Colorectal resection via natural orifice specimen extraction versus conventional laparoscopic extraction: a meta-analysis with meta-regression.

Background Studies have shown differences in postoperative outcomes between two minimally invasive extraction methods for colorectal lesions—natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLS). The aim of this study was to discover the major differences in NOSES and CLS to refine current practice.

Electronic databases were searched for articles comparing NOSES and CLS from inception till March 2020. Weighted mean differences (WMD) and odds ratio (OR) were estimated for continuous and dichotomous outcomes, respectively. Summary statistics were calculated using the DerSimonian and Laird random effects.

Twenty-one studies (15 on malignant disease, 4 on benign disease, 2 on both) were included in this meta-analysis, totalling 2378 patients (1079 NOSE, 1299 CLS). NOSE was associated with decreased: intraoperative bleeding (WMD: − 10.652 ml; 95% CI: − 18.818 ml to − 2.482 ml; p < 0.001), pain score (WMD: − 1.520; 95% CI − 1.965 to − 1.076; p < 0.001), time to flatus (WMD: − 0.306 days; 95% CI: − 0.526 to − 0.085 days; p < 0.001), length of hospital stay (WMD: − 1.048 days; 95% CI: − 1.488 to − 0.609 days; p < 0.001), and total morbidity (OR: 0.548; 95% CI: 0.387 to 0.777; p = 0.001). Subgroup analyses showed significant differences between malignant and benign lesions for intraoperative bleeding (p = 0.011) and pain score (p = 0.010). Meta-regression analyses showed an association between the American Society of Anaesthesiologists (ASA) physical status classification III with pain (p = 0.03) and ASA III with time to flatus (p = 0.04).

This meta-analysis and meta-regression demonstrated that NOSES had better postoperative outcomes compared to CLS. More comprehensive reviews should be conducted on the long-term outcomes specific to the extraction site to better inform clinical practice. Similar content being viewed by others

Taramasco C, Figueroa K, Lazo Y, Demongeot J (2017) Estimation of life expectancy of patients diagnosed with the most common cancers in the Valparaiso Region, Chile. Ecancermedicalscience 11:713. https://doi.org/10.3332/ecancer.2017.713 Favoriti P, Carbone G, Greco M, Pirozzi F, Pirozzi REM, Corcione F (2016) Worldwide burden of colorectal cancer: a review. Updates Surg 68(1):7–11. https://doi.org/10.1007/s13304-016-0359-y Izquierdo KM, Unal E, Marks JH (2018) Natural orifice specimen extraction in colorectal surgery: patient selection and perspectives. Clin Exp Gastroenterol 11:265–279. https://doi.org/10.2147/CEG.S135331 Velanovich V (2000) Laparoscopic vs open surgery: a preliminary comparison of quality-of-life outcomes. Surg Endosc 14(1):16–21. https://doi.org/10.1007/s004649900003 Allaix ME, Giraudo G, Mistrangelo M, Arezzo A, Morino M (2015) Laparoscopic versus open resection for colon cancer: 10-year outcomes of a prospective clinical trial. Surg Endosc 29(4):916–924. https://doi.org/10.1007/s00464-014-3752-y Quintana JM, Anton-Ladisla A, Gonzalez N, Lazaro S, Bare M, Fernandez de Larrea N, Redondo M, Briones E, Escobar A, Sarasqueta C, Garcia-Gutierrez S, group R-CC (2018) Outcomes of open versus laparoscopic surgery in patients with colon cancer. Eur J Surg Oncol 44(9):1344–1353. https://doi.org/10.1016/j.ejso.2018.05.030 Damin DC, Lazzaron AR (2014) Evolving treatment strategies for colorectal cancer: a critical review of current therapeutic options. World J Gastroenterol 20(4):877–887. https://doi.org/10.3748/wjg.v20.i4.877 Park JS, Kang H, Park SY, Kim HJ, Lee IT, Choi GS (2018) Long-term outcomes after Natural Orifice Specimen Extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study. Ann Surg Treat Res 94(1):26–35. https://doi.org/10.4174/astr.2018.94.1.26 Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM (2002) Wound complications of laparoscopic vs open colectomy. Surg Endosc 16(10):1420–1425. https://doi.org/10.1007/s00464-002-8837-3 Fujii S, Tsukamoto M, Fukushima Y, Shimada R, Okamoto K, Tsuchiya T, Nozawa K, Matsuda K, Hashiguchi Y (2016) Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients. World J Gastrointest Oncol 8(7):573–582. https://doi.org/10.4251/wjgo.v8.i7.573 Guan X, Liu Z, Longo A, Cai JC, Tzu-Liang Chen W, Chen LC, Chun HK, Manuel da costa Pereira J, Efetov S, Escalante R, He QS, Hu JH, Kayaalp C, Kim SH, Khan JS, Kuo LJ, Nishimura A, Nogueira F, Okuda J, Saklani A, Shafik AA, Shen MY, Son JT, Song JM, Sun DH, Uehara K, Wang GY, Wei Y, Xiong ZG, Yao HL, Yu G, Yu SJ, Zhou HT, Lee SH, Tsarkov PV, Fu CG, Wang XS, International Alliance of N (2019) International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf) 7(1):24–31. https://doi.org/10.1093/gastro/goy055 Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14(1):135. https://doi.org/10.1186/1471-2288-14-135 Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. https://doi.org/10.1186/1471-2288-5-13 Furukawa TA, Barbui C, Cipriani A, Brambilla P, Watanabe N (2006) Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol 59(1):7–10. https://doi.org/10.1016/j.jclinepi.2005.06.006 DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188. https://doi.org/10.1016/0197-2456(86)90046-2 Friedrich JO, Adhikari NKJ, Beyene J (2007) Inclusion of zero total event trials in meta-analyses maintains analytic consistency and incorporates all available data. BMC Med Res Methodol 7:5–5. https://doi.org/10.1186/1471-2288-7-5 Harbord RM, Higgins JPT (2008) Meta-regression in Stata. Stata J 8(4):493–519. https://doi.org/10.1177/1536867X0800800403 Knapp G, Hartung J (2003) Improved tests for a random effects meta-regression with a single covariate. Stat Med 22(17):2693–2710. https://doi.org/10.1002/sim.1482 Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315(7109):629–634. https://doi.org/10.1136/bmj.315.7109.629 GA Wells, B Shea, D O'Connell, J Peterson, V Welch, M Losos, P Tugwell. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JAC (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928. https://doi.org/10.1136/bmj.d5928 McGuinness LA (2019) robvis: An R package and web application for visualising risk-of-bias assessments. Park JS, Choi GS, Kim HJ, Park SY, Jun SH (2011) Natural orifice specimen extraction versus conventional laparoscopically assisted right hemicolectomy. Br J Surg 98(5):710–715. https://doi.org/10.1002/bjs.7419 Costantino FA, Diana M, Wall J, Leroy J, Mutter D, Marescaux J (2012) Prospective evaluation of peritoneal fluid contamination following transabdominal vs transanal specimen extraction in laparoscopic left-sided colorectal resections. Surg Endosc 26(6):1495–1500. https://doi.org/10.1007/s00464-011-2066-6 Christoforidis D, Clerc D, Demartines N (2013) Transrectal specimen extraction after laparoscopic left colectomy: a case-matched study. Colorectal Dis 15(3):347–353. https://doi.org/10.1111/codi.12006 Leung AL, Cheung HY, Fok BK, Chung CC, Li MK, Tang CN (2013) Prospective randomized trial of hybrid NOTES colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors. World J Surg 37(11):2678–2682 Awad ZT, Griffin R (2014) Laparoscopic right hemicolectomy: a comparison of natural orifice versus transabdominal specimen extraction. Surg Endosc 28(10):2871–2876. https://doi.org/10.1007/s00464-014-3540-8 Hisada M, Katsumata K, Ishizaki T, Enomoto M, Matsudo T, Kasuya K, Tsuchida A (2014) Complete laparoscopic resection of the rectum using natural orifice specimen extraction. World J Gastroenterol 20(44):16707–16713. https://doi.org/10.3748/wjg.v20.i44.16707 Kim HJ, Choi GS, Park JS, Park SY, Ryuk JP, Yoon SH (2014) Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study. Surg Endosc 