Propensity Score-Matched Comparison of Stenting as Bridge to Surgery and Emergency Surgery for Acute Malignant Left-Sided Colonic Obstruction

Abstract

PurposeBridge to elective surgery (BTS) using self-expanding metal stents (SEMS) is a common alternative to emergency surgery (ES) for acute malignant left-sided colonic obstruction (AMLCO). However, the study regarding long-term impact of BTS is limited and unclear.MethodsA 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.Results49 patients in both BTS and ES group were matched. Patients in the BTS group more often underwent laparoscopic resection (31 [63.3%] vs 8 [16.3%], p<0.001), 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). 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 the 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. ConclusionsSelf-expanding metal stents as “a bridge to surgery” is associated with more perineural invasion, higher recurrence rate and worse overall survival in patients with acute malignant left-sided colonic obstruction compared with emergency surgery.

What are the factors predictive of postoperative complications in patients with colorectal cancer undergoing stenting as a bridge to surgery?

“…Successful stenting as a bridge to curative surgery in patients with CRC and obstruction does not exclude the danger of disease progression. Contrary to other favorable studies of stenting for BTS, one randomized control trial, some propensity score‐matched studies, and some systemic meta‐analyses show that stenting as a BTS is associated with a greater chance of recurrence and poorer overall survival 27–29 . This may be due to dissemination of tumor cells into the peripheral circulation following mechanical compression of the tumor by the stent, 30 or this may represent the influence of stenting on pathologic features, including silent perforation 12,31,32 .…”

“…Contrary to other favorable studies of stenting for BTS, one randomized control trial, some propensity score-matched studies, and some systemic meta-analyses show that stenting as a BTS is associated with a greater chance of recurrence and poorer overall survival. [27][28][29] This may be due to dissemination of tumor cells into the peripheral circulation following mechanical compression of the tumor by the stent, 30 or this may represent the influence of stenting on pathologic features, including silent perforation. 12,31,32 The sudden increase in pressure inside the tumor could cause cells to detach, resulting in an increase in the expression of cytokeratin 20 mRNA, 30 circulating tumor DNA levels, 33 and viable circulating tumor cells 34 in the peripheral blood, which may induce distant metastases.…”

Impact of endoscopic metallic stent placement and emergency surgery on detection of viable circulating tumor cells for acute malignant left-sided colonic obstruction

“…Circulating tumor cells (CTCs) are potential substitutes for distant metastasis and promising novel biomarkers for tumors [7], which can gain access to the circulatory system and are detectable in the peripheral blood [8]. In our previous study [9], we found that compared with emergency surgery, SEMS are associated with more perineural invasion, a higher recurrence rate, and worse overall survival in patients. Nevertheless, the underlying mechanisms remain unresolved.…”

Impact of endoscopic metallic stent placement and emergency surgery on detection of viable circulating tumor cells for acute malignant left-sided colonic obstruction

“…Circulating tumor cells (CTCs), potential substitutes for distant metastasis and promising novel biomarkers for tumors [7], which can gain access to the circulatory system and are detectable in peripheral blood [8].In our previous study [9], we found that, compared with emergency surgery, SEMS are associated with more perineural invasion, a higher recurrence rate and worse overall survival in patients.…”