Long-term outcomes of palliative colonic stenting versus emergency surgery for acute proximal malignant colonic obstruction: a multicenter trial

Abstract

Background and study aims Long-term data are limited regarding clinical outcomes of self-expanding metal stents as an alternative for surgery in the treatment of acute proximal MBO. The aim of this study was to compare the long-term outcomes of stenting to surgery for palliation in patients with incurable obstructive CRC for lesions proximal to the splenic flexure. Patients and methods Retrospective multicenter cohort study of obstructing proximal CRC patients with who underwent insertion of a SEMS (n = 69) or surgery (n = 36) from 1999 to 2014. The primary endpoint was relief of obstruction. Secondary endpoints included technical success, duration of hospital stay, early and late adverse events (AEs) and survival. Results Technical success was achieved in 62/69 (89.8 %) patients in the SEMS group and in 36 /36 (100 %) patients who underwent surgery (P = 0.09). In the SEMS group, 10 patients underwent stenting as a bridge to surgery and 59 underwent stent placement for palliation. Clinical relief was achieved in 78 % of patients with stenting and in 100 % of patients who underwent surgery (P < 0.001). Patients with SEMS had significantly less acute AEs compared to the surgery group (7.2 % vs. 30.5 %, P = 0.003). Hospital mortality for the SEMS group was 0 % compared to 5.6 % in the surgery group (P = 0.11). Patients in the SEMS group had a significantly shorter median hospital stay (4 days) as compared to the surgery group (8 days) (P < 0.01). Maintenance of decompression without the recurrence of bowel obstruction until death or last follow-up was lower in the SEMS group (73.9 %) than the surgery group (97.3 %; P = 0.003). SEMS placement was associated with higher long-term complication rates compared to surgery (21 % and 11 % P = 0.27). Late SEMS AEs included occlusion (10 %), migration (5 %), and colonic ulcer (6 %). At 120 weeks, survival in the SEMS group was 5.6 % vs. 0 % in the surgery group (P = 0.8). Conclusions Technical and clinical success associated with proximal colonic obstruction are higher with surgery when compared to SEMS, but surgery is associated with longer hospital stays and more early AEs. SEMS should be considered the initial mode of therapy in patients with acute proximal MBO and surgery should be reserved for SEMS failure, as surgery involves a high morbidity and mortality.

Comparative outcomes between palliative ileostomy and colostomy in patients with malignant large bowel obstruction

“…All 82 patients achieved clinical success and had symptom improvement with stoma creation. The overall surgical complication rate of 35.4% is comparable to that reported by Scheidbach et al 13) , but the 30-day mortality included three patients in the ileostomy group. The three patients were in the terminal stage: one of them had cancer ascites due to recurrence of pancreatic cancer and the others had multiple liver metastases due to recurrence of colon cancer.…”

Colon metal stents as a bridge to surgery had no significant effects on the perineural invasion: a retrospective study

“…Therefore, randomized, wellbalanced trials should be conducted to make meaningful judgments about the role of the stent in prognosis. Second, patients mainly underwent ES and gastrointestinal surgery; however, the doctors were not from the same group, and lack of uniform criteria for treatment decisions may lead to bias in choice [11]. Third, due to the limitation of follow-up time, we could not prove the impact of perineural invasion on the long-term survival of patients.…”

“…We defined technical success as good placement and smooth expansion of stents under endoscopy and fluoroscopy. Clinical success was defined as intestinal decompression within 72 h after stent placement, with clinical and imaging evidence [11].…”

Endoscopic Placement of Stents for Malignant Colorectal Obstructions: Differences in Clinical Outcomes after Elective and Emergency Procedures

“…Although the conflicting results, the use of SEMS for palliation is recommended also for proximal obstructions [4]. A recent retrospective multicenter cohort study on palliation in patients affected by obstructing proximal colon cancer [16] showed higher technical and clinical success rates for emergency surgical treatment than SEMS. However, surgery had higher hospital stays and higher rates of early Adverse Events (AEs), so that author concluded that SEMS remains the first therapeutical option in this setting and surgery should be reserved in case of failure of endoscopic treatment.…”