Cutting-Edge Strategies in Minimal Invasive Left Hemicolectomy for Tumors around the Splenic Flexure: Analyzing the Short-term Outcomes Between Transrectal Natural Orifice Specimen Extraction and Conventional Laparoscopy

doi:10.21203/rs.3.rs-3941620/v1

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Cutting-Edge Strategies in Minimal Invasive Left Hemicolectomy for Tumors around the Splenic Flexure: Analyzing the Short-term Outcomes Between Transrectal Natural Orifice Specimen Extraction and Conventional Laparoscopy

https://doi.org/10.21203/rs.3.rs-3941620/v1

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Background

The short-term outcomes of laparoscopic anterior resection with natural orifice specimen extraction (NOSE) are favorable. NOSE is, however, rarely used during left hemicolectomy surgeries. We retrospectively compared the feasibility, safety, and short-term results of transrectal NOSE for patients undergoing laparoscopic left hemicolectomy with conventional mini-laparotomy specimen extraction.

Methods

All patients who received laparoscopic left hemicolectomy surgery between January 2018 and December 2021, including 144 who underwent conventional surgery with specimen extraction through mini-laparotomy and 23 who underwent transrectal NOSE surgery, were enrolled in a single hospital. Surgical outcomes were assessed, including complications, postoperative short-term recovery, and pain level.

Results

The NOSE group had a shorter operation time, earlier postoperative recovery, a lower degree of pain on postoperative day 1, and a shorter hospital stay compared with the conventional group. In addition, postoperative morbidity was not noted in the transrectal NOSE group but was found in seven patients in the conventional group.

Conclusion

Laparoscopic left hemicolectomy with transrectal NOSE is a safe and feasible technique that results in quicker postoperative recovery and a shorter hospital stay. The advantages of transrectal NOSE compared to traditional mini-laparotomy in laparoscopic left hemicolectomy are being conducted for the first time in this study.

Laparoscopic surgery

Left hemicolectomy

Natural orifice specimen extraction (NOSE)

Transrectal

Colon cancer

Laparoscopic surgery is a standard procedure for colorectal disease, with multiple studies demonstrating its advantages over open surgery. Laparoscopic colorectal surgery has been found to cause less postoperative pain, result in quicker bowel function recovery, shorter hospital stays, and fewer incision-related complications (1, 2). Moreover, the long-term outcomes of laparoscopic colectomy and open surgery are comparable (2–6). However, conventional laparoscopic colorectal operations require an additional abdominal incision wound of 3–8 cm (depending on the size of the specimen) for specimen extraction and intestinal anastomosis, which may lead to pain, incision site infection, or incisional hernia (7–9). To address these complications, natural orifice specimen extraction (NOSE) has been developed as a minimally invasive alternative that eliminates the need for an abdominal incision wound (10, 11).

The removal of a colectomy specimen through the vagina was first documented in 1991 and 1992 by Stewart et al. and Nezhat et al. (12, 13). In 1993, Franklin et al. described the first complete laparoscopic colectomy using transanal specimen extraction (14). Transanal specimen extraction has proven to be feasible, safe, and oncologically compatible for laparoscopic sigmoid colectomy and laparoscopic rectal cancer resection in certain cases (15, 16).

Randomized clinical trials have demonstrated that laparoscopic NOSE colectomy results in less pain and requires fewer analgesics compared to conventional laparoscopic extraction (17). Multiple meta-analyses have also shown that NOSE surgery, when compared to traditional laparoscopic surgery, leads to improved postoperative outcomes, including overall morbidity, pain scores, time to recovery of gastrointestinal function, and length of hospital stay (18, 19). Moreover, the long-term oncological outcomes of patients undergoing laparoscopic anterior resection with NOSE for sigmoid and upper rectal cancer are similar to those of patients undergoing conventional extraction (20). Most studies on NOSE techniques have focused on sigmoid colon and rectum specimens. However, research on laparoscopic right hemicolectomy with transvaginal NOSE has demonstrated its feasibility and favorable short-term surgical outcomes (21, 22). Right colectomy performed with transrectal NOSE under minimally invasive conditions has been linked to improved short-term surgical outcomes compared to traditional surgery (23). In contrast, the application of NOSE techniques in left hemicolectomy for colon tumors around the splenic flexure remains understudied.

