The transvaginal hybrid NOTES versus conventionally assisted laparoscopic sigmoid resection for diverticular disease (TRANSVERSAL) trial: study protocol for a randomized controlled trial

Long-Term Outcome Comparison Between Two Specimen Extraction Approaches for Middle Rectum Cancer: A Retrospective Study

Objective. There are few studies comparing the long-term results of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic-assisted resection (LA) in the treatment of middle rectal cancer. This retrospective analysis aimed to evaluate the reliability of NOSES. Method. From January 2013 to December 2017, all patients diagnosed with median rectal cancer in our hospital who underwent NOSES and LA were enrolled. We used propensity-score matching (PSM) to balance baseline data between the NOSES group and the laparoscopic group. The primary endpoint was overall survival (OS) and disease-free survival (DFS). We used the Kaplan-Meier method to estimate OS and DFS. Student's t-test was used to analyze the difference of continuous data. Categorical data were compared using the Kruskal-Wallis test or Fisher's exact test. Results. After PSM, 38 patients were included in each group. We found that surgical bleeding volume in the NOSES group was considerably lower than that in the LA group (49.5 ± 47.5 mL vs. 86.3 ± 83.5 mL, P = .01). From the short-term results, the first flatus and regular diet time in the NOSES group were shorter than those in the LA group (41.3 ± 25.2 vs. 54.0 ± 19.2 hours, P < .01 and 63.9 ± 42.6 hours vs. 105.1 ± 66.8 hours, P < .01, respectively). Long-term OS and DFS were not different between the groups. Conclusion. Therefore, NOSES is a reliable technique for middle rectal cancer treatment. Short-term outcomes are pointedly better than LA, while the two surgical approaches did not differ in the long-term outcomes or complication rate.

Natural Orifice Specimen Extraction Surgery versus Conventional Laparoscopic-Assisted Resection in the Treatment of Colorectal Cancer: A Propensity-Score Matching Study

Background

Natural orifice specimen extraction surgery (NOSES) has been successfully applied to the treatment of gastric, colorectal cancer (CRC). However, the development of NOSES is still in the exploratory stage, and there is still no strong evidence-based medical evidence.

Patients and Methods

From January 2013 to June 2017, consecutive patients with colorectal cancer who underwent transluminal resection, anastomosis, and specimen extraction and those who underwent conventional laparoscopic resection were enrolled. Propensity score matching was used to align clinicopathological features between the two groups.

Results

A total of 372 patients were eventually included in this study, 186 in each group. According to perioperative information and postoperative follow-up in both groups, the NOSES group had less blood loss (P = 0.011), shorter time to recovery of gastrointestinal function (P < 0.001), shorter postoperative hospital stay (P = 0.037). The NOSES group had fewer postoperative analgesics (P < 0.001), lower postoperative pain scores (P < 0.001), and lower incidence of postoperative complications (P = 0.017). Compared with the LA (laparoscopic) group, the NOSES group had better physical function (P<0.05), role function (P<0.001), emotional function (P<0.001) and global health status than LA group, while symptoms such as pain (P<0.001), insomnia (P<0.001), constipation (P<0.001) and diarrhea (P<0.05) were less severe in the NOSES group. In addition, the NOSES group had higher body image scores. Overall survival (OS) and disease-free survival (DFS) were not significantly different between the two groups.

Conclusion

For surgical treatment of colorectal cancer, NOSES has advantages in reducing postoperative pain, recovery of gastrointestinal function, postoperative quality of life, and improving patients' satisfaction with abdominal wall aesthetics. There was no difference in long-term survival between NOSES and conventional laparoscopic surgery.

Transvaginal hybrid-NOTES vs. traditional laparoscopic sigmoid resection for diverticulitis: a short-term comparative study

The aim was to compare short-term results of transvaginal hybrid-NOTES (NSR) with traditional laparoscopic technique in sigmoid resection (LSR) in cases of diverticulitis. Natural Orifice Transluminal Endoscopic Surgery has been evolved as a minimally invasive procedure to reduce the operative trauma due to the absence of specimen extraction through the abdominal wall causing less postoperative pain, and shorter hospital stay. Despite the increasing use and published case series of NSR for diverticulitis as a laparoscopic procedure with transvaginal stapling and specimen extraction, there are no studies comparing this procedure with LSR. Twenty NSR patients operated at the Cologne-Merheim Medical Center have been documented and compared with 20 female LSR patients matched for body mass index, American Society of Anesthesiologists-classification (ASA), Hansen/Stock classification, and age. To ensure comparability regarding peri- and postoperative care, only procedures performed by the same surgeon were included. Procedural time, intra- and postoperative complications, conversion rate, postoperative pain, the duration of an epidural catheter, analgesic consumption, and postoperative length of hospital stay were analyzed. There were no significant differences in the sum of pain levels (p = 0.930), length of procedure (p = 0.079), intra- and postoperative complications, as well as duration of an epidural catheter. On the contrary, there were significant positive effects for NSR on morphine requirement at day seven and eight (p = 0.019 and p = 0.035 respectively) as well as the postoperative length of hospital stay (p = 0.031). This retrospective study reveals significant positive effects for NSR compared to LSR regarding length of hospital stay as well as morphine consumption after removal of the epidural catheter, whereas there were no significant differences in complication rate and procedural time. In summary, NSR is an adequate alternative to traditional laparoscopic sigmoid resection considering the surgeons experience and the patient’s personal preferences.

Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal

Currently, transvaginal natural orifice transluminal endoscopic surgery (NOTES), the most minimally invasive option for laparoscopic surgery, suffers various technological restraints limiting its implementation. We discuss a simple modification for vaginal access to improve the existing hybrid NOTES technique. We retrospectively studied 18 women at our rural hospital in central India, who, under defined criteria, underwent transvaginal appendicectomy using innovative strategically designed submucosal tunnels. The procedure was successfully completed in all but the first three cases. None required additional abdominal trocar or analgesia beyond the first 6 h. The mean operative and hospitalisation times were 27.5 min and 18.5 h, respectively. We had no intraoperative complications and only one patient experienced postoperative self-limiting vaginal spotting. All patients were very pleased with the cosmetic results and sexual life as assessed by locally devised scales. On regular follow-up, all were progressing well. We recommend the method presented, as it is not only feasible and safe but has the potential to improve overall results. Clearly, a larger volume randomised trial would be optimal to confirm our conclusion.

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.

Hysterectomy and salpingo-oophorectomy by transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) assisted by an umbilical camera: Case report and new hybrid technique in gynecology

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Hybrid-Natural orifice transluminal endoscopic surgery (NOTES) makes us to perform NOTES more safer with the direct visualization of the abdominal cavity.

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Hybrid NOTES can lesser the exclusion criterias for NOTES.

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Hybrid NOTES can lesser the complications; by capability of seeing all the major structures such as ureters, uterine vessels, bowels and pelvic adhesions.

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) is a new development in the field of minimally invasive surgery. The aim of this study was to demonstrate a new hybrid NOTES technique in gynecology which can be used for hysterectomy and salpingo-oophorectomy in patients with adnexal pathology and multiple operation histories.

Presentation of case

A 50-year-old woman with gravida 2 para 2 was referred to our clinic with left-sided abdominal pain. She had a history of two previous abdominal surgeries and a persistent ovarian cyst for 2 years. An ultrasound examination revealed a left complex hypoechoic ovarian cyst of 10 cm. Tumor markers were normal and the patient had no suspicion for malignancy. The hybrid NOTES technique assisted by an umbilical camera was planned due to the possibility of pelvic adhesions and her concerns about cosmesis.

Discussion

The major difference between NOTES and umbilical camera assisted NOTES is seeing all of the major structures, such as the ureters, uterine vessels, bowels, and pelvic adhesions, which can lead to complications during the surgery. In fact, hybrid NOTES can make surgeries more feasible.

Conclusion

This new hybrid NOTES offers effective and safer surgical management in patients who have had previous surgery and adnexal masses.

Feasibility and Technique for Transvaginal Natural Orifice Transluminal Endoscopic Surgery Liver Resection: A Porcine Model

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).

MATERIALS AND METHODS

Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.

RESULTS

Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.

CONCLUSIONS

Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.

Reliability and validity of the Chinese version of the Liver Disease Quality of Life Questionnaire (LDQOL 1.0)

AIM: To evaluate the reliability and validity of Chinese version of Liver Disease Quality of Life Questionnaire (LDQOL 1.0)

METHODS: This was an observational, cross-sectional study in Chinese patients from Beijing University Shenzhen Hospital. Feasibility was assessed by analyzing administration times and missing responses. Ceiling and flooring effects were calculated and reliability was tested by examining internal consistency (Cronbach's alpha). Convergent validity was tested by examining correlations between LDQOL disease specific and Short Form health survey with 36 questions (SF-36) dimensions.

RESULTS: A total of 48 patients were included for analysis. Mean age was 39.3 years and 73% of the sample were male. Mean time to complete questionnaire was 35.8 min ±12.2 min. Missing responses were highest on the dimensions of sexual functioning. Ceiling effects were over 20% on 1 of the LDQOL's 12 disease-specific scales. Cronbach's alpha coefficients were over 0.70 on all but 6 dimensions. Correlations between SF-36 and LDQOL disease-specific dimensions generally fulfilled the hypotheses.

CONCLUSION: The Chinese version of the LDQOL 1.0 has shown satisfactory reliability and validity.