A "Scarless" Rebirth Beyond Trauma:
NOSES Surgery Combined with ERAS in a 65-Year-Old Rectal Cancer Patient

This article is a de-identified educational case review. It describes the clinical course of one patient managed at Beijing Arion Cancer Hospital and reflects the team's approach to integrating minimally invasive technique with Enhanced Recovery After Surgery (ERAS) principles. It is not medical advice, nor does it guarantee outcomes for other patients. Treatment decisions must be individualized by qualified physicians.

Case Introduction

This issue reviews the full diagnostic and therapeutic course of a 65-year-old female patient with rectal cancer. The patient, a 65-year-old woman, was diagnosed with a malignant rectal tumour. After comprehensive assessment, the gastrointestinal tumour centre team at Beijing Arion Cancer Hospital abandoned the conventional abdominal auxiliary incision for specimen extraction and successfully performed laparoscopic radical resection of rectal cancer with intracorporeal anastomosis and natural orifice specimen extraction surgery (NOSES). The patient's postoperative recovery followed Enhanced Recovery After Surgery (ERAS) principles; pathology confirmed stage II disease without high-risk features, achieving a dual victory in oncology and function.

Core Conflict

The core conflict of this case is no longer the traditional "race against life and death", but the challenge between "the core need to cure the tumour" and "the patient's very high expectation for a painless postoperative recovery and a rapid return to normal life". Although conventional laparoscopic surgery is already minimally invasive, the 5–7 cm specimen-extraction incision remains the main source of postoperative pain, delayed mobilisation and incision-related complications.

I. Case Overview: Baseline Status and Core Challenges

Baseline Status

A 65-year-old woman, physically fit with a high level of daily activity, who placed high demands on her postoperative quality of life and appearance. She had experienced a change in stool character with hematochezia for three months. She had no significant past medical history and no history of abdominal surgery.

Imaging: High-resolution pelvic MRI showed the tumour in the upper rectum, with its lower margin about 8 cm from the anal verge, above the peritoneal reflection, invading the muscularis propria and extending to the subserosa, without invading adjacent organs. The mesorectal fascia (MRF) was not involved, the circumferential resection margin (CRM) was assessed as negative, and there was no sign of definite regional lymph node metastasis; the imaging stage was considered cT3N0M0.

Diagnostic basis: Colonoscopy and pathology showed an ulcerative mass about 8 cm from the anal verge, confirmed as rectal adenocarcinoma. High-resolution pelvic MRI indicated an upper-rectal mass invading the bowel-wall muscularis and subserosa, with no definite enlarged lymph nodes (cT3N0M0).

Current Dilemma

What the patient faced was not an emergent life-threatening crisis, but a deep anxiety about the trauma of traditional surgery: although laparoscopic technique is now widespread, conventional surgery still requires a small abdominal incision to extract the specimen. For this patient, the incision meant not only the need for potent postoperative analgesia, but also slowed recovery of bowel function and delayed time to getting out of bed, greatly affecting the rhythm of her physiological and psychological recovery.

Key Assessment Results

Tumour-burden assessment: The maximum tumour diameter was about 3 cm, with no invasion of adjacent organs and good bowel conditions, providing the physical basis for extracting the specimen through a natural orifice (rectum/anus or vagina).

Physiological tolerance: Cardiopulmonary function was assessed as good, with no absolute surgical contraindications, providing the physical foundation for implementing ERAS (Enhanced Recovery After Surgery).

II. Decision-Making: MDT Core Analysis and Strategy Deliberation

1. Preoperative MDT: Did the Patient Have High-Risk Factors Requiring Neoadjuvant Therapy?

Combining the results of colonoscopy, MRI and thoraco-abdomino-pelvic contrast-enhanced CT, the patient had an upper-rectal cancer, imaging cT3N0M0, with the tumour confined to the rectal wall and mesorectum, and no definite high-risk factors for lymph node metastasis, distant metastasis or CRM involvement. Preoperative molecular testing, including mismatch repair (MMR) protein testing, was also completed, showing intact MMR protein expression (pMMR). The MDT comprehensively assessed the case as localized rectal cancer with good conditions for radical resection. Considering the high location of the tumour and the absence of definite locally advanced risk factors, and on the basis of fully assessing oncological safety, the team decided on laparoscopic radical resection rather than preoperative neoadjuvant chemoradiotherapy.

2. Treatment-Pathway Analysis and Trade-offs

Option A — conventional laparoscopic radical resection of rectal cancer: The most mature technique, with high adoption. But the presence of an abdominal wall incision increases the risks of wound infection and incisional hernia, and the pain directly hinders the patient's early postoperative mobilisation and cough/expectoration.

Option B — laparoscopic radical resection + NOSES: The benefit is "no auxiliary abdominal wall incision", which significantly reduces incision pain, greatly lowers abdominal wall complications, is highly aligned with ERAS principles, gives a good cosmetic result and has minimal psychological impact. The challenge lies in the stringent demands it places on the team's aseptic and tumour-free practice, intracorporeal anastomosis technique and specimen-extraction skills.

3. Decision Formation

Combining the patient's strong wish for rapid recovery and the oncological indications, the team reached a consensus: implement "minimally invasive within minimally invasive".

Strategy: Avoid nasogastric tube placement preoperatively; intraoperatively perform laparoscopic radical resection of rectal cancer with the specimen extracted through a natural orifice; postoperatively rely on the team's mature ERAS pathway to break traditional taboos and promote ultra-fast recovery for the patient.

