Bowel Obstruction: When Should Colon Stenting Be Considered as First-Line Strategy?

Prophylactic colonic stent placement

Stent bridge to elective surgery

Stent as palliation of malignant colonic obstruction

ASGE, 2013

“Colonic SEMS may also be used as a ‘bridge to surgery’ for patients with malignant obstruction who are surgical candidates”

ESGE, 2014

Not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation

Not recommended, unless increased risk of postoperative mortality, i.e., American Society of Anesthesiologists (ASA) physical status RIII and/or age >70 years (weak recommendation, low quality evidence)

SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction except in patients treated or considered for treatment with antiangiogenic drugs (e.g., bevacizumab)

EAST, 2016

We conditionally recommend endoscopic, colonic stenting (if available) as the initial therapy for colonic obstruction

WSES, 2017

SEMS as bridge to elective surgery offers a better short-term outcome than direct emergency surgery. The complications are comparable, but the stoma rate is significantly smaller. Long-term outcomes appear comparable, but evidence remains suboptimal; further studies are necessary. For these reasons, SEMS as BTS cannot be considered the treatment of choice in the management of OLCC, while it may represent a valid option in selected cases and in tertiary referral hospitals

In facilities with capability for stent placement, SEMS should be preferred to colostomy for palliation of OLCC since it is associated with similar mortality/morbidity rates and shorter hospital stay. Alternative treatments to SEMS should be considered in patients eligible to a bevacizumab-based therapy. Involvement of the oncologist in the decision is strongly recommended

Data from Refs. [10, 11, 16–20, 21–26]

ASGE American Society for Gastrointestinal Endoscopy, ESGE European Society for Gastrointestinal Endoscopy, EAST Eastern Association for the Surgery of Trauma, WSES World Society of Emergency Surgery, SEMS self-expanding metal stents, OLCC obstructing left colon carcinoma, BTS bridge to elective surgery

The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines state colonic SEMS may also be used as “bridge to surgery” for patients with malignant obstruction who are surgical candidates [10]. These were followed by the 2014 update of the European Society of Gastrointestinal Endoscopy (ESGE) guidelines [11]. Heavily influenced by outcomes from the halted STENT-In 2 trial [14], the largest multicenter randomized controlled trial (RCT) published at the time, the guidelines strongly recommended against colonic SEMS placement as a standard treatment for symptomatic left-sided malignant obstruction. Nonetheless, several critics of the STENT-In 2 study questioned the SEMS skills and experience of some of the centers, due to the low clinical and endoscopic success rate reported [15]. Though not a recommended first-line treatment for all patients with potentially curable left-sided obstructing colon cancer, the ESGE still conceded that SEMS placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, e.g., ASA > III and/or age > 70 years (weak recommendation, low quality evidence) [11].

More recent guidelines are no less at odds. In 2016, the Eastern Association for the Surgery of Trauma (EAST) conditionally recommended colonic stenting (if available) as the initial therapy for malignant colonic obstruction after finding stent use being associated with decreased mortality and decreased rates for emergency procedures, including reoperations [11], based on a meta-analysis of results from six RCTs [16–20]. These conclusions are supported by findings from the subsequent 2016 ESCO trial, the largest RCT published to date [21]. Here the findings indicate that the two treatment strategies (stent bridge to elective surgery and emergency surgery) are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favor of the stent bridge to elective surgery procedure when performed in expert hands.

The 2017 consensus conference of the World Society of Emergency Surgery (WSES) states SEMS as a bridge to elective surgery offers a better short-term outcome than direct emergency surgery with significantly lower stoma rates [21, 22]. However, SEMS could not with certainty be recommended as the treatment of choice in the management of obstructing left-sided colon cancer, because evidence remained suboptimal for long-term outcomes [23]. Further studies were deemed necessary to alleviate concerns that SEMS insertion may promote tumor progression and metastasis. A 2015 meta-analysis by Erichsen and coauthors reports a comparable 5-year survival of 49% among patients with SEMS vs 40% who underwent urgent resection. However, the same study also reports a 5-year recurrence risk of 39% after SEMS placement compared with 30% after urgent resection [24]. More recently, a 2017 meta-analysis of randomized trials and observational studies found SBTS had similar long-term oncologic outcomes to ES, leading the authors to conclude that it should be considered the best treatment option for left-sided malignant colonic obstructions in centers with appropriate experience [25]. A similar meta-analysis considering only RCTs showed that SBTS was associated with lower short-term overall morbidity and lower rates of temporary and permanent stoma [9]. The authors concluded that depending on multiple factors such as local expertise and clinical status, including level of obstruction and level of certainty of diagnosis, SBTS does offer some advantages with less risk than ES for left-sided malignant colonic obstruction in the short-term. Patients’ characteristics and main findings of the meta-analysis of only RCTs are summarized in Tables 27.2 and 27.3.