28(8):2342–2348. https://doi.org/10.1007/s00464-014-3466-1 Zhang X, Zhou H, Liang J, Hou H, Hu J, Zhou Z (2014) Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer. Int J Colorectal Dis 29(9):1119–1124. https://doi.org/10.1007/s00384-014-1950-7 Chen Y, Guo R, Xie J, Liu Z, Shi P, Ming Q (2015) Laparoscopy combined with transanal endoscopic microsurgery for rectal cancer: a prospective, single-blinded, randomized clinical trial. Surg Laparosc Endosc Percutaneous Tech 25(5):399–402. https://doi.org/10.1097/SLE.0000000000000186 Denost Q, Adam JP, Pontallier A, Celerier B, Laurent C, Rullier E (2015) Laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer. Ann Surg 261(1):138–143. https://doi.org/10.1097/sla.0000000000000855 Kim SJ, Choi BJ, Lee SC (2015) A novel single-port laparoscopic operation for colorectal cancer with transanal specimen extraction: a comparative study. BMC Surg 15:10. https://doi.org/10.1186/1471-2482-15-10 Wolthuis AM, Fieuws S, Van Den Bosch A, de Buck van Overstraeten A, D’Hoore A (2015) Randomized clinical trial of laparoscopic colectomy with or without natural-orifice specimen extraction. Br J Surg 102(6):630–637. https://doi.org/10.1002/bjs.9757 Bokor A, Lukovich P, Csibi N, D'Hooghe T, Lebovic D, Brubel R, Rigo J (2018) Natural orifice specimen extraction during laparoscopic bowel resection for colorectal endometriosis: technique and outcome. J Minim Invasive Gynecol 25(6):1065–1074. https://doi.org/10.1016/j.jmig.2018.02.006 Ng H-I, Sun W-Q, Zhao X-M, Jin L, Shen X-X, Zhang Z-T, Wang J (2018) Outcomes of trans-anal natural orifice specimen extraction combined with laparoscopic anterior resection for sigmoid and rectal carcinoma: an observational study. Medicine 97(38):e12347. https://doi.org/10.1097/MD.0000000000012347 Ding Y, Li Z, Gao H, Cao Y, Jin W (2019) Comparison of efficacy between natural orifice specimen extraction without abdominal incision and conventional laparoscopic surgery in the treatment of sigmoid colon cancer and upper rectal cancer. J BUON 24(5):1817–1823 Hu J-H, Li X-W, Wang C-Y, Zhang J-J, Ge Z, Li B-H, Lin X-H (2019) Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer. World J Clin Cases 7(2):122–129. https://doi.org/10.12998/wjcc.v7.i2.122 Li XW, Wang CY, Zhang JJ, Ge Z, Lin XH, Hu JH (2019) Short-term efficacy of transvaginal specimen extraction for right colon cancer based on propensity score matching: a retrospective cohort study. Int J Surg 72:102–108. https://doi.org/10.1016/j.ijsu.2019.07.025 Liu Z, Efetov S, Guan X, Zhou H, Tulina I, Wang G, Tsarkov P, Wang X (2019) A multicenter study evaluating natural orifice specimen extraction surgery for rectal cancer. J Surg Res 243:236–241. https://doi.org/10.1016/j.jss.2019.05.034 Wang R, Wei Z, Liu Q, Li W, Xiao L, Han FHH, Yang S (2019) Transanal versus transabdominal specimen extraction in laparoscopic rectal cancer surgery: a retrospective analysis from China. Wideochirurgia I Inne Techniki Maloinwazyjne 14(2):203–209. https://doi.org/10.5114/wiitm.2018.79529 Jingyu F, Yixiang X, Chuansi W, Yongsen W, Qi Z, Hongwu H (2019) A clinical comparative study of specimen collection through natural cavity and traditional laparoscopic surgery for rectal cancer. J Laparosc Surg. https://doi.org/10.13499/j.cnki.fqjwkzz.2019.06.414 Zhou S, Wang X, Zhao C, Pei W, Zhou H, Liu Q, Liang J, Zhou Z, Wang X (2019) Comparison of short-term and survival outcomes for transanal natural orifice specimen extraction with conventional mini-laparotomy after laparoscopic anterior resection for colorectal cancer. Cancer Manag Res 11:5939–5948. https://doi.org/10.2147/CMAR.S209194 Ma B, Huang X-z, Gao P, Zhao J-h, Song Y-x, Sun J-x, Chen X-w, Wang Z-n (2015) Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis. Int J Colorectal Dis 30(11):1479–1488. https://doi.org/10.1007/s00384-015-2337-0 He J, Hu