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Haas EM, Secchi Del Rio R, Reif de Paula T, Margain Trevino D, Presacco S, Hinojosa-Gonzalez DE, Weaver M, LeFave JP. The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis. Surg Endosc 2024; 38:390-399. [PMID: 37803185 DOI: 10.1007/s00464-023-10452-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/06/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018. METHODS A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes. RESULTS From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates. CONCLUSION When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.
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Affiliation(s)
- Eric M Haas
- Houston Methodist Hospital, Houston, TX, USA.
- HCA Gulf Coast Division, Houston, TX, USA.
- Houston Colon PLLC, Houston, TX, USA.
| | | | | | | | | | | | - Matthew Weaver
- HCA Gulf Coast Division, Houston, TX, USA
- Houston Colon PLLC, Houston, TX, USA
| | - Jean-Paul LeFave
- Houston Methodist Hospital, Houston, TX, USA
- Houston Colon PLLC, Houston, TX, USA
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Haas EM, Reif de Paula T, Ortiz de Elguea-Lizarraga JI, Secchi del Rio R, Maciel V, Schulberg S, Le-Fave JP. Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases. Surg Endosc 2023:10.1007/s00464-023-09973-0. [PMID: 37002495 DOI: 10.1007/s00464-023-09973-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 02/21/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis. METHODS Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications. RESULTS Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578). CONCLUSION Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.
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Xu SZ, Ding ZJ, Zhang SF, Yuan SB, Yan F, Wang ZF, Liu GY, Cai JC. Clinical outcomes of laparoscopic-assisted natural orifice specimen extraction colectomy using a Cai tube for left-sided colon cancer: a prospective randomized trial. Surg Endosc 2023; 37:749-758. [PMID: 35906459 DOI: 10.1007/s00464-022-09435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 07/03/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The role of laparoscopic-assisted natural orifice specimen extraction (LA-NOSE) colectomy in the treatment of left-sided colon cancer has not been well defined, and there remains confusion about how to conveniently exteriorize specimens through natural orifices. Therefore, we introduced a homemade invention, the Cai tube, to facilitate the extraction of specimens and compared the clinical outcomes of LA-NOSE with conventional laparoscopic (CL) colectomy for left-sided colon cancer. METHODS From March 2015 to August 2017, patients with left-sided colon cancer were randomly divided into LA-NOSE and CL groups. Specimens were extracted through the anus with the help of a Cai tube (Patent Number: ZL201410168748.2) in the LA-NOSE group. The primary outcome measure was postoperative pain. Secondary outcomes were the duration of operation, postoperative recovery, surgical morbidity, pathological quality of the specimen, and long-term outcomes, including 3-year overall survival, disease-free survival, local recurrence, and overall recurrence. RESULTS A total of 60 patients (30 per group) were recruited for this study. None of the patients required emergency conversion to conventional laparoscopic or open surgery during the operation. The postoperative maximum pain score was significantly lower in the LA-NOSE group (mean 2.5 vs. 5.1, P = 0.001), as was the additional analgesia requirement (mean 2/30 vs. 10/30, P = 0.021). Patients in the LA-NOSE group experienced a shorter first time to passage of flatus (mean 2.2 vs. 3.1 days, P = 0.026). All patients could control their defecation at 6 months after surgery. The comparison between the two groups showed no significant differences in the operative time, bleeding volume, postoperative hospital stay, surgical morbidity rates, number of lymph nodes harvested, or resection margin status. The mean follow-up was 48 months (range 7-59) and was similar in both groups. The results showed no differences in long-term outcomes between the two groups. CONCLUSION In the treatment of left-sided colon cancer, compared with conventional laparoscopic colectomy, LA-NOSE colectomy using the Cai tube exhibited lower postoperative pain, shorter recovery of gastrointestinal function, and similar long-term outcomes. REGISTRATION NUMBER ChiCTR-OOR-15007060 ( http://www.chictr.org.cn/ ).
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Affiliation(s)
- Shu-Zhen Xu
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Zhi-Jie Ding
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Shi-Feng Zhang
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Si-Bo Yuan
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Feng Yan
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Zhen-Fa Wang
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Guo-Yan Liu
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China
| | - Jian-Chun Cai
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China. .,Institute of Gastrointestinal Oncology, Medical College of Xiamen University, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China. .,Xiamen Municipal Key Laboratory of Gastrointestinal Oncology, No. 201-209, Hubin South Road, Xiamen, 361004, Fujian, China.
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Haas EM, de Paula TR, Luna-Saracho R, Smith MS, De Elguea-Lizarraga JIO, del Rio RS, Edgcomb M, LeFave JP. The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients. Surg Endosc 2023; 37:683-691. [PMID: 36418639 PMCID: PMC9839785 DOI: 10.1007/s00464-022-09717-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach. METHODS Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate. RESULTS A total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site. CONCLUSION The NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.