The aim of this study was to compare the short-term outcomes between patients who underwent laparoscopic left hemicolectomy for cancer around the splenic flexure using transrectal NOSE and those who underwent surgery with conventional mini-laparotomy specimen extraction.

Study design and patient selection

We conducted a prospective review of data obtained from the Colorectal Section Tumor Registry of Chang Gung Memorial Hospital. Our study focused on patients with colon cancer near the splenic flexure who underwent laparoscopic left hemicolectomy between January 2018 and December 2021. The study protocol was approved by the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 202100400B0).

Out of the initial cohort of 178 patients who underwent laparoscopic left hemicolectomy for colon cancer tumors located in the distal transverse colon, splenic flexure, or proximal descending colon, ten patients were excluded due to concomitant hepatectomy or additional small bowel resection. Additionally, two patients were excluded because they required conversion to laparotomy. The remaining 167 patients were included in the study, with 144 undergoing conventional laparoscopic surgery and specimen extraction through mini-laparotomy, while 23 underwent NOSE surgery. The choice of technique was based on the preference of the treating physician. However, patients with a body mass index (BMI) over 30 kg/m2, an American Society of Anesthesiologists (ASA) physical status rating higher than III, a tumor diameter larger than 4 cm, or a T4 substage determined by clinical computed tomography were deemed ineligible for NOSE.

Operative procedures

The standard techniques for laparoscopic left hemicolectomy involve the use of four ports and a medial-to-lateral surgical approach, as previously mentioned (24). The procedure begins by clearly identifying and dividing the inferior mesenteric vein at its roots. Once the lesser sac is accessed, a medial-to-lateral retroperitoneal dissection is performed, anterior to the pancreas, extending as far as possible into the splenic flexure. This step allows for the mobilization of the lateral bowel attachment, including the separation of the omentum, gastrocolic and gastrosplenic ligaments, as well as the lateral peritoneal attachment of the descending colon. This mobilization is crucial in order to prevent tension at the anastomotic site. After the complete division of the bowel segment being resected, the colo-colonic anastomosis is performed. This anastomosis can be accomplished either through extracorporeal anastomosis (EA) or intracorporeal anastomosis (IA).

In the conventional surgery group, where specimen extraction was performed through a mini-laparotomic wound, the specimen was removed either through a midline wound for EA or a Pfannenstiel incision for IA. In contrast, for the NOSE group, specimen extraction was carried out transrectally (25).

In the NOSE procedure, after rectal irrigation with povidone-iodine water and blocking the rectosigmoid colonic lumen with a bowel clamp, the upper rectum is accessed using a transanal endoscopic microsurgery (TEM) scope inserted through the anus. Once the TEM scope is positioned, any fecal spillage is cleared using a suction device, and an enterotomy is made in the upper rectum. The TEM scope is then advanced beyond the rectal opening to extract the specimen. After sealing the rectal incision with a barbed suture, an air leak test is conducted to check for any signs of anastomotic leakage.

Outcomes and covariables

The measurement outcomes of the study included short-term postoperative complications, recovery, and readmission. Postoperative complications were defined as any morbidity occurring within 30 days after the operation. These complications encompassed anastomosis-related issues such as leakage or stenosis, wound-related problems like infection or dehiscence, pulmonary complications such as atelectasis or pneumonia, cardiovascular events including myocardial infarction, stroke, or embolism, urinary complications like urinary tract infection or neurogenic bladder, gastrointestinal complications such as obstruction, ileus, or bleeding, abdominal complications including abscess or internal bleeding, as well as other rare complications.

