The prognostic impact of bowel perforation following self-expanding metal stent as a bridge to surgery in colorectal cancer obstruction

Colonic stent as a bridge to surgery versus emergency rection for malignant left-sided colorectal obstruction: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The role of self-expanding metal stent (SEMS) implantation as a bridge to surgery in malignant left-sided colorectal obstruction (MLCO) remains controversial.

OBJECTIVE

To evaluate the safety of SEMS implantation versus emergency surgery (ER) in the treatment of MLCO.

METHODS

Four major literature databases (Cochrane Library, Embase, PubMed, and Web of Science) were searched to collect articles published before April 20, 2023. After determining random or fixed-effect models based on heterogeneity tests, odds ratios (RR) or standardized mean differences (SMD) with their respective 95% confidence intervals (CI) were calculated.

RESULTS

Nineteen randomized controlled studies were included. The main outcomes included overall tumor recurrence rate, 30-day mortality rate, and overall incidence of complications. Secondary outcomes included mortality-related indicators, tumor recurrence-related indicators, surgery-related indicators, and other relevant indicators. The study found that there was no significant difference in the 30-day mortality rate between the SEMS group and the er group. However, the SEMS group had a lower overall incidence of complications (RR = 0.787, P = .004), lower incision infection rate (RR = 0.472, P = .003), shorter operation time (SMD = -0.591, P = .000), lower intraoperative blood loss (SMD = -1.046, P = .000), lower intraoperative transfusion rate (RR = 0.624, P = .021), lower permanent stoma rate (RR = 0.499, P = .000), lower overall stoma rate (RR = 0.520,P = .000), shorter hospital stay (SMD = -0.643, P = .014), and more lymph node dissections during surgery (SMD = 0.222, 95% CI: 0.021-0.423, P = .031), as well as a higher primary anastomosis rate (RR = 0.472, 95% CI: 0.286-0.7 77, P = .003), among other advantages. However, the SEMS group had a higher overall tumor recurrence rate (RR = 1.339, P = .048).

CONCLUSION

SEMS has significant advantages over er in relieving clinical symptoms and facilitating postoperative recovery in MLCO, but does not reduce the tumor recurrence rate. Neoadjuvant chemotherapy combined with SEMS may provide a new approach to the treatment of MLCO.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

Self-expandable metallic stents as a bridge to surgery in obstructive right- and left-sided colorectal cancer: a multicenter cohort study

The insertion of a self-expandable metal stent (SEMS) has been proposed as an alternative to emergent surgery (ES) for obstructive colorectal cancer (CRC). We aimed to evaluate the perioperative and oncologic outcomes of SEMS as a bridge to surgery in obstructive CRC, as compared with ES. We retrospectively reviewed the medical records of patients who underwent curative resection of obstructive CRC at four Hallym University-affiliated hospitals between January 2010 and December 2019. All patients were analyzed overall colon, then according to the side of obstruction (overall, right or left). Of 167 patients, 52 patients underwent ES and 115 underwent SEMS insertion and surgery (SEMS group). The postoperative hospital stay and time to soft diet were shorter in the SEMS group than in the ES group for overall and both sided cancer. The SEMS group had lower rates of stoma formation and severe complications for overall and for left-sided cancer. The 5-year overall survival (P = 0.682) and disease-free survival (P = 0.233) rates were similar in both groups. SEMS insertion as a bridge to surgery was associated with faster recovery, a lower rate of stoma formation with similar oncologic outcomes to those of ES.

Comparison of novel large-bore and conventional-bore covered self-expandable metal stents for malignant gastric outlet obstruction: Multicenter, retrospective study

OBJECTIVES

Covered self-expandable metal stent (cSEMS) for gastric outlet obstruction (GOO) has been developed to overcome tumor ingrowth but is prone to be associated with an increased risk of migration. Clinical impact of the novel large-bore cSEMS for malignant GOO remains unclear.

METHODS

A total of 117 patients undergoing endoscopic cSEMS placement for malignant GOO were enrolled in this multicenter retrospective study. Technical and clinical success, adverse events, recurrent GOO, and survival after stent placement were compared between 24 mm-cSEMS (n = 49) and 20 mm-cSEMS (n = 68).