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Affiliation(s)
- Eric M. Haas
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
- Houston Colon Foundation, Houston, TX USA
| | - Thais Reif de Paula
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
| | - Roberto Luna-Saracho
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
| | - Melissa S. Smith
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
- Houston Colon Foundation, Houston, TX USA
| | - Jose I. Ortiz De Elguea-Lizarraga
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
| | | | - Mark Edgcomb
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
- Houston Colon Foundation, Houston, TX USA
| | - Jean-Paul LeFave
- University of Houston College of Medicine, Chief Quality Colon and Rectal Surgery, HCA Healthcare Gulf Coast Division, 6560 Fannin Street, Houston, TX 77030 USA
- Houston Colon Foundation, Houston, TX USA
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5
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Muhammad S, Gao Y, Guan X, QingChao T, Fei S, Wang G, Chen Y, Liu Z, Jiang Z, Kaur K, Tatiana K, Ul Ain Q, Wang X, He J. Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients. J Int Med Res 2022; 50:3000605221134472. [PMID: 36440806 PMCID: PMC9712411 DOI: 10.1177/03000605221134472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 10/05/2022] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVE To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction. METHODS Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction. RESULTS The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient. CONCLUSION The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.
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Affiliation(s)
- Shan Muhammad
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - YiBo Gao
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Tang QingChao
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Shao Fei
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
| | - Guiyu Wang
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Yinggang Chen
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Kavanjit Kaur
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | | | - Qurat Ul Ain
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
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Guan X, Hu X, Jiang Z, Wei Y, Sun D, Wu M, Zhou H, Yao H, Song J, Wang G, Hu J, Ren M, Xu Q, Cai J, Peng J, Ma D, Zheng Y, He Q, Jiang B, Wang Z, Li T, Yan S, Chen L, Li T, Xiong Z, Chi P, Kang L, Yu G, Deng X, Zhang H, Xie M, Wei J, Gong H, Sun X, Zang W, Song Y, He P, Wen Z, Zhang C, Wang Y, Chen Y, Xie G, Li M, Yu S, Liu H, Pu M, Fu C, Wang X. Short-term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5055 patients. Sci Bull (Beijing) 2022; 67:1331-1334. [PMID: 36546264 DOI: 10.1016/j.scib.2022.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/14/2022] [Accepted: 04/05/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiyue Hu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Donghui Sun
- Department of Gastrointestinal and Anal Surgery, Jilin University First Hospital, Changchun 130021, China
| | - Miao Wu
- Department of Gastrointestinal Surgery, The Second People's Hospital of Yibin, Yibin 644000, China
| | - Haitao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hongliang Yao
- Department of Gastrointestinal Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Junmin Song
- Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Guiyu Wang
- Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, China
| | - Junhong Hu
- Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Mingyang Ren
- Department of Gastrointestinal Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Qing Xu
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200240, China
| | - Jianchun Cai
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen 361004, China
| | - Jian Peng
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Dan Ma
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yangchun Zheng
- Department of Gastrointestinal Surgery, Sichuan Cancer Hospital, Chengdu 610041, China
| | - Qingsi He
- Department of General Surgery, Shandong University Qilu Hospital, Jinan 250012, China
| | - Bo Jiang
- Department of Colorectal and Anal Surgery, Shanxi Cancer Hospital, Taiyuan 030013, China
| | - Zejun Wang
- Department of Gastrointestinal Surgery, The Affiliated Cancer Hospital of Guizhou Medical University, Guiyang 550008, China
| | - Taiyuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Su Yan
- Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining 810012, China
| | - Luchuan Chen
- Department of Gastrointestinal Surgery, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Tiegang Li
- Department of Gastrointestinal Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Zhiguo Xiong
- Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan 430079, China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Gang Yu
- Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao 266035, China
| | - Xiaodong Deng
- Department of Gastrointestinal Surgery, The Second People's Hospital of Yibin, Yibin 644000, China
| | - Hong Zhang
- Department of Colorectal Surgery, Shengjing Hospital of China Medical University, Shenyang 110022, China
| | - Ming Xie
- Department of Gastrointestinal Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563099, China
| | - Jianbao Wei
- Department of Gastrointestinal Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning 530011, China
| | - Hongyan Gong
- Department of Gastrointestinal Surgery, Yantaishan Hospital, Yantai 264008, China
| | - Xuejun Sun
- Department of General Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710065, China
| | - Weidong Zang
- Department of Gastrointestinal Surgery, Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Yongmao Song
- Department of Colorectal Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Peng He
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang 453100, China
| | - Zhengqi Wen
- Department of Surgical Oncology, First Affiliated Hospital of Kunming Medical University, Kunming 650032, China
| | - Chunxu Zhang
- Department of General Surgery, Hospital No. 988 of the Chinese People's Liberation Army Joint Support Force, Zhengzhou 450006, China
| | - Yusheng Wang
- Department of General Surgery, Jincheng People's Hospital, Jincheng 048026, China
| | - Yinggang Chen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen 518116, China
| | - Guangwei Xie
- Department of Gastrointestinal Surgery, Xuzhou Central Hospital, Xuzhou 221009, China
| | - Mingzhang Li
- Department of General Surgery, Baotou Central Hospital, Baotou 014042, China
| | - Shaojun Yu
- Department of Colorectal Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Haiying Liu
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, China
| | - Min Pu
- Department of Gastrointestinal and Hernia Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Chuangang Fu
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China.