Postoperative recovery was assessed based on various factors, including blood test results, time to first flatus and stool passage, time to resumption of a normal diet, level of pain intensity, and duration of hospital stay. Furthermore, 30-day postoperative hospital readmission cases were recorded. Pain intensity levels were measured using a numeric rating scale (NRS) ranging from 0 to 10, where a score of 10 represented the highest level of pain experienced by the patients. The highest pain scores reported by patients were recorded daily over a consecutive 3-day postoperative period for further evaluation.

Statistical analysis

All statistical analyses were performed using IBM SPSS version 24.0 (IBM; Armonk, NY, USA). Clinicopathological characteristics involving categorical variables were presented as frequencies and proportions, and the comparison between groups was conducted using a chi-squared test. Continuous variables were presented as means and standard deviations, and the analysis was performed using Student's t-test. Statistical significance was defined as a p-value less than 0.05 (P < 0.05).

A total of 167 patients with tumors located around the splenic flexure underwent minimally invasive left hemicolectomy and were included in the study. Among these patients, 144 underwent conventional specimen extraction using mini-laparotomy (conventional group), while 23 underwent NOSE surgery (NOSE group). Table 1 presents the demographic data of these patients. There were no statistically significant differences observed between the two groups in terms of age, sex, body mass index (BMI), presence of medical illnesses (such as hypertension, cardiac disease, cardiovascular accident, asthma, diabetes mellitus, peptic ulcer, hepatitis, liver cirrhosis, gallstone disease, or thyroid problems), or preoperative laboratory data (including white blood cell [WBC] count, percentage of segmented WBCs, creatinine, and carcinoembryonic antigen levels). Additionally, there were no significant differences between the two groups in terms of the T stage of colon cancer.

Table 1

Demographic characteristics of patients with tumors located around the splenic flexure who received laparoscopic left-hemicolectomy
	Conventional (144)	NOSE (23)	P value
Age	65.2 ± 13.5	64.90 ± 14.0	0.921
Sex			0.823
Male	80 (55.6%)	12 (52.2%)
Female	64 (44.4%)	11 (47.8%)
Body mass index			0.491
≤ 25	85 (59.4%)	16 (69.6%)
> 25	58 (40.6%)	7 (30.4%)
Mean	24.3 ± 4.2	24.3 ± 4.3	0.969
Underlying diseases
Hypertension	55 (38.7%)	10 (43.5%)	0.654
Cardiac diseases	16 (11.3%)	2 (8.7%)	0.714
Cerebral vascular diseases	6 (4.2%)	0 (0%)	0.597
Asthma	4 (2.8%)	2 (8.7%)	0.197
Diabetes mellitus	31 (21.8%)	3 (13.0%)	0.416
Peptic ulcer	5 (3.5%)	1 (4.3%)	0.844
Hepatitis	15 (10.6%)	4 (17.4%)	0.309
Liver cirrhosis	4 (2.8%)	0 (0%)	0.415
Thyroid diseases	3 (2.1%)	1 (4.3%)	0.455
Other	33 (23.2%)	6 (26.1%)	0.793
Laboratory data
Hb level (g/dL)	12.0 ± 2.3	12.2 ± 2.2	0.724
WBC count (/uL)	8.0 ± 9.7	6.0 ± 1.9	0.339
Seg (%)	64.5 ± 9.2	61.3 ± 9.5	0.133
Albumin level (g/dL)	4.1 ± 0.4	4.3 ± 0.3	0.013
Creatinine level (mg/dL)	1.0 ± 1.3	0.8 ± 0.3	0.403
CEA level ≥ 5	44 (31.0%)	3 (13.0%)	0.086
CEA level < 5	98 (69.0%)	20 (87.0%)
T stage
T1	16 (11.3%)	5 (21.7%)	0.464
T2	13 (9.2%)	1 (4.3%)
T3	75 (52.8%)	15 (65.2%)
T4a	31 (21.8%)	2 (8.7%)
T4b	5 (3.5%)	0 (0%)
Values are presented as the mean ± standard deviation unless otherwise indicated
Hb: hemoglobin; WBC: white blood cell; Seg: segmented neutrophils; CEA: carcinoembryonic antigen