RESULTS

Patient characteristics were well-balanced and thus similar survival was observed between the two groups (136 days vs. 89 days, P = 0.60). Technical success rate of 100% and clinical success rate of 96% were achieved both in 24 mm-cSEMS and 20 mm-cSEMS, respectively. The median cumulative time to recurrent GOO was significantly longer in 24 mm-cSEMS than in 20 mm-cSEMS (380 days vs. 138 days, P = 0.01). The incidence of adverse events and recurrent GOO was comparable: 12% vs. 15% (P = 0.91), and 16% vs. 31% (P = 0.11); however, no stent migration was observed in 24 mm-cSEMS. In a subgroup analysis, the superiority of 24 mm-cSEMS to 20 mm-cSEMS was demonstrated in extrinsic cancers (380 days vs. 121 days, P = 0.01) but not in intrinsic cancers (151 days vs. not reached, P = 0.47).

CONCLUSIONS

The 24 mm-cSEMS may improve time to recurrent GOO with ensuring acceptable safety in patients with malignant GOO.

Current practice for the treatment of obstructive left-sided colon cancer in China: a nationwide cross-sectional survey

PURPOSE

This study surveyed the current practice of surgical treatment of obstructive left-sided colon cancer (OLCC) in China.

METHODS

All colorectal surgery departments at tertiary or secondary hospitals in China were invited to complete a web-based questionnaire between August 27 and September 2, 2020.

RESULTS

Overall, completed questionnaire were received from 357 hospitals. Emergency surgery was the mainstay of treatment for OLCC, with the open approach accounting for up to 61.62%. The stoma rate of emergency surgery was up to 80%, mainly due to inadequate bowel preparation and severe edema of colon walls. Hartmann's procedure (61.62%) was the most preferred operation. A total of 243 hospitals (68.7%) reported that they would consider the use of a self-expanding metallic stent (SEMS) as a bridge for elective surgery. More than 50% of the hospitals participating in this study reported the success rate of SEMS placement, as well as the resolution rate of obstruction more than 80%, and the stent-related perforation rate was < 5%. A total of 126 hospitals considered carrying out a strategy of SEMS followed by neoadjuvant chemotherapy prior to elective surgery and believed that it might further improve treatment outcomes.

CONCLUSIONS

SEMS is a feasible option for the treatment of OLCC in addition to traditional emergency surgery, and its clinical benefits have been preliminarily recognized.

Clinical Significance of Surgical Resection Timing from Endoscopic Stenting for Left-Sided Large-Bowel Obstruction in Colorectal Cancer

BACKGROUND

The optimal interval between self-expanding metallic stent (SEMS) insertion and surgery remains controversial in malignant left-sided large-bowel obstruction (MLLO), especially with respect to oncologic aspects.

AIMS

The aim of this study is to examine whether the time interval to surgery is related to oncologic outcomes.

METHODS

Prospectively collected database of MLLO between January 2005 and December 2017 were reviewed. They were divided according to established cut-off value of 14 days for the time interval to surgery. The two groups (early and late groups) were compared with respect to disease-free survival (DFS) and overall survival (OS). Additional subgroup analysis was performed using the established cut-off values for patients with stage II and III tumors.

RESULTS

A total of 149 patients underwent surgery after SEMS insertion. There were no significant differences between the early and late groups in the 5-year DFS (78.0% vs 72.4%; P = 0.513) and the OS (74.2% vs 75.7%; P = 0.864) rates in all MLLO. Subgroup analysis showed that there were significant differences between the two groups for DFS and OS in stage II MLLO. The multivariate Cox regression analysis in stage II MLLO demonstrated that the time to surgery was a prognostic factor for DFS (HR, 2.051; 95% CI, 1.528-42.136; P = 0.014) and for OS (HR, 4.947; 95% CI, 1.520-16.107; P = 0.008).

CONCLUSIONS

The time to surgery was demonstrated not to be a significant prognostic factor in all MLLO. However, it was a prognostic factor for patients with stage II MLLO.

