Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy for Diverticular Disease: A Prospective Cohort Study.
BACKGROUND
Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected.


METHODS
Patients scheduled for trNS were entered into a prospective registry on an intention-to-treat basis. The primary endpoint was trNS feasibility, and secondary endpoints were morbidity, pain, length of stay, and inflammatory response. A medial-to-lateral dissection with full mobilization of the splenic flexure and total intracorporeal anastomosis was performed. The rectum was covered with a wound protector for transrectal extraction.


RESULTS
Of 95 elective sigmoidectomies, 81% (n = 77) were enrolled for either transvaginal NOTES resection (n = 37) or trNS (n = 40). There was no difference in body mass index or indication between patients undergoing laparoscopic-assisted sigmoidectomy (LAS), transvaginal resection, or trNS, although trNS patients were younger. Mainly because of a mismatch of bulky specimen and narrow pelvis, 17.5% of trNS were converted to LAS. Major morbidity was 10%, including 2 septic complications. During the study, the anastomosis technique was changed from double stapled end-to-end to side-to-end anastomosis.


CONCLUSIONS
Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.
Department of Surgery, Cantonal Hospital Baselland, Bruderholz, Switzerland.
Sebastian H
SH
Lamm
Department of Surgery, Cantonal Hospital Baselland, Bruderholz, Switzerland.
Andreas
A
Zerz
Department of Surgery, Cantonal Hospital Baselland, Bruderholz, Switzerland.
Anastasios
A
Efeoglou
Department of Surgery, Cantonal Hospital Baselland, Bruderholz, Switzerland. Electronic address: daniel.steinemann@gmx.ch.
Daniel C
DC
Steinemann
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D003082:Colectomy / Q000379:methods*; D012809:Colon, Sigmoid / Q000601:surgery*; D004241:Diverticulum, Colon / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000379:methods*; D019723:Endoscopes; D004867:Equipment Design; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation*; D011446:Prospective Studies; D012007:Rectum