The short-term postoperative outcomes of the patients are presented in Table 2. The NOSE group had significantly shorter operation times compared to the conventional group (mean: 267.1 ± 82.7 min vs. 201.5 ± 35.4 min; median: 257 min vs. 195 min; P < 0.001). The intra-abdominal bowel anastomosis was performed successfully in all patients in the NOSE group, resulting in a higher performance rate compared to the conventional group (conventional vs. NOSE: 47.6% vs. 100%; P < 0.001). The maximal tumor radius was significantly smaller in the NOSE group (conventional vs. NOSE: 4.0 ± 2.3 cm vs. 2.9 ± 1.4 cm; P = 0.028). There were no significant differences between the conventional and NOSE groups in terms of blood loss and specimen length. No immediate postoperative complications occurred in the NOSE group. In the conventional group, one patient experienced anastomotic bleeding, one patient experienced anastomotic leakage, and two patients experienced postoperative ileus. There were no cases of postoperative mortality in either group. Four patients in the conventional group were readmitted after discharge due to various reasons such as anastomotic leakage, anastomotic bleeding, incarcerated hernia, and poor postoperative appetite. One patient in the NOSE group was readmitted due to a duodenal ulcer.

Table 2

Perioperative measurements and short-term outcomes
	Conventional (144)	NOSE (23)	P value
Operative time (min)	267.1 ± 82.7	201.5 ± 35.4	< 0.001
Blood loss (mL)	56.5 ± 159.9	28.7 ± 13.9	0.408
Intracorporeal anastomosis	68 (47.6%)	23 (100%)	< 0.001
Specimen length (cm)	19.3 ± 6.7	20.0 ± 6.0	0.629
Maximum tumor size (cm)	4.0 ± 2.3	2.9 ± 1.4	0.028
Postoperative morbidity
Anastomotic bleeding	1	0
Anastomotic leakage	1	0
Urine retention	1	0
Postoperative intra-abdominal bleeding	1	0
Postoperative ileus	2	0
Postoperative pneumonia	1
Second operation	1^a	0
Readmission within 30 days	4^b	1^c
Values are presented as the mean ± standard deviation unless otherwise indicated
a: Due to anastomotic leakage
b: Four causes (anastomotic leakage, incarcerated inguinal hernia, anastomosis bleeding which was managed conservatively, and poor postoperative appetite)
c: Caused by perforated peptic ulcer

Table 3 presents the postoperative recovery outcomes. On postoperative day (POD) 3, laboratory tests including WBC count, percentage of segmented WBCs, and C-reactive protein (CRP) level showed no significant differences between the two groups. However, the NOSE group demonstrated shorter times to first flatus and stool passage, as well as shorter times to tolerating a liquid and soft diet, compared to the conventional group. Furthermore, patients in the NOSE group had significantly shorter postoperative hospital stays (mean: 4.3 ± 1.4 days; median: 4.0 days) compared to those in the conventional group (mean: 7.5 ± 4.3 days; median: 7.0 days), with the difference being statistically significant (P < 0.001).

Table 3

Postoperative recovery parameters
	Conventional (144)	NOSE (23)	P value
Laboratory data on postoperative day 3
WBC count (/uL)	10.2 ± 3.5	9.7 ± 3.1	0.520
Seg (%)	78.4 ± 7.6	78.9 ± 9.0	0.806
CRP level (mg/L)	91.9 ± 51.0	96.2 ± 73.6	0.739
Time to first flatus passage (days)	2.4 ± 1.4	1.4 ± 0.6	< 0.001
Time to first stool passage (days)	4.2 ± 2.3	2.6 ± 1.5	0.001
Time to toleration of a liquid diet (days)	3.5 ± 2.3	1.9 ± 1.0	< 0.001
Time to toleration of a soft diet (days)	5.3 ± 2.4	3.4 ± 1.3	< 0.001
Duration of postoperative hospital stay (days)	7.5 ± 4.3	4.3 ± 1.4	< 0.001
Values are presented as the mean ± standard deviation unless otherwise indicated
WBC: white blood cell; Seg: segmented neutrophils; CRP: C-reactive protein;

