Application Of Robotic Anterior Rectal Resection Plus Natural Orifice Specimen Extraction Surgery In Elderly Patients

Objective: The elderly may have more basic diseases,poorer anti-strike ability,and need more time recovering postoperatively.They belong to the high-risk group of rectal cancer surgery.Natural orifice specimen extraction surgery(NOSES)cause less trauma and offer quicker recovery,but there is little experience in the application of the elderly.This research aims to explore feasibility and advantages of robotic anterior rectal resection plus natural orifice specimen extraction surgery(NOSES)in elderly patients,further analyzing the risk factors of complications,so as to provide evidence for the use of this approach in suitable elderly patients.Methods: From June 2018 to June 2021,consecutive patients diagnosed as rectal cancer were retrospectively analyzed from the Gastrointestinal Surgery,the Second Xiangya Hospital of Central South University.According to age and surgical approach,patients were divided into three groups.Group A: age≥65y and accepted robotic rectal NOSES,Group B: age <65y and accepted robotic rectal NOSES,Group C:age≥65y and accepted robotic-assisted rectal surgery.Collecting perioperative datas and respectively comparing datas such as comorbidities,operation time,blood loss,exhaust time,postoperative WBC(white blood cell)count,postoperative stay and complications between group A and group B,group A and group C.Univariate and multivariate logistic regression were performed to analyze the risk factors of complications,also exploring the best indications for this approach.Results: All 327 cases were successfully completed based on the principle of total mesorectal excision with no conversion or perioperative death.There were 288 cases of robotic rectal NOSES :127 cases aged≥65years(Group A),161 cases aged<65 years(Group B).Robotic-assisted rectal surgeries were 39 cases(Group C).In the comparison between group A and group B:Group A had higher American Society of Anesthesiologists(ASA),more comorbidities and higher age-adjusted Charlson Comorbidity Index(a CCI),which means that it’s a high-risk group.The WBC count on the third day postoperative was lower in group A,and the number of more than one complication was higher in group A,the above differences are statistically significant(P<0.05).There was no significant difference in postoperative stay,exhaust time,the total number of complications and Clavien-Dindo grades between two groups.In the comparison between group A and group C: After propensity score matching,there were total 34 pairs.Postoperative stay,exhaust time,time to pull out the last drainage tube were shorter in group A.The WBC count third day postoperative was higher in group A.Postoperative pain scores and Clavien-Dindo grades were lower in group A.There was no significant difference in the total number of complications and the number of more than one complication between two groups.The top three complications of robotic rectal NOSES were: pelvic and abdominal infection(5.6%),anastomotic leakage(4.2%),and pulmonary infection(3.8%).In univariate and multivariate logistic regression analysis,high BMI index and low rectal tumor were independent risk factors of complications rather than advanced age.Conclusion: In this study,we demonstrated robotic rectal NOSES approach in our center and analyzed the relevant datas.Although the body reserve function is poor and may suffer multi-system complications,robotic rectal NOSES is safe and feasible for elderly patients.Free of abdominal incision can accelerate postoperative recovery and reduce the severity of complications in elderly patients.High BMI index and low rectal tumor are independent risk factors for complications rather than advanced age.Therefore,for elderly patients with rectal cancer who meet the indications and have good conditions,robotic rectal NOSES could be considered.