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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2026, Vol. 15 ›› Issue (01) : 17 -30. doi: 10.3877/cma.j.issn.2095-3224.2026.01.002

指南与共识

老年结直肠肿瘤经自然腔道取标本手术（NOSES）指南
中国医师协会结直肠肿瘤专业委员会, 中国抗癌协会NOSES专业委员会, 中国NOSES联盟   
  1. 1. 410008　长沙，国家老年疾病临床医学研究中心，中南大学湘雅医院老年外科/结直肠肿瘤NOSES微创医学中心
    2. 100176，北京美中爱瑞肿瘤医院胃肠肿瘤中心
    3. 710061，西安交通大学第一附属医院普通外科
    4. 330000，南昌大学第一附属医院普外科
    5. 310003　杭州，浙江大学医学院附属第二医院
    6. 100021　北京，中国医学科学院肿瘤医院结直肠外科
  • 收稿日期:2025-12-23 出版日期:2026-02-25
  • 基金资助:
    国家老年疾病临床医学研究中心临床研究重点项目(No. 2021LNJJ01); 湖南省卫生健康委科研项目(No. 202204014631); 湖南省自然科学基金面上项目(No. 2023JJ30869)

Guidelines for natural orifice specimen extraction surgery (NOSES) in elderly patients with colorectal cancer

Colorectal Cancer Professional Committee of the Chinese Medical Doctor Association;, Chinese Anti-Cancer Association NOSES Professional Committee;, Chinese NOSES Alliance   

  1. 1. Department of General Surgery/ NOSES Minimally Invasive Medicine Center for Colorectal Cancer, Xiangya Hospital, Central South University, National Clinical Research Center for Geriatric Diseases, Changsha 410008
    2. Gastrointestinal Cancer Center, Beijing Arion Cancer Hospital, Beijing 100176
    3. Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061
    4. Department of General Surgery, the First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330000
    5. Department of Colorectal Surgery and Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003
    6. Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021
  • Received:2025-12-23 Published:2026-02-25
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中国医师协会结直肠肿瘤专业委员会, 中国抗癌协会NOSES专业委员会, 中国NOSES联盟. 老年结直肠肿瘤经自然腔道取标本手术（NOSES）指南[J/OL]. 中华结直肠疾病电子杂志, 2026, 15(01): 17-30.

Colorectal Cancer Professional Committee of the Chinese Medical Doctor Association;, Chinese Anti-Cancer Association NOSES Professional Committee;, Chinese NOSES Alliance. Guidelines for natural orifice specimen extraction surgery (NOSES) in elderly patients with colorectal cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2026, 15(01): 17-30.

经自然腔道取标本手术（NOSES）作为微创外科的创新技术，在结直肠肿瘤领域已得到广泛应用并取得技术突破。当前全球人口老龄化进程加速，老年群体结直肠肿瘤发病率居高不下。人口老龄化给结直肠肿瘤诊疗带来多重挑战：老年患者生理机能减退、合并症复杂、术后康复缓慢，对手术耐受性及围手术期管理提出更高要求；同时，医生需在保证肿瘤根治性的前提下，平衡微创获益与手术风险，传统诊疗模式已难以适配这一特殊人群的需求。这些挑战成为本指南制定的内在动力。针对老年患者这一特殊人群，规范NOSES技术在老年结直肠肿瘤患者中的安全应用至关重要。编写组基于《结直肠肿瘤经自然腔道取标本手术指南（2023版）》并结合快速康复外科（ERAS）理念，制定本指南。本指南系统阐述老年结直肠肿瘤NOSES的核心原则、围手术期多学科协作等内容，重点聚焦老年患者术前综合评估、适应证与禁忌证的个体化原则、围手术期多学科协作优化策略（如器官功能维护、营养状况改善、麻醉管理、手术操作优化、ERAS路径等）及术后并发症防治等关键环节。通过整合循证医学证据与临床实践经验，旨在为老年患者提供兼顾肿瘤学安全性与微创获益的规范化技术标准，推动NOSES在老年群体中的科学应用与高质量发展。

