Natural Orifice Specimen Extraction Group Research Articles

Short-term clinical outcomes and five-year survival analysis of laparoscopic-assisted transanal natural orifice specimen extraction versus conventional laparoscopic surgery for sigmoid and rectal cancer: a single-center retrospective study.

The cosmetic benefits of natural orifice specimen extraction (NOSE) are easily noticeable, but its principles of aseptic and tumor-free procedure have caused controversy. We conducted a retrospective analysis of the clinical data of patients who underwent laparoscopic-assisted transanal NOSE or conventional laparoscopic surgery (CLS) for sigmoid and rectal cancer at our hospital between January 2018 and December 2018. The study aimed to compare the general characteristics, perioperative indicators, postoperative complications, and five-year follow-up results between the two groups. A total of 121 eligible patients were enrolled, with 52 underwent laparoscopic-assisted transanal NOSE and 69 underwent CLS. There were no significant differences observed between the two groups in terms of gender, age, body mass index (BMI), TNM stage, etc. (P > 0.05). However, the NOSE group exhibited significantly shorter total incision length and longer operation time compared to the CLS group (P < 0.05). There were no statistically significant differences observed between the two groups in terms of positive rate of bacterial culture, incidence rates of intraabdominal infections or anastomotic leakage (P > 0.05). Furthermore, during follow-up period there was no statistically significant difference observed between these two groups concerning overall survival rate and disease-free survival outcomes (P > 0.05). The management of surgical complications in CLS is exemplary, with NOSE presenting a sole advantage in terms of incision length albeit at the cost of prolonged operative time. Therefore, NOSE may be deemed appropriate for patients who place high emphasis on postoperative cosmetic outcomes.

Laparoscopic surgery for rectal cancer, specimen extraction: transanal or transabdominal?

BackgroundComparison of natural orifice specimen extraction (NOSE) and transabdominal specimen extraction (TASE) in colorectal surgery remains controversial. Herein, we aimed to perform a retrospective analysis on surgical outcomes of NOSE and TASE at three hospitals in east of Iran.MethodConsecutive locally advanced rectal adenocarcinoma patients who underwent laparoscopic surgery using either NOSE or TASE from 2011 to 2017 were recruited. These patients were followed-up till 2020. Data, including postoperative complications, long-term overall and recurrence-free survival were analyzed retrospectively.Results239 eligible patients were included in this study. 169 (70.71%) patients underwent NOSE, and 70 (29.29%) patients underwent TASE. Although this study has achieved similar outcomes in terms of overall and recurrence-free survival, metastasis, circumferential margin involvement as well as complications of intra-operative bleeding, obstruction, anastomosis-fail, rectovaginal-fistula in women and pelvic collection/abscess in both groups, we observed higher rates of locoregional recurrence, incontinency, stenosis and the close distal margins involvement in NOSE group and also obstructed defecation syndrome in TASE cases.ConclusionAccording to our findings, NOSE laparoscopic surgery showed significantly higher incontinency, impotency, stenosis and involvement of the close distal margins rates. Nevertheless, considering the similarity of long-term overall and recurrence-free survival, metastasis, circumferential margin involvement, NOSE procedure is still could be considered as a second choice for lower rectal adenocarcinoma patients.

Bacteriological and oncological safety of complete laparoscopic radical resection of colorectal cancer without incision anastomosis based on propensity-matched scores.

Complete laparoscopic radical resection of colorectal cancer without incision anastomosis is performed by means of natural orifice specimen extraction (NOSE), which avoids a large abdominal wall incision. Although this procedure is increasingly practiced, it is still underdeveloped, one reason being that controversy still exists regarding bacteriological and oncological safety. To demonstrate the safety of complete laparoscopic radical resection of colorectal cancer without incision anastomosis in bacteriology and oncology. This study was a retrospective study with prospectively collected data. This study continuously collected 420 patients who underwent colorectal cancer surgery in our hospital from January 2018 to March 2022. According to the different surgical methods, they were divided into the NOSE group (the natural orifice specimen extraction group) and the N-NOSE group (specimen removed through abdominal wall auxiliary incision). The two groups were matched 1 : 1 using the propensity score matching (PSM) method to balance at baseline. Bacteriological and oncological outcomes, short-term complications, and long-term prognosis were compared between the two groups. One hundred and eighty-four of the 420 included patients were successfully matched. The differences in gender, body mass index, T stage, N stage, and diabetes status between the two groups after matching were not statistically significant. There were no significant differences in oncological outcomes, short-term complications, and 2-year postoperative disease-free survival between the two groups. There was no significant correlation between positive bacterial culture results and intra-abdominal infection. Compared with traditional laparoscopic surgery, complete laparoscopic radical resection of colorectal cancer without incision anastomosis has satisfactory bacteriological and oncological effects and is worthy of further clinical promotion.

