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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 1  |  Page : 16-20

Natural orifice specimen extraction with single-stapling anastomosis for distal colon resection: Feasibility and outcomes


Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan

Date of Web Publication28-Feb-2017

Correspondence Address:
William Tzu-Liang Chen
Department of Colorectal Surgery, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City 404
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_7_17

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  Abstract 

Background: The double-stapling technique (DST) and triple-stapling technique used in laparoscopic anterior resection are considered risk factors of leakage or anastomotic leakage. A high anastomotic leakage rate could be avoided by the single-stapling technique (SST).
Purposes: This study analyzed the feasibility, as well as the operative and immediate postoperative outcomes of natural orifice specimen extraction (NOSE) with single-stapled anastomosis.
Materials and Methods: We retrospectively analyzed the data of 82 patients from China Medical University Hospital who underwent elective surgery from January 2012 to April 2015 for benign or malignant lesions that were between 10 and 40 cm from the anal verge, ≤5 cm in diameter on radiological examination, and in stage T1-T3/Nx/M0. All patients were monitored according to the enhanced recovery after surgery protocol.
Results: NOSE with SST was feasible and showed intraoperative complication and morbidity rates of 2% and 7.3%, respectively. No patients needed conversion to open surgery. The rate of conversion to NOSE with DST was 6.1%. Moreover, the anastomotic leakage rate was 2.4%. Total hospital stay required was 4.8 ± 3.4 days. The first postoperative bowel movement observed was at 1.2 ± 0.5 days.
Conclusions: Although SST is technically challenging, NOSE with SST is as feasible and as NOSE with DST.

Keywords: Colorectal cancer, double-stapling, laparoscopic surgery, natural orifice specimen extraction, single-stapling


How to cite this article:
Huang YC, Chang SC, Chiang HC, Ke TW, Wang HM, Chen WT. Natural orifice specimen extraction with single-stapling anastomosis for distal colon resection: Feasibility and outcomes. Formos J Surg 2017;50:16-20

How to cite this URL:
Huang YC, Chang SC, Chiang HC, Ke TW, Wang HM, Chen WT. Natural orifice specimen extraction with single-stapling anastomosis for distal colon resection: Feasibility and outcomes. Formos J Surg [serial online] 2017 [cited 2019 Mar 21];50:16-20. Available from: http://www.e-fjs.org/text.asp?2017/50/1/16/201186


  Introduction Top


Laparoscopic colectomy shows superior short-term outcomes and similar oncologic outcomes compared with those of open colectomy. Therefore, it is considered the standard treatment for colon cancer.[1],[2],[3] In the past decade, laparoscopic colorectal surgery has increasingly evolved. Natural orifice specimen extraction (NOSE) can provide additional advantages for eliminating the morbidity and postoperative pain at the specimen extraction site.[4],[5]

Various technical alternatives for performing colorectal anastomosis after laparoscopic anterior resection (LAR) or NOSE exist,[5],[6],[7],[8],[9],[10],[11],[12],[13] among which the double-stapling technique (DST) and triple-stapling technique (TST) are most frequently used.[7],[10],[11],[12] Although DST remains widely accepted, anastomotic leaks occur in 1%–19% of cases,[14] possibly because of technical factors such as the crossing of linear and circular staple lines and “dog-ears” at each extremity of the linear staple line.[15],[16],[17],[18] The single-stapling technique (SST), which has been reported in open rectal surgery, could be used to avoid the disadvantages of DST or TST. However, SST outcomes for laparoscopic colorectal surgery remain unknown, particularly for NOSE with SST. Therefore, we evaluated the feasibility as well as the operative and immediate outcomes of NOSE with SST.


  Materials and Methods Top


We retrospectively analyzed the data of 82 patients from China Medical University Hospital, Taiwan, with a body mass index (BMI) ≤30 kg/m 2 and an American Society of Anesthesiology Score I–III. From January 2012 to April 2015, these patients underwent elective laparoscopic NOSE with SST for benign or malignant lesions that were between 10 and 40 cm from the anal verge, ≤5 cm in diameter on radiological examination, and in stages T1-3/Nx/M0. The Departmental and Institutional Ethical Committees approved the study. All patients were monitored according to the enhanced recovery after surgery (ERAS) protocol.[19],[20] We identified anastomotic leakage through microbiological or radiological examination.

Surgical technique

The patients were placed in the Trendelenburg position. A 10 mm transumbilical port for the camera, two 5 mm working ports on either side of the camera port, and a 5 mm port was inserted in the right lower quadrant of the abdomen. All the following steps were standardized for performing NOSE with SST: mobilization of the splenic flexure, dissection along the Toldt's fascia, and ligation of the inferior mesenteric vein near the Treitz ligament. Depending on the tumor site, high or low ligation of the inferior mesentery artery was performed. Partial mesorectal excision was performed. The distal resection margin (usually more than 5 cm distal to the tumor) was identified. The lumen of the rectum was occluded by the placement of an intracorporeal free-tie suture proximal to the proposed line of rectal division to prevent intra-abdominal contamination. After the rectal stump irrigation, the rectum was divided with scissors.

