Abstract
BackgroundLaparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.MethodsThe study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.ResultsUpper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.ConclusionsNOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.
Highlights
The notion of natural orifice specimen extraction surgery or NOSES for rectal cancer (RC) defines a modified procedure of specimen extraction through natural passages and subsequent intracorporal digestive tract reconstruction in suitable patients with RC [1, 2]
Further comparison between the two groups showed that NOSES was more frequently performed in patients with a female gender, negative CEA/CA19-9 status and was associated with decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA)
No significant difference was seen in age, body mass index (BMI), tumor location, differentiation, lymph-vascular invasion, lymph node count (LNC)/positive lymph node count (PLNC) and TNM stages (Table 1)
Summary
The notion of natural orifice specimen extraction surgery or NOSES for rectal cancer (RC) defines a modified procedure of specimen extraction through natural passages (i.e., rectum and vagina) and subsequent intracorporal digestive tract reconstruction in suitable patients with RC [1, 2]. Compared with laparoscopy-assisted surgery (MiniLapa), patients receiving NOSES tend to experience an increased rate of comfortability [8] and a comparable frequency of complications with a shortened time for recovery and hospital stay [7, 9,10,11]. Improper application of NOSES in patients with upper RC may lead to potential surgical and oncological consequences and complications such as bacterial contamination and anastomotic bleeding and leak [2, 12, 13]. Improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making
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