III. The Breakthrough: Treatment Course and Technical Points

1. Preoperative "Prehabilitation" Management

Breaking with routine: abandon the traditional prolonged preoperative fasting and water restriction; a low-residue diet for three days; cancel routine mechanical bowel preparation; oral laxatives.

2. The Surgical Showdown: Precise Implementation of NOSES

Technical key: During the operation the principle of total mesorectal excision (TME) was followed, with fine skeletonisation of the vessels and lymph-node dissection. Under the strict protection of aseptic and tumour-free principles, a specimen-protection sleeve was placed and the tumour together with the resected bowel was smoothly delivered through the natural orifice. The abdominal wall retained only five puncture holes, achieving a truly "scarless abdomen". Intraoperative blood loss was minimal, and anaesthesia depth and fluid volume were precisely controlled.

3. The Postoperative "Acceleration Engine": Efficient Implementation of ERAS Principles

Thanks to NOSES eliminating incision pain, the ERAS measures dovetailed seamlessly:

Early feeding: The patient was allowed sips of water immediately after awakening from anaesthesia, and started a clear-fluid diet on postoperative day 1; bowel function was rapidly awakened, with no ileus.

Early mobilisation: Because there was no incision traction pain, no opioid-based intravenous patient-controlled analgesia pump was needed. The urinary catheter was removed on postoperative day 1, and the patient got out of bed and moved around independently with family accompaniment, effectively preventing lower-limb deep vein thrombosis and aspiration pneumonia.

IV. Outcome Assessment and Follow-up Strategy

Short-Term Efficacy

Throughout the entire hospital stay the patient had no significant pain, overturning her family's traditional perception of a "major cancer operation".

Pathology Result

(Rectum) moderately differentiated adenocarcinoma, invading to the subserosa. Both proximal and distal margins and the circumferential resection margin were negative (R0 resection). Lymph nodes (0/16) showed no metastatic carcinoma. No lymphovascular tumour embolus or perineural invasion was seen, and mismatch-repair (MMR) protein expression was normal. Final pathological stage: pT3N0M0, stage II (without high-risk factors).

Follow-up Plan

Preoperative MRI assessment showed no obvious high-risk local factors, and the postoperative pathology showed radical tumour resection without high-risk pathological features; after MDT discussion it was considered that the benefit of adjuvant chemotherapy would be limited, so close follow-up was chosen instead.

V. Insights from This Case

1. Clinical-Thinking Insight: Elevating from "Treating the Disease" to "Treating the Person"

This case perfectly illustrates that modern surgery must not only "remove the lesion" but also "protect function and psychology". NOSES is not merely minimally invasive at the physical level, but also at the psychological level — it spares the patient the psychological shock of a large scar and lets them face the disease and subsequent life with a more positive mindset.

2. ERAS-Model Insight: Technological Innovation Is the Cornerstone of Accelerated Recovery

ERAS is not a mere nursing concept, but a comprehensive system built on the iterative advancement of surgical technique. In this case, it was precisely because NOSES fundamentally solved the biggest obstacle — "incision pain" — that core ERAS measures such as "early feeding, early mobilisation" were no longer castles in the air but the natural result of a smooth process.

3. Technical-Application Insight: Standardisation Is the Prerequisite for NOSES to Endure

Although NOSES offers significant advantages, its indications must be strictly observed. While pursuing a scarless result, upholding the two great surgical bottom lines of "asepsis" and "tumour-free" principles is the core guarantee of the patient's long-term survival benefit.

Expert Commentary

Prof. Sergey Efetov

Director of Colorectal Surgery, First Moscow State Medical University, Russia

This case is a classic example of colorectal cancer surgery evolving from "minimally invasive" toward "ultra-minimally invasive". The diagnosis and treatment of this 65-year-old female patient not only demonstrate the surgeon's technical skill and advanced concepts, but also profoundly reflect the perfect synergistic effect between NOSES and ERAS.

The essence of this case lies in its ultimate pursuit of "recovery quality". For patients with earlier-stage rectal cancer, our goal is no longer merely oncological radicality, but the rapid return of physiological and psychological function after surgery. NOSES avoids an auxiliary abdominal wall incision, which is directly translated in clinical practice into milder postoperative pain and better abdominal-wall integrity. Precisely because there is no constraint of incision pain, the patient can truly get out of bed on the first postoperative day and eat immediately — exactly the ideal state pursued by ERAS principles. The pathology confirmed R0 resection and adequate lymph-node dissection, further proving the reliability of NOSES in ensuring oncological safety.

From the perspective of international influence, NOSES surgery is leading a conceptual revolution in colorectal surgery worldwide. Over the past decade, propelled by Prof. Wang Xishan of the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, this technique has evolved from an innovative surgical approach into a mature set of international standards. Prof. Liu Zheng's team has extensive experience in NOSES surgery and has accumulated substantial achievements — including publishing international consensus and guidelines, leading multicentre studies, and demonstrating NOSES surgery in Russia, promoting its dissemination and adoption there. Whether in China, Russia or Europe, a growing number of surgeons are coming to recognise that reducing abdominal-wall injury is of great significance for protecting patients' immune function and lowering the risk of complications. Through this case we can also see: NOSES surgery is not only a byword for "aesthetics", but also the cornerstone of "precision" and "rapid recovery". It is crossing national borders to bring higher-quality survival benefits to colorectal cancer patients around the world.

References

[1] Zhang M, Liu Z, Wang X. Is natural orifice specimen extraction surgery the future direction of minimally invasive colorectal surgery? Surg Open Sci. 2022 Aug 18;10:106-110.