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | -
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Wang K, Li W, Liu N, Cai J, Zhang Y. Safety and oncological outcomes of natural orifice specimen extraction surgery compared with conventional laparoscopic surgery for right hemicolectomy: a systematic review and meta-analysis. Updates Surg 2022; 74:833-842. [PMID: 35304899 DOI: 10.1007/s13304-022-01276-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/06/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Kang Wang
- Departments of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 361000, China.,Gastrointestinal Oncology Center of Xiamen University, Xiamen, 361000, China.,Medical College of Xiamen University, Xiamen, 361000, China
| | - Wenya Li
- Departments of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 361000, China.,Gastrointestinal Oncology Center of Xiamen University, Xiamen, 361000, China.,Medical College of Xiamen University, Xiamen, 361000, China
| | - Ningquan Liu
- Departments of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 361000, China.,Gastrointestinal Oncology Center of Xiamen University, Xiamen, 361000, China.,Medical College of Xiamen University, Xiamen, 361000, China
| | - Jianchun Cai
- Departments of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 361000, China. .,Gastrointestinal Oncology Center of Xiamen University, Xiamen, 361000, China. .,Medical College of Xiamen University, Xiamen, 361000, China.
| | - Yiyao Zhang
- Departments of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 361000, China. .,Gastrointestinal Oncology Center of Xiamen University, Xiamen, 361000, China. .,Medical College of Xiamen University, Xiamen, 361000, China.
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8
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Jong BK, Cheng CC, Hsu YJ, Chern YJ, Tsai WS, Hung HY, Liao CK, Yeh CY, Hsieh PS, You JF. Transrectal natural orifice specimen extraction in left hemicolectomy for tumours around the splenic flexure: Old wine in new bottles. Colorectal Dis 2022; 24:128-132. [PMID: 34601777 DOI: 10.1111/codi.15930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) has favourable short-term outcomes. However, NOSE is rarely adopted for left hemicolectomy procedures. This study aimed to review the feasibility, safety and short-term outcomes of transrectal NOSE in patients undergoing laparoscopic left hemicolectomy. METHOD All consecutive patients who underwent laparoscopic left hemicolectomy surgery with transrectal NOSE in a single institution between January 2018 and December 2020 were reviewed. Transrectal NOSE was performed with an enterotomy at the upper rectum. The specimen was brought out via a transanal endoscopic microsurgery scope inserted through the anus. A supplementary video demonstrates this technique. Surgical outcomes, including complications, postoperative short-term recovery and the level of pain intensity, are presented. RESULTS Twenty patients were reviewed. There were no immediate postoperative complications and no wound infections in these patients. The average time to tolerate a soft diet was 3.6 days, and the average postoperative hospital stay was 4.5 days. The average score on the numerical rating scale of postoperative pain was 3.0 on postoperative day 1. The median follow-up time was 23.5 months. CONCLUSION Laparoscopic left hemicolectomy with transrectal NOSE is a safe and feasible procedure that leads to early postoperative recovery and a short hospital stay.
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Affiliation(s)
- Bor-Kang Jong
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chung Cheng
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Jen Hsu
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yih-Jong Chern
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Sy Tsai
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Yuan Hung
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Chun-Kai Liao
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Yu Yeh
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Shiu Hsieh
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jeng-Fu You
- Colorectal Section, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
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9
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Brincat SD, Lauri J, Cini C. OUP accepted manuscript. BJS Open 2022; 6:6594734. [PMID: 35640267 PMCID: PMC9155237 DOI: 10.1093/bjsopen/zrac074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Svetlana Doris Brincat
- Correspondence to: Svetlana Doris Brincat, Department of Surgery, Mater Dei Hospital, Triq id-Donaturi tad-Demm, Msida, Malta (e-mail: )
| | - Josef Lauri
- Department of Mathematics and Statistics, University of Malta, Msida, Malta
| | - Charles Cini
- Department of Surgery, Mater Dei Hospital, Msida, Malta
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10
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Zhang H, Hu H, Huang R, Guan Z, Zheng M, Xu C, Li Z, Wang Y, Zhang W, Yu L, Jin Y, Tang Q, Wang G, Wang X. Natural orifice specimen extraction surgery versus conventional laparoscopic-assisted resection for colorectal cancer in elderly patients: a propensity-score matching study. Updates Surg 2021; 74:599-607. [PMID: 34370279 DOI: 10.1007/s13304-021-01143-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
Whether natural orifice specimen extraction surgery (NOSES) could provide beneficial effects in treating elderly patients is still under debate. The aim of the study was to compare the clinical outcomes of transanal NOSES with conventional laparoscopic-assisted resection (LA) in elderly colorectal cancer (CRC) patients. A retrospective analysis from the Second Affiliated Hospital of Harbin Medical University between 2013 and 2017 was performed. Outcomes related to surgery, body image, quality of life, anal function and long-term survival were compared between the two groups with the propensity-score matching (PSM) method. After PSM, 78 patients were successfully compared. Patients with NOSES had faster gastrointestinal function recovery (P = 0.028), less postoperative complications (P = 0.025), lower pain scores on days 1, 3 and 5 after surgery (P < 0.001). The body image score (P < 0.001) and cosmetic score (P < 0.001) were significantly higher in the NOSES group than the LA group at 1 month after surgery. Patients with NOSES posed better global health status (P < 0.001), role function (P = 0.009), emotional function (P = 0.011) and social function (P = 0.011) at 3 months after surgery. Moreover, NOSES showed non inferiority in anal function 6 months after surgery. No significant difference could be found regarding to overall survival (OS), disease-free survival (DFS), local recurrence (LR) and distant metastasis (DM). In elderly CRC patients, NOSES harbored favorable postoperative outcomes, excellent cosmetic properties and better quality of life. Besides, anal function and long-term outcomes of NOSES can be sure for elderly patients.
