Clinical Scorecard: Comparative Study of Natural Orifice Specimen Extraction Surgery (NOSES) Versus Conventional Laparoscopic Surgery (CLS) for Rectal Cancer Treatment: A Retrospective Analysis from a Single Center

At a Glance

Key Highlights

• NOSES offers a minimally invasive alternative to CLS with potential benefits in postoperative pain and complication rates.
• Propensity score matching was used to balance baseline characteristics between NOSES and CLS groups for comparative analysis.
• Postoperative outcomes assessed included surgical time, blood loss, inflammatory markers, pain scores, time to flatus, hospital stay, costs, complications, and analgesia requirements.

Guideline-Based Recommendations

Diagnosis

• Confirm rectal cancer histologically with tumor located 4–15 cm from the dentate line.
• Exclude patients with local invasion, distant metastasis, recurrent or multiple primary colorectal cancers, severe obstruction, perforation, or emergency bleeding.

Management

• Select surgical approach based on tumor location and Chinese Expert Consensus on NOSES for Colorectal Cancer (2023).
• Perform NOSES with transanal or rectal specimen extraction depending on tumor distance from dentate line (NOSES I-type A, II-type B, or IV).
• Perform CLS with specimen extraction via abdominal incision and consider protective stoma for high-risk anastomoses.
• Standardize postoperative analgesia with preemptive sufentanil and patient-controlled intravenous analgesia.

Monitoring & Follow-up

• Monitor surgical time, intraoperative blood loss, white blood cell count, and C-reactive protein levels.
• Assess postoperative pain using visual analog scale (VAS) on days 1, 3, and 7.
• Track time to first flatus, length of hospital stay, hospitalization costs, and postoperative complications including anastomotic leakage, infections, bleeding, and urinary retention.
• Evaluate additional analgesia requirements and response to rescue analgesics.

Risks

• Potential for anastomotic leakage, intestinal obstruction, surgical site infection, pulmonary infection, peritonitis, urinary tract infection, and urinary retention.
• Technical complexity of NOSES requiring specialized anastomosis techniques and surgical expertise.
• Risk of increased hospitalization costs related to complications or extended care.

Patient & Prescribing Data

221 patients with rectal cancer undergoing surgical treatment; 24 in NOSES group and 197 in CLS group after inclusion/exclusion criteria.

NOSES may reduce postoperative pain and wound complications compared to CLS; analgesia protocols standardized with sufentanil-based PCIA and rescue ketorolac for VAS ≥4.

Clinical Best Practices

• Use propensity score matching to balance patient baseline characteristics when comparing surgical approaches.
• Adhere to established consensus guidelines for NOSES surgical technique selection based on tumor location.
• Implement standardized perioperative analgesia protocols including preemptive analgesia and PCIA.
• Closely monitor inflammatory markers and pain scores postoperatively to guide analgesia and detect complications early.
• Consider protective stoma creation in CLS for high-risk anastomoses to reduce leakage risk.
• Comprehensively evaluate hospitalization costs including consumables, medications, bed fees, and complication-related expenses.

References

• Global colorectal cancer incidence and mortality
• Natural orifice specimen extraction surgery (NOSES) concept
• Postoperative pain and wound complication reduction with NOSES
• Surgical site infection and incision dehiscence reduction with NOSES
• Chinese Expert Consensus on NOSES for Colorectal Cancer (2023)