A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction

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Abstract

The best approach to resolve colonic obstruction in patients with left-sided colon cancer is not established.

In this meta-analysis the efficacy of stenting as bridge-to-surgery was compared to emergency surgery for the management of left-sided colonic obstruction. Fourteen studies (randomized and non controlled studies) were identified, including 405 patients in the stent group and 471 in the emergency group. The difference between proportions was evaluated as effect size (ESi). There was large heterogeneity among the studies.

Stenting offered advantages over emergency surgery in terms of increase in primary anastomosis (ES = 25.1%, p < 0.001), successful primary anastomosis (ES = 23.7%, p < 0.001), reduction of stoma creation (ES = −27.1%, p = 0.03), infections (ES = −7.9%, p = 0.006) and other morbidities (ES = −13.4%, p < 0.001). The interventions were similar in regards to length of hospitalization, preoperative mortality and long-term survival.

Introduction

Approximately 10–30% of patients with colorectal cancer present with acute obstructive symptoms requiring urgent surgical decompression, and 70% of all large bowel obstructions occur in left-sided lesions [1], [2].

Emergency colorectal surgery is associated with a mortality rate and a morbidity rate of 15–20% and 40–50%, respectively. Recently the 30-day postoperative mortality rate for emergency surgery (Em.S) has been reported to be 14.9% compared with 5.8% for elective surgery [2], [3], [4].

Em.S for colonic obstruction often includes a multistage procedure with resection and stoma formation in one procedure, followed by later reversion (Hartmann's procedure) or proximal colo- or ileostomy followed by resection [5].

However stomas are permanent in up to 40% of patients with consequent adverse effect on quality of life [6], [7].

A one-stage procedure, such as subtotal colectomy with ileocolic anastomoses or colonic resection and primary anastomosis with intraoperative colonic lavage or with manual decompression have been proposed as alternatives to Em.S [7].

A Cochrane systematic review found there was not enough evidence to determine which approach to colonic obstruction is preferable in patients with obstructive left-sided colon cancer [8].

Colonic stenting has been suggested as an alternative to surgery for malignant large bowel obstruction. Dohomoto et al. first described stenting in the early 1990s as palliative method to relieve the obstruction to avoid stoma formation [9]. In 1994 Tejero et al. reported the use of self-expanding metal stent (SEMS) as “bridge-to-surgery” in patients with resectable disease, allowing bowel decompression and a single stage surgical procedure with en bloc removal of the stent [10].

Decompression by SEMS has the potential to allow preoperative bowel preparation, medical stabilization with correction of dehydration and electrolyte abnormalities, optimization of comorbid illnesses, and tumor staging with imaging and preoperative colonoscopy or CT colonography to identify synchronous lesions [11], [12].

In patients affected by rectal cancer, the stent also provides the opportunity to administer neoadjuvant therapy after relief of the obstruction [13].

A pooled analysis of case series and a systematic review described a high overall technical success rate for insertion of stents at 93% and 92%, respectively, with a clinical success rate of 89% and 88%. When the stent was used as bridge to surgery the clinical success was 72% and 85%, respectively [5], [14].

Despite these findings, endoscopic stent placement for acute colonic obstruction is associated with risks of adverse events including bleeding, bowel perforation, stent obstruction, and stent migration.

Concern has been expressed regarding the effect of colonic stenting on long-term survival in patients whose disease is potentially curable, due to the potential risk of both local advancement of the cancer and metastatic spread if perforation after stent placement occurs [15], [16].

The purpose of this study was to compare the efficacy and safety of colonic stenting as bridge to surgery (SBTS) versus Em.S in the management of malignant left-sided large bowel obstruction in terms of treatments details, short-term adverse events, mortality and length of hospitalization by analyzing both randomized and non-controlled studies. Meta-analytic methods were used.

Section snippets

Study selection

A literature search was performed using MEDLINE, PubMed database and the Cochrane library database from January 1990 to May 2012 using the terms Colorectal Cancer combined with the following terms: (stent OR prosthesis OR endoprosthesis OR SEMS) AND (surgery OR bridge).

The search was conducted without language restriction and included only human studies.

The complete manuscript of all relevant studies published in English, French and Italian was retrieved and reference lists were searched to

Results

The literature search revealed a total of 689 publications. Following thorough review of the titles and abstracts, complete publications of 104 potentially relevant studies were obtained. Of these, 14 met the inclusion criteria for the meta-analysis: 5 RCTs, 3 prospective studies (PS), 5 retrospectives studies (RS) and 1 case matched (CM) study from 2002 to 2012, four of them were multicenter. In all studies the cancer site was in the left colon, rectosigmoid junction or upper rectum (Fig. 1)

Discussion

Emergency surgery is considered an independent risk factor for morbidity and mortality in patients with malignant acute colonic obstruction [34]. The conversion of an emergency surgery to an elective one can be achieved by SEMS insertion.

