Advances in cancer surgery: natural orifice surgery (NOTES) for oncological diseases

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

Introduction

It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established.

Methods

This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival.

Ethics and dissemination

The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Safety Issues in the Development of an Innovative Medical Parallel Robot Used in Renal Single-Incision Laparoscopic Surgery

Robotic-assisted single-incision laparoscopic surgery (SILS) is becoming an increasingly widespread field worldwide due to the benefits it brings to both the patient and the surgeon. The goal of this study is to develop a secure robotic solution for SILS, focusing specifically on urology, by identifying and addressing various safety concerns from an early design stage. Starting with the medical tasks and protocols, the technical specifications of the robotic system as well as potential; hazards have been identified. By employing competitive engineering design methods such as Analytic Hierarchy Process (AHP), Risk assessment, and Failure Mode and Effects Analysis (FMEA), a safe design solution is proposed. A set of experiments is conducted to validate the proposed concept, and the results strongly support the development of the experimental model. The Finite Element Analysis (FEA) method is applied to validate the mechanical architecture within a set of simulations, demonstrating the compliance of the robotic system with the proposed technical specifications and its capability to safely perform SILS procedures.

Feasibility of needlescopic surgery for colorectal cancer: safety and learning curve for Japanese Endoscopic Surgical Skill Qualification System-unqualified young surgeons

BACKGROUND

Needlescopic surgery (NS) is a minimally invasive technique for colorectal cancer. NS may be easier to perform than other minimally invasive surgery such as single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery because the port setting is the same while the shafts are thinner than in conventional laparoscopic surgery. We evaluated the capability of introducing this surgery for sigmoid and rectosigmoid colon cancer by assessing the learning curve in Japanese Endoscopic Surgical Skill Qualification System (JESSQS)-unqualified surgeons.

METHODS

In this retrospective study, 112 cases of sigmoidectomy and anterior resection were performed by NS from October 2011 to December 2015 in our institution. Surgical outcomes including operation time, blood loss, postoperative hospital stay, perioperative complications, and overall survival were compared between JESSQS-qualified surgeons (Group A) and JESSQS-unqualified surgeons (Group B). The learning curve for NS was established using the average operation times in JESSQS-unqualified surgeons.

RESULTS

Groups A and B comprised of 41 and 71 patients, respectively. Ninety patients underwent sigmoidectomy and 22 patients underwent anterior resection. No conversion to open surgery occurred. The operation time was significantly shorter in Group A than B (P = 0.0080). There were no significant differences in blood loss, the postoperative hospital stay, perioperative complications, or overall survival between the two groups. These variables were similar even when NS was considered relatively difficult, as in patients with obesity (body mass index of ≥ 25 kg/m²), bulky tumors (tumor size of ≥ 50 mm), and stage III/IV cancer. The average operation time in JESSQS-unqualified young surgeons was significantly shorter in the ninth and tenth cases than in the first and second cases of NS (P = 0.0282).

CONCLUSIONS

NS for sigmoid and rectosigmoid colon cancer was performed safely by both JESSQS-qualified surgeons and JESSQS-unqualified surgeons. Even JESSQS-unqualified young surgeons might be able to quickly learn NS techniques.

Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis

AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer.

METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding).

RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively.

CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the “several years” of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.

Needlescopic surgery for left-sided colorectal cancer

PURPOSE

Laparoscopic surgery has become the standard for colorectal cancers, but more minimally invasive surgery is continuously pursued. In June 2011, our institution started needlescopic surgery (NS). The aims of this study are to describe this technique and to investigate its feasibility for left-sided colorectal cancer surgery.

METHODS

From June 2011 to June 2013, 105 sigmoid colon and upper/middle rectal cancer patients underwent NS in our institution, involving one 5-mm port and three 3-mm ports, with the exception of an umbilical 12-mm port. A 10-mm scope is used through the umbilical 12-mm port, which will be extended to a small skin incision for specimen extraction. After dissection of the left colon, a 5-mm scope is inserted through the right lower 5-mm port and a linear stapler is inserted through the umbilical 12-mm port for rectal transection. The specimen is then extracted through umbilical incision, and the anastomosis is carried out by the double-staple technique.

RESULTS

TNM staging is stage 0/I/II/III/IV = 0/31/32/31/11. Fifty-one patients underwent sigmoidectomy and 54 patients underwent anterior resection. There was no conversion to open surgery, but one patient required a change to a 5-mm port from one of the 3-mm ports. Mean operating time was 193 min and mean estimated blood loss was 12 ml. There were ten (9 %) postoperative complications: two anastomotic leaks requiring reoperation, two anastomotic hemorrhages, and one wound infection. There was no mortality.

CONCLUSIONS

NS for left-sided colorectal cancer was a technically and oncologically feasible technique for selected patients.

Surgery via natural orifices in human beings: yesterday, today, tomorrow

BACKGROUND

We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated.

METHODS

Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated.

RESULTS

The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable.

CONCLUSIONS

NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

Transgastric pure-NOTES peritoneoscopy and endoscopic ultrasonography for staging of gastrointestinal cancers: a survival and feasibility study

BACKGROUND

Human natural orifice transluminal endoscopic surgery (NOTES) has mainly been based on simultaneous laparoscopic assistance (hybrid NOTES), forgoing the theoretical benefits of the NOTES technique. This is due to a lack of NOTES-specific instruments and endoscopes, making pure-NOTES procedures difficult and time consuming. An area where pure NOTES could be adopted at its present stage of development is minimally invasive staging of gastrointestinal (GI) cancer. The aim of this study is to evaluate the feasibility of combining transgastric (TG) pure-NOTES peritoneoscopy and intraperitoneal endoscopic ultrasonography (ip-EUS) with intraluminal EUS (il-EUS) for peritoneal evaluation.

METHODS

This was a feasibility and survival study where il-EUS followed by ip-EUS and peritoneoscopy was performed in 10 pigs subjected to TG pure NOTES. A score was given with regard to achieved visualisation of predefined anatomical structures. Survival was assessed at postoperative day (POD) 14.

RESULTS

All animals survived until POD 14. Median total procedural time was 94 min (range 74-130 min). Median time for il-EUS, ip-EUS and peritoneoscopy was 11 min (range 7-14 min), 13 min (range 8-20 min) and 10 min (range 6-23 min). Il-EUS, ip-EUS and peritoneoscopy resulted in a score of 15/15 points (range 14-15 points), 6/9 points (range 1-8 points) and 12/13 points (range 8-13 points).

CONCLUSIONS

TG pure-NOTES peritoneoscopy and ip-EUS combined with il-EUS is feasible and provides sufficient peritoneal evaluation. The technique could have potential for minimally invasive staging of GI cancers.

A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy

BACKGROUND

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).

METHODS

Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP.

RESULTS

Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p < 0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min).

CONCLUSION

Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.