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Affiliation(s)
- Hao Zhang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hanqing Hu
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rui Huang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zilong Guan
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Mingyu Zheng
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chao Xu
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhengliang Li
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuliuming Wang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Weiyuan Zhang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Yu
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yinghu Jin
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qingchao Tang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guiyu Wang
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Cancer Hospital of University of Chinese Academy of Sciences, Hangzhou, China.
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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11
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Zhang ZY, Zhu Z, Zhang Y, Ni L, Lu B. A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer. BMC Surg 2021; 21:296. [PMID: 34140016 PMCID: PMC8212478 DOI: 10.1186/s12893-021-01290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Zhen-Yu Zhang
- Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Zhe Zhu
- Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Yuanyuan Zhang
- Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Li Ni
- Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Bing Lu
- Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China.
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12
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Chen MZ, Cartmill J, Gilmore A. Natural orifice specimen extraction for colorectal surgery: Early adoption in a Western population. Colorectal Dis 2021; 23:937-943. [PMID: 33226716 DOI: 10.1111/codi.15455] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/27/2020] [Accepted: 11/14/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
| | | | - Andrew Gilmore
- Macquarie University, North Ryde, NSW, Australia.,Liverpool Hospital, Liverpool, NSW, Australia.,Concord Hospital, Concord, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
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13
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Natural orifice versus conventional mini-laparotomy for specimen extraction after reduced-port laparoscopic surgery for colorectal cancer: propensity score-matched comparative study. Surg Endosc 2021; 36:155-166. [PMID: 33532930 DOI: 10.1007/s00464-020-08250-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although reduced port laparoscopic surgery (RPLS), defined as laparoscopic surgery performed with the minimum possible number of ports and/or small-sized ports, is less invasive than conventional laparoscopic surgery by reducing the number of surgical wounds, an extension of the incision is still needed for specimen extraction, which can undermine the merits of RPLS. OBJECTIVE To determine the impact of natural orifice specimen extraction (NOSE) in patients undergoing RPLS for colorectal cancer. The endpoints were perioperative outcome and oncologic safety at 3 years. SETTING Single-center experience (2013-2019). PATIENTS We retrospectively analyzed our prospectively collected patient records (American Joint Committee on Cancer (AJCC) stage I-III sigmoid or upper rectal cancer (tumor diameter ≤ 5 cm) who underwent curative anterior resection via RPLS. We excluded patients who did not undergo intestinal anastomosis. INTERVENTIONS Perioperative and oncologic outcomes were compared between patients undergoing natural orifice (RPLS-NOSE) or conventional (mini-laparotomy) specimen extraction (RPLS-CSE). Patients were matched by propensity scores 1:1 for tumor diameter, AJCC stage, American Society of Anesthesiologists score and tumor location. RESULTS Of 119 eligible patients, 104 were matched (52 RPLS-NOSE; 52 RPLS-CSE) by propensity scores. Compared with RPLS-CSE, RPLS-NOSE was associated with longer operative time (223.9 vs. 188.7 min; p = 0.003), decreased use of analgesics (morphine dose 33.9 vs. 43.4 mg; p = 0.011) and duration of hospital stay (4.2 vs. 5.1 days; p = 0.001). No statistically significant difference was found in morbidity or wound-related complication rates between the two groups. After a median follow-up of 34.3 months, no local recurrence was observed in RPLS-NOSE. The 3-year disease-free survival did not differ statistically significantly between groups (90.9 vs. 90.5%; p = 0.610). CONCLUSION NOSE enhances the advantages of RPLS by avoiding the need for abdominal wall specimen extraction in patients with tumor diameter ≤ 5 cm. Surgical and oncologic safety are comparable to RPLS with CSE.
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14
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The safety and efficacy of laparoscopic surgery versus laparoscopic NOSE for sigmoid and rectal cancer. Surg Endosc 2021; 36:222-235. [PMID: 33475847 DOI: 10.1007/s00464-020-08260-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
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.
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15
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Masubuchi S, Okuda J, Yamamoto M, Inoue Y, Tanaka K, Uchiyama K. Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study. Int J Surg Case Rep 2020; 78:204-209. [PMID: 33360631 PMCID: PMC7773675 DOI: 10.1016/j.ijscr.2020.12.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023] Open
Abstract
Now that laparoscopic surgery is widespread, minimally invasive surgery is desired. Natural orifice specimen extraction is minimally invasive surgery. Transanal specimen extraction and transvaginal specimen extraction. Natural orifice specimen extraction appears to be feasible and safe.
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.