Systematic reviews of non-randomized studies support the use of stents as an effective and safe method to avoid colostomy, by facilitating safer single-stage surgery. When evaluating the results of these reviews it is however necessary to consider the

Conclusions

The available body of literature addressing the benefit of stents in the management of acute left-sided colonic obstruction is contradictory and randomized trials comparing stent placement with surgery are limited. Procedures performed by skilled endoscopists in high-volume centers may support the fact that SEMS achieve more favorable overall complication profiles compared with emergent surgery.

Further RCTs are needed in order to demonstrate if SBTS is better than Em.S.

Conflict of interest

All authors disclose no financial and personal relationships with other people or organizations that could inappropriately influence (bias) our work.

Funding

None.

Reviewers

Riccardo A. Audisio, MD, FRCS, Professor, University of LiverpoolSt Helens Hospital, Marshalls Cross Road, St Helens, Merseyside WA9 3DA, United Kingdom.

Geoffrey Vanbiervliet, MD, Paticien hospitalier, Endoscopie digestive, Pôle difestif, Hôpital L’Archet 2151, Route de Saint Antoine de Ginestière, F-06202 Nice Cedex 3, France.

Antonella De Ceglie graduated in Medicine at University of Bari, Italy. She completed specialty training in General Surgery at the University of Bari, Italy. She is a member of staff at the Unit of Digestive Endoscopy, IRCCS National Cancer Research Center in Bari, Italy. Her main areas of clinical research are oncologic endoscopy and Barrett's esophagus.

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  • Cited by (0)

    Antonella De Ceglie graduated in Medicine at University of Bari, Italy. She completed specialty training in General Surgery at the University of Bari, Italy. She is a member of staff at the Unit of Digestive Endoscopy, IRCCS National Cancer Research Center in Bari, Italy. Her main areas of clinical research are oncologic endoscopy and Barrett's esophagus.

    Rosa Filiberti graduated in Biological Sciences at University of Genova, Italy. She completed specialty training in General Pathology at the University of Genova, Italy. She is a member of staff at the Department of Epidemiology, Biostatistics and Clinical Trials at IRCCS AOU San Martino-IST, Genova, Italy. Her main area of research has been analytical and descriptive epidemiology. She worked at the Genova Cancer Registry. In the last years, she has been involved in studies on biological markers, in particular in respiratory diseases. She is involved in clinical and epidemiologic studies on gastroenterological diseases, in particular on Barrett's esophagus.

    Todd Baron is Professor of Medicine at Mayo Clinic, Rochester, MN, USA graduated in Medicine at University of Florida, USA, in 1986. He completed internal medicine and gastrointestinal medicine specialty training in at the University of Alabama (UAB), USA. He also obtained advanced training in endoscopic retrograde cholangiopancreatography (ERCP) at Duke University Medical Center, USA. He worked as staff member at UAB in the Division of Gastroenterology from 1993 to 1998. Since 1998 he has been Director of the Pancreaticobiliary Endoscopy Division of Gastroenterology & Hepatology at Mayo Clinic, Rochester, MN, USA. His main areas of clinical research are therapeutic endoscopy, expandable metal gastrointestinal stents, and ERCP.

    Marcello Ceppi graduated in Biological Sciences at University of Genova, Italy, and completed specialty training in Medical Statistics at the University of Milan, Italy. He is a researcher at AUO San Martino-IST in Genoa, Italy, in the field of molecular epidemiology related to cancer research. His main scientific interest is focused on the validation of some biomarkers as early predictors of cancer. His area of expertise is in the statistical analysis of epidemiologic data, meta-analysis and microarray analysis.

    Massimo Conio graduated in Medicine at University of Genova, Italy, in 1982. He completed specialty training in Gastrointestinal Surgery and Digestive Endoscopy at the University of Milano, Italy. He also obtained advanced training in Gastroenterology and Hepatology at the Centre Hospitalier Universitaire de Nice, France. He worked as member of staff at the Gastrointestinal Unit at the National Institute for Cancer Research of Genova and in the Division of Endoscopy at the National Cancer Institute of Milano. Since 2004 he has been Director of the Department of Gastroenterology at the General Hospital of Sanremo, Italy. He has been a research fellow at the National Medical Laser Centre of London, UK. He has also studied as a research fellow in the Developmental Endoscopy Unit of the Division of Gastroenterology at the Mayo Clinic, USA. From 01.10.09 to 01.07.10 he has been the head of the Digestive Endoscopy Unit at the Centre Hospitalier Universitaire, St. Antoine, Paris, France. His main areas of clinical research are therapeutic endoscopy and Barrett's esophagus.

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