Skip to main content

Advertisement

SpringerLink
Log in

Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES).

Methods

This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes.

Results

Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed.

Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence.

Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55).

Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence.

Conclusions

There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Fitzmaurice C, Akinyemiju TF, Al Lami FH, Alam T et al (2018) Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2016: a systematic analysis for the Global Burden of Disease Study. JAMA Oncol 4:1553–1568

    Article  PubMed  Google Scholar 

  2. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD (2004) The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg 240:76–81

    Article  PubMed  PubMed Central  Google Scholar 

  3. Aslam MI, Kelkar A, Sharpe D, Jameson JS (2010) Ten years experience of managing the primary tumours in patients with stage IV colorectal cancers. Int J Surg 8:305–313

    Article  PubMed  Google Scholar 

  4. Breitenstein S, Rickenbacher A, Berdajs D, Puhan M, Clavien PA, Demartines N (2007) Systematic evaluation of surgical strategies for acute malignant left-sided colonic obstruction. Br J Surg 94:1451–1460

    Article  CAS  PubMed  Google Scholar 

  5. McArdle CS, Hole DJ (2004) Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg 91:605–609

    Article  CAS  PubMed  Google Scholar 

  6. Cirocchi R, Farinella E, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A, Noya G, Sagar J (2013) Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis. Surg Oncol 22:14–21

    Article  PubMed  Google Scholar 

  7. Law WL, Choi HK, Chu KW (2003) Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer. Br J Surg 90:1429–1433

    Article  CAS  PubMed  Google Scholar 

  8. De Ceglie A, Filiberti R, Baron TH, Ceppi M, Conio M (2013) A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction. Crit Rev Oncol Hematol 88:387–403

    Article  PubMed  Google Scholar 

  9. Chok AY, Lim HJ, Lye WK, Samarakoon LB, Guo J, Tang CL, Mathew R (2020) Stenting as a bridge to surgery for obstructed stage IV colorectal cancers - long-term outcomes of a 10-year study. Asian J Endosc Surg 13:343–350

    Article  PubMed  Google Scholar 

  10. Brehant O, Fuks D, Bartoli E, Yzet T, Verhaeghe P, Regimbeau JM (2009) Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study. Colorectal Dis 11:178–183

    Article  CAS  PubMed  Google Scholar 

  11. Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M (2004) Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 99:2051–2057

    Article  PubMed  Google Scholar 

  12. Tan CJ, Dasari BV, Gardiner K (2012) Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg 99:469–476

    Article  CAS  PubMed  Google Scholar 

  13. Sloothaak DA, van den Berg MW, Dijkgraaf MG, Fockens P, Tanis PJ, van Hooft JE, Bemelman WA et al (2014) Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg 101:1751–1757

    Article  CAS  PubMed  Google Scholar 

  14. Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL (2011) Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc. https://doi.org/10.1007/s00464-010-1471-6

    Article  PubMed  Google Scholar 

  15. Sabbagh C, Browet F, Diouf M, Cosse C, Brehant O, Bartoli E, Mauvais F, Chauffert B, Dupas JL, Nguyen-Khac E, Regimbeau JM (2013) Is stenting as “a bridge to surgery” an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? Ann Surg 258:107–115

    Article  PubMed  Google Scholar 

  16. Amelung FJ, Burghgraef TA, Tanis PJ, van Hooft JE, Ter Borg F, Siersema PD, Bemelman WA, Consten ECJ (2018) Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis. Crit Rev Oncol Hematol 131:66–75

    Article  PubMed  Google Scholar 

  17. Fryer E, Gorissen KJ, Wang LM, Guy R, Chetty R (2015) Spectrum of histopathological changes encountered in stented colorectal carcinomas. Histopathology 66:480–484

    Article  PubMed  Google Scholar 

  18. Chok AY, Zhao Y, Lim HJ, Ng YYR, Tan EJKW (2023) Stenting as a bridge to surgery in obstructing colon cancer: long-term recurrence pattern and competing risk of mortality. World J Gastrointest Endosc 15(2):64–76

