Application of NOSES under the guidance of ERAS concept in 80 patients with mid-upper rectal neoplasms

Application of NOSES under the guidance of ERAS concept in 80 patients with mid-upper rectal neoplasms | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 January 2025 V1 Latest version Share on Application of NOSES under the guidance of ERAS concept in 80 patients with mid-upper rectal neoplasms Authors : Shiyou Long and Sheng Li 0009-0005-2295-7828 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173641930.02536550/v1 126 views 98 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: To investigate the clinical effects of the treatment of mid-superior rectal cancer with the natural orifice specimen extraction surgery (NOSES) guided by the concept of enhanced recovery after surgery (ERAS). Method: The clinical data of 80 patients with rectal cancer who met the inclusion criteria in Shaoyang’s Central Hospital from January 2018 to December 2020 were retrospectively analyzed. Results: All 80 patients underwent NOSES surgery and were managed with the ERAS concept during the perioperative period.Intraoperative conditions of 80 patients: The average operative time was (158.2±18.5)min; The average intraoperative bleeding was (26.0±14.5)ml; The average number of lymph nodes detected was (14.4±4.1). Postoperative complications related to 80 patients occurred: Postoperatively, two patients developed anastomotic leakage; One patient developed abdominal infection; One patient developed pulmonary infection; One patient developed postoperative intestinal obstruction; Three patients developed urinary retention. Postoperative recovery in 80 patients: The mean pain NRS score was (2.8±0.7); The firstly postoperative bedtime was (1.5±0.6)days; The average postoperative time to exhaustion was (2.0±0.5)days; And the average postoperative feeding time was (2.0±0.5)days. Postoperative psychological status of 80 patients: The postoperative psychological status of all 80 patients was excellent without depression and other adverse emotions. Conclusion: NOSES radical surgery for rectal cancer under the guidance of the ERAS concept further optimized the effect of minimally invasive, cosmetic, functional, and individualized treatment of laparoscopic rectal cancer surgery, and the combination of NOSES radical surgery for rectal cancer with ERAS concept has more tremendous advantages and is worth promoting and carrying out with good application prospects. Original Article Application of NOSES under the guidance of ERAS concept in 80 patients with mid-upper rectal neoplasms Author: Shiyou Long 11Department of Gastrointestinal Surgery, The Central Hospital of Shaoyang,Shaoyang,China ——————————————— Address for correspondence: Li Sheng,PhD, The Central Hospital of Shaoyang,Shaoyang 422000,China Email: [email protected] . Conflict of Interest statement: No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication. Abstract Background: To investigate the clinical effects of the treatment of mid-superior rectal cancer with the natural orifice specimen extraction surgery (NOSES) guided by the concept of enhanced recovery after surgery (ERAS). Method: The clinical data of 80 patients with rectal cancer who met the inclusion criteria in Shaoyang’s Central Hospital from January 2018 to December 2020 were retrospectively analyzed. Results: All 80 patients underwent NOSES surgery and were managed with the ERAS concept during the perioperative period.Intraoperative conditions of 80 patients: The average operative time was (158.2±18.5)min; The average intraoperative bleeding was (26.0±14.5)ml; The average number of lymph nodes detected was (14.4±4.1). Postoperative complications related to 80 patients occurred: Postoperatively, two patients developed anastomotic leakage; One patient developed abdominal infection; One patient developed pulmonary infection; One patient developed postoperative intestinal obstruction; Three patients developed urinary retention. Postoperative recovery in 80 patients: The mean pain NRS score was (2.8±0.7); The firstly postoperative bedtime was (1.5±0.6)days; The average postoperative time to exhaustion was (2.0±0.5)days; And the average postoperative feeding time was (2.0±0.5)days. Postoperative psychological status of 80 patients: The postoperative psychological status of all 80 patients was excellent without depression and other adverse emotions. Conclusion: NOSES radical surgery for rectal cancer under the guidance of the ERAS concept further optimized the effect of minimally invasive, cosmetic, functional, and individualized