Three-Port with Natural Orifice Specimen Extraction versus Conventional Laparoscopic Anterior Resection for Rectal-Sigmoid Cancer: A Matched Pair Analysis

Background The conventional laparoscopic colorectal surgery requires four or more ports to accomplish the laparoscopic dissection, and a mini-laparotomy to remove the specimen, which is a main cause of postoperative pain and incision complications, and compromise the cosmetic results. Reduced port surgery and natural orifice specimen extraction (NOSE) surgery hold the promise to overcome these drawbacks. This study planned to compare peri-operative outcomes of patients with rectal-sigmoid cancer undergoing three-port laparoscopic anterior resection with NOSE (three-port NOSE LAR) to those of patients receiving conventional LAR. Methods Twenty-five patients with rectal-sigmoid cancer underwent three-port NOSE LAR between December 2018 and October 2020. For comparison, 50 patients with rectal-sigmoid cancer underwent conventional LAR in the same period were matched. The peri-operative outcomes were compared. Results Operating time of three-port NOSE group was slightly longer than that of conventional group (135 min vs. 121 min, p = .147). The incision length of three-port NOSE group was shorter than that of conventional group (2.9 cm vs. 7.4 cm, p = .000). Complication rates in three-port NOSE group and conventional group were similar (12.0% vs. 20.0%, p = .524). The tumor size was smaller in three-port NOSE group than the conventional group (2.1 cm vs. 3.5 cm, p = .000). Pain score was lower in three-port NOSE group than the conventional group at postoperative day 1 (1.6 vs. 3.0, p = 0.045) and day 2 (0.2 vs. 2.1, p = .003). The BIQ score was significantly higher in the three-port NOSE group compared to the conventional group (42.9 ± 3.5 vs. 38.2 ± 2.5, p = .002). Conclusions Three-port NOSE LAR for rectal-sigmoid cancer is feasible and provides similar peri-operative outcomes compared to conventional LAR. It reduces postoperative pain and produces better cosmesis.

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 Versus Transabdominal Specimen Extraction Following Laparoscopic Minor Hepatectomy

Natural orifice specimen extraction (NOSE) is an emerging technique usually preferred for colorectal resections or cholecystectomy. NOSE following laparoscopic liver resections is limited to case reports, and there is no previous study comparing the outcomes of NOSE and transabdominal (TA) specimen extraction. Our aim was to compare NOSE and TA specimen extraction methods following laparoscopic minor hepatectomy. Thirty-one patients undergoing laparoscopic minor hepatectomy between 2014 and 2020 were evaluated. The patients were divided into two groups as NOSE (n: 12) and TA (n: 19). The patients’ demographics, preoperative and postoperative findings, pain, and cosmetic scores were compared. Female ratio was higher in the NOSE group (83.3% vs 31.6%, p=0.005); other demographics were similar. The median length of incision was 6 cm in the TA group but only trocar incisions in the NOSE group. There was no difference between intraoperative and postoperative findings except pain and cosmetic scores. Pain scores on postoperative days 1, 2, and 3 and in total were lower in the NOSE group (4.1±0.6 vs. 5.6±1.1, p=0.001; 2.2±04 vs. 4.1±0.9, p<0.001; 1.7±0.6 vs. 2.4±0.8, p=0.025; 8.1±1.4 vs. 12.2±2.5, p<0.001). In addition, patients in NOSE group had better cosmetic scores (9.2±0.6 versus 7.0±0.6, p<0.01). Laparoscopic minor hepatectomy combined with NOSE is a safe and effective procedure in selected patients with the advantages of less postoperative pain and better cosmesis. NOSE is ideal for female patients with high cosmetic expectancy.