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Affiliation(s)
- Shinsuke Masubuchi
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki 569-8686, Japan; Department of Gastroenterological Surgery, Hirakata City Hospital, Hirakata 573-1013, Japan.
| | - Junji Okuda
- Cancer Center, Osaka Medical College, Takatsuki 569-8686, Japan.
| | - Masashi Yamamoto
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki 569-8686, Japan.
| | - Yoshihiro Inoue
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki 569-8686, Japan.
| | - Keitaro Tanaka
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki 569-8686, Japan.
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki 569-8686, Japan.
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16
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Meta-analysis of natural orifice specimen extraction versus conventional laparoscopy for colorectal cancer. Langenbecks Arch Surg 2020; 406:283-299. [DOI: 10.1007/s00423-020-01934-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/10/2020] [Indexed: 12/14/2022]
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17
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Colorectal resection via natural orifice specimen extraction versus conventional laparoscopic extraction: a meta-analysis with meta-regression. Tech Coloproctol 2020; 25:35-48. [PMID: 32851500 DOI: 10.1007/s10151-020-02330-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/13/2020] [Indexed: 12/11/2022]
Abstract
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.
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He J, Yao HB, Wang CJ, Yang QY, Qiu JM, Chen JM, Shen Z, Yang GG. 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. World J Surg Oncol 2020; 18:215. [PMID: 32814583 PMCID: PMC7439723 DOI: 10.1186/s12957-020-01982-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/31/2020] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Jun He
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Hai-Bo Yao
- Departments of Gastroenterology & Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Chang-Jian Wang
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Qin-Yan Yang
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Jian-Ming Qiu
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Jin-Ming Chen
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Zhong Shen
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Guan-Gen Yang
- Department of Colorectal Surgery, Hangzhou Third Hospital, Hangzhou, 310009, Zhejiang, People's Republic of China.
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Long-term Oncologic Outcomes of Laparoscopic Anterior Resections for Cancer with Natural Orifice Versus Conventional Specimen Extraction: A Case-Control Study. Dis Colon Rectum 2020; 63:1071-1079. [PMID: 32692072 DOI: 10.1097/dcr.0000000000001622] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although the short-term advantages of natural orifice specimen extraction are widely recognized, controversy exists concerning oncologic safety after laparoscopic surgery for colorectal cancer. OBJECTIVE This study aimed to investigate the impact of natural orifice specimen extraction on local recurrence and long-term survival of patients undergoing colorectal cancer surgery. DESIGN This is a propensity score-matched comparative study. SETTING This study presents a single-center experience. PATIENTS We retrospectively analyzed the records of patients who underwent curative laparoscopic anterior resection for American Joint Committee on Cancer stage I to III sigmoid or upper rectal cancer in 2011 to 2014, based on prospectively collected data. INTERVENTIONS Oncologic outcomes were compared between patients undergoing natural orifice or conventional specimen extraction by minilaparotomy. Patients were matched 1:1 according to propensity scores calculated by logistic regression analysis with the following covariates: American Joint Committee on Cancer stage, tumor diameter, age, sex, BMI, and T stage. Cox proportional hazards regression analysis was performed to determine the impact on oncologic outcome. MAIN OUTCOME MEASURES The primary outcomes measured were local recurrence and disease-free survival rates at 5 years. RESULTS Of 392 eligible patients, 188 were matched (94 undergoing natural orifice specimen extraction and 94 undergoing conventional extraction by minilaparotomy). Median follow-up was 50.3 months. The cumulative local recurrence risk at 5 years was 2.3% and 3.5% (p = 0.632), whereas 5-year disease-free survival for all tumor stages combined was 87.3% and 82.0% (p = 0.383) in laparoscopic anterior resection with natural orifice specimen extraction and conventional extraction groups. T3 and T4 stages were the only variables independently associated with disease-free survival. LIMITATIONS This study was limited because it focused on a single center, was a retrospective analysis, contained no long-term anorectal function testing, and had a small sample size. CONCLUSION Long-term oncologic outcomes of patients undergoing laparoscopic anterior resection with natural orifice specimen extraction for sigmoid and upper rectal cancer do not differ from those undergoing conventional extraction. Thus, natural orifice specimen extraction could be a viable alternative to reduce abdominal wall insult in laparoscopic colorectal operations for malignancy in selected patients. See Video Abstract at http://links.lww.com/DCR/B241. RESULTADOS ONCOLÓGICOS A LARGO PLAZO DE RESECCIONES ANTERIORES LAPAROSCÓPICAS PARA CÁNCER A TRAVÉS DE ORIFICIO NATURAL FRENTE A EXTRACCIÓN CONVENCIONAL DEL ESPÉCIMEN: UN ESTUDIO DE CASOS Y CONTROLES: Si bien las ventajas a corto plazo de la extracción de especímenes por orificio natural son ampliamente