treatment of laparoscopic rectal cancer surgery, and the combination of NOSES radical surgery for rectal cancer with ERAS concept has more tremendous advantages and is worth promoting and carrying out with good application prospects. , Sheng Li 1 . Keywords: Enhanced recovery after surgery,ERAS;Rectal neoplasms; Natural orifice specimen extraction surgery, NOSES; Introduction In recent years, the incidence rate of colorectal cancer in China has been increasing yearly, and surgical treatment is the primary treatment method. Furthermore, minimally invasive is the mainstream direction in recent years, natural orifice specimen extraction surgery (NOSES) has the advantages of a small abdominal incision, beautiful incision, no abdominal auxiliary incision, and early recovery after surgery. Meanwhile, the feasibility and superiority of the concept of accelerated recovery after surgery (ERAS) in colorectal cancer has been recognized by more and more scholars. Exploring NOSES surgery with the ERAS concept in the practice of wards in our center has achieved excellent results, which are reported as follows. Materials and Methods General Information Retrospective analysis of 80 patients admitted for NOSES surgery for rectal cancer from January 2018 to December 2020, using the ERAS concept with perioperative management. Clinical data were collected and statistically analyzed. All 80 patients had perfected preoperative colonoscopy and pathological tissue biopsy, with a clear diagnosis of mid-upper rectal cancer (tumor distance from the dentate line diameter <5 cm, no emergency signs such as obstruction, bleeding, or perforation, no preoperative history of gastrointestinal surgery, no distant metastasis, no neoadjuvant radiotherapy, no prophylactic stoma, and adequate organ function.The basic information of 80 patients is shown in Table 1. Age (years) Gender BMI (kg /m2) Carcinoembryonic antigen (ng/ml) Preoperative imaging tumor diameter (cm) Depth of infiltration on preoperative imaging Type of preoperative pathological tissue biopsy Average distance of the preoperative mass from the anal verge (cm) Male / Female pT 1-2 /pT 3 Highly differentiated adenocarcinoma/low- to medium-differentiated adenocarcinoma 60.7±6.5 47/33 22.2±1.5 5.46±2.87 2.95±0.78 42/38 30/50 10±3.5 Table1 Basic information of 80 patients admitted to the hospital Surgical procedure All patients underwent D3 lymph node dissection, proximal tract cutting, and distal rectal dissection under five-hole lumpectomy according to the TME (or TSME) principle, and the specimens were removed through the rectum. NOSES II or IV was adopted according to the tumor’s location and the tract’s length, as appropriate. The aseptic and tumor-free principle was strictly followed during the operation, as shown in Fig 1. Figure 1 Intraoperative steps ①Laparoscopic completion of lymph node clearing;②Distal tumor is dissected;③Rectal stump is dissected and disinfected; ④Protective sleeve is placed through the main operation hole and pulled out through the anus, and then a nail holders is placed inside the anal protective sleeve; ⑤Proximal sigmoid colon is dissected about 10 cm from the tumor and disinfected; ⑥Proximal sigmoid colon is placed inside the nail holders and fixed in place; ⑦The specimen is removed through the anal protective sleeve; ⑧The tumor and rectum are dragged out through the anal protective sleeve; ⑨After resection of the tumor, the proximal sigmoid colon was inserted into the staple holder and delivered into the abdomen; ⑩The rectal stump was separated again; ⑪The end-to-end recto-sigmoid anastomosis was completed through the anus; ⑫No postoperative abdominal incision. The steps of NOSES-II type surgery are: ①②③⑧⑨⑩⑪. The steps of NOSES-IV style surgery are: ①②③④⑤⑥⑦⑩⑪. Perioperative ERAS management 1. Preoperative preparation: Personalized assessment, intensive preoperative education and communication, detailed introduction of anesthesia, surgery, perioperative management, and other treatment matters to patients, comprehensive screening of patients’ nutritional status, cardiopulmonary function, underlying diseases, maintenance of preoperative hemoglobin >100Hg/L, platelets administration of compound polyethylene glycol the night before surgery 60g of electrolyte dispersion + 2000 mL of warm boiled water for bowel cleansing, fasting and taking sugar saline 8h before surgery, and abstaining from drinking after taking 300 ml of 10% glucose solution orally 2h before surgery; Using ceftriaxone prophylactically 30min before surgery for anti-infection; No indwelling gastric tube before surgery. 