Colonic stenting<i>vs</i>emergent surgery for acute left-sided malignant colonic obstruction: A systematic review and meta-analysis

Introduction Emergency resection represents the traditional treatment for left-sided malignant obstruction. However, the placement of self-expanding metallic stents and delayed surgery has been proposed as an alternative approach. The aim of the current meta-analysis was to review the available evidence, with particular interest for the short-term outcomes, including a recent multicentre RCT. MethodsWe considered randomized controlled trials comparing stenting as a bridge to surgery and emergency surgery for the management of left-sided malignant large bowel obstruction, performing a systematic review in MEDLINE, PubMed database, and the Cochrane libraries. ResultsWe initially identified a total of 2543 studies. After the elimination of duplicates and the screening of titles and abstracts, seven studies, for a total of 448 patients, were considered. The current meta-analysis revealed no difference in the mortality rate between the stent group and the emergency surgery group; the postoperative complication rate (37.84% versus 54.87%, P = 0.02), the stoma rate (28.8% versus 46.02%, P < 0.0001), and the incidence of wound infection (8.11% versus 15.49%, P = 0.01) were reduced after stent as a bridge to surgery. Conclusion Colonic stenting as a bridge to surgery appears to be a safe approach to malignant large bowel obstruction. Possible advantages of this treatment can be identified in a reduced incidence of postoperative complications and a lower stoma rate. Further RCTs considering long-term outcomes and cost-effectiveness analysis are needed.

show abstract

“…The incidence of anastomotic leak, as reported elsewhere [15, 17, 25], did not show statistical difference between SBTS and ES.…”

Section: Discussionsupporting

confidence: 60%

Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis

Allievi

Ceresoli

Fugazzola

et al. 2017

International Journal of Surgical Oncology

View full text Add to dashboard Cite

show abstract

“…A prospective, randomized trial analyzed on an intention-to-treat basis failed to demonstrate that preoperative SEMS use for patients with left colon-cancer obstruction decreased the need for stoma placement because SEMS insertion was technically successful in only 47% of the patients [10]. Therefore, a preoperative SEMS procedure does not clearly have more advantageous outcomes than emergency surgery [2021]. However, a recent randomized trial with a 70% successful stenting rate found that SEMS insertion followed by interval elective surgery may be safer than emergency surgery, with a trend towards lower morbidity and mortality [7].…”

Section: Discussionmentioning

confidence: 99%

Obstructive Left Colon Cancer Should Be Managed by Using a Subtotal Colectomy Instead of Colonic Stenting

et al. 2016

View full text Add to dashboard Cite

PurposeThis study compared a subtotal colectomy to self-expandable metallic stent (SEMS) insertion as a bridge to surgery for patients with left colon-cancer obstruction.MethodsNinety-four consecutive patients with left colon-cancer obstruction underwent an emergency subtotal colectomy or elective SEMS insertion between January 2007 and August 2014. Using prospectively collected data, we performed a retrospective comparative analysis on an intention-to-treat basis.ResultsA subtotal colectomy and SEMS insertion were attempted in 24 and 70 patients, respectively. SEMS insertion technically failed in 5 patients (7.1%). The mean age and rate of obstruction in the descending colon were higher in the subtotal colectomy group than the SEMS group. Sex, underlying disease, American Society of Anesthesiologists physical status, and pathological stage showed no statistical difference. Laparoscopic surgery was performed more frequently in patients in the SEMS group (62 of 70, 88.6%) than in patients in the subtotal colectomy group (4 of 24, 16.7%). The overall rate of postoperative morbidity was higher in the SEMS group. No Clavien-Dindo grade III or IV complications occurred in the subtotal colectomy group, but 2 patients (2.9%) died from septic complications in the SEMS group. One patient (4.2%) in the subtotal colectomy group had synchronous cancer. The total hospital stay was shorter in the subtotal colectomy group. The median number of bowel movements in the subtotal colectomy group was twice per day at postoperative 3–6 months.ConclusionA subtotal colectomy for patients with obstructive left-colon cancer is a clinically and oncologically safer, 1-stage, surgical strategy compared to SEMS insertion as a bridge to surgery.

show abstract

“…This is the explanation for the restrictive and decreasing use over time of SEMS. Recent meta-analyses of trials comparing SEMS as bridge to surgery and emergency surgery confirmed the higher primary anastomoses and initial lower stoma rates after SEMS, but did not demonstrate a significant difference in mortality and morbidity between the 2 approaches [14,15]. Insufficient data on long-term survival are available from the randomized trials and do not allow for definitive conclusions [16,17].…”

Section: Discussionmentioning

confidence: 99%

Resection of Obstructive Left-Sided Colon Cancer at a National Level: A Prospective Analysis of Short-Term Outcomes in 1,816 Patients

Tanis¹,

Pereira²,

Hooft

et al. 2015

Dig Surg

View full text Add to dashboard Cite

Background/Aims: The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. Methods: Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. Results: In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients >70 years, but mortality rates up to 32.2% were observed in high-risk elderly patients. Conclusion: Acute resection as first choice treatment seems justified for patients >70 years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.

show abstract

Colonic stentingvsemergent surgery for acute left-sided malignant colonic obstruction: A systematic review and meta-analysis

Abstract: SEMS is not obviously more advantageous than emergent surgery for patients with acute left-sided malignant colonic obstruction.

Cited by 45 publications

References 25 publications

Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis

Endoscopic Stenting as Bridge to Surgery versus Emergency Resection for Left-Sided Malignant Colorectal Obstruction: An Updated Meta-Analysis

Obstructive Left Colon Cancer Should Be Managed by Using a Subtotal Colectomy Instead of Colonic Stenting

Resection of Obstructive Left-Sided Colon Cancer at a National Level: A Prospective Analysis of Short-Term Outcomes in 1,816 Patients

Contact Info

Product

Resources

About