Self-Expandable Metal Stent as a Bridge to Surgery for Left-Sided Acute Malignant Colorectal Obstruction: Optimal Timing for Elective Surgery

OBJECTIVES

This randomized, single-center, retrospective, comparative cohort study is aimed at investigating the optimal time interval from self-expandable metal stent (SEMS) placement to surgery and potential risk factors for complications in patients with acute malignant colorectal obstruction.

METHODS

A total of 64 patients with left-sided acute malignant colorectal obstruction treated with SEMS placement and subsequent surgery between January 2013 and September 2020 were enrolled and allocated to a case group (SEMS placing time ≤ 14 days; n = 19 patients) and a control group (SEMS placing time > 14 days; n = 45 patients). The primary outcome was the difference in baseline information, patients' conditions during surgery, and postoperative conditions between the two groups. The secondary outcome included potential risk factors of postoperative complications. The propensity score matching (PSM) and super learner (SL) methods were used to eliminate multiple confounding factors of baseline data. A cohort of 21 samples was used for external validation, comprising 6 cases and 15 controls.

RESULTS

A significant difference was observed between the two groups in intraoperative blood loss (P = 0.009), postoperative hospital stay (P = 0.002), postoperative complications (Clavien-Dindo grading ≥ II) (P < 0.001), stoma creation (P < 0.001), and primary anastomosis (P < 0.001). After a 1 : 3 PSM analysis, no statistically significant differences between eight confounding variables of the two groups were observed (P > 0.05). Caliper set as 0.2 multiple logistic regression analysis showed that the potential risk factor for postoperative complications was SEMS placing time (RR = 0.109, 95% confidence interval (CI) = 0.028-0.433; P = 0.002), indicating that SEMS placing time > 14 days was an independent risk factor for postoperative complications in bridge-to-surgery (BTS) setting. The area under the AUC curve was 76.7% and validated using the validation cohort.

CONCLUSIONS

Long duration of SEMS placement (>14 days) may not influence surgical difficulty but could increase the risk of postoperative complications.

Radiological Reporting of Urgencies Related to Medical Devices: Commentary on a Possible Systematic Approach

Most medical devices are routinely recognized on radiological images and described as normal findings in the radiological report, but sometimes they can cause patient access to the emergency department. Multiple possible complications have been described and most of them require prompt recognition by radiologists for proper clinical management. This commentary proposes a systematic approach to radiological reporting of the most common emergent complications related to medical devices with the intent to avoid the omission of important findings in the final radiological report.

Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression

PURPOSE

After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes.

METHODS

Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated.

RESULTS

36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2 weeks compared to < 2 weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival.

CONCLUSIONS

Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

Propensity score-matched comparison of stenting as a bridge to surgery and emergency surgery for acute malignant left-sided colonic obstruction

Background

Bridge to elective surgery (BTS) using self-expanding metal stents (SEMSs) is a common alternative to emergency surgery (ES) for acute malignant left-sided colonic obstruction (AMLCO). However, studies regarding the long-term impact of BTS are limited and have reported unclear results.

Methods

A multicenter observational study was performed at three hospitals from April 2012 to December 2019. Propensity score matching (PSM) was introduced to minimize selection bias. The primary endpoint was overall survival. The secondary endpoints included surgical approaches, primary resection types, total stent-related adverse effects (AEs), surgical AEs, length of hospital stay, 30-day mortality and tumor recurrence.

Results

Forty-nine patients in both the BTS and ES groups were matched. Patients in the BTS group more often underwent laparoscopic resection [31 (63.3%) vs. 8 (16.3%), p < 0.001], were less likely to have a primary stoma [13 (26.5%) vs. 26 (53.1%), p = 0.007] and more often had perineural invasion [25 (51.0 %) vs. 13 (26.5 %), p = 0.013]. The median overall survival was significantly lower in patients with stent insertion (41 vs. 65 months, p = 0.041). The 3-year overall survival (53.0 vs. 77.2%, p = 0.039) and 5-year overall survival (30.6 vs. 55.0%, p = 0.025) were significantly less favorable in the BTS group. In multivariate Cox regression analysis, stenting (hazard ratio(HR) = 2.309(1.052–5.066), p = 0.037), surgical AEs (HR = 1.394 (1.053–1.845), p = 0.020) and pTNM stage (HR = 1.706 (1.116–2.607), p = 0.014) were positively correlated with overall survival in matched patients.

