Prospective randomized trial of hybrid NOTES colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors

Natural Orifice Extraction Techniques (Natural Orifice Specimen Extraction and Natural Orifice Transluminal Endoscopic Surgery) for Left-Sided Colorectal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose: Minimally invasive surgery is the standard approach for colorectal cancers and requires an abdominal incision for specimen removal. Natural orifice specimen extraction (NOSE) may improve outcomes, reducing trauma, and speeding postoperative recovery. This study compares both techniques regarding postoperative complications, operative outcomes, and recurrence. Methods: We searched PubMed, Scopus, and Cochrane Central Register of Clinical Trials for studies published up to November 2024. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model, and heterogeneity was assessed with I2 statistics. Statistical analyses were conducted using R Software version 4.4.1 (R Foundation for Statistical Computing). Results: Four randomized controlled trials involving 439 patients with colorectal cancer were included, with 212 (48.2%) undergoing NOSE and 227 (51.7%) undergoing conventional laparoscopic specimen extraction. NOSE significantly reduced postoperative pain (visual analog scale score: mean difference [MD] -1.8; 95% confidence interval [CI] -2.5 to -1.1; P = .01), time to pass flatus (MD -0.8; 95% CI -1.1 to -0.6; P < .01), and surgical site infection rates (OR 0.15; 95% CI 0.03-0.69; P = .015) but was associated with a longer operative time (MD 11.1 minutes; 95% CI 1.5-20.6; P = .02). No significant differences were observed between the groups in bowel leaks, lymph nodes harvested, intraoperative blood loss, hospital stay duration, or local recurrence rates. Conclusion: NOSE was associated with reduced postoperative pain, faster time to pass flatus, and lower infection rates but required longer operative time than conventional laparoscopic specimen extraction. Other outcomes, including complications, operative characteristics, and recurrence, showed no significant differences between the techniques.

Natural Orifice Specimen Extraction for Right-Sided Colon Cancer: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies

Minimally invasive surgery is the standard approach for right-sided colon cancer, but conventional laparoscopic specimen extraction (CVT) requires additional abdominal incisions, increasing the risk of postoperative complications and delayed recovery. Natural orifice specimen extraction (NOSE) minimizes abdominal incisions, potentially improving patient outcomes. This meta-analysis compares NOSE and CVT in terms of postoperative complications, operative characteristics, and long-term outcomes. A comprehensive literature search was conducted in PubMed, Scopus, the Cochrane Central Register of Clinical Trials, and Web of Science for studies available up to December 2024. A random-effects model was applied to compute ORs and mean differences (MDs) with 95% CIs. Heterogeneity was evaluated using the I² statistic. All statistical analyses were performed using R software (version 4.4.1, R Foundation for Statistical Computing). Seven propensity score-matched studies with 566 patients were included, with 240 (42.4%) undergoing NOSE and 326 (57.6%) undergoing CVT. NOSE was associated with significantly reduced postoperative pain on the 3rd day (MD -1.1; 95% CI -1.7 to -0.5; p < 0.01), lower SSI rates (OR 0.23; 95% CI 0.08-0.73; p = 0.012), and a shorter time to pass flatus (MD -0.8; 95% CI -1.2 to -0.4; p < 0.01). However, NOSE was linked to longer operative times (MD 36.4 minutes; 95% CI 3.4-69.4; p = 0.03). No significant differences were found in hospital stay (MD -0.5 days; 95% CI -2.1 to 1.1; p = 0.57), blood loss (MD -2.1; 95% CI -9.6 to 5.4; p = 0.58), or local recurrence (OR 0.44; 95% CI 0.07-3.01; p = 0.405). In conclusion, NOSE offers advantages such as reduced postoperative pain, lower SSI rates, and faster bowel recovery, with prolonged operative time as its main limitation. These findings support NOSE as a viable alternative to CVT for right-sided colon cancer without compromising safety or long-term outcomes.

Development and prospects of natural orifice specimen extraction surgery for colorectal cancer: a review article

The natural orifice specimen extraction surgery (NOSES) procedure is an innovative approach to treating colorectal cancer that offers several advantages. First, the NOSES technique is minimally invasive, reducing the incidence of postoperative complications such as wound infection and fat liquefaction. Second, it provides excellent pain relief and improves cosmetic outcomes by requiring fewer abdominal incisions, thereby increasing patient satisfaction. Additionally, NOSES provides all of the advantages of minimally invasive surgery and enables patients to recover quickly, helping patients return to their normal lives faster. This approach aligns with the concept of patient-centered care and significantly improves patient quality of life. The positive results noted at both short- and long-term postoperative follow-up indicate that NOSES is a valuable option in cancer care. Despite its many benefits, NOSES has also been challenged by bacteriology, oncology, and ethics. This paper presents a review of recent research progress regarding NOSES in the treatment of colorectal cancer. In this article, we examined the advantages and disadvantages of NOSES in clinical practice and discussed potential issues and solutions.