Figure 1 depicts the difference in NRS scores over the three consecutive days following the surgery for the two groups (patients who used patient-controlled analgesia [PCA] postoperatively were excluded from this analysis). In the conventional group, there were 136 patients who did not use PCA, while in the NOSE group, there were 22 patients without PCA. On postoperative day 1 (POD1), the conventional group had significantly higher NRS scores compared to the NOSE group (conventional vs. NOSE: 4.1 ± 2.0 vs. 3.0 ± 1.1; P < 0.001). However, there were no significant differences in NRS scores between the two groups on POD2 or POD3.

This study represents the first analysis of the application of the NOSE method in left hemicolectomy at a single academic medical center for treating colon cancer around the splenic flexure. Our findings demonstrate that compared to the conventional laparoscopic left hemicolectomy group, the NOSE group exhibited a shorter operation time, earlier postoperative recovery, lower pain levels on POD1, and a shorter hospital stay. Postoperative morbidity was similar between the two groups. Additionally, one patient from the NOSE group and four patients from the conventional group required readmission.

The NOSE method offers several advantages for laparotomy specimen extraction. A meta-analysis (18) revealed that compared to conventional laparoscopic surgery, NOSE is associated with reduced intraoperative bleeding, lower pain scores, shorter time to flatus, shorter hospital stays, and lower overall morbidity. In a prospective randomized controlled experiment conducted by Zhou et al. (26), the NOSE method demonstrated favorable outcomes including low postoperative visual analog scale scores, faster recovery of intestinal function, and shorter hospital stays. Patients recover faster when the specimen is not removed via laparotomy, resulting in less discomfort, decreased postoperative opiate use, and expedited return of intestinal function. These factors contribute to a shorter hospital stay and quicker return to normal activities after surgery. However, a randomized controlled trial by Wolthuis et al. (17) found no statistically significant difference in postoperative hospital stay duration between the NOSE and conventional laparoscopic groups. This result may be due to a relatively small sample size, which could have affected the study's power. In our study, patients in the NOSE group exhibited nearly one day earlier recovery of intestinal function, lower NRS scores on POD1, comparable postoperative morphine use (conventional vs. NOSE: 11.6 mg vs. 7.3 mg, P = 0.231), and discharge from the hospital approximately three days earlier compared to the conventional group.

Fecal spillage and bacterial contamination are important considerations when employing the NOSE method. Ouyang et al. (27) conducted an analysis of 185 patients who underwent either conventional laparoscopic colectomy or NOSE, and they found that the rate of bacterial positivity in peritoneal lavage fluid immediately after anastomosis was similar in both groups. This suggests that there is no significant difference in bacterial contamination between the two approaches. In our study, we also observed no statistically significant differences in C-reactive protein (CRP) levels or white blood cell (WBC) counts on postoperative day 3, indicating an acceptable inflammatory response to the NOSE procedure despite the potential for bacterial contamination during the operation.

According to Leung et al. (28), conventional laparoscopic surgery is associated with a higher risk of postoperative wound infection. However, with the NOSE procedure, all trocar wounds remain clean and uncontaminated, which minimizes the risk of infection. In our study, there were no cases of wound infection in either the conventional laparoscopic or NOSE group.

Most studies on the topic have consistently reported either similar or significantly longer operative times for patients undergoing the NOSE procedure compared to conventional laparoscopy (17, 26, 28). However, in our study, we found that the operative time was significantly shorter in the NOSE group compared to the conventional group. This discrepancy may be attributed to the fact that a large proportion of patients in the conventional group underwent an extracorporeal anastomosis (EA), which requires extensive dissection to extract a segment of the large bowel. In contrast, the intracorporeal anastomosis (IA) technique used in the NOSE procedure eliminates the need for such extensive dissection. Additionally, for experienced surgeons, the NOSE procedure is likely to be less time-consuming than laparotomy, as there is no need to close a large incision following specimen extraction.