Conclusions

Self-expanding metal stents as “a bridge to surgery” are associated with more perineural invasion, a higher recurrence rate and worse overall survival in patients with acute malignant left-sided colonic obstruction compared with emergency surgery.

Does preoperative stent positioning in obstructive left sided colon cancer increase the risk of perineural invasion?

Colonic stenting as a bridge to surgery has been shown to be a safe and effective treatment for left-sided malignant colonic obstruction depending on local expertise. However, concerns still exist regarding its oncological safety. In particular, several reports showed an increased prevalence of perineural tumor invasion following stent placement. Since perineural invasion negatively affects oncological outcomes, the present study sought to evaluate this controversial association. We retrospectively reviewed 114 patients presenting with left-side obstructing colon cancer over a 10-year period. The relationship between perineural invasion and colonic stenting was analyzed using univariate and multivariate analyses. Perineural invasion was found to be strongly associated with pathological features, including TNM stage, (p < 0.001), poor differentiation (p = 0.002), vascular invasion (p < 0.001), lymphatic invasion (p < 0.001), whereas no significant association with preoperative stenting was observed (p = 0.918) after performing univariate analysis. In the multivariate model, only TNM stage III-IV (OR: 6.810, 95% CI 1.972-23.518, p = 0.002) and venous invasion (OR: 5.325, 95% CI 1.911-14.840, p = 0.001) were independently associated with perineural invasion. The results of this study suggest no association between preoperative colonic stenting and perineural invasion.

Does the diameter of colonic stent influence the outcomes in bridge-to-surgery patients with malignant large bowel obstruction?

PURPOSE

This study investigated the short- and long-term outcomes of 18- and 22-mm-diameter self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) in patients with malignant large bowel obstruction (MLBO).

METHODS

Sixty-nine pathological stage II and III colorectal cancer patients who underwent BTS were included in this multi-institutional retrospective study. Patients were divided into two groups regarding the diameter of SEMS: an 18-mm group (n = 30) and a 22-mm group (n = 39).

RESULTS

There was no significant difference in the clinical success rate, but both of the two re-obstructions observed occurred in the 18-mm group. The 18-mm group showed a trend toward a higher incidence of overall postoperative complications (Clavien-Dindo grading ≥ II) than the 22-mm group (33.3% vs. 10.3%, P = 0.061). The 3-year disease-free and overall survival showed no significant differences between the 18- and 22-mm groups (78.2% vs. 68.8%, P = 0.753 and 92.8% vs. 82.1%, P = 0.471, respectively).

CONCLUSION

SEMS of 18 and 22 mm diameter confer statistically equivalent short- and long-term outcomes as a BTS.

Colonic stent vs surgical resection of the primary tumor. Effect on survival from stage-IV obstructive colorectal cancer

BACKGROUND AND OBJECTIVES

the impact of surgical primary tumor resection on survival of obstructive metastatic colorectal cancer remains controversial. The primary goal of this study was to analyze survival in patients with obstructive metastatic colorectal cancer after treatment with either resection surgery or a colonic stent.

MATERIAL AND METHODS

a prospective study was performed of all patients with stage-IV colorectal cancer and obstructive manifestations, diagnosed from 2005 to 2012 and managed with either resection surgery or a colonic stent. Cases with a perforation, abscess, right colon or distal rectal malignancy, multiple colorectal cancer or derivative surgery were excluded.

RESULTS

a total of 95 patients were included, 49 were managed with resection surgery and 46 with a colonic stent. The colonic stent group had a higher Charlson index (9.5 ± 2.1 vs 8.6 ± 1.5, p = 0.01), a shorter time to oral intake (0.9 ± 1.1 vs 16.4 ± 53.5 days, p = 0.05), a shorter hospital stay (4 ± 4.8 vs 16.7 ± 15.5 days, p = 0.0001), less need for stomata (11.1 % vs 32.7 %, p = 0.01), fewer early complications (4.3 % vs 46.9 %, p = 0.0001) and more late complications (33.3 % vs 6.4 %, p = 0.001). Undergoing chemotherapy (p = 0.008) was the only independent factor related to increased survival. In the subgroup of patients managed with chemotherapy, surgical primary tumor resection was an independent factor associated with increased survival.

