title: The evolving practice of hybrid natural orifice transluminal endoscopic surgery (NOTES) for rectal cancer.
abstract: BACKGROUND
  Natural orifice transluminal endoscopic surgery (NOTES) has emerged as the area of focus in laparoscopic surgery. Hybrid NOTES (hNOTES) has some potential advantages for treating rectal cancer.
  
  
  METHODS
  Between May 2013 and November 2013, a total of 20 patients (11 males) who received hNOTES at two institutes participating in the study were documented and reviewed. Surgical outcomes, including complications and pathological outcomes, were analyzed.
  
  
  RESULTS
  The mean age of patients was 57.8 ± 10.1 years (range 34-78). Eleven patients received preoperative neoadjuvant chemoradiotherapy, with the mean distance between tumor and anal verge being 5.9 ± 1.7 cm (mean 2-8). The mean estimated intraoperative blood loss was 68 ± 106 ml (range 30-500), with one case converted to open procedure due to uncontrolled bleeding. Eight cases underwent simultaneous two-team approach. The mean operative time was 200.8 ± 47.7 min (range 110-285). Circular stapling was performed for 14 cases (70 %) as the anastomosis, and protective stoma performed for 17 cases (85 %). The overall postoperative complication rate was 25 %. Two cases (10 %) develop pelvic abscess due to leakage, which were controlled by medical treatments. The distal and circumferential margins were all free of tumor cells, and the mean distal margin length was 2.4 ± 0.98 cm (range 0.5-4).
  
  
  CONCLUSIONS
  Hybrid NOTES for rectal cancer is safe and feasible. Rapid experience-building accelerates its evolution, as reflected here by the high stapling rate and the idea of a two-team approach. It has the potential to become an option of treating rectal cancers.
authors.affiliation: Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors.forename: Chien-Chih
authors.initials: CC
authors.lastname: Chen
authors.forename: Yi-Ling
authors.initials: YL
authors.lastname: Lai
authors.forename: Jeng-Kae
authors.initials: JK
authors.lastname: Jiang
authors.forename: Chun-Ho
authors.initials: CH
authors.lastname: Chu
authors.forename: I-Ping
authors.initials: IP
authors.lastname: Huang
authors.forename: Wei-Shone
authors.initials: WS
authors.lastname: Chen
authors.forename: Andy Yi-Ming
authors.initials: AY
authors.lastname: Cheng
authors.forename: Shung-Haur
authors.initials: SH
authors.lastname: Yang
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical; D016063:Blood Loss, Surgical; D003106:Colon / Q000601:surgery; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D018358:Neuroendocrine Tumors / Q000601:surgery*; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology; D011230:Precancerous Conditions / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D016896:Treatment Outcome