J-F, Shao S-X, Yao H-B, Zhang X-F, Yang G-G, Shen Z (2020) The comparison of laparoscopic colorectal resection with natural orifice specimen extraction versus mini-laparotomy specimen extraction for colorectal tumours: a systematic review and meta-analysis of short-term outcomes. J Oncol 2020:1–11. https://doi.org/10.1155/2020/6204264 Thompson EV, Bleier JI (2017) Transanal minimally invasive surgery. Clin Colon Rectal Surg 30(2):112–119. https://doi.org/10.1055/s-0036-1597315 Feng X, Morandi A, Boehne M, Imvised T, Ure BM, Kuebler JF, Lacher M (2015) 3-Dimensional (3D) laparoscopy improves operating time in small spaces without impact on hemodynamics and psychomental stress parameters of the surgeon. Surg Endosc 29(5):1231–1239. https://doi.org/10.1007/s00464-015-4083-3 Gagliese L, Gauthier LR, Macpherson AK, Jovellanos M, Chan VW (2008) Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients. Pain Med 9(3):299–314. https://doi.org/10.1111/j.1526-4637.2008.00426.x Ip HY, Abrishami A, Peng PW, Wong J, Chung F (2009) Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology 111(3):657–677. https://doi.org/10.1097/ALN.0b013e3181aae87a Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A (2008) The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg 61(9):1049–1058. https://doi.org/10.1016/j.bjps.2008.03.020 Ngu J, Wong AS (2016) Transanal natural orifice specimen extraction in colorectal surgery: bacteriological and oncological concerns. ANZ J Surg 86(4):299–302. https://doi.org/10.1111/ans.13383 Liu RJ, Zhang CD, Fan YC, Pei JP, Zhang C, Dai DQ (2019) Safety and oncological outcomes of laparoscopic nose surgery compared with conventional laparoscopic surgery for colorectal diseases: a meta-analysis. Front Oncol 9:597. https://doi.org/10.3389/fonc.2019.00597 Doyle DJ, Goyal A, Bansal P, Garmon EH (2020) American Society of Anesthesiologists Classification (ASA Class). In: StatPearls. Treasure Island (FL) Kinjo S, Sands LP, Lim E, Paul S, Leung JM (2012) Prediction of postoperative pain using path analysis in older patients. J Anesth 26(1):1–8. https://doi.org/10.1007/s00540-011-1249-6 Stevens RA, Mikat-Stevens M, Robert Flanigan W, Bedford Waters PAT, Furry TS, Frey K, Olson M, Kleinman B (1997) Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy? Urology 52(2):213–218. https://doi.org/10.1016/S0090-4295(98)00147-2 Biondo S, Kreisler E, Millan M, Fraccalvieri D, Golda T, Frago R, Miguel B (2010) Impact of surgical specialization on emergency colorectal surgery outcomes. Arch Surg 145(1):79–86. https://doi.org/10.1001/archsurg.2009.208

We would like to thank Ms. Annelissa Chin from Yong Loo Lin School of Medicine, Medical Library, for advising us with the search strategy for this meta-analysis. Author information Authors and Affiliations Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by YHC, GMD, and HQMT. The analysis was performed by CHN, YHC, and GMD. The first draft of the manuscript was written by YHC and GMD. All authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript. Corresponding author Ethics declarations Conflict of interest The authors declare no conflicts of interest. Ethical approval This article does not contain any studies with human participants or animals by any of the authors. Informed consent For this type of study formal consent is not required. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material Below is the link to the electronic supplementary material. Rights and permissions About this article Cite this article Chin, Y.H., Decruz, G.M., Ng, C.H. et al. Colorectal resection via natural orifice specimen extraction versus conventional laparoscopic extraction: a meta-analysis with meta-regression. Tech Coloproctol 25, 35–48 (2021). https://doi.org/10.1007/s10151-020-02330-6 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s10151-020-02330-6