Propensity score–matched comparison between totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction and conventional laparoscopic surgery with mini-laparotomy in the treatment of ascending colon cancer (with video)

Now that the debate about the safety and effectiveness of laparoscopic versus open surgery is over, attention has turned to innovations that can verify whether minimizing the impact of laparoscopy on the abdominal wall can further reduce pain, improve patient comfort, lead to superior cosmesis, and reduce morbidity. The aim of this study was to further explore the application value of totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction (NOSE) and to evaluate the short-term efficacy of transcolonic NOSE surgery for resecting specimens of ascending colon cancer. From January 2016 to May 2017, a retrospective study was conducted in Guangxi. Propensity score matching was used to minimize the bias from nonrandomized treatment assignment. Patients were followed up through May2020. Forty-nine patients underwent totally laparoscopic right hemicolectomy with transcolonic NOSE and 116 patients laparoscopic right hemicolectomy with mini-laparotomy (ML) procedures at our institution. After propensity score matching, each group included 45 patients, and all covariate imbalances were alleviated. The transcolonic NOSE group and the ML group did not differ significantly in terms of baseline clinical characteristics. The transcolonic NOSE group was associated with a shorter time to first flatus (NOSE vs ML: 1.8 ± .5 vs 3.2 ± .8, P= .032), a shorter length of hospital stay (11.3 ± 2.5 days vs 13.0 ± 3.1 days, P= .034), a shorter time to first liquid intake (2.6 ± .8 vs 3.8 ± .9, P= .068), less pain (1.8 ± .8 vs 4.2 ± .7, P= .013), less analgesia requirement (6 [13.3%] vs 21 [46.7%], P= .001), and lower C-reactive protein levels on postoperative day 1 (3.6 ± 1.7 vs 8.2 ± 2.2, P= .001) and postoperative day 3 (NOSE 2.4 ± 1.4 vs M: 4.6 ± 1.7 [P= .013]) than the ML group. The median follow-up was 28.4 months (interquartile range, 18.0-36.0). The 3-year overall survival rates were similar between the transcolonic NOSE group and the ML group. In total, laparoscopic right hemicolectomy with transcolonic specimen extraction appears to be safe for selected patients with ascending colon cancer as a minimally invasive surgery.

Clinical outcomes and prognostic factors of robotic assisted rectal cancer resection alone versus robotic rectal cancer resection with natural orifice extraction: a matched analysis

Robotic rectal cancer resection with natural orifice extraction is a recently developed minimally invasive surgery used in the treatment of patients with rectal cancer. However, its safety and feasibility remain undiscussed and controversial. This study reported the clinical outcomes and prognostic factors pertaining to traditional robotic assisted rectal cancer resection alone against that of robotic rectal cancer resection with natural orifice extraction to provide a discussion on this issue. 49 patients who underwent robotic rectal cancer resection with natural orifice extraction and 49 matched patients who underwent conventional robotic assisted rectal cancer resection were systematically analyzed in this study. Regarding the baseline characteristics, after matching, no significant differences were observed between the natural orifice specimen extraction (NOSE) group and the robotic assisted rectal cancer resection (RARC) group. Patients in the NOSE group had a reduced visual analog scale (p < 0.001), passed flatus more quickly (p = 0.002) and suffered less surgical stress than those in the RARC group. Moreover, 4 complications were observed in the NOSE group and 7 complications in the RARC group with no significant difference (p = 0.337) in terms of complications. The two groups had a similar survival outcomes, where the 3-year overall survival (p = 0.738) and 3-year progression-free survival (p = 0.986) were all comparable between the two groups. Histological differentiation and T stage could be regarded as independent prognostic factors for 3-year overall survival and 3-year progression-free survival. Robotic rectal cancer resection with natural orifice extraction is a safe and feasible minimally invasive surgery for patients suffering from rectal cancer as it encompasses considerable several advantages. Histological differentiation and T stage may serve as independent prognostic factors for 3-year overall survival and 3-year progression-free survival.