According to rectal stump length, either a transanal endoscopic operation (TEO) port (Karl Storz, Tuttlingen, Germany) [Figure 1] for long rectal stumps (10–20 cm) or a double-ring wound protector (Alexis wound retractor, Applied Medical, Rancho Santa Margarita, CA, USA) [Figure 2] for short rectal stumps (6–10 cm) was introduced through the anus. The transected bowel was pulled out in continuity through the TEO port or wound protector. Extra- or intracorporeal anvil head fixation was performed at the proximal bowel end. An intracorporeal purse-string suture was placed around the rectal stump using polypropylene 2-0.
Figure 1: Transanal endoscopic operation port was set through the anus when long rectal stump

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Figure 2: (a) The resected colon specimen was pulled through the wound retractor. (b) The anvil head was placed through the wound retractor. Then, the anvil head is fixed in the proximal colon end

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Statistical analysis

Continuous variables were recorded as means ± standard deviations and were compared using Student t-test. Categorical variables were recorded as numbers or percentages and were compared using Fisher's exact test or Chi-square tests, as appropriate. Statistical calculations were performed using SPSS (version 17.0) software (SPSS, Inc., Chicago, IL, USA).


  Results Top


The basic characteristics of the 82 patients are shown in [Table 1]. The mean age and BMI were 63.3 ± 13.9 years and 24.4 ± 4.2 kg/m 2, respectively. Nine (11%) patients had undergone previous abdominal surgeries. The tumor site was the sigmoid colon and rectosigmoid junction in 69 (84.1%) patients and the upper rectum in 13 (15.8%) patients [Table 1].
Table 1: Basic characteristics of the patients undergoing the laparoscopic natural orifice specimen extraction with single-stapling technique

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The operative time was 227.9 ± 55 min. The mean number of retrieved lymph nodes was 17.

All patients were monitored according to the ERAS protocol. Postoperative meperidine requirement was 29.3 ± 53.9 mg. Moreover, the total hospital stay was 4.8 ± 3.4 days. The first postoperative bowel movement occurred at 1.2 ± 0.5 days. The overall readmission rate was 3.2% [Table 2].
Table 2: Perioperative outcome of the patients undergoing the laparoscopic natural orifice specimen extraction with single-stapling technique

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No patient needed the conversion to open surgery. The intraoperative complication rate was 2% (2/82). Two patients underwent blood transfusion because of bleeding caused by injury to adjacent viscera. No mortality occurred among the enrolled patients. In addition, the morbidity rate was 7.3% (6/82). Two patients suffered from anastomotic leakage, one experienced anastomotic bleeding, and one had prolonged ileus. A postoperative anal fissure was identified in two patients [Table 3]. The conversion rate of NOSE with SST to NOSE with DST was 6.1%
Table 3: Perioperative complications of the patients undergoing the laparoscopic natural orifice specimen extraction with single-stapling technique

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  Discussion Top


The anastomosis performed in NOSE with SST was completely circular, thereby avoiding “dog-ears” and reducing anastomotic leakage.[21] The purse-string technique for the rectal stump has been described by Kim et al.[18] and Hisada et al.[5] Purse-string closure of the rectal stump prevented further distal rectal stump dissection and mechanical linear stapler applications. Thus, the risk of anastomotic leakage was eliminated. The anastomotic leakage rate (2.4%) in our study is close to the lower end of the range reported in the literature (2%–10%).[5],[6],[7],[18]

Marecik et al.[22] and Nachiappan et al.[23] have reported the possibility of extracting the colon specimen through the anus after a natural orifice transluminal endoscopic surgery procedure. Thereafter, many reports have described the use of NOSE-LAR with coloanal anastomosis or DST.[9],[24],[25],[26],[27],[30] Subsequently, NOSE-LAR has been used for sigmoid and upper rectal tumors with similar outcomes to that of conventional LAR.[7],[11],[12],[13]

In addition to superior cosmesis,[4] the absence of an abdominal incision for specimen extraction in NOSE results in less postoperative pain, early return of gastrointestinal function, and early ambulation [4],[5],[6],[7],[18] as observed in our study.[29],[31] Hisada et al.,[5] as well as a recently published randomized study by Wolthuis et al.,[4] also reported similar results. Moreover, NOSE may reduce the occurrence of surgical site infection and incisional hernia.[7],[28] However, a postoperative anal fissure was noted in two patients who underwent NOSE with SST, possibly because of anal canal stretching during specimen extraction.

Wolthuis et al.[4] reported that in NOSE with DST, more time was necessary required to perform the purse-string closure of the rectal stump. However, in that study, the operative time had no significance in both groups. In some cases, the increased surgical duration could be because of the time required to create the purse string in the rectal stump and in the proximal colon.

In addition, the conversion rate of NOSE with SST to NOSE with DST was 6.1%. An inability to transanally retrieve the bulky specimen or a difficulty in purse-string suturing because of a deep, narrow pelvis is the possible reason for SST failure. Despite the technical difficulty of SST, an acceptable perioperative morbidity rate (9.8%) was observed.

Limitation

Our study has several limitations: first, this is a single-center study, and this could result in recusal bias. Second, the level of this retrospective case series study is not as high as that of other controlled studies.


  Conclusions Top


Although SST is technically demanding, NOSE with SST is as feasible and safe as NOSE with DST.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Kim HJ, Choi GS, Park JS, Park SY. Comparison of intracorporeal single-stapled and double-stapled anastomosis in laparoscopic low anterior resection for rectal cancer: A case-control study. Int J Colorectal Dis 2013;28:149-56.  Back to cited text no. 18
    
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Takeyama H, Yamamoto H, Hata T, Takahashi Y, Ohtsuka M, Nonaka R, et al. A novel single-stapling technique for colorectal anastomosis: A pre-ligation single-stapling technique (L-SST) in a porcine model. Surg Endosc 2015;29:2371-6.  Back to cited text no. 21
    
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