Retrospective analysis of immediate and long-term results of NOSES technique and conventional laparoscopic-assisted resection in patients with colorectal cancer

Introduction

The aim of research was to study the feasibility and safety of surgery providing specimen extraction through natural orifices in patients with colorectal cancer.

Materials and methods

This study is a comparative retrospective analysis of findings obtained from 265 patients who underwent surgical treatment using NOSES technique and 275 patients who underwent laparoscopic-assisted (LA) resection. Data included preoperative patients' information, intraoperative findings, results of postoperative pathological examination of surgical specimens, early postoperative period analysis, and follow-up.

Results

Both groups were comparable in terms of gender, age and BMI. The duration of surgery was similar in both groups (p = 0.94). Intraoperative blood loss under NOSES interventions was slightly lower than in laparoscopic-assisted surgeries (p < 0.001). There was no significant difference in the number of lymph nodes removed and anal function scores between the two groups (p > 0.05). It was revealed that in the NOSES group, the function of the gastrointestinal tract normalized at an earlier time, slightly the time to start liquid food intake and the duration of postoperative hospital stay were reduced (p < 0.001). A statistically significant difference between groups was found in complications, such as pneumonia (p = 0.03). The absolute number of complications was observed more often in the LA surgery group (10.4%) than in the NOSES group (5.8%). Local recurrence was less common in the NOSES group (p = 0.01). There were no statistically significant differences in disease progression (p = 0.16). When analyzing disease-free and overall survival rate in this study, there was no statistically significant difference between the two surgical techniques in terms of their effect on postoperative survival (p > 0.05).

Conclusion

The results of this study demonstrate that NOSES technique is a relatively safe and effective surgical option in patients with colorectal cancer. It has high surgical efficiency providing no increased risk of surgical intervention, reducing total number of postoperative complications, reducing duration of postoperative hospital stay, reducing the time for gastrointestinal function recovery and the start of food intake. This study supports that NOSES has clear advantages over conventional laparoscopic-assisted surgery.

Short-term outcomes of Transrectal Natural Orifice Specimen extraction compared with conventional minimally invasive surgery for selected patients with colorectal cancer: a propensity score matching analysis and literature review

PURPOSE

Conventional minimally invasive surgery requires mini-laparotomy to extract the pathological specimen. However, by using a natural orifice as the delivery route, natural orifice specimen extraction (NOSE) surgery avoids the need for a large incision. This study analyzed the short-term outcome of NOSE compared with conventional mini-laparotomy (CL) for colorectal cancer surgery.

METHODS

We conducted a retrospective analysis of 1,189 patients who underwent surgery for primary colorectal cancer between the cecum and upper rectum. Propensity score analyses were applied to the NOSE and CL groups in a 1:1 matched cohort.

RESULTS

After propensity score matching, each group included 201 patients. The NOSE group and CL group did not differ significantly in terms of baseline characteristics. Postoperative morbidity and mortality rates were comparable. Compared with the CL group, the NOSE group experienced a shorter time to first flatus (1.6 ± 0.8 vs. 2.0 ± 1.2 days, p < 0.001), first stool (2.7 ± 1.5 vs. 4.1 ± 1.9, p < 0.001), liquid diet (2.3 ± 1.3 vs. 3.6 ± 1.8 days, p < 0.001), soft diet (3.9 ± 2.0 vs. 5.2 ± 1.9 days, p < 0.001) and a shorter hospital stay (5.1 ± 3.5 vs. 7.4 ± 4.8 days, p < 0.001). The NOSE group exhibited lower mean pain intensity and lower highest pain intensity on postoperative days 1, 2, and 3.