reconocidas, existe controversia con respecto a la seguridad oncológica después de la cirugía laparoscópica para el cáncer colorrectal.Investigar el impacto de la extracción de especímenes por orificio natural en la recurrencia local y la supervivencia a largo plazo de pacientes sometidos a cirugía de cáncer colorrectal.Estudio comparativo con emparejamiento por puntuación de propensión.Experiencia en un centro único.Analizamos retrospectivamente los registros de pacientes que se sometieron a resección anterior laparoscópica curativa para cáncer sigmoideo o rectal superior AJCC en estadio I-III en 2011-2014, con base en datos recolectados prospectivamente.Los resultados oncológicos se compararon entre pacientes sometidos a extracción por orificio natural o convencional mediante minilaparotomía de especímenes. Los pacientes fueron emparejados 1:1 de acuerdo con los puntajes de propensión calculados por análisis de regresión logística con las siguientes covariables: estadio AJCC, diámetro del tumor, edad, sexo, índice de masa corporal y estadio T. Se realizó un análisis de regresión de riesgos proporcionales de Cox para determinar el impacto en el resultado oncológico.Recurrencia local y tasas de supervivencia libre de enfermedad a los 5 años.De 392 pacientes elegibles, 188 fueron emparejados (94 sometidos a extracción de espécimen por orificio natural y 94 a extracción convencional por minilaparotomía). La mediana de seguimiento fue de 50.3 meses. El riesgo cumulativo de recurrencia local a 5 años fue de 2.3% y 3.5% (p = 0.632), mientras que la supervivencia libre de enfermedad a 5 años para todas las etapas tumorales combinadas fue de 87.3% y 82.0% (p = 0.383) en los grupos de resección anterior laparoscópica con extracción de espécimen por orificio natural y extracción convencional, respectivamente. Las etapas T3 y T4 fueron las únicas variables asociadas independientemente con la supervivencia libre de enfermedad.Centro único, análisis retrospectivo, ausencia de pruebas de función anorrectal a largo plazo y tamaño de muestra pequeño.Los resultados oncológicos a largo plazo de los pacientes sometidos a resección anterior laparoscópica con extracción de espécimen por orificio natural para cáncer sigmoideo y rectal superior no difieren de los de aquellos sometidos a extracción convencional. Por lo tanto, la extracción de especímenes por orificio natural podría ser una alternativa viable para reducir el insulto a la pared abdominal en operaciones colorrectales laparoscópicas por malignidad en pacientes selectos. Consulte Video Resumen en http://links.lww.com/DCR/B241.
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Cheng CC, Hsu YR, Chern YJ, Tsai WS, Hung HY, Liao CK, Chiang JM, Hsieh PS, You JF. Minimally invasive right colectomy with transrectal natural orifice extraction: could this be the next step forward? Tech Coloproctol 2020; 24:1197-1205. [PMID: 32632708 PMCID: PMC7536150 DOI: 10.1007/s10151-020-02282-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/23/2020] [Indexed: 12/15/2022]
Abstract
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
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Affiliation(s)
- C-C Cheng
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-R Hsu
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-J Chern
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - W-S Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H-Y Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-K Liao
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - J-M Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - P-S Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - J-F You
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan, Taiwan. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan.
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21
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Zhou S, Wang X, Zhao C, Zhou H, Pei W, Liang J, Zhou Z, Wang X. Can transanal natural orifice specimen extraction after laparoscopic anterior resection for colorectal cancer reduce the inflammatory response? J Gastroenterol Hepatol 2020; 35:1016-1022. [PMID: 31692119 DOI: 10.1111/jgh.14919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/26/2019] [Accepted: 10/27/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Sicheng Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuewei Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chuanduo Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianwei Liang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhixiang Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Zhu Z, Wang KJ, Orangio GR, Han JY, Lu B, Zhou ZQ, Gao W, Fu CG. Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer. J Gastrointest Oncol 2020; 11:260-268. [PMID: 32399267 DOI: 10.21037/jgo.2020.03.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Zhe Zhu
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Kai-Jing Wang
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Guy R Orangio
- Department of Surgery, Louisiana State University, New Orleans, LA, USA
| | - Jun-Yi Han
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Bing Lu
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Zhu-Qing Zhou
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Gao
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Chuan-Gang Fu
- Department of Colorectal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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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. JOURNAL OF ONCOLOGY 2020; 2020:6204264. [PMID: 32454825 PMCID: PMC7218971 DOI: 10.1155/2020/6204264] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/28/2019] [Indexed: 01/10/2023]
Abstract
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.
