Comparison of survival and perioperative outcome of the colonic stent and the transanal decompression tube placement and emergency surgery for left-sided obstructive colorectal cancer: a retrospective multi-center observational study "The CODOMO study"

Impact of self-expanding metal stents on long-term survival outcomes as a bridge to surgery in patients with colon cancer obstruction: Current state and future prospects

Since self-expanding metal stents (SEMS) were first introduced in acute colon cancer obstruction, the increased rate of primary anastomosis and improved quality of life following SEMS placement have been clearly shown. However, it was demonstrated that SEMS are associated with higher recurrence rates. Although several trials have shown that overall and disease-free survival in patients following SEMS placement is similar with patients undergoing emergency surgery, obstruction and a high incidence of recurrence imposed many concerns. The optimal time interval from SEMS to surgery is still a matter of debate. Some studies have recommended a time interval of ~2 weeks between SEMS insertion and elective surgery. A prolonged interval of time from SEMS insertion to elective surgery and the administration of neoadjuvant chemotherapy (NAC) has been proposed. SEMS-NAC might have advantages for improving the surgical and long-term survival outcomes of patients with acute colon cancer obstruction, which is an optional approach in the management of acute colon cancer obstruction.

Short-term and long-term oncologic outcomes of self-expandable metallic stent compared with tube decompression for obstructive colorectal cancer: a systematic review and meta-analysis

Purpose

Patients with obstructive colorectal cancer managed by emergency surgery show high morbidity, mortality, and stoma formation rates. Decompression modalities, including the self-expandable metallic stent (SEMS) and tube drainage (TD), have been used to improve surgical outcomes. However, there have been limited studies comparing the 2 modalities. We performed a meta-analysis on short- and long-term outcomes between SEMS and TD.

Methods

PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. Data were pooled, and the overall effect size was calculated using random effect models. Outcome measures were perioperative short-term and 3-year survival outcomes.

Results

We included 20 nonrandomized studies that examined 2,047 patients in the meta-analysis. The meta-analysis showed SEMS had better short-term outcomes in clinical success rate, decompression-related complications, laparoscopic surgery rate, stoma formation rate, and postoperative complication rate with a relative risk (RR) of 0.36 (95% confidence interval [CI], 0.24-0.54; I2 = 20%), 0.32 (95% CI, 0.20-0.50; I2 = 0%), 0.47 (95% CI, 0.34-0.66; I2 = 87%), 0.34 (95% CI, 0.24-0.49; I2 = 52%), and 0.70 (95% CI, 0.54-0.89, I2 = 28%), respectively. However, there was no significant difference between the 2 groups in 3-year overall survival (RR, 0.99; 95% CI, 0.77-1.27; I2 = 0%).

Conclusion

Although the long-term oncologic impact of SEMS is still unclear compared with TD, the results of this meta-analysis may suggest that SEMS insertion can be performed more successfully and safely and may have benefits for short-term perioperative outcomes compared with TD. Further studies are warranted to provide more definitive survival results.

Short- and long-term outcomes of transanal decompression tube and self-expandable metallic stent for obstructive colorectal cancer based on a multicenter database (KYCC2110)

AIM

There are well-known methods for decompressing the colorectal tract before surgery, including transanal decompression tubes (TDT) and self-expanding metallic stents (SEMS). This study aimed to compare the short and long-term results in patients with malignant large bowel obstruction in whom TDT or SEMS were placed before surgery.

METHODS

This retrospective observational study enrolled 225 patients with malignant large bowel obstruction in whom TDT or SEMS were placed preoperatively and underwent R0 resection between 2008 and 2020. One-to-two propensity score matching was performed according to patient characteristics. Short- and long-term outcomes were compared. The primary endpoint was relapse-free survival (RFS). The secondary endpoints were the overall survival (OS) and postoperative complication rate.

RESULTS

Fifty-seven patients in the TDT group and 114 in the SEMS group were matched. The 3-year RFS rates were 66.7% in the TDT group and 69.9% in the SEMS group (p = 0.54), and the 3-year OS rates were 90.5% in the TDT group and 87.1% in the SEMS group (p = 0.52). No significant differences in the long-term results were observed between the two groups. Regarding short-term results, the SEMS group had significantly fewer stoma construction (p = 0.007) and shorter postoperative hospitalization (p < 0.001). The incidence of postoperative complications (grade ≥ 2) was significantly lower in the SEMS group (p = 0.04).