CONCLUSION

NOSE has several advantages over conventional mini-laparotomy following minimally invasive surgery for colon cancer. These advantages include reduced time to oral intake, shorter hospital stays, and less postoperative pain. NOSE can be adopted and applied to highly selective patients without additional risk of short-term complications.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Comparative long-term outcomes of natural orifice specimen extraction surgery and conventional laparoscopic colectomy for left-sided colorectal cancer: a propensity score-matched analysis

BACKGROUND

Natural orifice specimen extraction surgery (NOSES) is currently widely used in left-sided colorectal cancer. Some clinical comparative studies have been conducted, providing evidence of its safety and oncological benefits. However, these studies are typically characterized by small sample sizes and short postoperative follow-up periods. Consequently, in this research, the authors adopt the propensity score matching method to undertake a large-scale retrospective comparative study on NOSES colectomy for left-sided colorectal cancer, with the goal of further augmenting the body of evidence-based medical support for NOSES.

METHODS

This retrospective study involved patients who underwent NOSES colectomy and conventional laparoscopic (CL) colectomy for left-sided colorectal cancer between January 2014 and April 2021. In the NOSES group, specimens were extracted through the anus with the help of a Cai tube (homemade invention: ZL201410168748.2). The patients were matched at a ratio of 1:1 according to age, sex, BMI, tumor diameter, tumor location (descending and splenic flexure colon/ sigmoid colon/ middle and upper rectum), tumor height from anal verge, ASA grade, previous abdominal surgery, clinical pathologic stage, preoperative CEA. After matching, 132 patients in the NOSES group and 132 patients in the CL group were eligible for analysis.

RESULTS

Compared with CL group, NOSES group was associated with decreased postoperative maximum pain score (2.6±0.7 vs. 4.7±1.7, P=0.000), less additional analgesia required (6.8 vs. 34.8%, P=0.000), faster time to passage of flatus (2.3±0.6 days vs. 3.3±0.7 days, P=0.000), less wound infection (0.0 vs. 6.1%, P=0.007), and longer operative time (212.5±45.8 min vs. 178.0±43.4 min, P=0.000). No significant differences were observed in estimated blood loss, time to resume regular diet, postoperative hospital stay, conversion to open surgery or conventional minilaparotomy, total morbidity, readmission, mortality, pathologic outcomes, and Wexner incontinence score between groups. After a median follow-up of 63.0 months, the 5-year overall survival rates were 88.3 versus 85.0% (P=0.487), disease-free survival rates were 82.9 versus 83.6% (P=0.824), and the local recurrence rates were 4.4 versus 4.0% (P=0.667) in the NOSES and CL groups, respectively.

CONCLUSIONS

This study suggests that NOSES colectomy using a Cai tube for left-sided colorectal cancer is a safe and feasible option with better cosmetic results, less pain, faster recovery of gastrointestinal function, and comparable long-term clinical and oncologic outcomes to CL colectomy.

The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis

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.

Robotic-assisted rectosigmoid resection rectopexy with natural orifice specimen extraction (NOSE): technical notes, short-term results, and functional outcome

PURPOSE

Rectosigmoid resection rectopexy has been established as an effective therapy for obstructive defecation syndrome. The addition of the NOSE-technique provides an even less invasive approach avoiding minilaparotomy, but can be technically challenging. Application of a robotic platform has been proposed to facilitate the specimen extraction and fashioning of the intracorporeal anastomosis and has been proven to be effective in left-sided colectomies.

METHODS

After establishing laparoscopic rectosigmoid-resection-rectopexy with NOSE, we modified our technique by addition of the robotic platform. Whenever robotic capacity was available, elective patients scheduled for rectosigmoid resection rectopexy for obstructive defecation syndrome were operated robotically assisted. Demographic and intraoperative data were prospectively collected. Follow up was assessed using the Wexner constipation score, Wexner incontinence score, and Altomare ODS score.

RESULTS

The NOSE-RRR technique was completed in all 31 patients. The mean operative time was 166 min (range 67-230). No conversion was required. The median hospital stay was 5 days (range 3-28). Four patients had minor complications (Clavien I). Two patients were reoperated (Clavien IIIb). Functional scores improved significantly postoperatively. Mean Wexner incontinence score was 7.1 preoperatively, 6.9 after 1 month, and decreased significantly to 3.93 after 3 months (p < 0.001). Mean Altomare ODS score was 17.47 preoperatively and 6.93/5.03 after 1/3 months (p < 0.001). Wexner constipation score (12.83) also showed a significant improvement after 1/3 months (6.97/6.67; p < 0.001).

CONCLUSION

NOSE-RRR can be performed safely with a low rate of manageable complications. The technique provides a significant improvement for ODS-Symptoms.

Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases

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.