CONCLUSION

both treatments are effective for resolving obstructive manifestations in patients diagnosed with stage-IV obstructive colorectal cancer. Resection surgery has no positive impact on survival and thus cannot be recommended as a therapy of choice.

Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: A systematic review and meta-analysis of high quality prospective and randomised controlled trials

Self-expanding metallic stent placement as a bridge to surgery has been reported as an alternative to emergency surgery for acute malignant colorectal obstruction. However, results from clinical trials and previous meta-analyses are conflicting. We carried out a meta-analysis to compare the surgical and oncological outcomes between emergency surgery and self-expanding metallic stents for malignant large bowel obstruction. Pubmed, Embase, CINAHL, Web of Science and Cochrane were searched for prospective and randomised controlled trials. The outcomes of focus included 3- and 5-year overall and disease-free survival, overall tumour recurrence, overall complication and 30-day mortality rate, length of hospital and ICU stay, overall blood loss, number of patients requiring transfusion, total number of lymph nodes harvested, stoma and primary anastomosis rate. Twenty-seven studies were included with a total of 3894 patients. There was no significant difference in terms of 3-year and 5-year disease-free and overall survival. Stenting resulted in less blood loss (mean difference -234.72, P < 0.00001) and higher primary anastomosis rate (RR 1.25, P < 0.00001). For curative cases, bridge to surgery groups had lower 30-day mortality rate (RR 0.65, P = 0.01), lower overall complication rate (RR 0.65, P < 0.0001), more lymph nodes harvested (mean difference 2.51, P = 0.005), shorter ICU stay (mean difference -2.27, P = 0.02) and hospital stay (mean difference -7.24, 95% P < 0.0001). Compared to emergency surgery, self-expanding metallic stent interventions improve short-term surgical outcomes, especially in the curative setting, but have similar long-term oncological and survival outcomes.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis

PURPOSE

The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease.

METHODS

MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation.

RESULTS

Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38).

CONCLUSION

Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.

Quasi-elective left colectomy after endoscopic colon stenting for obstructive cancer yields comparable oncologic outcome to full-elective operation

PURPOSE

Whether deferring surgery after endoscopic self-expandable metal stent (SEMS) placement for neoplastic stricture, and operating patients in a quasi-elective situation, may result in similar oncologic outcomes to elective operations is unclear. This study aimed to evaluate the disease-free survival (DFS) rates of patients who underwent an interval colon resection after SEMS placement or an elective operation with comparable cancer stages.

METHODS

From a prospective dataset, we retrospectively selected patients with the following characteristics: (1) left-sided colon cancer and (2) cancer stage I to III. Exclusion criteria were as follows: (1) palliative surgery and (2) emergency operation. Then we stratified patients into two groups: (A) full-elective left colon resection and (B) quasi-elective left colon resection, defined as surgery performed after SEMS placement for obstructive colon cancer. DFS function was studied by the Kaplan-Meier method.

RESULTS

After 1:2 matching based on cancer stage, 106 patients of the group A were compared with 53 patients of group B. In each group, there were 9.4% of stage I, 39.4% of stage II, and 50.9% of stage III patients. The rate of technical failure in SEMS placement was 3.8%. After a mean follow-up of 54 months, 16 (15.1%) patients in the full-elective groups and 10 (18.9%) in the quasi-elective group experience cancer recurrence (log rank = 0.588). DFS curve did not reach the median value.

CONCLUSIONS

SEMS placement with interval colon resection for obstructive neoplastic strictures seems to provide similar long-term oncologic outcomes to operations performed in an elective setting when a low rate of technical failure is achieved.

Technical and Clinical Outcomes After Colorectal Stenting in Malignant Large Bowel Obstruction: A Single-Center Experience

Purpose

Malignant large bowel obstruction is a surgical emergency that requires urgent decompression. Stents are increasingly being used, though reported outcomes are variable. We describe our multidisciplinary experience in using stents to manage malignant large bowel obstruction.

