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Received 12 January 2014; accepted 6 April 2014; Accepted Article online 19 May 2014
Abstract
Aim This study aimed to evaluate both the short- and P = 0.001). With a median follow-up of 26.5 and
long-term outcomes associated with colonic stenting as 31.3 months for the stenting and surgical resection
a bridge to surgery in patients with obstructing adeno- groups, there was no difference in overall and disease-
carcinoma of the colon. free survival (overall survival 30 vs 31 months,
P = 0.858; disease-free survival 13 vs 12 months,
Method Patients with potentially curable acute left-
P = 0.989). There was no difference in the rate of sys-
sided colonic obstruction treated with stenting as a
temic recurrence (8 vs 13, P = 0.991).
bridge to surgery (n = 28) or with emergency surgical
resection (n = 39) from January 1998 to December Conclusion Stenting as a bridge to surgery is a safe
2008 were identified from a prospectively maintained strategy for acute left-sided colonic obstruction with
database. Short-term data on postoperative mortality, improved short-term outcome and comparable long-
morbidity, necessity of intensive care and length of hos- term oncological results.
pital stay were compared. Overall survival and disease-
Keywords Metallic stents, bridge to surgery, colorectal
free survival were also analysed.
obstruction, outcomes
Results Patients in the two study arms had similar
What does this paper add to the literature?
demographic profiles. Those receiving preoperative
The study provides data on the oncological outcome of
stenting had a higher likelihood of a laparoscopic resec-
patients who underwent stenting for obstructing colo-
tion (P < 0.001). The emergency surgery group had a rectal cancer as a bridge to surgery and shows that
higher rate of postoperative complications (P = 0.024), stenting is a safe strategy compared with immediate
rate of intensive care unit admission (P = 0.013) and emergency surgery.
longer total length of hospital stay (9 vs 12 days,
788 Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
F. A. Quereshy et al. Outcome of stent as bridge to surgery
fewer peri-operative complications and shorter hospital the stenting procedure for patients in the treatment
stay [19]. Recently published randomized controlled arm. This is not a randomized trial and the choice of
trials, however, have challenged the value of preopera- management was decided by the preferences of the
tive colonic stenting [20,21]. Specifically, van Hooft patient and surgeon. After surgery, all patients were
et al. [20] found a statistically significant increase in 30- referred to a medical oncologist for consideration of
day morbidity in the stenting group mostly related to adjuvant chemotherapy.
colonic perforation. In addition to acute septic
complications, colonic perforation may result in poorer
Statistical analysis
long-term oncological outcome and overall survival.
Furthermore Maruthachalam et al. [22] found that the Statistical analysis was conducted using SPSS version 21.0
use of colonic stenting was associated with an increase (SPSS, Chicago, Illinois, USA). Comparisons of baseline
in circulating tumour cells and therefore may increase characteristics and the short-term postoperative out-
the risk of systemic disease. comes were performed using the Mann–Whitney U test
Despite the controversies surrounding the oncological for continuous variables and the chi-squared test for
safety of preoperative colonic stenting, there is little infor- categorical variables. Disease-free and overall survival
mation on the long-term outcome associated with this probabilities were estimated using the Kaplan–Meier
treatment. For this reason we conducted the present method and differences were compared using the log-
study involving a retrospective analysis of prospectively rank test. Chemotherapy completion rate and the likeli-
collected data to compare the disease-free and overall sur- hood of a permanent colostomy were used as secondary
vival of patients treated with SEMS as a bridge to surgery outcome measures and evaluated using the chi-squared
relative to surgery relative to emergency surgical resection. test. A two-sided P value of less than 0.05 was consid-
ered statistically significant.
Method
Results
Using a prospectively maintained colorectal cancer data-
base, all patients presenting with acute left-sided colonic
Demographic data and baseline patient characteristics
obstruction from 1998 to 2008 were identified. This
study period was selected to enable survival analysis with Demographic variables are summarized in Table 1. The
a follow-up period of at least 3 years. Patients with median age of patients within the treatment and control
incurable disease (radiographic evidence of peritoneal or arms was 73.5 (45–88) years and 74 (42–88) years
extrahepatic metastases at the time of presentation) respectively. While only 24% of all patients were female,
were excluded. During the study period 130 patients there was no significant difference in gender distribu-
were treated with SEMS for a malignant obstruction at tion between the two cohorts (P = 0.327). Twenty-four
the Queen Mary Hospital. Of these, 28 were treated (61.5%) patients in the control group had at least one
with colonic stenting as a bridge to curative surgery pre-existing comorbidity (coronary artery disease,
(treatment arm) and 39 by emergency resection (con- chronic obstructive pulmonary disease, type II diabetes
trol arm). Each patient was confirmed to have acute and/or a cerebral vascular accident) compared with only
colonic obstruction on the basis of clinical and radio- nine (32.1%) patients in the treatment arm (P = 0.018).
graphic evaluation. In the treatment arm, insertion of a Despite this difference, the American Society of Anes-
SEMS was performed on an urgent basis by an experi- thesiologists (ASA) score was not significantly different
enced colorectal surgeon using both endoscopic and between the two groups (P = 0.121), implying a com-
fluoroscopic guidance. The senior author has previously parable peri-operative risk profile between each study
described the specific technical details related to stent arm. 83.5% of all patients had a T3 tumour on final
placement [19]. The success of the procedure was doc- pathology with a comparable American Joint Commit-
umented by clinical return of normal bowel function tee on Cancer (AJCC) stage distribution between the
and radiological resolution of the obstruction. At two groups (P = 0.176).
