Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Oct 24, 2022; 13(10): 789-801
Published online Oct 24, 2022. doi: 10.5306/wjco.v13.i10.789
Outcomes after natural orifice extraction vs conventional specimen extraction surgery for colorectal cancer: A propensity score-matched analysis
Isaac Seow-En, Lionel Raphael Chen, Yi-Xin Li, Yun Zhao, Jing-Hui Chen, Hairil Rizal Abdullah, Emile Kwong-Wei Tan
Isaac Seow-En, Lionel Raphael Chen, Yun Zhao, Emile Kwong-Wei Tan, Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
Yi-Xin Li, Department of Surgery, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
Jing-Hui Chen, Hairil Rizal Abdullah, Department of Anaesthesiology, Singapore General Hospital, Singapore 169608, Singapore
Author contributions: Seow-En I conceived the research and study design; Seow-En I, Chen LR, Li YX, and Tan EKW contributed to data acquisition and analysis; Zhao Y performed the statistical analysis; all authors were involved in interpretation of data and writing of the manuscript, as well as editing and revision of the article, read and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by the SingHealth Institutional Review Board.
Informed consent statement: All natural orifice specimen extraction study participants provided informed written consent prior to study enrolment.
Conflict-of-interest statement: All authors declare no conflict-of-interest.
Data sharing statement: No additional data are available.
STROBE statement: All authors have read the STROBE Statement - checklist of items, and the manuscript was prepared and revised according to the STROBE Statement - checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Isaac Seow-En, FRCS (Ed), MBBS, MMed, Assistant Professor, Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. isaac.seow.en@gmail.com
Received: August 30, 2022
Peer-review started: August 30, 2022
First decision: September 26, 2022
Revised: October 8, 2022
Accepted: October 12, 2022
Article in press: October 12, 2022
Published online: October 24, 2022
Processing time: 50 Days and 21.7 Hours
Abstract
BACKGROUND

Natural orifice specimen extraction (NOSE) via the anus or vagina replaces conventional transabdominal specimen retrieval via the transabdominal route through a limited mid-line laparotomy or Pfannenstiel incision. Reducing the number of laparoscopic ports further decreases operative abdominal wall trauma. These techniques reduce the surgical wound size as well as the risk of incision-related morbidity.

AIM

To compare short-term outcomes following 3-port NOSE surgery with a matched cohort of conventional non-NOSE colorectal cancer surgery.

METHODS

Patients who underwent elective 3-port laparoscopic colorectal NOSE surgery between February to October 2021 were identified. Selection criteria for NOSE surgery was adapted from the 2019 International Consensus on Natural Orifice Specimen Extraction Surgery for colorectal cancer. Patients with clinical T4 or N2 tumors on staging computed tomography were also excluded. The propensity score-matched cohort was identified amongst patients who underwent conventional laparoscopic colorectal surgery from January 2019 to December 2020. Matching was performed in the ratio of 1:4 based on age, gender, type of resection, and p - tumor node metastasis staging.

RESULTS

Over the eight-month study duration, 14 consecutive cases (nine female, five male) of elective 3-port laparoscopic surgery with NOSE were performed for colorectal cancer. Median age and body mass index were 70 (range 43-82) years and 24.1 (range 20.0-31.7) kg/m2 respectively. Six patients underwent transanal NOSE and eight had transvaginal NOSE. Median operative time, intraoperative blood loss and postoperative length of stay were 208 (range 165-365) min, 30 (range 10-150) mL and 3 (range 2-6) d respectively. Two (14%) suffered minor postoperative compilations not attributable to the NOSE procedure. Median follow-up duration was 12 (range 8-15) mo. No instances of mortality, local or distant disease recurrence were recorded in this cohort. Compared to the conventional surgery cohort of 56 patients, the 3-port NOSE cohort had significantly quicker mean return of bowel function (2.6 vs 1.2 d, P < 0.001), reduced postoperative pain and patient-controlled analgesia use, and decreased length of hospital stay (6.4 vs 3.4 d, P < 0.001). There were no statistical differences in surgical duration and perioperative complication rates between the NOSE and non-NOSE cohorts.

CONCLUSION

3-port laparoscopic colorectal surgery with NOSE is a feasible technique, augmenting the minimally invasive nature of surgery and producing good outcomes. Appropriate patient selection and expertise in conventional laparoscopy are required.

Keywords: 3-port laparoscopy; Colorectal surgery; Natural orifice specimen extraction; Transanal; Transvaginal; Minimally invasive surgery

Core Tip: This paper demonstrates the benefit of reduced port laparoscopic colorectal surgery with natural orifice specimen extraction compared to conventional laparoscopic colorectal surgery. This technique represents a natural progression towards scarless surgery - the holy grail of minimally invasive surgery.