Methods

All patients undergoing colorectal stent insertion for acute large bowel obstruction in a teaching hospital were included. Outcomes, complications, and length of stay (LOS) were recorded.

Results

Over a 7-year period, 73 procedures were performed on 67 patients (37 male, mean age of 76 years). Interventional radiology was involved in all cases. Endoscopic guidance was required in 24 cases (32.9%). In 18 patients (26.9%), treatment intent was to bridge to elective surgery; 16 had successful stent placement; all had subsequent curative resection (laparoscopic resection, 8 of 18; primary anastomosis, 14 of 18). Overall LOS, including both index admission and elective admission, was 16.4 days. Treatment intent was palliative in 49 patients (73.1%). In this group, stents were successfully placed in 41 of 49 (83.7%). Complication rate within 30 days was 20%, including perforation (2 patients), per rectal bleeding (2), stent migration (1), and stent passage (5). Nineteen patients (38.8%) required subsequent stoma formation (6, during same admission; 13, during subsequent admission). Overall LOS was 16.9 days.

Conclusion

In our experience colorectal stents can be used effectively to manage malignant large bowel obstruction, with only selective endoscopic input. As a bridge to surgery, most patients can avoid emergency surgery and have a primary anastomosis. In the palliative setting, the complication rate is acceptable and two-thirds avoid a permanent stoma.

Long-term tumour outcomes of self-expanding metal stents as 'bridge to surgery' for the treatment of colorectal cancer with malignant obstruction: a systematic review and meta-analysis

PURPOSE

To explore the long-term oncological results of self-expanding metal stents (SEMS) as a surgical transition compared with those of simple emergency surgery.

METHODS

A systematic review of studies involving long-term tumour outcomes comparing SEMS with emergency surgery was conducted. All studies included information on 3-year and 5-year survival rates, 3-year and 5-year disease-free survival (DFS) rates, and local and overall recurrence rates; the results were expressed as odds ratios.

RESULTS

Overall, 24 articles and 2508 patients were included, including 5 randomised controlled trials, 3 prospective studies, and 16 retrospective studies. The 3-year survival rate (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.69-1.12, P = 0.05), 5-year survival rate (OR = 0.91, 95% CI 0.70-1.17, P = 0.67), 3-year DFS rate (OR = 1.14, 95% CI 0.91-1.42, P = 0.65), 5-year DFS rate (OR = 1.35, 95% CI 0.91-2.02, P = 0.17), overall recurrence rate (OR 1.04, 95% CI 0.77-1.41, P = 0.14), and local recurrence rate (OR 1.37, 95% CI 0.84-2.23, P = 0.92) were determined. There was no significant difference between the randomised and observational studies in the subgroup analysis, and the 5-year survival rate was higher in studies with a stent placement success rate of ≥ 95%.

CONCLUSION

SEMS implantation was a viable alternative in malignant left colon obstruction as a transition to surgery; its long-term survival results, including 5-year DFS and overall survival, were equivalent to those of emergent surgery.

Outcomes following colonic stenting for malignant left-sided bowel obstruction: a systematic review of randomised controlled trials

PURPOSE

Malignant bowel obstruction is a common presentation and is associated with high morbidity and mortality. Emergency resection is the traditional treatment modality. In recent years, colonic stenting as a bridge to surgery has become more prevalent. However, there is considerable debate surrounding its use. The aim of this review was to examine the technical and clinical success of self-expanding metal stent (SEMS) as a bridge to surgery for obstructing colorectal tumours.

METHODS

We systematically reviewed randomised controlled trials using PubMed, Cochrane and SCOPUS databases. Included studies must have compared outcomes in SEMS as a bridge to surgery with those proceeding straight to emergency resection.

RESULTS

A total of 1245 studies were identified. After removal of duplicates and non-relevant studies, we identified seven articles which met the predefined criteria. This review observed that 81% of SEMS were technically successful, with 76% of patients having restoration of gastrointestinal function. Iatrogenic perforation rate was 5%. One-fifth of patients required emergency surgery following stent placement, and permanent stoma rate was 8.7%.