Surgical approaches to colonic and rectal anastomosis: systematic review and meta-analysis

PURPOSE

Postoperative complications after a colonic and rectal surgery are of significant concern to the surgical community. Although there are different techniques to perform anastomosis (i.e., handsewn, stapled, or compression), there is still no consensus on which technique provides the least number of postoperative problems. The objective of this study is to compare the different anastomotic techniques regarding the occurrence or duration of postoperative outcomes such as anastomotic dehiscence, mortality, reoperation, bleeding and stricture (as primary outcomes), and wound infection, intra-abdominal abscess, duration of surgery, and hospital stay (as secondary outcomes).

METHODS

Clinical trials published between January 1, 2010, and December 31, 2021, reporting anastomotic complications with any of the anastomotic technique were identified using the MEDLINE database. Only articles that clearly defined the anastomotic technique used, and report at least two of the outcomes defined were included.

RESULTS

This meta-analysis included 16 studies whose differences were related to the need of reoperation (p < 0.01) and the duration of surgery (p = 0.02), while for the anastomotic dehiscence, mortality, bleeding, stricture, wound infection, intra-abdominal abscess, and hospital stay, no significant differences were found. Compression anastomosis reported the lowest reoperation rate (3.64%) and the handsewn anastomosis the highest (9.49%). Despite this, more time to perform the surgery was required in compression anastomosis (183.47 min), with the handsewn being the fastest technique (139.92 min).

CONCLUSIONS

The evidence found was not sufficient to demonstrate which technique is most suitable to perform colonic and rectal anastomosis, since the postoperative complications were similar between the handsewn, stapled, or compression techniques.

[Transanal specimen extraction after left-sided laparoscopic colectomy: a systematic review and meta-analysis]

OBJECTIVE

To compare the short-term results after left-sided laparoscopic colectomy with transanal and transabdominal specimen extraction.

MATERIAL LAND METHODS

We selected 998 appropriate manuscripts and subsequently excluded 995 ones due to exclusion criteria. Thus, the meta-analysis was based on 3 randomized trials in accordance with PRISMA recommendations.

RESULTS

A total of 353 patients were enrolled in meta-analysis including 169 resections with transanal specimen extraction and 184 surgeries with transabdominal extraction. Overall risk of postoperative complications (OR=0.60; 95% CI 0.31-1.14; p=0.12) including anastomotic leakage (OR=1.83; 95% CI 0.43-7.89; p=0.42) was similar in both groups. At the same time, severity of pain syndrome (mean difference = -2.35; 95% CI -2.51-2.19), time to the first flatus discharge (mean difference = -0.92; 95% CI -0.99-0.85) and postoperative hospital stay (mean difference = -1.5; 95% CI -2.03-0.98) were significantly lower in the group of transanal extraction (p<0.00001).

CONCLUSION

Transanal specimen extraction in left-sided laparoscopic colectomy does not increase overall risk of postoperative complications. In addition, the NOSE technique has some advantages in short-term results compared to procedures with transabdominal specimen extraction.

Clinical outcomes of laparoscopic-assisted natural orifice specimen extraction colectomy using a Cai tube for left-sided colon cancer: a prospective randomized trial

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/ ).

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

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.

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

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.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

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

Laparoscopic Natural Orifice Specimen Extraction Surgery versus Conventional Surgery in Colorectal Cancer: A Meta-Analysis of Randomized Controlled Trials

Objective

This study was to quantitatively synthesize data in randomized controlled trials (RCTs) of laparoscopic resection comparing natural orifice specimen extraction (NOSE) versus conventional laparoscopy (CL) in colorectal cancer.

Methods

We identified eligible RCTs by searching seven electronic databases (PubMed, Cochrane Library, Embase, Web of Science, CNKI, CQVIP, Wanfang, and Sinomed). Mean differences (MDs) between groups with 95% confidence intervals (CIs) were used for continuous outcomes. Event rate ratios (RRs) were also calculated with their 95% CIs.

Results

1,569 citations were identified from electronic database as of June 2020, and finally, 21 RCTs involving 2,112 patients met the study eligibility criteria and were included. Compared to the CL group, NOSE had longer operation time (MD: 8.14 min, 95% CI: 3.02 to 13.25, and p < 0.01), less estimated blood loss (-10.64 ml, 95% CI: -14.92 to -6.36, and p < 0.01), less hospital stay after surgery (-2.21 days, 95% CI: -3.36 to -1.06, and p < 0.01), shorter time of gas passage after surgery (-0.58 days, 95% CI: -0.82 to -0.34, and p < 0.01), better pain score (-1.06, 95% CI: -3.74 to -0.37, and p < 0.01), and improved cosmetic scores (1.93, 95% CI: 0.77 to 3.10, p < 0.01). Rate ratios of total complications, infection, and incision infection all favored NOSE surgery, with RRs (95% CIs) of 0.81 (0.71 to 0.93), 0.34 (0.21 to 0.54), and 0.24 (0.12 to 0.51), respectively.