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

BackgroundThe 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.MethodsA 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.ResultsWe 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.ConclusionsNOSE 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

Transrectal Natural Orifice Specimen Extraction (NOSE) With Oncological Safety: A Prospective and Randomized Trial

BackgroundIn the present paper, we introduce our experience with the novel method during laparoscopic anterior resection of upper rectal or sigmoid colon cancer by transrectal natural orifice specimen extraction (NOSE). MethodsA prospective randomized controlled trial was performed from June 2016 to May 2019. Patients with upper rectal or sigmoid colon cancer were randomized in a 1:1 ratio to the NOSE group and the non-NOSE group. Preoperative and postoperative clinical variables were analyzed and compared between groups. Postoperative pain was analyzed utilizing a visual analog scale. Postoperative overall survival was analyzed using a Kaplan–Meier curve. ResultsA total of 276 patients were enrolled, of whom 254 were randomly divided into the NOSE group (n = 122) and the conventional laparoscopic group (n = 119). NOSE failed in 22 cases, which were converted to transabdominal specimen extraction. Intention-to-treat analysis was performed, and these 22 cases were included in the NOSE group. The incidence of postoperative complications was significantly lower in the NOSE group (11/122, 9%) than in the non-NOSE group (25/119, 21%). The NOSE group had a longer operation time, less blood loss, and a lower postoperative visual analog scale score than the non-NOSE group. The time for intestinal function recovery (ventilation) and the length of hospital stay were significantly longer in the non-NOSE group. The Kaplan–Meier survival curve showed no statistically significant difference in the disease-free survival rate between the NOSE group and the non-NOSE group. ConclusionsThe novel NOSE method is safe and feasible to use in patients having colorectal cancer. Compared with traditional laparoscopic surgery, the postoperative complication rates of NOSE surgery were lower with an improved short-term clinical recovery.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer.

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL). A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire. A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups. Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

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

ObjectiveThe 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. MethodsFrom 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.ResultsEstimated 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. ConclusionsFor 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 short-term and survival outcomes for transanal natural orifice specimen extraction with conventional mini-laparotomy after laparoscopic anterior resection for colorectal cancer.

BackgroundTransanal natural orifice specimen extraction (NOSE) in colorectal surgery has been introduced as a less invasive surgery. However, its long-term survival effects remain controversial. The aim of this study was to compare the short-term and long-term survival outcomes of transanal NOSE with those of the conventional laparoscopic approach with mini-laparotomy (LAP) for anastomosis construction and specimen extraction in sigmoid colon cancer or rectal cancer.MethodsFrom January 2007 to January 2018, a retrospective study was conducted at the China National Cancer Center. In total, 52 consecutive patients who underwent laparoscopic anterior resection with NOSE were matched with an additional 52 patients who underwent conventional LAP for colorectal cancer.ResultsPatients in the NOSE group experienced shorter time to passage of flatus (2.8±0.8 vs 3.2±0.9 days; p=0.042), less pain (4.2±1.4 vs 5.4±1.7; p=0.003) and less analgesia required (7.7% vs 25.0%; p=0.032). After a median follow-up of 68.5 (range, 8–83) months, the two groups had similar 5-year overall survival rates (92.3% vs 94.2%; p=0.985) and disease-free survival rates (84.6% vs 86.5%; p=0.802).ConclusionTransanal NOSE for total laparoscopic anterior resection is safe and feasible with more advantages, including lower pain, lower tissue trauma and faster recovery of intestinal function. Moreover, with proper protection of the surgical route, transanal NOSE has the same long-term outcomes as conventional laparoscopic surgery.

A Comparison of Natural Orifice Versus Transabdominal Specimen Extraction Following Laparoscopic Total Colectomy.