2 weeks after SEMS insertion, patients had either stan-
dard or laparoscopic resection with curative intent. In
Operative characteristics and peri-operative course
the control arm, patients had emergency segmental
resection or subtotal colectomy according to the same All patients undergoing preoperative colonic stenting as
oncological principles. All patients in both arms received a bridge to curative surgery underwent definitive seg-
no bowel preparation. Length of stay was defined as the mental resection. In this cohort, 43% of operations were
total hospitalization, including the time associated with performed laparoscopically while all patients in the con-
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793 789
Outcome of stent as bridge to surgery F. A. Quereshy et al.
Table 1 Demographic data and baseline patient characteristics. Table 2 Peri-operative course and short-term outcome.
790 Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
F. A. Quereshy et al. Outcome of stent as bridge to surgery
[95% confidence interval (CI) 3, 23] months in the Table 3 Long-term outcome.
treatment group and 12 (95% CI 0, 25) months in the
Stenting Control
control group. The median overall survival was 30 (95%
(n = 28) (n = 39) P value
CI 21, 39) months in the treatment group and 31
(95% CI 5, 57) months in the control group (Figs 1
Median follow-up 26.5 (0–155) 31.3 (0–164) 0.638
and 2, Table 3). (months)
Stoma at last 7 14 0.343
Discussion follow-up
Disease failure
The study summarizes the results of colonic stenting as All recurrences 10 16 0.944
a bridge to surgery compared with emergency surgery Distant metastases 8 13 0.991
as curative treatment of malignant left-sided large bowel Survival outcomes
obstruction. There was no difference in 3-year disease- 3-year DFS 27.0% 33.3% 0.875
3-year OS 35.7% 43.6% 0.859
Disease-free survival (DFS) functions DFS, disease-free survival; OS, overall survival.
1.0
Stent Group free or overall survival between the two study arms.
Surgery-First Group
0.8 case-censored Given that the oncological outcomes are comparable
control-censored
between the study cohorts, this analysis supports the
Cum DFS survival
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793 791
Outcome of stent as bridge to surgery F. A. Quereshy et al.
the meta-analysis had developed specialized surgical result, it is difficult to define the true risk of develop-
programmes with expertise in endoluminal stenting. ing distant metastases and further prospective studies
The relative difference in the results may therefore be a are necessary.
reflection of the learning curve rather than a true In a recent study by Gorissen et al. [30] SEMS was
treatment failure. In this series, there were no stent- associated with an increased risk of local recurrence.
associated perforations and successful stent deployment This is in contrast to the results of our study which did
was achieved in all patients, further affirming the impor- not show a significant difference in the rate of local
tance of institutional expertise as a prerequisite for this recurrence between the two groups. This difference may
strategy. be attributable to our smaller sample size, although the
The results of our study further support the meta- median follow-up was comparable between the studies.
analysis and emphasize the role of preoperative colonic Despite the increased rate of local recurrence in younger
stenting in reducing postoperative complications. In patients in the SEMS group observed by Gorissen et al.,
addition to institutional expertise, these findings are this did not translate into a statistically significant differ-
likely to be related to improved optimization of the ence in overall survival. Our results further affirm this
patient’s general condition through the early involve- finding with comparable 3-year disease-free and overall
ment of a multidisciplinary team and the correction of survival between the SEMS and emergency surgery
fluid and electrolyte abnormalities. Furthermore, groups. Furthermore, Gorissen et al. also demonstrated
patients in the stenting group were more likely to that patients treated with colonic stenting were more
undergo successful laparoscopic colectomy. The use of likely to undergo laparoscopic surgery without differ-
minimally invasive techniques has been shown to reduce ences in the rate of primary anastomosis and stoma for-
length of stay and is accompanied by enhanced recovery mation, similar to our series.
following surgery [26–28]. Preoperative bowel decom- The present study is limited by its retrospective
pression through colonic stenting enables the use of design, the small number of patients and the single
minimally invasive techniques and, as a result, was asso- institutional experience. This will inevitably result in
ciated in the present study with a 3-day reduction in selection bias of the distribution of patients to each
median length of stay, fewer peri-operative complica- study arm. Although there was no difference in ASA
tions and a lower ICU admission rate. class, differences in presentation and acuteness may have
In a recent study conducted by Ghazal et al. [29], influenced the treatment decisions. The findings must
patients were randomized to SEMS followed by elective therefore be interpreted with caution. Nevertheless
surgical resection vs subtotal/total colectomy for an despite recent concerns over the safety of SEMS and
obstructing left-sided neoplasm. The authors concluded poor short-term results, our study reinforces the need
that both strategies yielded similar long-term results but for a multicentre randomized controlled trial to estab-
with higher peri-operative complications and worse func- lish definitely the role of preoperative colonic stenting
tion in the emergency resection group. In our study, as a bridge to surgery in patients with acute left-sided
patients treated with emergency surgery were more likely malignant obstruction.
to have a subtotal colectomy rather than a standard seg-
mental resection. While not included as a primary out-
Author contributions
come variable, changes in bowel function and quality of
life may be significantly preserved through a SEMS Study conception and design: Law. Acquisition of data:
approach. Further studies are necessary, however, to Quereshy, Law, Poon. Analysis and interpretation of
define the utility of stenting as a bridge to surgery related data: Law, Poon, Quereshy. Writing the manuscript:
to quality of life and patient satisfaction. Quereshy, Law.
According to Maruthachalam et al. [22], the use of
colonic stenting results in an increase in circulating
Conflicts of interest
tumour cells and may therefore increase the risk of
systemic metastases, but the results of the present Drs Quereshy, Poon and Law have no conflicts of inter-
study do not support this theoretical association. The est or financial ties to disclose.
results of Maruthachalam et al. are limited by two
independent factors: first, the follow-up period may
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