Conclusion

This report appeared the first comprehensive meta-analysis of RCTs to synthesize data of laparoscopic resection with NOSE versus conventional laparoscopy. NOSE surgery seemed favorable with shorter hospital stay, less pain score, a shorter time to recover along with better cosmetic scores, and less postoperative complications.

The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: A meta-analysis of efficacy and long-term oncological outcomes

PURPOSE

Natural orifice specimen extraction surgery (NOSES) has gradually become established in treating colorectal cancer. This meta-analysis assesses NOSES in the treatment of colorectal cancer compared with conventional laparoscopy (CL) and determines the effect of long-term prognosis.

METHODS

Various medical databases were searched up to May 2021. We included retrospective and randomized trials on the treatment of colorectal cancer with NOSES. Pooled weighted/standardized mean differences (WMD/SMD), odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals (CIs) were calculated using either fixed- or random-effects models. STATA was conducted for the meta-analysis.

RESULTS

This meta-analysis included 16 studies comprising 2266 patients. Compared with CL, NOSES had more benefits in terms of overall postoperative complications (OR = 0.47, 95%CI [0.35,0.64]; Z = 4.91, P < 0.001), incision-related complications (OR = 0.15, 95%CI [0.07,0.31]; Z = 4.97, P < 0.001), time to first flatus (SMD = -0.58, 95%CI [-0.68,-0.48]; Z = 11.21, P < 0.001), hospital stay (WMD = -1.03, 95%CI [-1.55,-0.51]; Z = 3.86, P < 0.001), cosmetic scores (WMD = 1.37, 95%CI [0.59,2.14]; Z = 3.47, P = 0.001), the visual analogue scale on postoperative day 1（WMD = -1.46, 95%CI [-2.39,-0.52]; Z = 3.06, P = 0.002), additional analgesics usage (OR = 0.33, 95%CI [0.26, 0.43]; Z = 8.43, P < 0.001), whereas the operative time of NOSES was prolonged (WMD = 13.09, 95%CI [7.07,19.11]; Z = 4.26, P < 0.001). Postoperative anastomotic complications, intra-abdominal infection, pelvic floor function, intraoperative blood loss, number of lymph node dissection, 3-year disease-free and overall survival in the NOSES group were comparable with those in the CL group.

CONCLUSIONS

NOSES is a safe and reliable surgical procedure for the treatment of colorectal cancer and provides good long-term oncological outcomes. Large-scale multicenter studies are required to confirm its clinical benefits.

Natural orifice specimen extraction surgery versus conventional laparoscopic-assisted resection for colorectal cancer in elderly patients: a propensity-score matching study

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.

Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome

Colon cancer is the third most common cancer in man and woman in the developed world. Laparoscopic right colectomy is the standard of care for right colon cancer. Since the first report on laparoscopic approach in 1991, the surgical technique has been improved and currently all procedure is performed intracorporeally. The ileo-colic anastomosis can be performed either intracorporeal and extracorporeal: the differences in clinical outcome, complications rate, hospital stay and quality of life between that two techniques are not still clear and a large number of studies has been published about that. According to most recent meta-analysis, intracorporeal anastomosis have showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function.

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

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

Comparison of natural orifice specimen extraction surgery and conventional laparoscopic-assisted resection in the treatment effects of low rectal cancer

Natural orifice specimen extraction surgery (NOSES) is an intra-abdominal procedure that does not require an auxiliary incision to take a surgical sample from the abdominal wall through the natural orifice, but there are few systematic clinical studies on it. The aim of this study was to demonstrate the safety and feasibility of NOSES. We retrospectively analyzed the clinical data and follow-up of 165 patients with low rectal cancer who underwent NOSES or conventional laparoscopic surgery at our center from January 2013 to June 2015. From the perioperative data and postoperative follow-up results of both groups, patients in the NOSES group had less intraoperative bleeding (49.3 ± 55.8 ml vs. 75.1 ± 57.3 ml, p = 0.02), shorter postoperative gastrointestinal recovery (42.3 ± 15.5 h vs. 50.1 ± 17.0 h, p = 0.01), less postoperative analgesic use (35.6% vs. 57.6%, p = 0.02), lower postoperative pain scores, lower rate of postoperative complications (6.8% vs. 25.4%, p = 0.01), better satisfaction of the image and cosmesis of the abdominal wall postoperatively, and higher quality of life. Moreover, there was no significant difference in overall survival (OS) and disease-free survival (DFS) between two groups. Overall, NOSES is a safe and reliable minimally invasive surgical technique for patients with low rectal cancer.