关键词: 结直肠癌, 老年患者, 经自然腔道取标本手术, 指南

As an innovative minimally invasive surgical technique, natural orifice specimen extraction surgery (NOSES) has been widely applied in the field of colorectal cancer with significant technological breakthroughs. Currently, amid the accelerating global aging process, the incidence of colorectal cancer among the elderly remains persistently high. Population aging poses multiple challenges to the diagnosis and treatment of colorectal cancer: elderly patients exhibit diminished physiological functions, complex comorbidities, and delayed postoperative recovery, which places higher demands on surgical tolerance and perioperative management. Meanwhile, physicians must balance the benefits of minimal invasiveness with surgical risks while ensuring oncological radicality, making traditional diagnosis and treatment models increasingly inadequate to meet the needs of this special population. These challenges serve as the intrinsic motivation for formulating this guideline. For the specific group of elderly patients, standardizing the safe application of NOSES in elderly colorectal cancer patients is of paramount importance. Based on the Guidelines for natural orifice specimen extraction surgery (NOSES) in colorectal cancer (2023 Edition) and integrated with the concept of enhanced recovery after surgery (ERAS), this guideline is formulated. It systematically elaborates on the core principles of NOSES for elderly colorectal cancer, perioperative multidisciplinary collaboration, and other key content, with a focus on critical aspects such as comprehensive preoperative assessment of elderly patients, individualized principles for indications and contraindications, optimized strategies for perioperative multidisciplinary collaboration (including organ function preservation, nutritional status improvement, anesthetic management, surgical technique optimization, ERAS pathways, etc.), and prevention and treatment of postoperative complications. By integrating evidence-based medical evidence with clinical practice experience, this guideline aims to provide standardized technical standards that balance oncological safety and minimally invasive benefits for elderly patients, thereby promoting the scientific application and high-quality development of NOSES in the elderly population.

Key words: Colorectal cancer, Elderly patients, Natural orifice specimen extraction surgery(NOSES), Guideline
表1 老年结直肠肿瘤男性与女性患者的处理要点及差异分析
对比维度 老年男性患者 老年女性患者
共同原则 术前全面评估器官功能、优化基础疾病；术中精准操作，减少创伤，注重"无菌、无瘤"原则；术后预防感染、深静脉血栓等并发症 同左
术前评估重点 前列腺功能（增生情况、排尿功能、前列腺特异性抗原检测）、心血管疾病（冠心病、高血压病、房颤抗凝方案）、脑血管疾病（血压管理、血糖血脂调控）、营养与肺功能（吸烟、饮酒史相关） 除心脑血管及肺功能外，阴道条件（黏膜弹性、宽度、炎症）、阴道分泌物检查、盆底功能（子宫脱垂、阴道壁膨出）、骨质疏松与关节疾病
手术路径选择 经直肠取标本为主 同时具有直肠和阴道两个取标本途径，可根据术中具体情况选择
术中操作要点 沿Denonvilliers筋膜分离，避免损伤前列腺；直肠前壁切开及缝合需远离前列腺 沿直肠阴道隔锐性分离，避免阴道壁撕裂；需提拉子宫以暴露视野，防止子宫韧带损伤；阴道后壁切开位置远离宫颈
主要术中风险 前列腺损伤（可能导致血尿、尿瘘）、系膜血管撕裂 阴道壁撕裂、子宫脱垂加重
术后管理重点 尿潴留（常规留置导尿管2~3天，拔管前训练膀胱功能，拔管后首次排尿时间一般不超过8 h，重点关注残余尿量及尿失禁情况）；心血管监测（48 h心电监护，控制血压） 阴道残端护理（碘伏纱布阴道填塞消毒，每日更换一次，连用5~7天）；预防盆腔感染；避免用力排便（使用缓泻剂）
术后常见并发症 尿潴留、心血管事件（心肌缺血、血压波动） 阴道切口愈合不良（渗血、感染）、盆腔感染、盆底功能异常加重
特殊管理措施 术前/术后使用α受体阻滞剂（如坦索罗辛）改善排尿；营养不良者围手术期营养干预 术前3天阴道消毒；部分阴道黏膜变薄、弹性降低的患者可局部使用雌激素软膏改善黏膜状态；术后1周开始盆底肌训练（如凯格尔运动，每日3次，每次10~15 min）
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