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Liu RJ, Zhang CD, Fan YC, Pei JP, Zhang C, Dai DQ. Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis. Front Oncol 2019; 9:597. [PMID: 31334119 PMCID: PMC6617713 DOI: 10.3389/fonc.2019.00597] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/17/2019] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Rui-Ji Liu
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China.,Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yu-Chen Fan
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Jun-Peng Pei
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Cheng Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Dong-Qiu Dai
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China.,Cancer Center, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
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Zhou S, Wang X, Zhao C, Pei W, Zhou H, Liu Q, Liang J, Zhou Z, Wang X. Comparison of short-term and survival outcomes for transanal natural orifice specimen extraction with conventional mini-laparotomy after laparoscopic anterior resection for colorectal cancer. Cancer Manag Res 2019; 11:5939-5948. [PMID: 31303795 PMCID: PMC6611704 DOI: 10.2147/cmar.s209194] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/04/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sicheng Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Xuewei Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Chuanduo Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Haitao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Jianwei Liang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Zhixiang Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, People's Republic of China
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Clinical application of laparoscopic total mesorectal excision using the intersphincteric approach through the sacrococcygeal incision for treating patients with rectal cancer. Wideochir Inne Tech Maloinwazyjne 2019; 14:210-215. [PMID: 31118985 PMCID: PMC6528129 DOI: 10.5114/wiitm.2019.81316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 10/30/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Colorectal cancer is the third most common cancer causing death in Western countries; laparoscopic surgery for colorectal cancer has many advantages and thus has been used widely. Laparoscopic total mesorectal excision through the sacrococcygeal incision under direct visualization to excise distal rectal cancer is an important procedure for super-low rectal carcinomas. Aim To investigate the feasibility of mesorectal excision and super-low rectal carcinoma excision using the intersphincteric approach through the sacrococcygeal incision. Material and methods From December 2009 to June 2017, intersphincteric resection was performed through the sacrococcygeal incision; the mesentery was excised in 27 patients with rectal cancer and a contracted pelvis (the lower edge of the tumor was 4 to 7 cm to the anal verge) through laparoscopy in the Gastrointestinal Surgery Department of our hospital. Results No death was recorded during surgery. The surgical time ranged from 190 to 310 min, the bleeding volume was 50 to 150 ml, and the post-surgical length of stay was 6 to 19 days. There were three cases of anastomotic fistulas, one case of anastomotic stenosis, and one case of fecal incontinence. Follow-up visits were scheduled for 19 patients, with a mean time of 37 months, ranging from 3 to 92 months; one case of local recurrence, one case of peritoneal metastasis, and two cases of hepatic metastasis were observed. Conclusions Laparoscopic total mesorectal excision using the intersphincteric approach through the sacrococcygeal incision is feasible for treating patients with a contracted pelvis and super-low rectal carcinoma.
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Minjares-Granillo RO, Dimas BA, LeFave JPJ, Haas EM. Robotic left-sided colorectal resection with natural orifice IntraCorporeal anastomosis with extraction of specimen: The NICE procedure. A pilot study of consecutive cases. Am J Surg 2019; 217:670-676. [DOI: 10.1016/j.amjsurg.2018.11.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/21/2022]
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Hu JH, Li XW, Wang CY, Zhang JJ, Ge Z, Li BH, Lin XH. Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer. World J Clin Cases 2019; 7:122-129. [PMID: 30705889 PMCID: PMC6354094 DOI: 10.12998/wjcc.v7.i2.122] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This case-control study compared the short-term clinical efficacy of natural orifice specimen extraction surgery (NOSES) using a prolapsing technique and the conventional laparoscopic-assisted approach for low rectal cancer.
AIM To further explore the application value of the transanal placement of the anvil and to evaluate the short-term efficacy of NOSES for resecting specimens of low rectal cancer, as well as to provide a theoretical basis for its extensive clinical application.
METHODS From June 2015 to June 2018, 108 consecutive laparoscopic-assisted low rectal cancer resections were performed at our center. Among them, 26 specimens were resected transanally using a prolapsing technique (NOSES), and 82 specimens were resected through a conventional abdominal wall small incision (LAP). A propensity score matching method was used to select 26 pairs of matched patients, and their perioperative data were analyzed.
RESULTS The baseline data were comparable between the two matched groups. All 52 patients underwent the surgery successfully. The operative time, blood loss, number of harvested lymph nodes, postoperative complication rate, circumferential margin involvement, postoperative follow-up data, and postoperative anal function were not statistically significant. The NOSES group had shorter time to gastrointestinal function recovery (2.6 ± 1.0 d vs 3.4 ± 0.9 d, P = 0.006), shorter postoperative hospital stay (7.1 ± 1.7 d vs 8.3 ± 1.1 d, P = 0.003), lower pain score (day 1: 2.7 ± 1.8 vs 4.6 ± 1.9, day 3: 2.0 ± 1.1 vs 4.1 ± 1.2, day 5: 1.7 ± 0.9 vs 3.3 ± 1.0, P < 0.001), a lower rate of additional analgesic use (11.5% vs 61.5%, P = 0.001), and a higher satisfaction rate in terms of the aesthetic appearance of the abdominal wall after surgery (100% vs 23.1%, P < 0.001).
CONCLUSION NOSES for low rectal cancer can achieve satisfactory short-term efficacy and has advantages in reducing postoperative pain, shortening the length of postoperative hospital stay, and improving patients’ satisfaction in terms of a more aesthetic appearance of the abdominal wall.
