With the advancement of economic and medicine, patients' demands for quality of life and cosmetic effects after surgery are increasing. At the same time, higher requirements and challenges have been put forward to surgeons.
In the past 20 years, from traditional open surgery to conventional laparoscopic surgery to NOSES surgery, surgery has been developed rapidly. NOSES surgery uses conventional laparoscopic surgical instruments and familiar surgical paths to complete the radical resection of the tumor under laparoscopy, and then removes the specimen through the natural port and completes the digestive tract reconstruction [1]. There are only a few small puncture holes in the abdomen, without assistance incisions, and overcoming NOTES surgical instruments and technical obstacles, to obtain good cosmetic and minimally invasive results, and to maximize the benefits of conventional laparoscopic platforms. At present, it is believed that the NOSES radical resection of rectal cancer is mainly applicable to tumors with a depth of no more than T3. Transanal specimens require a maximum peripheral diameter of less than 5 cm, and transvaginal specimens require a maximum peripheral diameter of less than 5-7cm. At the same time, we should fully grasp the operation specifications of specimen collection, and strictly abide by the principles of aseptic operation and no tumor [1, 2]. According to the location of the rectal tumor and the way of removing the specimen, rectal NOSES surgery is currently divided into five types of surgery: Ⅰ, Ⅱ, Ⅲ, Ⅳ, and Ⅴ [1, 4]. Because the anastomosis position of type I is very low, prophylactic colostomy is often required, and type III / V type requires a vaginal incision, which causes some patients and their families to be unacceptable. Transanal specimens are not restricted by gender, so they have become the most widely used method for specimen collection.
At present, the NOSES operation in our center is mainly type Ⅱ and type Ⅳ. In this study, compared with patients with traditional laparoscopy (traditional nursing control group and ERAS control group), NOSES surgery does not affect the radical dissection of the tumor, and does not increase the risk of surgery time, bleeding, abdominal infection and anastomotic leakage, but it has obvious advantages in terms of postoperative pain, incision infection, and postoperative hospital stay. It not only achieves a radical resection of the tumor, but also greatly reduces the patient's trauma, postoperative wound pain, and stress response is reduced, and then to promote the patient's postoperative recovery.
On the other hand, with the long-term clinical observation of specialists and the introduction of evidence-based medicine theory, the feasibility and superiority of the application of the ERAS concept in colorectal cancer have been recognized by many scholars in recent years. Studies show that ERAS can reduce postoperative complications and the risk of death, reduce hospitalization costs and length of stay, improve patient compliance and satisfaction, and thus obtain good treatment results.[4–7] In addition, Gustafsson and their team’s studies have shown that ERAS can not only achieve satisfactory short-term effects, but also significantly improve the 5-year survival rate of patients with colorectal cancer after surgery, and the higher the compliance with the ERAS program, the more obvious the effect [8]. In this study, postoperative complications such as lung infection and urinary tract infection in patients treated with ERAS were significantly lower than those in the traditional care group. At the same time, the incidence of postoperative anastomotic leakage was not increased, indicating that the application of ERAS is safe. The postoperative pain of patients treated with ERAS was significantly lower than that of the traditional care group, at the same time, patients with ERAS intervention had faster recovery, shorter hospital stays, and higher satisfaction, indicating that ERAS is more effective in promoting postoperative rehabilitation of patients with rectal cancer.
NOSE surgery and ERAS are mutually reinforcing. In this study, the patients in the NOSE + ERAS group were not significantly different from the traditional nursing control group and the ERAS control group in terms of surgical time, bleeding volume, degree of tumor resection (number of lymph node dissection), postoperative abdominal infection, and anastomotic leakage, which indicates that NOSE combined with ERAS does not affect the radicalness of the tumor and does not increase the risk of postoperative abdominal infections and anastomotic leakage. At the same time, patients in the NOSE + ERAS group were significantly better than the other two control groups in terms of postoperative pain score, postoperative hospital stays, and patient satisfaction, further indicating that NOSE surgery combined with ERAS treatment is more superior in the field of postoperative rehabilitation. NOSE surgery makes full use of the advantages of laparoscopic clear vision and convenient operation. At the same time, removing specimens from natural channels, NOSES is less invasive than traditional laparoscopic surgery, and can reduce incision infection, postoperative incision pain, reduce complications, thereby enable patients to get out of bed early, promote intestinal peristalsis of patients, and promote rapid recovery after surgery.
In summary, in the ERAS treatment plan for patients with rectal cancer, choosing the appropriate case for NOSES minimally invasive surgery will greatly reduce the incidence of postoperative complications and accelerate the recovery of patients. NOSE minimally invasive surgery conforms to the basic concept of ERAS, and is also a fundamental need for ERAS, the perfect combination of the two is worthy of clinical promotion and will benefit more patients. However, in the exploration process of NOSES combined with the ERAS, the indications should be fully evaluated and selected. Regardless of the ERAS treatment or the resected specimen removed through the natural orifice, the safety, tumor-free principle and sterility principle need to be fully considered.