Abstract
Background:
With the development of surgical technology, surgeons are paying more and more attention to minimally invasive procedures such as injury reduction, pain reduction, and beautiful incisions to ensure the effectiveness of surgical treatment. This article discusses the safety, feasibility, and clinical outcomes of laparoscopic resection of sigmoid colon and rectal tumors via natural orifice specimen extraction surgery (NOSES).
Materials and Methods:
The clinical data of 39 patients who underwent complete laparoscopic resection of sigmoid colon tumor or rectal tumor at Chengde Medical College Hospital between 2018 and 2020, including general patient data (gender, age, body mass index [BMI], etc.), surgery-related data, general postoperative conditions, and postoperative pathological data, were retrospectively analyzed to explore the feasibility and safety of NOSES.
Results:
The specimens were all removed through the anorectal resection drag out type. The average age of 39 patients was 61.3 ± 10.2 years, the average BMI was 24.0 ± 3.1 kg/m2, the average postoperative hospital stay was 11.2 ± 4.4 days, 12 patients with sigmoid colon tumors, including 11 malignant tumors and 1 schwannoma, 27 rectal tumors, including 1 rectal villous tubular adenoma, among the 37 patients with malignant tumors, ulcer type 32 cases of adenocarcinoma and 5 cases of mass adenocarcinoma, mean number of lymph nodes detected intraoperatively (11.9 ± 3.9), mean operative time (162.9 ± 43.0 minutes), mean operative bleeding (36.9 ± 13.0 mL), mean time of initial exhaust (4.3 ± 3.0) days, mean time of laparoscopic drainage tube removal (9.8 ± 1.4) days, mean time of postoperative feeding (4.4 ± 3.0) days, the average maximum tumor diameter (3.7 ± 1.4 cm), and the average distance of the tumor from the anal margin (14.1 ± 6.1 cm); after surgery, there were two cases of anastomotic fistula.
Conclusion:
Laparoscopic resection of sigmoid colon and rectal tumors via natural orifice specimen extraction has the advantages of less pain, reduced incisional complications, good safety, and accurate efficacy in clinical applications.
Introduction
With the development of laparoscopic technology, laparoscopic technology has irreplaceable advantages in the treatment of colorectal cancer.1,2 Most doctors will choose the standard five-hole method. When the specimen is taken out, there will be a 5 cm long incision in the abdomen. Studies have shown that conventional laparoscopic colorectal cancer surgery will have 10%–22.7% infection risk, 3 and there will be 6%–10.8% incidence of incisional hernia. 4 To reduce the abdominal incision infection, incisional hernia and other complications, the operation of natural orifice specimen extraction surgery (NOSES), which is connected with the outside world (rectum, vagina), takes out the tumor samples, thus avoiding the abdominal incision, reducing the complications of the surgical incision, while maintaining the beauty. 5 Compared with the traditional laparoscopic surgery, there is no abdominal incision scarTrace, reduce the psychological burden of patients. 6
In the past few years, the major hospitals across the country have gradually carried out NOSES, 7 and their experience in colorectal cancer surgery has gradually matured, and achieved good results. However, NOSES is still in the initial stage of development, and its feasibility and safety still need big data analysis. The Department of Gastroenterology, Affiliated Hospital of Chengde Medical College, is the first hospital in Chengde area to carry out NOSES, which has accumulated a lot of clinical cases. In this article, the clinical data of patients with NOSES in our department in recent years were analyzed retrospectively, and the feasibility and safety of the operation were discussed, so as to promote the operation development and accumulate clinical data.
Materials and Methods
Patients
The research method of this study is a clinical retrospective study, retrospective analysis of patients with sigmoid and rectal tumors treated in the Department of Gastroenterology, Affiliated Hospital of Chengde Medical University from 2018 to 2020. Fifty-two patients underwent complete NOSES. The incomplete data were excluded, and 39 samples were actually included. All patients were completed under laparoscopy and no conversion to laparotomy or death during perioperative period was found. The basic information of the patients is shown in Table 1. Research data approved by IRB.
Basic Information of Patients (39 Cases)
BMI, body mass index.
Inclusion and exclusion criteria
Inclusive criteria: (1) complete preoperative colonoscopy, confirmed as sigmoid or rectal tumors, including benign and malignant tumors; (2) complete laparoscopic tumor resection, no auxiliary abdominal incision, anal removal through natural orifice, and (3) the expected survival time is more than 3 months.
Exclusion criteria: (1) patients with severe surgical contraindications, accompanied by severe cardiovascular and cerebrovascular diseases or liver and kidney dysfunction; (2) patients with distant metastasis; (3) patients who need to be converted to open surgery due to other diseases; and (4) patients undergoing neoadjuvant chemotherapy.
