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CC BY-NC-ND 4.0 · Endosc Int Open 2018; 06(05): E558-E567
DOI: 10.1055/a-0591-2883
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Owner and Copyright © Georg Thieme Verlag KG 2018

Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis

Igor Braga Ribeiro
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Wanderley Marques Bernardo
2   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Thoracic Surgery Department, São Paulo, Brazil
,
Bruno da Costa Martins
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Diogo Turiani Hourneaux de Moura
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Elisa Ryoka Baba
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Iatagan Rocha Josino
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Nelson Tomio Miyajima
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Martin Andrés Coronel Cordero
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Thiago Arantes de Carvalho Visconti
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Edson Ide
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Paulo Sakai
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
,
Eduardo Guimarães Hourneaux de Moura
1   Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HC/FMUSP, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
› Author Affiliations
Further Information

Publication History

submitted 10 January 2018

accepted after revision 12 February 2018

Publication Date:
08 May 2018 (online)

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Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysisEndosc Int Open 2018; 06(05): C1-C1
DOI: 10.1055/a-0628-1314

Abstract

Background and study aims Colorectal cancer (CRC) is the third most common malignancy and the third leading cause of cancer death worldwide. Malignant colonic obstruction (MCO) due to CRC occurs in 8 % to 29 % of patients.The aim of this study was to perform a systematic review and meta-analysis of RCTs comparing colonic SEMS versus emergency surgery (ES) for MCO in palliative patients. This was the first systematic review that included only randomized controlled trials in the palliative setting.

Methods A literature search was performed according to the PRISMA method using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Primary outcomes were: mean survival, 30-day adverse events, 30-day mortality and length of hospital stay. Stoma formation, length of stay on intensive care unit (ICU), technical success and clinical success were recorded for secondary outcomes. Technical success (TS) was defined as successful stent placement across the stricture and its deployment. Clinical success (CS) was defined as adequate bowel decompression within 48 h of stent insertion without need for re-intervention.

Results We analyzed data from four RCT studies totaling 125 patients. The 30-day mortality was 6.3 % for SEMS-treated patients and 6.4 % for ES-treated patients, with no difference between groups (RD: – 0.00, 95 % CI [–0.10, 0.10], I2: 0 %). Mean survival was 279 days for SEMS and 244 days for ES, with no significant difference between groups (RD: 20.14, 95 % CI: [–42.92, 83.21], I2: 44 %). Clinical success was 96 % in the ES group and 86.1 % in the SEMS group (RD: – 0.13, 95 % CI [–0.23, – 0.02], I2: 51 %). Permanent stoma rate was 84 % in the ES group and 14.3 % in the SEMS group (RR: 0.19, 95 % CI: [0.11, 0.33], I2: 28 %). Length of hospital stay was shorter in SEMS group (RD: – 5.16, 95 % CI: [–6.71, – 3.61], I2: 56 %). There was no significant difference between groups regarding adverse events (RD 0.18, 95 % CI: [–0.19, 0.54;]) neither regarding ICU stay. (RD: – 0.01, 95 % CI: [–0.08, 0.05], I2: 7 %). The most common stent-related complication was perforation (42.8 % of all AE).

Conclusion Mortality, mean survival, length of stay in the ICU and early complications of both methods were similar. SEMS may be an alternative to surgery with the advantage of early hospital discharge and lower risk of permanent stoma.

 

