Long-term Oncologic Results After Stenting as a Bridge to Surgery Versus Emergency Surgery for Malignant Left-sided Colonic Obstruction

Nowadays, colorectal cancer (CRC) is the third most frequent cancer, and about a third of patients with CRC presents themselves with symptoms of large bowel obstruction. Historically, surgical resection was the treatment of choice for colonic obstruction, but this kind of approach is burdened by a high risk of postoperative morbidity and mortality. In recent times, the use of a colonic stent has been proposed to overcome the obstruction and transform an emergency surgical case into an elective one to avoid emergency surgery complications. Endoscopic stenting is the first-line treatment option in the palliative management of colonic obstruction, and there is sufficient scientific evidence to support this approach. However, endoscopic stent used as a bridge to surgery is not yet widely adopted because the concern was raised about the long-term survival and cancer safety of this approach. The recent scientific evidence has shown that this approach improves the short-term outcomes, such as postoperative complications and the stoma rate, without differences in long-term outcomes compared to emergency surgery. Therefore, the European Society for Gastrointestinal Endoscopy in 2020 has reconsidered stenting as a bridge to surgery as a valid alternative to emergency surgery.

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

BMC Surgery ◽

10.1186/s12893-021-01144-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yuepeng Cao ◽

Qing Chen ◽

Zhizhan Ni ◽

Feng Wu ◽

Chenshen Huang ◽

...

Keyword(s):

Overall Survival ◽

Propensity Score ◽

Emergency Surgery ◽

Perineural Invasion ◽

Cox Regression ◽

Colonic Obstruction ◽

Metal Stents ◽

Bridge To Surgery ◽

Cox Regression Analysis ◽

Self Expanding Metal Stents

Abstract 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.

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Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis

Journal of Gastrointestinal Oncology ◽

10.21037/jgo.2017.09.04 ◽

2017 ◽

Vol 8 (5) ◽

pp. 867-876 ◽

Cited By ~ 21

Author(s):

Marco Ceresoli ◽

Niccolò Allievi ◽

Federico Coccolini ◽

Giulia Montori ◽

Paola Fugazzola ◽

...

Keyword(s):

Emergency Surgery ◽

Meta Analysis ◽

Oncologic Outcomes ◽

Bridge To Surgery

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Comparison of safety between self-expanding metal stents as a bridge to surgery and emergency surgery based on pathology: a meta-analysis

BMC Surgery ◽

10.1186/s12893-020-00908-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Yang Hu ◽

Jiajun Fan ◽

Yifan Xv ◽

Yingjie Hu ◽

Yuan Ding ◽

...

Keyword(s):

Colorectal Cancer ◽

Emergency Surgery ◽

Meta Analysis ◽

Metal Stents ◽

Bridge To Surgery ◽

Sems Group ◽

Obstructive Colorectal Cancer ◽

Significant Difference ◽

Self Expanding Metal Stents

Abstract Background To explore the long-term oncological safety of using self-expanding metal stents (SEMS) as a bridge to surgery for acute obstructive colorectal cancer by comparing the pathological results of emergency surgery (ES) with elective surgery after the placement of SEMS. Methods Studies comparing SEMS as a bridge to surgery with emergency surgery for acute obstructive colorectal cancer were retrieved through the databases of Pubmed, Embase, and Cochrane libraries, and a meta-analysis was conducted based on the pathological results of the two treatments. Risk ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) were calculated for the outcomes under random effects model. Results A total of 27 studies were included, including 3 randomized controlled studies, 2 prospective studies, and 22 retrospective studies, with a total of 3737 patients. The presence of perineural invasion (RR = 0.58, 95% CI 0.48, 0.71, P < 0.00001), lymphovascular invasion (RR = 0.68, 95% CI 0.47, 0.99, P = 0.004) and vascular invasion (RR = 0.66, 95% CI 0.45, 0.99, P = 0.04) in SEMS group were significantly higher than those in ES group, and there was no significant difference in lymphatic invasion (RR = 0.92, 95% CI 0.77, 1.09, P = 0.33). The number of lymph nodes harvested in SEMS group was significantly higher than that in ES group (MD = − 3.18, 95% CI − 4.47, − 1.90, P < 0.00001). While no significant difference was found in the number of positive lymph nodes (MD = − 0.11, 95% CI − 0.63, 0.42, P = 0.69) and N stage [N0 (RR = 1.03, 95% CI 0.92, 1.15, P = 0.60), N1 (RR = 0.99, 95% CI 0.87, 1.14, P = 0.91), N2 (RR = 0.94, 95% CI 0.77, 1.15, P = 0.53)]. Conclusions SEMS implantation in patients with acute malignant obstructive colorectal cancer may lead to an increase in adverse tumor pathological characteristics, and these characteristics are mostly related to the poor prognosis of colorectal cancer. Although the adverse effect of SEMS on long-term survival has not been demonstrated, their adverse effects cannot be ignored. The use of SEMS as the preferred treatment for patients with resectable obstructive colorectal cancer remains to be carefully weighed, especially when patients are young or the surgical risk is not very high.

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