Operation procedures
Dissection and separation: after anesthesia, the lithotomy position was taken and pneumoperitoneum was established, and the operation was performed by conventional five-hole method. The left colonic artery was preserved, the superior rectal artery was clamped with hemostasis clamp, the peripheral lymph and adipose tissue were free, the sigmoid colon and mesorectum were free, the Toldt's space was extended to the lateral side, the mesocolon was free, the bilateral lateral rectum ligament was cut off, the anterior rectal wall was dissociated along Denonvilliers' fascia, and the upper rectum and middle and lower sigmoid colon were separated segment and corresponding mesentery were resected.
The removal of tumor specimens and reconstruction of digestive tract: the distance from the upper edge of tumor was 15 cm, the intestinal tube was cut, the purse string was sewn, the stapler head was placed, and the purse string was tightened. After anal dilation, iodophor cotton ball disinfection was carried out. A protective sleeve was placed from the anus, and the specimen was put into the sheath and pulled out from the anus. The rectum stump was closed, and the stapler was inserted from the anus, and the sigmoid colon stump was anastomosed with the rectal stump.
Observation
Preoperative general clinical indicators: gender, age, body mass index (BMI), preoperative colonoscopy pathology, tumor location, and size.
Operation related conditions: operation time, intraoperative blood loss, ways and methods of specimen removal, conversion to laparotomy, and preventive fistulation.
Postoperative clinical indicators: postoperative hospital stay, postoperative ambulation time, first exhaust and defecation time, postoperative first eating time, postoperative abdominal drainage, postoperative infection (body temperature, white blood cell count, C-reactive protein), postoperative complications (Clavien–Dindo rating scale), and postoperative pathology.
Statistical analysis
All patients' medical records were established by Excel and analyzed by SPSS 22.0 software. The measurement data are expressed as mean ± standard deviation (x ± s) and count data are expressed by n.
Result
Postoperative pathological results
According to the pathological classification, 29 cases (74.4%) were moderately differentiated ulcerative adenocarcinoma, 1 case (2.6%) was poorly differentiated ulcerative adenocarcinoma, 5 cases (12.8%) were moderately differentiated mass adenocarcinoma, 2 cases (5.1%) were well differentiated ulcerative adenocarcinoma, 1 case (2.6%) was rectal villous tubular adenoma, and 1 case (2.6%) was sigmoid colon schwannoma. The average maximum diameter of tumor was 3.7 ± 1.4 cm. The number of tumors with the diameter of 2.5–4.0 cm was the most, accounting for 64.1%. The average distance between the tumor and the anal margin was 14.1 ± 6.1 cm, the farthest distance from the anal margin was 30.0 cm, and the nearest distance was 6 cm. The average number of lymph nodes dissected during operation was 11.9 ± 3.9, and 27 (69.2%) patients had more than 10 lymph nodes detected. The number of positive margins in 39 pathological specimens was 0. According to American joint committee on cancer tumor node metastasis classification staging, the number of stage I patients was 2 cases (5.4%), the number of stage II patients was 21 cases (56.8%), and the number of stage III patients was 14 cases (37.8%). Details are shown in Table 2.
Analysis of Pathology Results
A total of 39 cases resulted, of which 37 were malignant tumor and 2 benign tumors.
TNM, tumor node metastasis classification.
Analysis of operation-related indexes
All patients completed the operation successfully, no conversion to laparotomy or intraoperative death. Thirty-seven patients recovered smoothly after the operation, 2 patients developed anastomotic leakage after operation, and underwent transverse colostomy. Among the 39 patients, the average operation time was 162.9 ± 43.1 minutes; the average operation blood loss was 36.9 ± 13.0 mL; the average postoperative hospital stay was 11.3 ± 4.5 days; the average postoperative exhaust time was 4.4 ± 3.1 days; the average postoperative fluid intake time was 4.4 ± 3.1 days; and the average postoperative drainage tube removal time was 9.9 ± 4.5 days. There were no deaths during hospitalization. According to Clavien–Dindo rating scale, 37 patients with grade II had postoperative pain and electrolyte disturbance and were relieved after symptomatic analgesia and fluid infusion. Two patients with grade III B had anastomotic leakage and underwent transverse colostomy. No postoperative infection occurred in all patients. All patients had no abnormal anal function.
Discussion
The development of a surgical technique must be based on the premise that the patients will benefit the most. The particularity of the specimen taken from the operation of NOSES and the way of digestive tract reconstruction under total laparoscopy decide that the feasibility of this technique is the focus of discussion among surgeons, which makes the promotion of this technology controversial.