2. Intraoperative preparation: Intraoperative transverse abdominal fascial block and general anesthesia were used. Intraoperative α-adrenergic agonist was used prophylactically to guide perioperative fluid management and maintain isovolumic; Intraoperative thermal blankets were used to keep warm, and fluids were warmed to maintain the core temperature at 36°C; Urinary catheter was left in place after intraoperative anesthesia and removed 24h after surgery. 3. Postoperative fluid rehydration should be controlled within 2000 ml/day, and the amount of fluid infusion should be reduced step by step with the increase of transoral feeding; Start drinking water after 6h postoperative anesthesia wake-up, start a full-fluid diet of 200-400 ml on the first day after surgery, enter semi-fluid when the anus is exhausted (or defecation), and anastomotic leakage is excluded; Pelvic drainage tube should be removed 3-5 days after surgery according to the inflammatory index, drainage tube volume, and drainage fluid color; Postoperative to be COX-2 inhibitor for regular analgesia; Encourage patients to get out of bed after waking up from anesthesia, and get out of bed for >2h daily; Perform postoperative screening for anemia. All patients were given ceftriaxone to prevent infection in the perioperative period. Postoperative discharge criteria: Patients were able to eat a semi-liquid diet, had an apparent bowel movement, were able to move freely, did not require intravenous rehydration, showed no signs of infection, had adequate analgesia with oral pain medication and accepted discharge from the hospital. Evaluation Methodology The tumor cell smear was taken from the last lavage fluid for the last time during the operation. The ascites from the drainage tube were taken for bacterial culture on the first postoperative day. Patients were observed and recorded for length of surgery, blood loss, number of lymph node dissections, the occurrence of postoperative complications (pulmonary infection, urinary tract infection, abdominal infection, anastomotic leak, lower limb venous thrombosis, and incision-related complications), as well as postoperative pain scores, time to first get out of bed, time to resume eating, time to exhaustion, number of postoperative hospital days, patient satisfaction, patient psychological status, postoperative patient pathology data, and other indicators were collected. The NRS pain scale (numerical scale) was used to evaluate the postoperative incisional pain of patients: 0 was no pain; 1~3 was mild pain; 4~6 was moderate pain; 7~10 was severe pain. The patients’ postoperative psychological status was evaluated by using the Depression Self-Assessment Scale (SDS) and the Anxiety Self-Assessment Scale (SAS).SDS and SAS are defined by a score of 50, with a score greater than or equal to 51 indicating the presence of anxiety and a score less than or equal to 50 indicating a normal mood, with higher scores representing more significant anxiety. The postoperative quality of life was assessed by the Quality of Life Scale (QOL), including mental status, psychological status, self-perception, and health status, and scored 60 out of 60, with 50-60 indicating good, 40-50 indicating good, 30-40 indicating fair, 20-30 indicating poor, and <20 indicating very poor. Inpatient satisfaction was assessed using the Inpatient Care Satisfaction Scale. Surgical conditions and postoperative pathological data of 80 patients All 80 patients were operated successfully without intermediate abdominal assisted incision surgery, and no intraoperative hemorrhage or anesthesia complications occurred. The average operative time was (158.2±18.5) min; the average intraoperative bleeding was (26.0±14.5) ml; the average number of lymph nodes detected was (14.4±4.1); the positive rate of specimens with upper and lower cut margins, circumferential cut margins, vascular and nerve infiltration was 0%; The detection rate of ascites tumor cells was 0%; One patient had postoperative ascites bacteria identified as E. coli, and the positive rate of ascites bacteria culture was 1.25%. The overall situation is shown in Table 2. Table 2 Surgical conditions and postoperative pathological data of 80 patients Average surgery time (min) Intraoperative bleeding (ml) Number of lymph nodes detected (pieces) Positive rate of upper and lower cut edges of specimens (%) Positive rate of specimen peri-annular margin (%) Vascular and nerve infiltration rate (%) Positive ascites bacterial culture rate (%) Detection rate of ascites tumor cells(%) 158.2±18.5 