The NOSE procedure is commonly performed through the vagina or anus. The transrectal approach varies depending on the type of colectomy, while the transvaginal approach involves a posterior colpotomy. The distal stump opening can be utilized for NOSE during colectomies involving the rectum, sigmoid colon, or distal descending colon. Some surgeons have also attempted using a colonoscopic snare to retrieve specimens from the more proximal colon. In our study, we presented an innovative method for specimen extraction involving an upper rectum enterotomy.

Transrectal NOSE is not limited to a specific gender, unlike transvaginal NOSE. It offers a universal technique applicable to various locations of colorectal tumors. In our approach, using a TEM (transanal endoscopic microsurgery) scope can minimize tumor cell spillage during the pull-through process, assuming that the anal canal can be traversed effortlessly. However, the size of the specimen to be extracted, including the tumor size and mesentery thickness, is constrained by the radius of the TEM scope. Patients with rectal strictures or anal stenosis that hinder the advancement of TEM scopes, as well as those who have undergone previous pelvic surgery resulting in severe adhesions, are not suitable candidates for this procedure.

In terms of closure, it is simpler to close a rectal incision compared to a posterior vaginal opening, when performed under laparoscope. Moreover, there is no risk of future sexual dysfunction or infertility, as the repair is limited to the gastrointestinal tract. So far, no adverse consequences such as leakage, abscess formation, stricture, or defecation dysfunction have been recorded with our approaches.

This study had several limitations that should be acknowledged. Firstly, the analysis was based on retrospective evaluation of prospectively collected data, which introduces the possibility of bias. This is especially relevant considering that the NOSE group was comprised of highly selected patients in terms of T-stage and tumor size. Secondly, the sample size of the NOSE group was relatively small, which may have resulted in insufficient statistical power to detect certain differences.

Another limitation is that the study focused solely on short-term outcomes and did not include long-term follow-up data on oncological outcomes. Therefore, the impact of the NOSE procedure on long-term survival rates or recurrence rates remains unknown.

Despite these potential limitations, it is important to note that this study represents the first investigation into the application of NOSE for left hemicolectomy specifically in cases involving tumors located around the splenic flexure.

Transrectal NOSE can be performed in selected patients who require laparoscopic left hemicolectomy for tumors located around the splenic flexure and can achieve short-term postoperative outcomes comparable to those of traditional approaches. Compared with conventional laparoscopy, NOSE is associated with less postoperative wound pain, more rapid bowel function recovery, and a shorter hospital stay. More prospective trials with larger patient groups and long-term follow-ups are needed.

NOSE, Natural orifice specimen extraction; BMI, Body mass index; EA, Extracorporeal anastomosis; IA, Intracorporeal anastomosis; TEM, Transanal endoscopic microsurgery; NRS, Numeric rating scale; WBC, White blood cells; POD, Post-operative day; CRP, C-reactive protein; PCA, Patient controlled analgesia.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 202100400B0). Patient consent was waived due to the retrospective nature of the study. Comprehensive informed consent was obtained from all patients before surgery for their data to be used.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was obtained for this study.

Authors' contributions

Study conception and design: BKJ and JFY. Acquisition of data: CCC, WST, SHH, ILL, YJH and YJC. Analysis and interpretation of data: CCC, WST, SHH, ILL, YJH and YJC. Drafting of manuscript: BKJ and JFY. Critical revision of manuscript: all the authors.

Acknowledgements

Not applicable.

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No competing interests reported.

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Cutting-Edge Strategies in Minimal Invasive Left Hemicolectomy for Tumors around the Splenic Flexure: Analyzing the Short-term Outcomes Between Transrectal Natural Orifice Specimen Extraction and Conventional Laparoscopy

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