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

Abstract

Purpose: The 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.

Methods: We 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.

Results: After 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.

Conclusion: In 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.

Keywords: Laparoscopy; Natural Orifice Endoscopic Surgery; Rectal cancer; Survival.

Fig. 1. A Natural Orifice Specimen Extraction (NOSE) approach for rectal cancer. (A) The rectum distal to the tumor was divided using monopolar cautery. (B) During transrectal NOSE, a plastic bag was introduced to remove the specimen through the anus. (C) Double purse-string sutures were applied after placement of the circular stapler. (D) The proximal colon was exteriorized through the vagina to place the anvil after transvaginal specimen extraction.

Fig. 2. Kaplan-Meier survival curve of disease-free survival (A) and local recurrence (B) in conventional laparoscopy-assisted surgery (CL) and Natural Orifice Specimen Extraction (NOSE) groups.

Fig. 3. Preoperative and postoperative follow-up scores after transrectal Natural Orifice Specimen Extraction (NOSE) and conventional laparoscopy-assisted surgery (CL). POD, postoperative day.