Abstract
Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.
Highlights
Laparoscopic technology has been widely used to treat colorectal cancer (CRC) over the past two decades, and many studies have demonstrated the advantages of laparoscopic surgery and have suggested that it is a less traumatic procedure, with similar oncological outcomes to those of open surgery (1– 3)
Inclusion criteria were as follows: (1) participants: patients were diagnosed with colorectal diseases, either benign or malignant; (2) interventions: totally intraabdominal laparoscopic colorectal surgery, with the specimen extracted via the rectum, vagina or anus; (3) comparisons: laparoscopic colorectal surgery, with the specimen extracted through the abdominal wall; (4) outcomes: 5-year diseasefree survival (DFS), lymph node harvest, proximal margin, distal margin, operation time, hospital stay, total perioperative complications, pain score, time to first flatus, anastomotic leakage, surgical site infection (SSI), blood loss, and intraabdominal abscess; (5) study design: randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials based on natural orifice specimen extraction (NOSE)
A total of 14 studies were included in the meta-analysis [two RCTs (12, 24), seven retrospective studies (4, 5, 10, 11, 25– 27), and five prospective non-randomized studies (9, 16, 28– 30)]
Summary
Laparoscopic technology has been widely used to treat colorectal cancer (CRC) over the past two decades, and many studies have demonstrated the advantages of laparoscopic surgery and have suggested that it is a less traumatic procedure, with similar oncological outcomes to those of open surgery (1– 3). Laparoscopic natural orifice specimen extraction (NOSE) surgery is widely regarded as one of the representative new technologies in minimally invasive surgery (4, 9–12). It combines the concept of incisionless surgery and laparoscopy to complete intra-abdominal procedures (including exploration, dissection, and resection of lesions) and uses a natural orifice as a delivery route for specimen extraction without laparotomy incision (13). We conducted a meta-analysis to determine the safety and oncological outcomes of laparoscopic NOSE surgery compared with conventional laparoscopic (CL) surgery for colorectal diseases
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