CONCLUSION

No significant differences in the long-term results were observed between the TDT and SEMS group. The SEMS showed significant usefulness in terms of improving short-term outcomes.

Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis

PURPOSE

This study aimed to determine the best treatment for acute left-sided malignant colonic obstruction (ALMCO) among emergency surgery (ES), self-expanding metallic stent (SEMS), transanal drainage tube (TD), and decompressive stoma (DS).

METHOD

Articles that compared two or more treatments of ALMCO were searched from PubMed, Cochrane Library, and Embase. Network meta-analyses were performed to calculate the outcomes of primary anastomosis, stoma creation, morbidity, mortality, and 5-year survival.

RESULTS

Fifty-one articles met inclusion criteria. TD was the optimal treatment in performing primary anastomosis [probability of ranking first (Pro-1) 0.96], while ES was the worst [probability of ranking fourth (Pro-4) 0.99]. More permanent stoma was formed in ES and TD groups than in SEMS and DS groups [OR (95%CI): TD vs SEMS: 4.12 (1.89, 9.45); TD vs DS: 3.39 (1.46, 8.75); ES vs DS: 2.55 (1.73, 4.17); SEMS vs ES: 0.33 (0.24, 0.42)]. More morbidity occurred in ES group than in SEMS group [OR (95%CI): ES vs SEMS: 1.44 (1.14, 1.82)]. Besides, SEMS was ranked first in avoiding infection (Pro-4 0.95). For in-hospital mortality, ES was ranked first (Pro-1 0.93). TD was ranked first in recurrence (Pro-1 0.97) and metastasis (Pro-1 0.98). There was no discrepancy in 5-year overall and disease-free survival among all strategies.

CONCLUSION

SEMS as a bridge to surgery reduces stoma formation, and morbidity especially the infection rate with relatively great oncological outcomes. Therefore, SEMS should be recommended first for ALMCO in the medical center with experience and conditions.

Long-term outcomes between self-expandable metallic stent and transanal decompression tube for malignant large bowel obstruction: A multicenter retrospective study and meta-analysis

Aim

To compare the oncological outcomes between self-expandable metallic stent (SEMS) as a bridge to surgery and transanal decompression tube (TDT) placement for malignant large bowel obstruction (MLBO).

Methods

A total of 287 MLBO patients who underwent SEMS (n = 137) or TDT placement (n = 150) were enrolled in this multicenter retrospective study. Overall survival (OS) and disease-free survival (DFS) between the two groups were compared. A meta-analysis was performed using random-effects models to calculate odd ratios (OR) with 95% confidence intervals (CIs).

Results

Postoperative complications of Clavien-Dindo grade ≥II and ≥III occurred frequently in the TDT group compared with the SEMS group (P = 0.002 and 0.005, respectively). The 3-y OS in the overall cohort and 3-y DFS in the pathological stage II/III cohort in the SEMS and TDT groups were 68.6% and 71.4%, and 71.0% and 72.6%, respectively. The survival differences were not significantly different in the OS and DFS analyses (P = 0.819 and P = 0.892, respectively). A meta-analysis of nine studies (including our cohort data) demonstrated no significant difference between the SEMS and TDT groups for 3-y OS and DFS (OR = 0.96, 95% CI = 0.57-1.62, P = 0.89 and OR = 0.69, 95% CI = 0.46-1.04, P = 0.07, respectively).

Conclusion

Our study demonstrated that SEMS placement had no inferiority regarding long-term outcomes, including OS and DFS, compared with TDT placement. Considering the short-term benefits of SEMS placement, this could be a preferable preoperative decompression method for MLBO.

A multicenter case-control study of self-expanding metallic stent versus trans-anal colorectal tube for stage II/III non-right-sided obstructive colon cancer

BACKGROUND

Self-expanding metallic stent (SEMS) and trans-anal colorectal tube (TCT) are alternative treatments to conventional emergency surgery for non-right-sided obstructive colon cancer (NROCC). However, the one with better short- and long-term outcomes remains controversial. Thus, this multicenter case-control study aimed to analyze and compare SEMS and TCT for NROCC.

METHODS

Patients with stage II/III NROCC who underwent surgery between January 2010 and December 2019 at either of the eight selected Japanese affiliate hospitals were, retrospectively, reviewed. Baseline characteristics between the SEMS and TCT groups were adjusted by propensity score (PS) matching.