The reasons for the wide application of NOSES in colorectal cancer are as follows: (1) beautiful appearance after operation and (2) less trauma and less postoperative pain. Compared with the traditional laparoscopic surgery, NOSES avoids the auxiliary incision of abdominal wall specimen, reduces the incidence of postoperative incision infection, and reduces the psychological burden of patients, which is in line with the current “minimally invasive” concept. 9 However, NOSES has its own limitations. The first problem is the patient's indication. Whether the patient meets the operation standard should be evaluated. The key problem in the operation is whether the tumor specimen can be removed through the natural lumen. The second is the safety of the operation, whether it can achieve the principle of no tumor and sterility, reduce the incidence of postoperative complications, do not affect the normal function of natural lumen, do not affect the recurrence rate of tumor, and prolong the survival time of patients.8,9 Domestic scholars suggested that the suitable criteria for the operation of NOSES are as follows: the depth of tumor invasion should be T2–T3, the circumferential diameter of transrectal NOSES should be less than 3 cm, and that of transvaginal NOSES should be 3–5 cm. The relative contraindications included late local tumor stage, larger lesions, and obesity (BMI ≥30). 10
In this study, the average BMI of patients was 24.0 ± 3.1 kg/m2, and only one patient with BMI >30 kg/m2 was taken out smoothly. We found that preoperative assessment of patient's BMI value can preliminarily estimate the size of mesorectum, but whether the specimen can be successfully removed still depends on intraoperative investigation. Preoperative assessment of patient's BMI and intraoperative exploration are the key to successful specimen collection. It cannot be decided by BMI or intraoperative exploration alone. Among the 39 patients, 37 patients with malignant tumor, 2 patients with T2 stage, 19 patients with T3 stage, and 16 patients with T4 stage were included in the study. The maximum diameter of tumor in this study was 9 cm, which was far beyond the standard of perirectal nodes less than 3 cm in the standard and consensus on the selection of indications for colorectal cancer. When choosing indications in accordance with the “norms and consensus on the selection of indications for colorectal cancer NOSES,” doctors should correctly treat the word “appropriate.” During the operation, it is not possible to mechanically copy the indications. Due to the differences in anatomy of different patients, it is difficult to define a unified standard with an accurate number. When NOSES cannot be continued, surgeons should immediately switch to traditional laparoscopic surgery.
In a report, 11 all patients with sigmoid nodes surgery had abdominal infection, while patients who underwent traditional open surgery had abdominal infection. However, there was no statistical significance in the complications caused by infection. In this study, Clavien–Dindo classification scale was used for postoperative complications. The results showed that there were 37 patients with Clavien–Dindo grade II, only postoperative pain and other general complications occurred. After symptomatic treatment, all patients were improved and discharged. The score of 2 patients was Clavien–Dindo grade IIB, and anastomotic leakage occurred after operation. Analysis of the cases revealed that these 2 patients had more preoperative underlying disease, resulting in poor healing of the anastomosis, and to ensure the effectiveness of the patient's treatment, they were treated with a transverse colostomy, followed by stoma reimbursement and discharged with improvement. The average blood loss was 36.9 ± 13.0 mL, which was lower than some domestic reports. The NOSES is required to be operated under total laparoscope, and the principle of tumor free is the fundamental operation.15 In this study, all patients did not have positive circumscribed margin cases and abdominal infection, which requires NOSES operators to have rich experience in laparoscopic surgery. In actual operation, the operation is more and more standardized, and the operation is gradually skilled. During the operation, dilute iodophor and distilled water repeatedly wash the abdominal cavity. In order to ensure the safety of the operation, the tacit cooperation between the doctors is essential.11,12
Conclusion
With the concept of minimally invasive surgery, deeply rooted in the hearts of the people, the continuous progress and development of NOSES technology has good feasibility, safety, and short-term efficacy in the radical surgery of sigmoid and rectal tumors. NOSES can avoid the related complications caused by abdominal incision to the greatest extent, at the same time, it can reduce the impact on the quality of life of patients, reduce the psychological pressure of patients, and help patients to return to normal life and work in the shortest time. For the current popular concept of fast track surgery, NOSES also caters to this point. 13
Footnotes
Acknowledgments
We thank all the staff in Department of gastrointestinal surgery, Affiliated Hospital of Chengde Medical University for their contribution on our research.
Ethics Approval and Consent to Participate
Data were obtained from the medical records database of Affiliated Hospital of Chengde Medical University, and the study was exempted by the database administrators.
Availability of Data and Materials
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Authors' Contributions
Conceptualization: Z.Z. and E.Z.; data curation: Z.Z. and Q.C.; formal analysis: Z.Z., H.Z., and J.L.; methodology: Z.Z. and S.Z.; supervision: E.Z.; writing—original draft: Z.Z.; writing—review and editing: Z.Z. and E.Z.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.