A study search was undertaken in PubMed, EMBASE, and Cochrane databases for eligible studies until December 2014. Duration of hospital stay, operation time, time to first flatus, pain score, cosmetic result, postoperative complications, and disease-free survival (DFS) were the main endpoints. The results were analyzed using RevMan v5.3.

RESULTS

Nine clinical studies involving 837 patients were included for final analyses. Laparoscopic resection with NOSE had a shorter duration of hospital stay (weighted mean difference (WMD) = -0.62 days, 95 % confidence interval (CI) [-0.95, -0.28], p < 0.01) and time to first flatus (WMD = -0.59 days, 95 % CI [-0.78, -0.41], p < 0.01), less postoperative pain (WMD = -1.43, 95 % CI [-1.95, -0.90], p < 0.01), and postoperative complications (odds ratio (OR) = 0.51, 95 % CI [0.36, 0.74], p < 0.01) with better cosmetic result (WMD = 1.37, 95 % CI [0.59, 2.14], p < 0.01). However, the operation time was significantly longer in the NOSE group (WMD = 20.97 min, 95 % CI [4.33, 37.62], p = 0.01). No significant difference was observed in DFS (hazard ratio (HR) = 0.88, 95 % CI [0.49, 1.57], p = 0.67).

CONCLUSION

Our meta-analysis supported the notion that laparoscopic resection with NOSE for colorectal disease can significantly reduce the duration of hospital stay, accelerate postoperative recovery with better cosmetic results, and in particular, result in less postoperative pain and fewer complications.