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

Background

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

Patients and Methods

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

Results

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

Conclusion

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

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer: A case report

BACKGROUND

Pure natural orifice transluminal endoscopic surgery (NOTES) for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges, including loss of triangulation, in-line orientation, and instrument collision. Transvaginal (v) NOTES, however, can overcome these technical challenges. We report a case of pure vNOTES right hemicolectomy for colon cancer, attached with surgical video.

CASE SUMMARY

A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy. Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons. The operative time was 200 min and the estimated blood loss was 30 mL. No intraoperative or postoperative complications occurred within 30 d after the surgery. The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3. The patient was discharged at postoperative day 6. The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.

CONCLUSION

vNOTES right hemicolectomy, performed by well-experienced surgeons, overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis

Background

Totally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort.

Methods

Consecutive, elective, unselected patients presenting with complicated diverticulitis defined as fistula, abscess and stricture underwent the NICE procedure over a 24-month period. Demographic and intraoperative data were collected, and video recordings were reviewed and edited on encrypted server.

Results

A total of 60 patients (50% female) underwent the NICE procedure for complicated diverticulitis with a mean age of 58.9 years and mean BMI of 30.7 kg/m². The mean operative time was 231.6 min. All cases (100%) were achieved with intracorporeal anastomosis using a circular stapling device. All but one patient (98.3%) had successful transrectal extraction of the specimen. Forty-four (73%) of the specimens required a specimen-thinning maneuver to successfully extract the specimen and there were no conversions. We identified seven key technical modifications and considerations to facilitate successful completion of the procedure which are illustrated, including early release of the disease, mesentery-sparing dissection, dual instrument control of the mesenteric vasculature, release of the rectal reflection, use of NICE back table, specimen-thinning maneuver, and closure of the rectal cuff.

Conclusion

We present a stepwise approach with key modifications to successfully achieve totally robotic intracorporeal resection for those presenting with complicated diverticulitis. This approach may help overcome the technical challenges and provide a foundation for reproducible results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08350-z.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term Oncologic Outcomes of Laparoscopic Anterior Resections for Cancer with Natural Orifice Versus Conventional Specimen Extraction: A Case-Control Study

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.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Comparison of NOSES and Conventional Laparoscopic Surgery in Colorectal Cancer: Bacteriological and Oncological Concerns

Background: Colorectal natural orifice specimen extraction surgery (NOSES) is considered to be a scarless operation that avoids the laparotomy of extraction specimen, but bacteriological and oncological concerns are raised with this technique. Objective: The purpose of this study was to compare the oncological and bacteriological outcomes of NOSES and conventional laparoscopic (CL) procedures. Methods: This is a retrospective study of prospectively collected outcomes data. Patients operated with colorectal cancer from January 2016 to December 2019 in Xiangya Hospital were assigned to the group NOSES and the group CL according to the size of the tumor. Prior to dissection, peritoneal lavage fluid was collected for cytological assessment. At the end of the procedure, peritoneal lavage fluid was collected for aerobic culture and cytological assessment. Baseline characteristics and short-term and long-term outcomes for NOSES and CL were compared. Results: Between January 2016 and December 2019, 212 patients were enrolled from our center and 185 patients were analyzed (96 and 89 in NOSES and CL groups, respectively). The bacterial positive rate of peritoneal lavage fluid was 34.4 vs. 32.6% in NOSES and CL groups, respectively (P = 0.80). The positive rate of tumor cells in peritoneal lavage fluid was 7.3 vs. 9.0% in NOSES and CL groups, respectively (P = 0.67). Univariate analysis showed that the positive rate of tumor cells in peritoneal lavage fluid was significantly associated with tumor invasion depth and lymph node metastasis (P < 0.05). T4 (OR = 20.47, 95%CI = 1.241-337.661; P = 0.04), N1 (OR = 5.445, 95%CI = 1.412-20.991; P = 0.01), and N2 (OR = 6.315, 95%CI = 1.458-27.348; P = 0.01) served as independent predictors of peritoneal lavage fluid positive oncology patients. Local recurrence-free survival was not significantly different between two groups (HR = 0.909, 95%CI = 0.291-2.840; P = 0.87). Conclusions: Compared with conventional laparoscopic procedure, NOSES is in conformity with the principle of asepsis and tumor-free technique and can be worthy of clinical application and promotion.

