Current Status of the Self-Expandable Metal Stent as a Bridge to Surgery Versus Emergency Surgery in Colorectal Cancer: Results from an Updated Systematic Review and Meta-Analysis of the Literature

Abstract

Background: The current use of endoscopic stenting as a bridge to surgery is not always accepted in standard clinical practice to treat neoplastic colonic obstructions. Objectives: The role of colonic self-expandable metal stent (SEMS) positioning as a bridge to resective surgery versus emergency surgery (ES) for malignant obstruction, using all new data and available variables, was studied and we focused on short- and long-term results. Materials and Methods: A systematic review with meta-analysis was performed. PubMed, SCOPUS and Web of Science databases were included. The search comprised only randomized controlled trials (RCTs) investigating the interventions that included SEMS positioning versus ES. The primary outcomes were the rates of overall postoperative mortality, clinical and technical success. The secondary outcomes were the short- and long-term results. Results: A total of 12 studies were eligible for further analyses. A laparoscopic colectomy was the most common operation performed in the SEMS group, whereas the traditional open approach was commonly used in the ES group. Intraoperative colonic lavage was seldomly performed during ES. There were no differences in mortality rates between the two groups (RR 1.06, 95% CI 0.55 to 2.04; I2 = 0%). In the SEMS group, the rate of successful primary anastomosis was significantly higher in of SEMS (69.75%) than in the ES (55.07%) (RR 1.26, 95% 245 CI 1.01 to 1.57; I2 = 86%). Conversely, the upfront Hartmann procedure was performed more frequently in the ES (39.1%) as compared to the SEMS group (23.4%) (RR 0.61, 95% CI 0.45 to 0.85; I2 = 23%). The overall postoperative complications rate was significantly lower in the SEMS group (32.74%) than in the ES group (48.25%) (RR 0.61, 95% CI 0.41 to 0.91; I2 = 65%). Conclusions: In the presence of malignant colorectal obstruction, SEMS is safe and associated with the same mortality and significantly lower morbidity than the ES group. The rate of successful primary anastomosis was significantly higher than the ES group. Nevertheless, recurrence and survival outcomes are not significantly different between the two groups. The analysis of short- and long-term results can suggest the use of SEMS as a bridge to resective surgery when it is performed by an endoscopist with adequate expertise in both colonoscopy and fluoroscopic techniques and who performed commonly colonic stenting.

Case report: Stent-first strategy as a potential approach in the management of malignant right-sided colonic obstruction with cardiovascular risks

“…These concerns elicited surgeons to find a safer approach such as stent-first strategy. A recently published meta-analysis concluded a significantly higher rate of successful primary anastomosis in stenting than the emergency surgery group ( 39 ). Stent placement also favors mechanical bowel preparation finally resulting in end-to-end anastomosis without use of colostomy and stoma ( 40 ), thereby significantly improving quality of life.…”

“…Thus, stent placement has been recommended only in high-risk patients with an ASA score of 3 or higher and in patients older than 70 ( 32 ). Noteworthy, given that different studies brought different results and conclusions, stenting should be performed by endoscopist with adequate expertise ( 39 ). This could be a possible hypothesis as to why different studies have different conclusions.…”

Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects

“…In 2021, Cirocchi et al [ 54 ] conducted a systematic review and meta-analysis of RCTs and found that compared with ES, SEMS placement as BTS had a higher rate of successful primary anastomosis (RR: 1.26; 95%CI: 1.01-1.57), lower stoma rate (RR: 0.62; 95%CI: 0.45-0.85), and lower postoperative complication (RR: 0.61; 95%CI: 0.45-0.85). The mortality rate was comparable between the two modalities.…”

“…Similarly, the CReST trial found a comparable 3-year recurrence rate and overall survival between SEMS as BTS and ES, with a low SEMS-related perforation rate of 3.3%[ 53 ]. The latest systematic review and meta-analysis of five RCTs by Cirocchi et al [ 54 ] revealed comparable recurrence rates and oncologic outcomes between SEMS placement as BTS and ES. We conducted a meta-analysis of these six RCTs that reported the recurrence rate.…”

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

“…The purpose of this review was to collect the latest (since 2020) research on SEMS for BTS use. In one of the more updated systematic reviews and meta-analyses[ 7 ], only two studies published after 2020 were included (Arezzo et al [ 8 ] multicentric study and Allievi et al [ 9 ] single center study). Both the international guidelines and the short-term/long-term outcomes focusing on the new data published after 2020 have been analyzed (the “update” part of each chapter).…”