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Affiliation(s)
- Jun-Hong Hu
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Xing-Wang Li
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Chen-Yu Wang
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Jun-Jie Zhang
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Zheng Ge
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Bing-Hui Li
- Department of Anorectal Surgery, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
- Evidence-Based Medicine Center, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
| | - Xu-Hong Lin
- Department of Clinical Laboratory, Translational Medicine Center, Huaihe Hospital Affiliated to Henan University, Kaifeng 475000, Henan Province, China
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Guan X, Liu Z, Longo A, Cai JC, Tzu-Liang Chen W, Chen LC, Chun HK, Manuel da Costa Pereira J, Efetov S, Escalante R, He QS, Hu JH, Kayaalp C, Kim SH, Khan JS, Kuo LJ, Nishimura A, Nogueira F, Okuda J, Saklani A, Shafik AA, Shen MY, Son JT, Song JM, Sun DH, Uehara K, Wang GY, Wei Y, Xiong ZG, Yao HL, Yu G, Yu SJ, Zhou HT, Lee SH, Tsarkov PV, Fu CG, Wang XS. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf) 2019; 7:24-31. [PMID: 30792863 PMCID: PMC6375350 DOI: 10.1093/gastro/goy055] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 12/26/2018] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Antonio Longo
- Department of Coloproctology and Pelvic Diseases, Humanitas Gavazzeni, Bergamo, Italy
| | - Jian-Chun Cai
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China
| | | | - Lu-Chuan Chen
- Department of Abdominal Surgery, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Sergey Efetov
- Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ricardo Escalante
- Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela
| | - Qing-Si He
- Department of General Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Jun-Hong Hu
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China
| | - Cuneyt Kayaalp
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey
| | - Seon-Hahn Kim
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Li-Jen Kuo
- Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan, China
| | - Atsushi Nishimura
- Department of Surgery, Nagaka Chuo General Hospital, Nagaoka City, Japan
| | | | - Junji Okuda
- Innovation Unit / Colorectal Cancer, Osaka Medical College Hospital Cancer Center, Osaka, Japan
| | - Avanish Saklani
- Department of GI Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Ali A Shafik
- Department of Colorectal Surgery, Cairo University, Cairo, Egypt
| | - Ming-Yin Shen
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China
| | - Jung-Tack Son
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun-Min Song
- Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Dong-Hui Sun
- Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, China
| | - Keisuke Uehara
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gui-Yu Wang
- Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi-Guo Xiong
- Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Gang Yu
- Department of Surgery, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China
| | - Shao-Jun Yu
- Department of Surgical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hai-Tao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Suk-Hwan Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Petr V Tsarkov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Chuan-Gang Fu
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
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Izquierdo KM, Unal E, Marks JH. Natural orifice specimen extraction in colorectal surgery: patient selection and perspectives. Clin Exp Gastroenterol 2018; 11:265-279. [PMID: 30087574 PMCID: PMC6063249 DOI: 10.2147/ceg.s135331] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Kevin M Izquierdo
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA,
| | - Ece Unal
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA,
| | - John H Marks
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA,
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Zattoni D, Popeskou GS, Christoforidis D. Left colon resection with transrectal specimen extraction: current status. Tech Coloproctol 2018; 22:411-423. [PMID: 29948523 DOI: 10.1007/s10151-018-1806-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/25/2018] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- D Zattoni
- Department of General Surgery, Ospedale per gli Infermi di Faenza, 48018, Faenza, Italy.
| | - G S Popeskou
- Department of General Surgery, Queen Elisabeth University Hospital, Birmingham, UK
| | - D Christoforidis
- Department of General Surgery, Ospedale Civico di Lugano, 6900, Lugano, Switzerland
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Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer Using Natural Orifice Specimen Extraction Techniques. Surg Laparosc Endosc Percutan Tech 2018; 27:e74-e79. [PMID: 28731950 DOI: 10.1097/sle.0000000000000438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A minilaparotomy for specimen extraction during laparoscopy occasionally results in postoperative wound complications. We have performed a totally laparoscopic resection for early colorectal cancer using the natural orifice specimen extraction technique. METHODS From 2008 to 2013, we have performed a totally laparoscopic resection for clinical stage I and IIA low sigmoid colon and rectal cancers. A prospectively maintained database was reviewed to assess the outcomes after surgery. RESULTS In total, 40 patients had high anterior resections using transanal specimen extraction, and 32 patients had low anterior resections with transanal pull-through. Eight patients (11%) reported conversion to conventional laparoscopic colorectal resections; anastomotic leakages occurred in 4 patients (5.6%). No mortality or cancer recurrence was observed during 42.5±16.2 months of follow-up. CONCLUSIONS One natural orifice specimen extraction technique, known as transanal specimen extraction, has emerged as a promising form of totally laparoscopic surgical intervention for early-stage cancers of the low sigmoid colon and rectum.
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Steinemann DC, Müller PC, Probst P, Schwarz AC, Büchler MW, Müller-Stich BP, Linke GR. Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery. Br J Surg 2017; 104:977-989. [DOI: 10.1002/bjs.10564] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 02/06/2023]
Abstract
Abstract
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 < 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 < 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P < 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 < 0·001).
Conclusion
Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.
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Affiliation(s)
- D C Steinemann
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - P C Müller
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - A-C Schwarz
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - G R Linke
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
- Department of Surgery, Spital STS AG, Thun, Switzerland
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Natural Orifice Specimen Extraction With Single Stapling Colorectal Anastomosis for Laparoscopic Anterior Resection: Feasibility, Outcomes, and Technical Considerations. Dis Colon Rectum 2017; 60:43-50. [PMID: 27926556 DOI: 10.1097/dcr.0000000000000739] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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36
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Ma B, Huang XZ, Gao P, Zhao JH, Song YX, Sun JX, Chen XW, Wang ZN. Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis. Int J Colorectal Dis 2015; 30:1479-88. [PMID: 26238472 DOI: 10.1007/s00384-015-2337-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Bin Ma
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xuan-Zhang Huang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jun-Hua Zhao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Yong-Xi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jing-Xu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xiao-Wan Chen
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Zhen-Ning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
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