    Article  PubMed  PubMed Central  Google Scholar 

  19. Huang X, Lv B, Zhang S, Meng L (2014) Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg. https://doi.org/10.1007/s11605-013-2344-9

    Article  PubMed  PubMed Central  Google Scholar 

  20. Pattarajierapan S, Sukphol N, Junmitsakul K, Khomvilai S (2022) Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: current evidence and prospects. World J Clin Oncol 13(12):943–956. https://doi.org/10.5306/wjco.v13.i12.943

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kavanagh DO, Nolan B, Judge C, Hyland JM, Mulcahy HE, O’Connell PR, Winter DC, Doherty GA (2013) A comparative study of short- and medium-term outcomes comparing emergent surgery and stenting as a bridge to surgery in patients with acute malignant colonic obstruction. Dis Colon Rectum 56:433–440

    Article  PubMed  Google Scholar 

  22. Saunders DI, Murray D, Pichel AC, Varley S, Emergency PCJUK, Network L (2012) Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth 109:368–375

    Article  CAS  PubMed  Google Scholar 

  23. Alcántara M, Serra-Aracil X, Falcó J, Mora L, Bombardó J, Navarro S (2011) Prospective, controlled, randomized study of intraoperative colonic lavage vs stent placement in obstructive left-sided colonic cancer. World J Surg 35:1904–1910

    Article  PubMed  Google Scholar 

  24. Ghazal AH, El-Shazly WG, Bessa SS, El-Riwini MT, Hussein AM (2013) Colonic endolumenal stenting devices and elective surgery vs emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg 17:1123–1129

    Article  PubMed  Google Scholar 

  25. Tung KL, Cheung HY, Ng LW, Chung CC, Li MK (2013) Endo-laparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: long-term follow-up of a randomized trial. Asian J Endosc Surg 6:78–81

    Article  PubMed  Google Scholar 

  26. Arezzo A, Forcignanò E, Bonino MA, Balagué C, Targarona E, Borghi F, Giraudo G, Ghezzo L, Passera R, Morino M et al (2020) Long-term oncologic results after stenting as a bridge to surgery versus emergency surgery for malignant left-sided colonic obstruction: a multicenter randomized controlled trial (ESCO Trial). Ann Surg 272:703–708

    Article  PubMed  Google Scholar 

  27. CReST Collaborative Group (2022) Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial. Br J Surg 109:1073–1080

    Article  Google Scholar 

  28. van Hooft JE, Bemelman WA, Oldenburg B, Marinelli AW, Lutke Holzik MF, Grubben MJ, Sprangers MA, Dijkgraaf MG, Fockens P et al (2011) Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol 12(4):344–352. https://doi.org/10.1016/S1470-2045(11)70035-3

    Article  PubMed  Google Scholar 

  29. Sadeghi Arvieux C, Glehen O, Beaujard AC, Rivoire M, Baulieux J, Fontaumard E (2000) Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study. Cancer 88:358–363

    Article  PubMed  Google Scholar 

  30. Mayanagi S, Kashiwabara K, Honda M (2018) Risk factors for peritoneal recurrence in stage II to III colon cancer. Dis Colon Rectum 61(7):803–808

    Article  PubMed  PubMed Central  Google Scholar 

  31. Quere P, Facy O, Manfredi S (2015) Epidemiology, management, and survival of peritoneal carcinomatosis from colorectal cancer: a population-based study. Dis Colon Rectum 58:743–752

    Article  CAS  PubMed  Google Scholar 

  32. Kim SJ, Kim HW, Park SB, Kang DH, Choi CW, Song BJ, Hong JB, Kim DJ, Park BS, Son GM (2015) Colonic perforation either during or after stent insertion as a bridge to surgery for malignant colorectal obstruction increases the risk of peritoneal seeding. Surg Endosc. https://doi.org/10.1007/s00464-015-4100-6