26.0±14.5 14.4±4.1 0 0 0 1.25 0 Occurrence of postoperative complications To observe the occurrence of postoperative incisional complications (incisional infection, incisional dehiscence, incisional hernia, etc.), anastomotic leakage, abdominal infection, pulmonary infection, postoperative intestinal obstruction, and other complications. The overall postoperative complications are shown in Table3.80 patients did not have postoperative incision-related complications;2 patients had postoperative anastomotic leak: One was a 60-year-old female patient with a BMI of 23(kg/m2). A preoperative colonoscopy suggested that the mass was 8 cm from the anal verge. On the second postoperative day, diarrhea started, with 5 episodes of diarrhea, accompanied by abdominal distension. The blood picture showed a mild increase in leukocytes and CRP, a small amount of air, and fluid accumulation next to the anastomosis seen on the CT abdomen. The patient recovered basically 3 weeks after surgery by fasting for 3 days, appropriate enteral nutrition with parenteral nutrition support, meropenem anti-infection, and ensuring patency of the drainage tube; One case was a 67-year-old male patient with a previous history of diabetes mellitus, poor glycemic control, a 50-year history of smoking, a preoperative BMI of 22 (kg/m2), and a preoperative colonoscopy suggesting a mass 6.5 cm from the anal verge. There is no tendency for the drainage fluid from the drainage tube to decrease in the postoperative period. The patient began to have diarrhea on the third postoperative day, with diarrhea up to 8 times, a sudden rise in body temperature to 39℃, apparent signs of peritoneal irritation, a change in color of the drainage fluid from light red to turbid-purulent with a foul odor. Blood sampling indicated increased leukocytes and CRP, and abdominal CT examination showed a large amount of air and fluid accumulation next to the anastomosis. An immediate emergency ileostomy was performed. After the operation, the patient was given fasting, total parenteral nutrition, meropenem anti-infection, and unobstructed drainage. The patient’s symptoms basically resolved on the 5th day after the stoma surgery. He was given enteral nutrition with appropriate parenteral nutrition, and basically recovered 4 weeks after surgery. One patient presented with an abdominal infection:The patient was a 66-year-old male with a previous history of cirrhosis and had been drinking alcohol for more than 45 years. A preoperative colonoscopy suggested a mass 10 cm from the anal verge. The patient had a fever of 38.3℃ on the third postoperative day, the drainage fluid suggested E. coli, and he continued to have a fever on the fourth postoperative day with signs of total peritoneal irritation.An open abdominal exploration was performed, a large amount of pus was found intraoperatively, and a large amount of pus moss was seen in the intestinal wall. Repeated inspections did not reveal anastomotic leakage, intestinal necrosis, and intestinal perforation. A drainage tube was placed to drain the patient, and anti-infection was continued postoperatively.The patient’s condition basically improved on the fifth postoperative day after the open abdominal exploration. One patient presented with incomplete intestinal obstruction: the patient was a 58-year-old female patient. Intraoperatively, severe intestinal wall adhesions were seen, and intestinal mucosa was released. The patient did not get out of bed after the operation due to pain and started to have apparent abdominal distension on the third day. The abdominal CT indicated incomplete intestinal obstruction, and conservative treatment such as antispasmodic, pain relief, and hot compress was given. On the seventh postoperative day, the patient basically recovered. Three patients had urinary retention after surgery: All three patients were elderly men with a history of prostate enlargement, and it improved after treatment with 5α-reductase inhibitors combined with α1-adrenoceptor blockers; One patient presented with pulmonary infection and atelectasis: the patient was a 65-year-old male with a previous history of COPD who improved with nebulized expectoration and piperacillin anti-infective treatment. Table 3 Occurrence of postoperative complications in 80 patients (cases, %) Incision-related complications Anastomotic leak Lung infection Postoperative intestinal obstruction Abdominal infection Lower Extremity Vein Thrombosis Urinary retention Cardiovascular and cerebrovascular accidents Other Total complications 0 (0.00) 2 (2.50) 1 (1.25) 1 (1.25) 1 (1.25) 0 (0.00) 3 (3.75) 0 (0,00) 0 (0.00) 8 (10.00) Postoperative recovery-related situations Patients were counted in terms of time to start venting, time to the first bed, time to fluid intake, length of stay, and pain NRS scores after surgery, and the overall situation is shown in Table 4:The postoperative time to first anal discharge (defecation) was (2.0±0.5)days; The postoperative time to first bed was (1.5±0.6)days; The postoperative time to liquid food was (1.2±0.4)days; The number of hospital days was (6.2±1.8)days; The mean pain NRS score was (2.9±0.7); All 80 patients recovered and were discharged. Table 4 Postoperative recovery of 80 patients Time to first anal discharge (days) First time out of bed after surgery (days) Duration of postoperative fluid feeding (days) Number of days in hospital (days) Pain score (points) 2.0±0.5 1.5±0.6 1.2±0.4 6.2±1.8 2.8±0.7 Evaluation of postoperative psychological condition of 80 patients The overall situation of the 80 patients on the first day of admission and discharge depression self-rating scale (SDS), anxiety self-rating scale (SAS), quality of life measurement scale (QOL) scores and patient satisfaction is shown in Table 5: 80 patients on the first day of admission and discharge SDS scores were on average: (35.69±3.04), (31.28±3.19); SAS scores mean (40.11±4.21), (38.39±3.81); QOL scores mean: (36.41±2.1), (42.26±2.46); patient satisfaction scores Table 5 Postoperative psychological status of 80 patients SDS score (points) SAS score (points) QOL score (points) Patients’ satisfaction > 90 points (Example %) First day of admission/discharge First day of admission/discharge First day of admission/discharge 35.69±3.04/31.28±3.19 40.11±4.21/38.39±3.81 36.41±2.1/42.26±2.46 78 (97.5) Discussions The promotion of minimally invasive concepts has led to the gradual development of colorectal cancer from traditional open surgery to laparoscopic surgery. Traditional laparoscopic surgery requires a 5-cm incision in the abdomen as a way to retrieve the specimen, which to a certain extent increases the complications associated with the incision and impairs the aesthetics of the incision. The proposed NOSES surgery is a clever solution to this problem. NOSES surgery uses conventional laparoscopic surgical instruments and a familiar surgical path to complete laparoscopic radical resection of the tumour, followed by removal of the specimen through the natural orifice and completion of the GI reconstruction,1 without additional incisions and with a less abdominal injury. The ERAS concept refers to the reduction of postoperative morbidity and mortality by reducing pain during colorectal resection, combined with active postoperative activities,and early feeding to reduce the body’s stress response and reduce the occurrence of organ dysfunction, thereby promoting early recovery. Studies have shown that ERAS can reduce the risk of postoperative complications as well as death in patients, can reduce hospital costs and length of stay and improve patient compliance and satisfaction, resulting in good outcomes. 2 In addition, Gustafsson et al. showed that ERAS not only achieved satisfactory short-term results, but also significantly improved the 5-year survival rate of colorectal cancer patients after surgery. The higher compliance with the ERAS regimen, the more pronounced the effect was. 3 NOSES surgery has few postoperative complications, facilitates early recovery of patients, and is in line with the ERAS concept. First, NOSES surgery does not require abdominal incision route to take specimens, which is small and aesthetically pleasing, avoids postoperative incision-related complications and postoperative incision pain from the fundamental source, reduces the stress response of the organism, and facilitates postoperative recovery. The pain reduction not only encourages patients to cough and sputum after surgery, avoiding postoperative pulmonary infection and pulmonary atelectasis, but also benefits patients to get out of bed early and promotes postoperative intestinal motility and gastrointestinal function recovery. Pain relief is the key to reducing the stress response of the organism, and reducing the stress response is essential to the ERAS concept. Studies have pointed out that the factors in the ERAS protocol that can reduce the metabolic stress response include laparoscopic surgery, epidural analgesia, maintenance of normal body temperature, pain avoidance and preoperative carbohydrate therapy, 3 and the ERAS concept encourages patients to get out of bed early and resume transoral diet early after surgery. Thus, it seems that NOSES surgery coincides with the ERAS concept and the implementation of NOSES surgery facilitates the development of ERAS concept.Second, NOSES surgery did not increase the postoperative psychological burden of patients, but rather reduced their anxiety. Patients with rectal cancer are often accompanied by different degrees of psychological disorders, mainly manifested as depression and low self-esteem about postoperative abdominal wall fistula and change in bowel habits, as well as fear and anxiety before cancer and laparoscopic surgery. 