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

Background

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

Methods

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

Results

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

Conclusions

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

Evolution of Transanal Total Mesorectal Excision

Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.

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

Aim

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

Methods

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

Results

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

Conclusions

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

Safety and survival outcomes of transanal natural orifice specimen extraction using prolapsing technique for patients with middle- to low-rectal cancer

Objective

The transanal approach to specimen collection, combined with the prolapsing technique, is a well-established and minimally invasive surgery for treating rectal cancer. However, reports on outcomes for this approach are sparse. We compared short- and long-term outcomes of conventional laparoscopic surgery (CLS) vs. transanal natural orifice specimen extraction (NOSE) using the prolapsing technique for patients with middle- to low-rectal cancer.

Methods

From January 2013 to December 2017, we enrolled consecutive patients with middle- to low-rectal cancer undergoing laparoscopic anterior resection. Totally, 50 patients who underwent transanal NOSE using the prolapsing technique were matched with 50 patients who received CLS. Clinical parameters and survival outcomes between the two groups were compared.

Results

Estimated blood loss (29.70±29.28 vs. 52.80±45.09 mL, P=0.003), time to first flatus (2.50±0.79 vs. 2.86±0.76, P=0.022), time to liquid diet (3.62±0.64 vs. 4.20±0.76 d, P<0.001), and the need for analgesics (22%vs. 48%, P=0.006) were significantly lower for the NOSE group compared to the CLS group. The incidences of overall complications and fecal incontinence were comparable in both groups. After a median follow-up of 44.52 months, the overall local recurrence rate (6% vs. 5%, P=0.670), 3-year disease-free survival (86.7% vs. 88.0%, P=0.945) and 3-year overall survival (95.6% vs. 96.0%, P=0.708), were not significantly different.

Conclusions

For total laparoscopic rectal resection, transanal NOSE using the prolapsing technique is effective and safe, and associated with less trauma and pain, a faster recovery, and similar survival outcomes compared to CLS.

Comparison of Major Clinical Outcomes Between Transvaginal NOTES and Traditional Laparoscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

The advent of transvaginal natural orifice transluminal endoscopic surgery (transvaginal NOTES) aims to minimize surgical trauma and reduce recovery time.

MATERIALS AND METHODS

Clinical trials comparing transvaginal NOTES and traditional laparoscopy were identified by searching EMBASE, MEDLINE, and Web of Science (from 2004 to March 2018). Major outcomes evaluated were risk of postoperative complications and secondary outcomes were pain on postoperative day (POD) 1, POD2, and POD3, time needed for full recovery, risk of intraoperative complications, the duration of surgery, and hospital stay. The results of the meta-analysis are presented as standardized mean difference (SMD) and risk difference (RD) with 95% confidence intervals (CIs).

RESULTS

Thirteen trials with 1340 patients were identified. There were no statistical differences for risk of complications between transvaginal NOTES and traditional laparoscopy (intraoperative complications: RD -0.01, 95% CI -0.03 to 0.01; P = 0.37; postoperative complication: RD -0.02, 95% CI -0.05 to 0.01; P = 0.148). The pain score was lower in transvaginal NOTES on POD1 (SMD: -0.71, 95% CI: -1.30 to -0.11, P = 0.019), on POD2 (SMD -0.41, 95% CI -0.75 to -0.07; P = 0.018), and on POD3 (SMD -0.43, 95% CI -0.63 to -0.23; P < 0.001). Patients in transvaginal NOTES needed much shorter time to fully recover after surgery (SMD -1.36, 95% CI -1.84 to -0.87; P < 0.001). In addition, patients underwent transvaginal NOTES had less pain and shorter time of recovery.

CONCLUSIONS

It is recommended that patients have cholecystectomy, adnexectomy, and appendectomy using transvaginal NOTES as it is safe and minimally invasive.

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

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

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

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

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

Clinical impact of single-incision laparoscopic right hemicolectomy with intracorporeal resection for advanced colon cancer: propensity score matching analysis

BACKGROUND

Laparoscopic right hemicolectomy has become an acceptable treatment for right-sided colon cancer. Most centers use multiport laparoscopic right hemicolectomy extracorporeally (MRHE), whereas single-incision laparoscopic right hemicolectomy intracorporeally (SRHI) remains controversial. The aim of this study was to compare these two techniques using propensity score matching analysis.

