Preliminary surgical outcomes of laparoscopic right hemicolectomy with transrectal specimen extraction: a propensity score matching study of 120 cases (with video)

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.

Evaluation of the efficacy of natural orifice specimen extraction surgery versus conventional laparoscopic surgery for colorectal cancers: A systematic review and meta‐analysis

Aim

Natural orifice specimen extraction surgery (NOSES) has gained significant importance in treating cancers. The current study is a meta‐analysis that aimed to assess the short‐term efficacy and long‐term prognostic impact of NOSES and conventional laparoscopic (CL) surgery in the treatment of colorectal cancer (CRC).

Method

Published reports in several medical databases up to February 2024 were searched and information pertinent to outcomes of NOSES and CL in retrospective and randomized studies to treat CRC was collected. Pooled weighted/standardized mean difference (WMD/SMD), odds ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated using a fixed‐effects model or random‐effects model, and meta‐analysis was subsequently performed using Stata.

Results

Thirty‐one studies with a total of 4637 patients were included in this meta‐analysis. When compared with CL, NOSES had significant advantages in several indicators, such as wound infection [OR = 0.22 (95% CI 0.13–0.38); Z = 5.56, p = 0], incisional hernia [OR = 0.24 (95% CI 0.11–0.54); Z = 3.44, p = 0.001], blood loss [WMD = −10.17 (95% CI −14.75 to −5.60); Z = 4.36, p = 0], incision length [WMD = −4.94 (95% CI −5.27 to −4.60); Z = 29.10, p = 0.00], postoperative pain [WMD = −1.43 (95% CI −1.69 to −1.18); Z = 11.02, p = 0.00], use of additional analgesics [OR = 0.57 (95% CI 0.39–0.82); Z = 3.06, p = 0.002], hospital stay [WMD = –1.25 (95% CI −1.58 to –0.93); Z = 7.65, p = 0.00], gastrointestinal recovery [WMD = −13.42 (95% CI −17.77 to −9.07); Z = 6.05, p = 0.00], first flatus [WMD = −0.50 (95% CI −0.68 to −0.32); Z = 5.34, p = 0.00] and cosmetic result [WMD = 2.11 (95% CI 0.92–3.30); Z = 3.47, p = 0.001]. However, NOSES required a significantly longer duration of surgery [WMD = 14.13 (95% CI 6.70–21.56); Z = 3.73, p = 0.00]. There were no significant differences in postoperative anastomotic leakage, intra‐abdominal infection, lymph node harvest, proximal and distal margins, 5‐year disease‐free and 5‐year overall survival and pelvic floor function.

Conclusion

NOSES is considered an efficient surgical method of treatment for CRC that allows patients to have long‐term favourable oncological outcomes while recovering faster with minimal pain. However, these findings still require confirmation through studies on large population cohorts.

Reduced-port laparoscopic right colonic resection with D3 lymph node dissection and transvaginal specimen extraction (NOSES VIIIa) for right colon cancer: clinical features

BACKGROUND

Reduced-port laparoscopic surgery (RPLS) uses the minimum possible number of ports or small-sized ports in laparoscopic surgery. The combination of RPLS and natural orifice specimen extraction (NOSE) minimizes the procedural damage.

METHODS

A total of 17 patients diagnosed with right colon cancer were included: 5 patients in the RPLS + NOSE group and 12 patients in the conventional laparoscopic surgery (CL) + mini-laparotomy (ML) group. We highlight the key steps of the RPLS + NOSE procedure and compare the clinicopathological characteristics and short-term postoperative outcomes of the two groups.

RESULTS

Compared to CL + ML, RPLS + NOSE was associated with short hospitalization (8.80 ± 1.30 vs 13.75 ± 2.63, p = 0.001), faster first flatus (1.80 ± 0.45 vs 3.4 ± 0.90, p = 0.020) and less postoperative pain on the first day (2.40 ± 0.55 vs 4.25 ± 1.60, p = 0.025). Regarding operation time, intraoperative bleeding, tumor size, proximal and distal margin, number of lymph nodes harvested, number of positive lymph nodes, R0 resection, bowel movements, postoperative complications, Clavien-Dindo classification, Benz's classification and postoperative pain on day 1, day 3 and day 5, no significant difference was observed.

CONCLUSION

In selected patients, RPLS with D3 lymph node dissection and transvaginal specimen extraction results in fast recovery and is indicated for colon cancer patients.

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.

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

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

Short-term and long-term outcomes of intracorporeal anastomosis in laparoscopic segmental left colectomy for splenic flexure cancer - a multicenter retrospective cohort study of 342 cases

INTRODUCTION

While intracorporeal anastomosis (IA) has been widely used in totally laparoscopic right colectomy, its application in laparoscopic segmental left colectomy for splenic flexure cancer remains underexplored, particularly in large-scale studies with long-term outcomes. This research aims to assess the technical feasibility and oncological efficacy of IA in treating colonic splenic flexure carcinoma, drawing insights from both short-term and long-term outcomes of a retrospective cohort.

MATERIALS AND METHODS

A retrospective analysis was conducted on 342 patients diagnosed with colonic splenic flexure carcinoma in three Chinese medical centers. These patients underwent laparoscopic segmental left colectomy between December 2014 and December 2019 across three medical institutions. Comprehensive data encompassing demographics, disease features, pathological characteristics, operative details, and both short-term and long-term outcomes were gathered and scrutinized. Using propensity scores, each patient from the IA cohort was paired with a counterpart from the extracorporeal anastomosis (EA) cohort.

RESULTS

IA was performed on 129 patients, while 213 underwent EA. Post-propensity score matching resulted in 129 matched pairs. After matching, many baseline characteristics were balanced. The IA cohort exhibited several advantages, including shorter incision lengths ( P <0.001) and more extensive proximal and distal resection margins ( P =0.003, P <0.001). Additionally, the IA method facilitated a more rapid postoperative recovery as indicated by quicker return of bowel movements (resumption of passing flatus [2.7 (1.0-7.0) days vs. 3.3 (2.0-8.0) days, P <0.001] and defecation [3.7 (1.0-9.0)] days vs. 4.5 (2.0-9.0) days, P <0.001]), faster discharges [6.6 (3.0-15.0) days vs. 8.3 (5.0-20.0) days, P <0.001], and decreased need for rescue analgesics ( P <0.001). The rate of postoperative complications, as rated by the Clavien-Dindo classification, remained consistent across both techniques ( P =0.087). Furthermore, the cosmetic outcome rated by Patient Scar Assessment Questionnaire and Scoring System (PSAQ) was markedly superior in the IA group ( P <0.001). Both approaches demonstrated equivalent 5-year overall (82.7% vs. 82.1%, P =0.419) and disease-free survival (80.9% vs. 78.1%, P =0.476). Subsequent stratification analysis revealed that IA achieved comparable 5-year overall (80.7% vs. 82.0%, P =0.647) and disease-free survival (78.1% vs. 76.4%, P =0.734) in patients with locally advanced colon cancer.

CONCLUSION

Employing IA for laparoscopic segmental left colectomy in cases of splenic flexure carcinoma is not only safe but also offers enhanced cosmetic results and expedited postoperative recovery. Oncologically speaking, IA in left segmental colectomy for splenic flexure carcinoma can yield therapeutic outcomes comparable to those of EA, even in patients with locally advanced colon cancer.