Is the ESGE guideline recommendation against the placement of stents for left-sided malignant colonic obstruction still open to debate?

We have developed an interest recently in the subject of self-expandable metallic stent (SEMS) placement for obstructive, left-sided, colonic cancer. On reviewing the published literature on this topic, we noted that the European Society of Gastrointestinal Endoscopy (ESGE) guideline published in 2014 recommends not to use SEMS as a standard treatment for symptomatic, left-sided, malignant, colonic obstruction [1].

However, we think there are conflicting results in three of the randomized controlled trials (RCT) cited in the guideline [2] [3] [4], and we wonder, therefore, whether there is still a debate about this subject. The guideline stated that “all three report higher disease recurrence rate.” In fact, only one of the RCTs [2] presented a statistical difference in disease-free survival (DFS); the other two studies showed no significant difference in DFS [3] [4]. Even when the guideline analyzed the tendency of the survival graph, the 5-year DFS of SEMS was not inferior to that of emergency resection (52 % vs. 48 %; P = 0.63 according to the report of Tung et al. [4]).

The meta-analysis published in 2015, which was submitted at a similar time to the guidelines, included two of the three RCTs cited in the guideline, together with nine other prospective or retrospective reports [5]. This analysis concluded that SEMS in this setting is a “promising alternative strategy.”

Thus, we think there remains some debate about the use of SEMS in left-sided, malignant, colonic obstruction. We would be very interested to hear further opinions on this issue.

• References

• 1 van Hooft JE, van Halsema EE, Vanbiervliet G et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2014; 46: 990-1053
• 2 Sloothaak DA, van den Berg MW, Dijkgraaf MG et al. Oncological outcome of malignant colonic obstruction in the dutch stent-in 2 trial. Br J Surg 2014; 101: 1751-1757
• 3 Alcántara M, Serra-Aracil X, Falcó 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
• 4 Tung KLM, Cheung HYS, Ng LWC et al. Endo-laparoscopic approach versus conventional open surgery in the treatment of obstructing left-sided colon cancer: long-term follow-up of a randomized trial. Asian J Endosc Surg 2013; 6: 78-81
• 5 Matsuda A, Miyashita M, Matsumoto S et al. Comparison of long-term outcomes of colonic stent as “bridge to surgery” and emergency surgery for malignant large-bowel obstruction: a meta-analysis. Ann Surg Oncol 2015; 22: 497-504