A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

Background Laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making. Methods The study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis. Results Upper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit. Conclusions NOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.

Colocutaneous fistula following Clostridioides difficile infection managed as an ‘autocolostomy’: a novel approach to a recognised complication

Colocutaneous fistula is a rare entity in colorectal disease. We present a case of colocutaneous fistula in a patient whose postoperative course following a laparoscopic anterior resection for sigmoid cancer was complicated by Clostridioides difficile colitis. During the follow-up period, it was found that his bowel contents were preferentially discharging through this fistula which had taken up the role of an ‘autocolostomy’. Given the physiological impact of an additional surgical procedure, a definitive repair of the fistula was deferred and instead the patient was taught to manage it in keeping with general principles of stoma care. Over the subsequent follow-up period, he has now developed a large parastomal hernia and is being considered for definitive repair.

A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

BackgroundLaparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in selected patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to investigate independent clinical-pathological predictors for selection of candidates for NOSES surgery in upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.MethodsThe study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. A consecutive and eligible serial of 111 patients with upper RC underwent elective laparoscopic anterior resection with or without NOSES between February and October of 2017. Multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the ability of predictors for selection of NOSES. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.ResultsUpper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL)，ratio of diameter (ROD) and ratio of area (ROA) values, while no significant correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD achieved a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.ConclusionsNOSES for patients with upper RC is multifactorial. The first nomogram is useful for proper patient selection in the future.