4 The advantage of NOSES is that there is no abdominal wall incision, large scar, or fistula, and there is no negative emotion and negative psychology brought to patients by the stimulation of scar pulling in the early postoperative period, which is consistent with the purpose of ERAS concept of early education to relieve patients’ anxiety and fear. In our study, postoperative complications occurred in only 8 out of 80 patients, with an incidence of 10%. According to Tjandra’s study, postoperative complication rates were as high as 15% and 20% for open and laparoscopic surgery, respectively, 5 and our study was much lower than Tjandra’s study. 80 patients did not show depression and anxiety and had significantly better psychological status scores at discharge than at admission, indicating that NOSES surgery did not increase negative psychology in patients. Despite the obvious advantages of NOSES surgery, there are still controversies regarding aseptic principles and tumour safety issues. Some intraperitoneal operations of NOSES surgery do carry the risk of causing abdominal infections, such as intraperitoneal dissection of the intestinal canal and transanal placement of the anastomosis against the staple holder into the abdominal cavity. 6 Only 1 patient in 80 patients in our centre had an abdominal infection, with an incidence of 1.25%. 80 patients had no tumour cells detected in the lavage fluid, with a detection rate of 0%. Combined with the experience of 80 cases of NOSES surgery in our centre, the principles regarding asepsis and tumor-free are summarized as follows: 1. The operator must have a good concept of asepsis and tumour-free; 2. Adequate intestinal preparation must be performed before surgery; 3. The operator must master certain surgical operation skills and pay attention to the overall cooperation of the surgical team. Gastrointestinal reconstruction and specimen removal are the core steps to complete high-quality NOSES surgery, such as the wonderful use of intra-abdominal iodophor gauze strips, close cooperation of assistant suction device, transanal injection of iodophor water to irrigate the intestinal cavity, a large amount of iodophor distilled water to rinse the operating area, the use of protective sleeve for specimen removal, and a series of operation skills can reduce the risk of abdominal contamination and tumour implantation; 4. Rational use of tumour control drugs and antibacterial drugs. In conjunction with our study, NOSES surgery basically meets the aseptic and tumour-free principles, but Dr James Ngu 7 pointed out that long-term follow-up is still needed to be used to ensure the efficacy of NOSES surgery in the long term and tumour safety issues. The development of the ERAS concept provides help for the success of NOSES surgery. First, the traditional perioperative program is complicated, including long time fasting, preoperative placement of gastric tube and urinary catheter, postoperative fasting for 3~5 days, and long-term rehydration. The traditional postoperative rehydration methods tend to aggravate the edema of the intestinal wall and increase the postoperative complications of patients. 8 The ERAS concept optimizes the perioperative protocol through a lot of evidence-based medicine: good preoperative education and assessment, drinking carbohydrates 2h before surgery; maintaining isovolemia and avoiding hypothermia during surgery; early postoperative ERAS treatment modalities such as feeding, limiting the amount of intravenous rehydration, and early bed mobility reduce postoperative complications and stress reactions, accelerate organ function recovery, and ensure the success of NOSES surgery. Second, the ERAS regimen can avoid tumor recurrence to some extent by reducing the stress response of the body and avoiding postoperative immune deficiency. Natural killer (NK) cells play an important role in tumor cell destruction and limiting tumor growth. In patients undergoing resection for colorectal, gastric and lung cancers, cancer mortality is higher in patients with reduced NK cell activity. 