RESULTS

Among 239 reviewed patients (SEMS: 76, TCT: 163), 180 were finally included in two well-balanced cohorts through PS: SEMS group (65 patients) and TCT group (115 patients). Technical success, clinical success, morbidity, and short-term mortality were not significantly different between the two groups. SEMS placement achieved significantly higher rates for primary resection/anastomosis without stoma (SEMS: 90.8% vs. TCT: 77.4%, p < 0.001) and laparoscopic surgery (SEMS: 64.6% vs. TCT: 43.5%, p < 0.001) than TCT placement. However, 5-year overall survival (SEMS: 83.7% vs. TCT: 86.4%; p = 0.822) and 5-year relapse-free survival (SEMS: 64.7% vs. TCT: 66.4%; p = 0.854) showed no significant differences between these groups.

CONCLUSIONS

Both SEMS and TCT revealed similar long-term outcomes, but SEMS placement was better in achieving primary resection/anastomosis and laparoscopic surgery in patients with stage II/III NROCC.

Comparison of long-term outcomes of colonic stenting as a "bridge to surgery" and emergency surgery in patients with left-sided malignant colonic obstruction

PURPOSE

Long-term oncologic outcomes of colonic stenting as a "bridge to surgery" in patients with left-sided malignant colonic obstruction (LMCO) are unclear. This study was performed to compare long-term outcomes of self-expandable metal stent (SEMS) insertion as a bridge to surgery and emergency surgery in patients with acute LMCO.

METHODS

This retrospective cohort study included patients with acute LMCO who underwent SEMS insertion as a bridge to surgery or emergency surgery. The primary outcomes were 5-year disease-free survival (DFS), overall survival (OS), and recurrence rate. Survival outcomes were determined using the Kaplan-Meier method and compared using log-rank tests.

RESULTS

There was a trend of worsening 5-year OS rate in the SEMS group compared with emergency surgery group (45% vs. 57%, P=0.07). In stage-wise subgroup analyses, a trend of deteriorating 5-year OS rate in the SEMS group with stage III (43% vs. 59%, P=0.06) was observed. The 5-year DFS and recurrence rate were not different between groups. The overall median follow-up time was 58 months. On multivariate analysis, age of ≥65 years and American Joint Committee on Cancer stage of ≥III, and synchronous metastasis were significant poor prognostic factors for OS (hazard ratio [HR], 1.709; 95% confidence interval [CI], 1.007-2.900; P=0.05/HR, 1.988; 95% CI, 1.038-3.809; P=0.04/HR, 2.146; 95% CI, 1.191-3.866; P=0.01; respectively).

CONCLUSION

SEMS as a bridge to surgery may have adverse oncologic outcomes. Patients in the SEMS group had a trend of worsening 5-year OS rate without higher recurrence.

Oncologic impact of colonic stents for obstructive left-sided colon cancer

Colonic stenting has had a significant positive impact on the management of obstructive left-sided colon cancer (OLCC) in terms of both palliative treatment and bridge-to-surgery (BTS). Notably, many studies have convincingly demonstrated the effectiveness of stenting as a BTS, resulting in improvements in short-term outcomes and quality of life, safety, and efficacy in subsequent curative surgery, and increased cost-effectiveness, whereas the safety of chemotherapy after stenting and the long-term outcomes of stenting as a BTS are controversial. Several studies have suggested an increased risk of perforation in patients receiving bevacizumab chemotherapy after colonic stenting. In addition, several pathological analyses have suggested a negative oncological impact of colonic stenting. In contrast, many recent studies have demonstrated that colonic stenting for OLCC does not negatively impact the safety of chemotherapy or long-term oncological outcomes. The updated version of the European Society of Gastrointestinal Endoscopy guidelines released in 2020 included colonic stenting as a BTS for OLCC as a recommended treatment. It should be noted that the experience of endoscopists is involved in determining technical and clinical success rates and possibly oncological outcomes. This review discusses the positive and negative impacts of colonic stenting on OLCC treatment, particularly in terms of oncology.