CONCLUSION

This study observed that SEMS as a bridge to surgery is associated with good technical and clinical success, with low rates of perforation and permanent stoma. SEMS should be part of the treatment armamentarium for obstructing colorectal neoplasms, but careful patient selection and institutional expertise are important factors for success.

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction

BACKGROUND

Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS.

METHODS

Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1 : 2 propensity score matching.

RESULTS

Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7·7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11·4 and 13·6 per cent (P = 0·457), disease-free survival rates were 58·8 and 52·6 per cent (P = 0·175), and overall survival rates were 74·0 and 68·3 per cent (P = 0·231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23·9 versus 45·3 per cent; P < 0·001), especially in elderly patients (29·0 versus 57·9 per cent; P < 0·001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11·0 per cent (P = 0·432), disease-free survival rates were 49 and 59·6 per cent (P = 0·717), and overall survival rates 61 and 75·1 per cent (P = 0·529), respectively.

CONCLUSION

Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.

Bridge-to-surgery versus emergency surgery in the management of left-sided acute malignant colorectal obstruction - Efficacy, safety and long-term outcomes

OBJECTIVE

Compare efficacy, safety and long-term outcomes of bridge-to-surgery and emergency surgery in acute malignant colorectal obstruction.

METHODS

Retrospective study of 94 consecutive patients with left-sided acute malignant colorectal obstruction treated with curative intent between 2010-2017.

RESULTS

48 patients underwent stent placement and 46 underwent emergency surgery. Technical and clinical success were 100% and 87%. Laparoscopy and one-staged operation were more frequent in bridge-to-surgery (44% vs 2%, p < 0.001; 73% vs 30%, p < 0.001). Fewer permanent stomas were created in bridge-to-surgery (15% vs 35%, p = 0.013). Overall morbidity was 36%. Immediate and post-procedure stent related-complications occurred in 6% and 13%; surgery-related complications occurred in 28% (bridge-to-surgery: 15% vs emergency surgery: 41%, p = 0.004). No differences were found regarding tumor recurrence, recurrence-free survival and overall survival. R1 resection (HR 47.2, _95%CI:4.1-543.7), number of lymph nodes harvested (HR 0.9 _95%CI:0.8-0.99) and adjuvant therapy (HR 0.1 _95%CI:0.01-0.9) predicted recurrence-free survival; pTMN stage IV (HR 7.3, _95%CI:1.1-47.6), number of lymph nodes harvested (HR 0.90, _95%CI:0.8-0.97), adjuvant therapy (HR 0.1, _95%CI:0.02-0.4) and surgery-related complications (HR 5.3, _95%CI:1.02-27.3) influenced overall survival.

CONCLUSION

Stent placement has a high success, similarly to emergency surgery, being associated with higher primary anastomosis and lower stoma rates. Tumor recurrence rate, recurrence-free survival and overall survival were comparable between groups; surgery-related complications influenced overall survival.

Mortality after emergency treatment of colorectal cancer and associated risk factors-a nationwide cohort study

PURPOSE

The aim of this study was to investigate if postoperative mortality after acute surgical treatment of colorectal cancer has decreased in Denmark during this period and to investigate risk factors associated with early death.

METHODS

This is a nationwide and population-based cohort study. From the Danish Colorectal Cancer Group database and National Patient Registry, we collected data on all patients operated with bowel resection, diverting stoma only, or placement of an endoscopic stent from 2005 to 2015. Year of surgery was the main exposure variable and 90-day postoperative mortality the primary outcome.

RESULTS

We included 6147 patients. The incidence of patients per year was stable during 2005-2015. The 90-day mortality decreased from 31% in 2005 to 24% in 2015 with a significant time trend (p < 0.0001). Other factors associated with postoperative mortality were increasing age, presence of comorbidity (measured as Charlson comorbidity index score ≥ 1), and stage IV disease. Insertion of self-expanding metallic stent was protective for 90-day postoperative mortality compared with other surgical procedures.

CONCLUSION

Ninety-day postoperative mortality from acute colorectal surgery has improved in Denmark from 2005 to 2015. Nevertheless, almost one out of four patients undergoing acute surgery for colorectal cancer dies within 90 days.