Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer Using Natural Orifice Specimen Extraction Techniques

Comparison of the safety and efficacy of robotic natural orifice specimen extraction surgery and conventional robotic colorectal cancer resection: a propensity score matching study

Robotic resection is widely used to treat colorectal cancer. Although the novel natural orifice specimen extraction surgery (NOSES) results in less trauma, its safety and effectiveness are relatively unknown. In the present study, we used propensity score matching to compare the effectiveness and safety of NOSES and robotic resection for treating colorectal cancer. Present retrospective cohort study included patients who underwent robotic colon and rectal cancer surgery between January 2016 and December 2019 at the Department of Gastrointestinal Surgery, the Second Xiangya Hospital of Central South University. The intraoperative time, intraoperative bleeding, postoperative recovery, postoperative complications, and survival status of the conventional robotic colorectal cancer resection (CRR) (78 patients) and NOSES (89 patients) groups were compared. These results showed that no significant differences were observed between the two groups in terms of early postoperative complications, operation time, and the number of lymph nodes dissected. Compared with the CRR group, NOSES group had shorter postoperative exhaust time [3.06 (0.76) vs. 3.53 (0.92)], earlier eating time [4.12 (1.08) vs. 4.86 (1.73)], lesser intraoperative bleeding [51.23 (26.74) vs. 67.82 (43.44)], lesser degree of pain [80.8% vs. 55.1%], and shorter length of hospital stay [8.73 (2.02) vs. 9.50 (3.45)]. All these parameters were statistically significant (P < 0.05). However, no significant differences were observed in the 3-year overall survival rate and disease-free survival rate between both groups (P > 0.05). Collectively, robotic NOSES is a safe and effective approach for treating rectal and sigmoid colon cancers, could decrease intraoperative bleeding and postoperative complications, and accelerate the speed of intestinal function recovery.

A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

Background

Laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.

Methods

The study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.

Results

Upper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.

Conclusions

NOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01290-4.

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

Laparoscopy-Assisted Natural Orifice Specimen Extraction to Treat Tumors of the Sigmoid Colon and Rectum: The Short- and Long-Term Outcomes of a Retrospective Study

Background: Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum. Methods: Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15-30 cm), Group 2 (5-15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured. Results: In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction. Conclusions: NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

Outcomes of trans-anal natural orifice specimen extraction combined with laparoscopic anterior resection for sigmoid and rectal carcinoma: An observational study

Colorectal carcinoma is currently the third most frequent cancer worldwide. Conventional open surgery was replaced by laparoscopic anterior resection with total mesorectal excision for the treatment of sigmoid and rectal carcinomas; however, it needed an incision to harvest the specimen, which contributed to complications. In 2013, trans-anal natural orifice specimen extraction laparoscopic anterior resection (Ta-NOSE-LAR) to treat sigmoid and rectal carcinoma was performed in our hospital for the first time. The aim of this study was to investigate the outcomes of Ta-NOSE-LAR in sigmoid and rectal carcinoma.Seventy-three patients diagnosed with sigmoid and rectal carcinoma were enrolled between September 2013 and June 2016. Thirty-five patients underwent Ta-NOSE-LAR, whereas the others underwent traditional laparoscopic anterior resection (LAR). We compared the operative data, postoperative complications, pathological evaluation results, and incision-related complications between the 2 groups.Our result showed that the operative time, specimen length, tumor size, amount of total lymph nodes, and lymph node metastasis between the 2 groups were not statistically different. Further, without abdominal scaring for harvesting the specimen, the operative blood loss (49.29 ± 14.63 vs 69.29 ± 13.54 mL, P < .001) and post-operation hospital stay (5.77 ± 0.94 vs 6.76 ± 0.75 days, P < .001) of the Ta-NOSE-LAR group were less than those of the LAR group. Besides, the follow-up data showed that 2 patients were lost to follow-up, and 1 patient had liver metastasis 2 years after surgery in the LAR group, whereas the others showed no regional recurrence, distant metastases, or critical complications.Ta-NOSE-LAR is a valuable and alternative surgical method to treat sigmoid and rectal carcinoma, with the advantages of being a scarless procedure and having a lower post-operation hospital stay duration.

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.