  • References

  • 1 Sagar J, Winslet M. Colorectal stents for the management of malignant colonic obstructions. Cochrane database Syst Rev 2008; CD007378
    PubMedSearch in Google Scholar
  • 2 Van Hooft J, Van Halsema E, Vanbiervliet G. et al. European Society of Gastrointestinal Endoscopy Clinical Guideline: Self-expandable metal stents for obstructing colonic and extra-colonic cancer. Endoscopy 2014; 46: 990-1002
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Shimura T, Joh T. Evidence-based Clinical Management of Acute Malignant Colorectal Obstruction. J Clin Gastroenterol 2016; 50: 273-285
    CrossrefPubMedSearch in Google Scholar
  • 4 Tilney HS, Lovegrove RE, Purkayastha S. et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc Other Interv Tech 2007; 21: 225-233
    PubMedSearch in Google Scholar
  • 5 Khot UP, Lang AW, Murali K. et al. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002; 89: 1096-1102
    CrossrefPubMedSearch in Google Scholar
  • 6 Ribeiro IB, Gestic MA, Utrini MP. et al. Drain amylase levels may indicate gastrojejunostomy leaks after Roux-en-Y gastric bypass. Arq Gastroenterol 2018; 55: 66-72
    CrossrefPubMedSearch in Google Scholar
  • 7 Hourneaux G, de Moura E, Sakai P. et al. Comparative study: auto-expandable metal stent and isoperistaltic esophgogastric bypass]. Acta Gastroenterol Latinoam 2001; 31: 13-22
    PubMedSearch in Google Scholar
  • 8 Gilson K, Paulo S, de Moura E. et al. Assesment of placement of the esophageal self-expandable metallic stent in esophageal cancer in patients with or without citorreduction therapy. Arq Bras Cir Dig 2007; 20: 154-160
    CrossrefPubMedSearch in Google Scholar
  • 9 Minata M, Bernardo W, Rocha R. et al. Stents and surgical interventions in the palliation of gastric outlet obstruction: a systematic review. Endosc Int Open 2016; 4: E1158-E1170
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Young CJ, De-loyde KJ, Young JM. et al. Improving Quality of Life for People with Incurable Large-Bowel Obstruction. Dis Colon Rectum 2015; 58: 838-849
    CrossrefPubMedSearch in Google Scholar
  • 11 Liang TW, Sun Y, Wei YC. et al. Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: A self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today 2014; 44: 22-33
    CrossrefPubMedSearch in Google Scholar
  • 12 Arezzo A, Balague C, Targarona E. et al. Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial). Surg Endosc 2017; 31: 3297-3305
    CrossrefPubMedSearch in Google Scholar
  • 13 Oistamo E, Hjern F, Blomqvist L. et al. Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction. World J Surg Oncol 2016; 14: 232
    CrossrefPubMedSearch in Google Scholar
  • 14 Sloothaak DAM, van den Berg MW, Dijkgraaf MGW. et al. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg 2014; 101: 1751-1757
    CrossrefPubMedSearch in Google Scholar
  • 15 van den Berg MW, Sloothaak DAM, Dijkgraaf MGW. et al. Bridge-to-surgery stent placement versus emergency surgery for acute malignant colonic obstruction. Br J Surg 2014; 101: 867-873
    CrossrefPubMedSearch in Google Scholar
  • 16 Ghazal A-HA, El-Shazly WG, Bessa SS. et al. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg 2013; 17: 1123-1129
    CrossrefPubMedSearch in Google Scholar
  • 17 Cheung DY, Kim JY, Hong SP. et al. Outcome and safety of self-expandable metallic stents for malignant colon obstruction: a Korean multicenter randomized prospective study. Surg Endosc 2012; 26: 3106-3113
    CrossrefPubMedSearch in Google Scholar
  • 18 Ho K-S, Quah H-M, Lim J-F. et al. Endoscopic stenting and elective surgery versus emergency surgery for left-sided malignant colonic obstruction: a prospective randomized trial. Int J Colorectal Dis 2012; 27: 355-362
    CrossrefPubMedSearch in Google Scholar
  • 19 Alcantara M, Serra-Aracil X, Falco J. et al. Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer. World J Surg 2011; 35: 1904-1910
    CrossrefPubMedSearch in Google Scholar
  • 20 Pirlet IA, Slim K, Kwiatkowski F. et al. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 2011; 25: 1814-1821
    CrossrefPubMedSearch in Google Scholar
  • 21 van Hooft JE, Bemelman WA, Oldenburg B. et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol 2011; 12: 344-352
    CrossrefPubMedSearch in Google Scholar
  • 22 Cui J, Zhang J-L, Wang S. et al. A preliminary study of stenting followed by laparoscopic surgery for obstructing left-sided colon cancer. Zhonghua Wei Chang Wai Ke Za Zhi 2011; 14: 40-43
    PubMedSearch in Google Scholar
  • 23 Kim JS, Hur H, Min BS. et al. Oncologic outcomes of self-expanding metallic stent insertion as a bridge to surgery in the management of left-sided colon cancer obstruction: comparison with nonobstructing elective surgery. World J Surg 2009; 33: 1281-1286
    CrossrefPubMedSearch in Google Scholar
  • 24 Martinez-Santos C, Lobato RF, Fradejas JM. et al. Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: Comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 2002; 45: 401-406
    CrossrefPubMedSearch in Google Scholar
  • 25 Fiori E, Lamazza A, Schillaci A. et al. Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: Colostomy versus endoscopic stenting: Final results of a prospective randomized trial. Am J Surg 2012; 204: 321-326
    CrossrefPubMedSearch in Google Scholar
  • 26 van Hooft J, Fockens P, Marinelli A. et al. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 2008; 40: 184-191
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Dohmoto M. New method; endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Dig 1991; 3: 1507-1512
    PubMedSearch in Google Scholar
  • 28 Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T. et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis. Surg Endosc Other Interv Tech 2004; 18: 421-426
    PubMedSearch in Google Scholar
  • 29 Arezzo A, Passera R, Lo Secco G. et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc 2017; 86: 416-426
    CrossrefPubMedSearch in Google Scholar
  • 30 Frago R, Ramirez E, Millan M. et al. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2014; 207: 127-138
    CrossrefPubMedSearch in Google Scholar
  • 31 Watt AM, Faragher IG, Griffin TT. et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: A systematic review. Ann Surg 2007; 246: 24-30
    CrossrefPubMedSearch in Google Scholar
  • 32 Takahashi H, Okabayashi K, Tsuruta M. et al. Self-Expanding Metallic Stents Versus Surgical Intervention as Palliative Therapy for Obstructive Colorectal Cancer: A Meta-analysis. World J Surg 2015; 39: 2037-2044
    CrossrefPubMedSearch in Google Scholar
  • 33 Zhao XD, Cai BB, Cao RS. et al. Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis. World J Gastroenterol 2013; 19: 5565-5574
    CrossrefPubMedSearch in Google Scholar
  • 34 Young CJ, Zahid A. Randomised controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post-hoc cost analysis. Colorectal Dis 2017; [Epub ahead of print Nov 1]
    CrossrefPubMedSearch in Google Scholar
  • 35 Clarke L, Abbott H, Sharma P. et al. Impact of restenting for recurrent colonic obstruction due to tumour ingrowth. BJS Open 2018; 1: 202-206
    PubMedSearch in Google Scholar
  • 36 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine. Published: July 21, 2009
    PubMed