Stents effective as bridge to surgery for left-sided malignant colon obstruction

Last Updated: 2017-04-18

By Will Boggs MD

NEW YORK (Reuters Health) - Stents can be an effective bridge to surgery for patients with left-sided colonic obstruction, according to a systematic review and meta-analysis.

"Stents as bridge to surgery (SBTS) should be used in all patients with a neoplastic obstruction of the left colon,” Dr. Alberto Arezzo from University of Torino, Italy told Reuters Health by email.

Emergency surgery for left-sided malignant colonic obstruction is complicated by a high rate of anastomotic leakage (as high as 33%). Self-expandable metallic stents (SEMS) have been used in this setting, with conflicting results.

To evaluate whether SBTS conveys clinically relevant advantages over emergency surgery in the treatment of symptomatic left-sided malignant colonic obstruction, Dr. Arezzo and colleagues pooled data from eight randomized controlled trials including 251 patients in the SBTS group and 246 in the emergency surgery group.

Overall mortality at 60 days was 9.6% in the SBTS group and 9.9% in the emergency surgery group, according to the April 6th Gastrointestinal Endoscopy online report.

Overall morbidity, defined as any diagnosed morbidity related to the endoscopic or surgical technique within 60 days after surgery, was significantly lower with SBTS than with emergency surgery (33.9% vs 51.2%; p=0.023).

Compared with emergency surgery, SBTS was associated with a lower temporary stoma rate, lower permanent stoma rate, higher primary anastomosis success rate, shorter operative time, and longer (by 1 day) hospital length of stay. The two groups did not differ in the rates of surgery for adverse events.

Tumor recurrence rates, reported in only 4 studies with median follow-ups ranging from 18-65 months, were nonsignificantly higher in the SBTS group than in the emergency surgery group (40.5% vs 26.6%; p=0.09).

“The analysis of data regarding tumor recurrence rate raises concerns about oncological safety of stenting,” the researchers note. “Until more long-term oncological data become available, SBTS strategy cannot be established as preferred or as a standard of care.”

Dr. Arezzo, however, concluded, “As far as it is not demonstrated in RCTs that there is an issue in oncologic outcome of SBTS, and currently this is far from being true, physicians should consider SBTS as the treatment of choice for any acute neoplastic obstruction of the left colon.”

He added, “There is much to learn about the correct preparation of the patient to surgery after stent placement. Should the bowel be prepared with laxatives? Which should be the right time for surgery after stent placement? There is still a too high rate of stomas at surgery after stent placement with technical success.”

In contrast, Dr. Hyung Ook Kim from Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea, who recently compared colonic stenting with subtotal colectomy for obstructive left colon cancer, told Reuters Health by email, “I think a subtotal colectomy for treating patients with obstructive left colon cancer is a clinically safer, one stage, surgical strategy compared to SEMS insertion as a bridge to surgery. The reported frequency of perforation after colonic stenting is about 4%, and technical failure rate of SBTS is high, up to about 30-50%, from my reference. Four percent is not a reasonable perforation rate.”

“If you want to do SBTS, you should keep in mind its clinical and oncologic pitfalls,” he concluded.

SOURCE: http://bit.ly/2oICjjj

Gastrointest Endosc 2017.