METHODS

We analyzed the data from 111 patients who underwent laparoscopic right hemicolectomy between December 2015 and December 2016. The propensity score was calculated according to age, gender, body mass index, the American Society of Anesthesiologists score, previous abdominal surgery, and D3 lymph node dissection. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use was an outcome measure.

RESULTS

The length of skin incision in SRHI was significantly shorter than in MRHE [3 (3.5-6) versus 4 (3-6) cm, respectively; P = 0.007]. The VAS score on day 1 and day 2 after surgery was significantly less in SRHI than in MRHE [30 (10-50) versus 50 (20-69) on day 1, P = 0.037; 10 (0-50) versus 30 (0-70) on day 2, P = 0.029]. Significantly fewer patients required analgesia after SRHI on day 1 and day 2 after surgery [1 (0-3) versus 2 (0-4) on day 1, P = 0.024; 1 (0-2) versus 1 (0-4) on day 2, P = 0.035]. There were no significant differences in operative time, intraoperative blood loss, number of lymph nodes removed, and postoperative course between groups.

CONCLUSIONS

SRHI appears to be safe and technically feasible. Moreover, SRHI reduces the length of the skin incision and postoperative pain compared with MRHE.

Contamination After Disinfectant Rectal Washout in Left Colectomy as a Model for Transrectal NOTES: A Randomized Controlled Trial

BACKGROUND

In natural orifice transluminal endoscopic surgery (NOTES) with transrectal (TR) access the intraoperative opening of the rectal wall poses a risk of intraperitoneal contamination and subsequent infectious complications. A rectal washout with a disinfectant may reduce this risk. The aim of the study was to assess the intraoperative contamination on the circular stapler pin when a rectal washout with povidone-iodine (RW-PI) or Ringer solution was performed in patients undergoing left-sided colectomy. Furthermore, the additional effect of an irrigation instrument on the contamination was evaluated.

METHODS

In a patient and assessor blinded randomized controlled trial, patients undergoing left-sided colectomy were assigned to rectal washout with PI with an irrigation instrument (RW-PI; n = 23), rectal washout with Ringer solution with an irrigation instrument (RW-R; n = 21) or rectal washout with Ringer solution without an irrigation instrument (RW; n = 25). An end-to-end anastomosis with a circular stapler was performed. The contamination on the pin of the circular stapler was chosen as primary endpoint in order to simulate the intraabdominal contamination risk during TR NOTES. Secondary endpoints were contamination of the rectal mucosa, peritoneal contamination and postoperative morbidity.

RESULTS

The contamination rate of the pin of the circular stapler did not differ (RW-PI 39.1%, RW-R 33.3%, RW 52.0%; P = 0.421), but contamination of the rectal mucosa was reduced (47.8% versus 95.2% versus 100%; P < 0.001) and peritoneal contamination tended to be reduced (39.1% versus 71.4% versus 60.0%; P = 0.09) when a rectal washout with PI was performed. The rates of infectious complications (17.4% versus 9.5% versus 12.0%; P = 0.821) and of overall complications (30.4% versus 28.6% versus 44.0%; P = 0.476) did not differ.

CONCLUSIONS

Despite an intense rectal washout with PI, contamination of the stapler pin did not differ. Intraabdominal bacterial translocation was frequently encountered even after disinfectant rectal washout with PI. Further studies might focus on the clinical impact of intraabdominal contamination in TR NOTES.

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

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

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Hybrid NOTES can lesser the exclusion criterias for NOTES.

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

Introduction

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

Presentation of case

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

Discussion

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

Conclusion

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

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

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

Left colon resection with transrectal specimen extraction: current status

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study

BACKGROUND AND STUDY AIMS

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.

METHODS

Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.

RESULTS

Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).

CONCLUSIONS

After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Randomized Clinical Trials in Colon and Rectal Cancer

Surgery remains the mainstay of treatment for colon and rectal cancers. Colon cancer outcomes have improved with laparoscopic techniques, enhanced recovery pathways, and adjuvant chemotherapy. Adjuvant 5-fluorouracil with or without oxaliplatin in stage III and possibly high-risk stage II colon cancer is associated with improved survival. Multimodality management of rectal cancer continues to evolve; total mesorectal excision is the cornerstone. Oncologic results do not support the use of laparoscopic resection in rectal cancer. Preoperative short- or long-course radiation for stage II or III rectal cancer is the standard of care. Long course chemoradiation is recommended for bulky tumors.

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

Background

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

Methods

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

Results

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

Conclusion

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