9 Jonathan Hiller 10 stated that stressful conditions suppress NK cells, which in turn affects tumor recurrence. Immune function is better maintained after surgery in the ERAS setting. Less stressed ERAS patients have a better immune function. 3 The ERAS concept and the NOSES operation are not rigidly implemented, but should be combined with the patient’s actual situation and from the perspective of facilitating the patient’s recovery. 1. The ERAS concept does not recommend routine preoperative mechanical bowel preparation, but the NOSES operation requires intra-abdominal dissection of the intestinal tube, which is more demanding on the bowel.2, ERAS does not recommend routine placement of drains because there is no clear evidence that drains prevent anastomotic leaks and other complications 11 . The drainage tube is an important window for the surgeon to observe the presence of anastomotic leak after surgery and does not affect the patient’s early bedtime activity, and most grade A and B anastomotic leaks can be cured by effective antibiotics and unobstructed drainage. Therefore, we should decide whether to place a drain or not according to the actual situation of the patient (blood tension of the anastomosis, intestinal conditions, presence of abdominal inflammation and underlying diseases, nutritional status, etc.) and should not generalize. In summary, in the treatment of rectal cancer patients with ERAS, the selection of appropriate cases for NOSES minimally invasive surgery will greatly reduce the occurrence of postoperative complications and accelerate the recovery of patients. Both the ERAS treatment plan and the dragging out of the resected specimen via the natural cavity need to be fully considered in terms of safety, tumour-free principle and aseptic principle. References 1. Guan X, Liu Z, Longo A, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer[J]. Gastroenterol Rep (Oxf),2019,7(1):24-31. 2. Spanjersberg W R, Reurings J, Keus F, et al. Fast track surgery versus conventional recovery strategies for colorectal surgery[J]. Cochrane Database Syst Rev,2011(2):D7635. 3. Gustafsson U O, Oppelstrup H, Thorell A, et al. Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study[J]. World J Surg,2016,40(7):1741-1747. 4. Kwoun HJ, Shin YH. Impact of bowel function, anxiety and depression on quality of life in patients with sphincter-preserving resection for rectal cancer[J]. J Korean Acad Nurs, 2015, 45(5):733-741. 5. Tjandra JJ, Chan MK. Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis 2006 Jun;8(5):375–88. 6. Guan X, Wang GY, Zhou ZQ et al Retrospective study of 718 colorectal neoplasms treated by natural orifice specimen extraction surgery in 79 hospitals. Chin J Colorec Dis (Electronic Edition) 2017;6:469–77. 7. Ngu J, Wong A S. Transanal natural orifice specimen extraction in colorectal surgery: bacteriological and oncological concerns[J]. ANZ J Surg,2016,86(4):299-302. 8. Birgitte Brandstrup et al. Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens[J]. Annals of Surgery, 2003, 238(5) : 641-648. 9. Gottschalk A, Sharma S, Ford J, et al. Review article: the role of the perioperative period in recurrence after cancer surgery. Anesth Analg 2010;1 10(6):1636–43. 10. Hiller J, Brodner G, Gottschalk A (2013) Understanding clinical strategies that may impact tumour growth and metastatic spread at the time of cancer surgery. Best Pract Res Clin Anaesthesiol.27(4):427–439 11. Jesus E C, Karliczek A, Matos D, et al. Prophylactic anastomotic drainage for colorectal surgery[J]. Cochrane Database Syst Rev,2004(4):D2100. Information & Authors Information Version history V1 Version 1 09 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords enhanced recovery after surgery eras natural orifice specimen extraction surgery noses rectal neoplasms Authors Affiliations Shiyou Long Central Hospital of Shaoyang Department of Gastrointestinal Surgery View all articles by this author Sheng Li 0009-0005-2295-7828 [email protected] Central Hospital of Shaoyang Department of Gastrointestinal Surgery View all articles by this author Metrics & Citations Metrics Article Usage 126 views 98 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Shiyou Long, Sheng Li. Application of NOSES under the guidance of ERAS concept in 80 patients with mid-upper rectal neoplasms. Authorea . 09 January 2025. DOI: https://doi.org/10.22541/au.173641930.02536550/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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