Natural orifice surgery has been increasingly used in colon surgery since the early 2000s. However, it is rarely used for total colectomy. In this study, we aimed to retrospectively compare natural orifice specimen extraction (NOSE) with transabdominal specimen extraction in patients undergoing laparoscopic total colectomy. Twenty-six patients who underwent laparoscopic total colectomy between 2013 and 2017 were enrolled and the patients were divided into two groups: NOSE (n = 13) and transabdominal group (n = 13). The patients' demographic characteristics, perioperative and postoperative outcomes, pathology results, visual analog scale scores, and cosmetic scores were compared. There was no significant difference between the two groups in terms of demographic characteristics as well as perioperative and postoperative outcomes, including complications. Benign pathologies were more common in the NOSE group (85% versus 15%, P = .001). The pain scores of the postoperative first, second, and third days were significantly lower in the NOSE group 4.1 ± 2.1 versus 7.1 ± 1.3 (P = .005), 3.7 ± 2.2 versus 6.0 ± 1.5 (P = .003), and 2.2 ± 2.0 versus 4.1 ± 0.9 (P = .03), respectively. As expected, the mean cosmetic score was significantly better in the NOSE group (8.3 ± 1.5 versus 6.7 ± 1.8, P = .02). NOSE combined with laparoscopic total colectomy provided better patient comfort in benign diseases and small-sized malignant diseases.

Natural Orifice Specimen Extraction during Laparoscopic Bowel Resection for Colorectal Endometriosis: Technique and Outcome

Study ObjectiveTo present a detailed description of a modified natural orifice specimen extraction (NOSE) colectomy technique. We also report the postoperative outcomes of our prospective case series when compared with conventional laparoscopic bowel resection in a relatively large series of patients. DesignCanadian Task Force classification II-1. SettingA university tertiary referral center. PatientsThe last 90 consecutive patients in our care with deep infiltrating endometriosis of the bowel are presented in this study. Patients were diagnosed at the 1st Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary. InterventionsWe performed laparoscopic bowel resection using the transrectal NOSE technique and compared the results of the new operative method (n = 30) with traditional laparoscopic bowel resection (n = 60). Measurements and Main ResultsThe median duration of surgery was 121 minutes in the control group and 96 minutes in the NOSE group (p = .005). According to the Clavien-Dindo classification, we observed a severe, grade IIIb or higher, overall complication rate of 3.3% among all 90 patients. In the control group, anastomosis insufficiency occurred in 3.3% of patients (2/60 cases), and in 1 patient with anastomotic leakage a rectovaginal fistula was observed (1.7%). There was no significant difference in the rates of severe postoperative complications (p = .55). The length of hospital stay in the control group was a median of 7 days (range, 5–13 days), whereas in the NOSE group it was 6 days (range, 3–11 days) (p < .001). ConclusionAccording to our findings, the use of NOSE colectomy offers a shorter recovery time and can eventually lead to a shorter surgery duration compared with traditional laparoscopic bowel resection.

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

PurposeThe 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.MethodsWe 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.ResultsAfter 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.ConclusionIn 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.

Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis.

We wished to determine the effects of laparoscopic resection using natural orifice specimen extraction (NOSE) for patients with colorectal disease through a meta-analysis. A study search was undertaken in PubMed, EMBASE, and Cochrane databases for eligible studies until December 2014. Duration of hospital stay, operation time, time to first flatus, pain score, cosmetic result, postoperative complications, and disease-free survival (DFS) were the main endpoints. The results were analyzed using RevMan v5.3. Nine clinical studies involving 837 patients were included for final analyses. Laparoscopic resection with NOSE had a shorter duration of hospital stay (weighted mean difference (WMD) = -0.62 days, 95 % confidence interval (CI) [-0.95, -0.28], p < 0.01) and time to first flatus (WMD = -0.59 days, 95 % CI [-0.78, -0.41], p < 0.01), less postoperative pain (WMD = -1.43, 95 % CI [-1.95, -0.90], p < 0.01), and postoperative complications (odds ratio (OR) = 0.51, 95 % CI [0.36, 0.74], p < 0.01) with better cosmetic result (WMD = 1.37, 95 % CI [0.59, 2.14], p < 0.01). However, the operation time was significantly longer in the NOSE group (WMD = 20.97 min, 95 % CI [4.33, 37.62], p = 0.01). No significant difference was observed in DFS (hazard ratio (HR) = 0.88, 95 % CI [0.49, 1.57], p = 0.67). Our meta-analysis supported the notion that laparoscopic resection with NOSE for colorectal disease can significantly reduce the duration of hospital stay, accelerate postoperative recovery with better cosmetic results, and in particular, result in less postoperative pain and fewer complications.