Colonic Transendoscopic Enteral Tubing Is a New Pathway to Microbial Therapy, Colonic Drainage, and Host-Microbiota Interaction Research

The limitation of traditional delivery methods for fecal microbiota transplantation (FMT) gave birth to colonic transendoscopic enteral tubing (TET) to address the requirement of frequent FMTs. Colonic TET as a novel endoscopic intervention has received increasing attention in practice since 2015 in China. Emerging studies from multiple centers indicate that colonic TET is a promising, safe, and practical delivery method for microbial therapy and administering medication with high patient satisfaction. Intriguingly, colonic TET has been used to rescue endoscopy-related perforations by draining colonic air and fluid through the TET tube. Recent research based on collecting ileocecal samples through a TET tube has contributed to demonstrating community dynamics in the intestine, and it is expected to be a novel delivery of proof-of-concept in host-microbiota interactions and pharmacological research. The present article aims to review the concept and techniques of TET and to explore microbial therapy, colonic drainage, and microbial research based on colonic TET.

Self-expanding metal stent placement and pathological alterations among obstructive colorectal cancer cases

BACKGROUND

Experimental studies suggest that self-expanding metal stents (SEMSs) enhance the aggressive behavior of obstructive colorectal cancer. The influence of SEMS placement on pathological alterations remains to be elucidated.

AIM

To determine whether SEMS placement is associated with molecular or pathological features of colorectal carcinoma tissues.

METHODS

Using a nonbiased molecular pathological epidemiology database of patients with obstructive colorectal cancers, we examined the association of SEMS placement with molecular or pathological features, including tumor size, histological type, American Joint Committee on Cancer (AJCC)-pTNM stage, and mutation statuses in colorectal cancer tissues compared with the use of transanal tubes. A multivariable logistic regression model was used to adjust for potential confounders.

RESULTS

SEMS placement was significantly associated with venous invasion (P < 0.01), but not with the other features examined, including tumor size, disease stage, mutation status, and lymphatic invasion. In both the univariable and multivariable models with adjustment for potential factors including tumor location, histological type, and AJCC-pT stage, SEMS placement was significantly associated with severe venous invasion (P < 0.01). For the outcome category of severe venous invasion, the multivariable odds ratio for SEMS placement relative to transanal tube placement was 19.4 (95% confidence interval: 5.24–96.2). No significant differences of disease-free survival and overall survival were observed between SEMS and transanal tube groups.

CONCLUSION

SEMS placement might be associated with severe venous invasion in colorectal cancer tissue, providing an impetus for further investigations on the pathological alterations by SEMSs in colorectal cancer development.

Colon cancer patient with long-term colon stent placement: Case report and literature review

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer mortality globally. Large bowel obstruction (occurring in 15-30% of patients with CRCs) accounts for approximately 80% of medical emergencies related to CRC. Currently, there is no standard treatment of this condition. The European Society of Gastrointestinal Endoscopy (ESGE) recommends self-expandable metal stent (SEMS) as a bridge (two weeks) to surgery for left-sided obstructing colon cancer. In the present report, we describe an 81-year-old male with colon cancer who underwent colon stent placement for 32 months, but later underwent radical resection. A follow-up of more than four-months revealed that his condition was normal. The history as well as application and advantages of SEMS are discussed in this report.

Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group

Background

There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan.

Methods

A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined.

Results

No change in the decompression method, T3 cancer, negative postoperative complications (grades 0–1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors.

Conclusions

Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

Short- and long-term outcomes of a self-expandable metallic stent versus a transanal decompression tube for pathological stage II and III left-sided obstructive colorectal cancer: a retrospective observational study

PURPOSE

Few studies have investigated the long-term oncological outcomes of the self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (OCRC). We conducted this study to compare the short- and long-term outcomes of the SEMS with those of the traditional transanal decompression tube (TDT) in patients with stage II and III left-sided OCRC.

METHODS

The subjects of this retrospective study were 78 patients with pathological stage II and III left-sided OCRC who underwent radical surgery after SEMS or TDT placement, between April, 2005 and September, 2019. We compared perioperative data, including decompression success rates and 3-year relapse-free survival (RFS), between the SEMS and TDT groups.

RESULTS

A SEMS was placed in 60 (76.9%) patients and a TDT was placed in 18 (23.1%) patients, achieving a clinical success rate of decompression of 98.3% in the SEMS group and 77.8% in the TDT group (P = 0.009). The 3-year RFS of the overall cohort was better in the SEMS group than in the TDT group (74.9% vs. 40.9%, respectively; P = 0.003).

CONCLUSIONS

Decompression using a SEMS as the BTS may improve oncological outcomes over those achieved by a TDT in patients with left-sided stage II and III OCRC.