Table 27.2

Characteristics of included studies and principal outcomes

Author	Year	Country	Type of publication	Recruitment	Type of surgery	Stent type	Time from SEMS to surgery	Significant difference	No significant difference	Notes
Cheung [16]	2009	China	Single center; RCT	Jan 2002/May 2005	SBTS and lap Versus ES open	Wallstent	<2 weeks	Blood loss, pain, wound infection, anastomotic leak rates, stoma rate	–	–
Alcántara [18]	2011	Spain	Single center; RCT	Feb 2004/Dec 2006	SBTS and lap versus open ES	N/A	<10 days	Blood loss, permanent stoma pain, postoperative complications	–	Trial included 2 SBTS groups, operated at 3 or at 10 days, these showing higher 1-stage treatment and lower conversion rate
Cui [38]	2011	China	Single center; RCT	–	SBTS and open versus open ES with IOCL	Wallstent	5–7 days	Overall morbidity and anastomotic leak	SSI, hospital stay, mortality	Trial stopped as emergency surgery group had significantly increased rate of anastomotic leak
Van Hooft [14]	2011	Netherlands	Multicenter; RCT	Mar 2007/Aug 2009	SBTS and open surgery versus open ES	Wallstent/Wallflex	<4 weeks	Initial stoma rates	Mean global health status, mortality, morbidity, stoma rates	Trial stopped as SBTS group had increased absolute risk of 30-day morbidity on interim analysis
Pirlet [20]	2011	France	Multicenter; RCT	Dec 2002/Oct 2006	SBTS and open surgery versus open ES	Bard	N/A	–	Stoma, colonic resection, in-hospital mortality, surgical and medical morbidity rates	Trial stopped owing to 3 colonic perforations during stent placement and high rate of technical failure of stent placement (16 of 30)
Ho [19]	2012	Singapore	Single center; RCT	Oct 2004/Feb 2008	SBTS and surgery versus ES	Wallflex	1–2 weeks	Shorter hospital stay	Stoma, overall complications, mortality	12 IOCL and 7 STC in ES group
Ghazal [17]	2013	Egypt	Single center RCT	Jan 2009/May 2012	SBTS and surgery versus subtotal colectomy	N/A	<10 days	Postoperative complications, bowel movements	–	30 TACIR in ES group
Arezzo [21]	2017	Italy; Spain	Multicenter; RCT	Mar 2008/Nov 2015	SBTS and surgery versus ES	Wallflex/Hanaro	<4 weeks	Initial stoma rates (pro SBTS), hospital stay (pro ES)	Morbidity, mortality, blood transfusion, relapse, OS, and PFS curves	13% misdiagnosis at CT

Cui et al. [38]

RCT randomized controlled trial, SBTS stent bridge to surgery, ES emergency surgery, SSI surgical site infection, IOCL intra-operative colonic lavage, TACIR total abdominal colectomy and ileorectal anastomosis, SEMS self-expandable metallic stents, CT computed tomography, OS overall survival, PFS progression-free survival

Table 27.3

Characteristics of patients

Author	No. of randomized patients	Group	No. of analyzed patients	M/F	Mean age in years (SD or range)	BMI Kg/m² (SD or range)	ASA score (I/II/III/IV)	POSSUM score	Mean follow-up in months (SD or range)
Cheung (2009) [16]	50	SBTS	24	14/10	64.5 (39–68)	23.8 (17.5–27.2)	–	–	65 (18–139)
Cheung (2009) [16]	50	ES	24	12/12	68.5 (27–86)	24 (17.4–30.3)	–	–	32 (4–118)
Alcántara (2011) [18]	28	SBTS	15	5/10	71.9 (8.96)	–	−/5/8/2	17.13	37.6 (16.08) ^a
Alcántara (2011) [18]	28	ES	13	7/6	71.15 (9)	–	−/1/9/3	19.15	37.6 (16.08) ^a
Cui (2011) [38]	49	SBTS	29	16/13	64	22.3	–	–	–
Cui (2011) [38]	49	ES	20	9/11	67.5	23.7	–	–	–
Van Hooft (2011) [14]	98	SBTS	47	24/23	70.4 (11.9)	–	16/24/6/0	–	6
Van Hooft (2011) [14]	98	ES	51	27/24	71.4 (9.7)	–	17/27/6/0	–	6
Pirlet (2011) [20]	67	SBTS	30	16/14	70.4 (10.3)	24.2 (5.1)	–	24.2 (7.6)	–
Pirlet (2011) [20]	67	ES	30	13/17	74.7 (11.3)	23.3 (4.2)	–	21 (5.2)	–
Ho (2012) [19]	40	SBTS	20	13/7	68 (51–85)	–	–	–	–
Ho (2012) [19]	40	ES	19	9/10	65 (49–84)	–	–	–	–
Ghazal (2013) [17]	60	SBTS	30	12/18	52 (37–68)	–	–	–	18 (6–40)
Ghazal (2013) [17]	60	ES	30	11/19	51 (35–66)	–	–	–	18 (6–40)
Arezzo (2017) [21]	144	SBTS	56	28/28	72 (43–90)	24.8 (19.5–40.2)	12/27/14/3	–	36 (16–38)
Arezzo (2017) [21]	144	ES	59	32/27	71 (44–94)	24.5 (18–35)	11/28/16/4	–	36 (16–38)
Total	536	SBTS	251	128/123
Total	536	ES	246	120/126

Cui et al. [38]

SBTS stent bridge to surgery, ES emergency surgery, BMI body-mass index, ASA American Society of Anesthesiologists, SD standard deviation, POSSUM physiological and operative severity score for the enumeration of mortality and morbidity

^aMean + SD

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