Randomized clinical trial of laparoscopic colectomy with or without natural-orifice specimen extraction.

Although conventional laparoscopic colectomy is a validated technique, laparoscopic natural-orifice specimen extraction (NOSE) colectomy might improve outcome. This randomized clinical trial compared analgesia requirements, postoperative pain, anorectal function, inflammatory response and cosmesis in laparoscopic NOSE colectomy and conventional laparoscopic colectomy. Patients were randomly assigned to undergo laparoscopic NOSE colectomy or conventional laparoscopic colectomy for left-sided colonic disease. The primary endpoint was analgesia requirement. Secondary endpoints were operative outcome, inflammatory response, anorectal function and cosmesis. Forty patients were enrolled in the study, 20 in each group (15 with diverticulitis and 5 with colorectal cancer in each group). A significant difference was observed in morphine analogue requirements (1 of 20 patients in the NOSE group versus 10 of 20 in the conventional group; P = 0·003). Patient-controlled epidural analgesia was lower in the NOSE group (mean 116 ml versus 221 ml in the conventional group; P < 0·001), as was paracetamol use (mean 11·0 versus 17·0 g respectively; P < 0·001). Postoperative pain scores were lower in the NOSE group: mean maximum visual analogue score of 3·5 versus 2·1 (P < 0·001). One week after hospital discharge, pain scores remained higher in the conventional group: 15 of 20 patients in the conventional group reported pain, compared with one of 20 in the NOSE group (P < 0·001). Inflammatory responses were greater in patients undergoing NOSE colectomy: higher peak C-reactive protein and interleukin 6 levels were observed on postoperative day 2 (P < 0·001) and day 1 (P = 0·002) respectively. Postoperative anorectal function, complications and hospital stay were similar in the two groups. Laparoscopic NOSE colectomy was associated with less pain and lower analgesia requirements than the conventional laparoscopic extraction. NCT01033838 (http://www.clinicaltrials.gov).

Totally Laparoscopic Intracorporeal Anastomosis With Natural Orifice Specimen Extraction (NOSE) Techniques, Particularly Suitable for Bowel Endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ2 test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections

Natural orifice specimen extraction (NOSE) in colorectal surgery prevents the need for an enlarged port site or minilaparotomy to extract the surgical specimen. The downside of this technique may be an increased risk of bacterial contamination of the peritoneal cavity from the external milieu. The aim of this study was to prospectively analyze the peritoneal bacterial contamination in NOSE and non-NOSE laparoscopic colorectal procedures. Consecutive patients operated for sigmoid diverticulitis with laparoscopic approach and transanal extraction of the specimen from January to December 2010 at our university hospital were enrolled. Patients who underwent a laparoscopic sigmoidectomy in the same study period with conventional specimen extraction were used as reference. Peritoneal fluid samples were collected under sterile conditions at the end of the procedure and sent for gram stain as well as anaerobic, aerobic, and fungal cultures. Twenty-nine patients underwent laparoscopic sigmoidectomy for diverticulitis with transanal NOSE, while 9 patients underwent laparoscopic sigmoidectomy with conventional specimen extraction during the same period. The two groups were successfully matched 1:2 (17 NOSE and 9 non-NOSE) according age, sex, ASA, and Charlson comorbidity score. The contamination rate of peritoneal fluid was 100% vs. 88.9% in NOSE and non-NOSE procedures, respectively (P = 0.23). Overall and major complications rates were 27.6% vs. 11.10% (P = 0.41) and 5.08% vs. 11.1% (P = 1) in NOSE vs. non-NOSE procedures, respectively. In the NOSE group there was a statistically significant lower consumption of oral paracetamol (P = 0.007) and of oral tramadol (P = 0.02). Although a higher peritoneal contamination was found in the NOSE procedures, there were no significant differences in clinical outcomes relative to standard approach. Avoiding a minilaparotomy to extract the specimen resulted in a significantly lower postoperative analgesic requirement in the NOSE group.