    Article  PubMed  PubMed Central  Google Scholar 

  33. Lemoine L, Sugarbaker P, Van der Speeten K (2016) Pathophysiology of colorectal peritoneal carcinomatosis: role of the peritoneum. World J Gastroenterol 22:7692–7707

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Kang SI, Oh HK, Yoo JS, Ahn S, Kim MH, Kim MJ, Son IT, Kim DW, Kang SB, Park YS, Yoon CJ, Shin R, Heo SC, Lee IT, Youk EG, Chang TY, Park SC, Sohn DK, Oh JH, Park JW, Ryoo SB, Jeong SY, Park KJ et al (2018) Oncologic outcomes of preoperative stent insertion first vs immediate surgery for obstructing left-sided colorectal cancer. Surg Oncol 27:216–224

    Article  PubMed  Google Scholar 

  35. So JS, Cheong C, Oh SY, Lee JH, Kim YB, Suh KW (2017) Accuracy of preoperative local staging of primary colorectal cancer by using computed tomography: reappraisal based on data collected at a highly organized cancer center. Ann Coloproctol 33(5):192–196. https://doi.org/10.3393/ac.2017.33.5.192

    Article  PubMed  PubMed Central  Google Scholar 

  36. Ling S, Brown K, Miksza JK, Howells L, Morrison A, Issa E, Yates T, Khunti K, Davies MJ, Zaccardi F (2020) Association of type 2 diabetes with cancer: a meta-analysis with bias analysis for unmeasured confounding in 151 cohorts comprising 32 million people. Diab Care 43:2313–2322. https://doi.org/10.2337/dc20-0204

    Article  Google Scholar 

  37. Mills KT, Bellows CF, Hoffman AE, Kelly TN, Gagliardi G (2013) Diabetes mellitus and colorectal cancer prognosis: a meta-analysis. Dis Colon Rectum 56(11):1304–1319

    Article  PubMed  PubMed Central  Google Scholar 

  38. Vekic J, Zeljkovic A, Stefanovic A, Giglio RV, Ciaccio M, Rizzo M (2021) Diabetes and colorectal cancer risk: a new look at molecular mechanisms and potential role of novel antidiabetic agents. Int J Mol Sci 22(22):12409. https://doi.org/10.3390/ijms222212409

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Vulcan A, Manjer J, Ohlsson B (2017) High blood glucose levels are associated with higher risk of colon cancer in men: a cohort study. BMC Cancer 17:842. https://doi.org/10.1186/s12885-017-3874-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Ma YS, Yang IP, Tsai HL, Huang CW, Juo SH, Wang JY (2014) High glucose modulates antiproliferative effect and cytotoxicity of 5-fluorouracil in human colon cancer cells. DNA Cell Biol 33:64–72. https://doi.org/10.1089/dna.2013.2161

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Yang IP, Miao ZF, Huang CW, Tsai HL, Yeh YS, Su WC, Chang TK, Chang SF, Wang JY (2019) High blood sugar levels but not diabetes mellitus significantly enhance oxaliplatin chemoresistance in patients with stage III colorectal cancer receiving adjuvant FOLFOX6 chemotherapy. Ther Adv Med Oncol 11:1758835919866964. https://doi.org/10.1177/1758835919866964

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

There was no funding for this study.

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore

    Wenjie Lin, Aik Yong Chok, Isaac Seow-En & Emile Kwong-Wei Tan

Authors
  1. Wenjie Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Aik Yong Chok
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Isaac Seow-En
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emile Kwong-Wei Tan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wenjie Lin.

Ethics declarations

Disclosures

Wenjie Lin, Aik Yong Chok, Isaac Seow-En and Emile Kwong Wei Tan have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lin, W., Chok, A.Y., Seow-En, I. et al. Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes. Surg Endosc (2024). https://doi.org/10.1007/s00464-024-10780-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00464-024-10780-4

Keywords

Search

Navigation