Reply to Kim

We thank our colleague Dr. Min Ki Kim for his interest in the European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline “Self-expandable metal stents [SEMSs] for obstructing colonic and extracolonic cancer” [1]. We completely agree that the results in the literature on the oncological outcomes of the use of SEMS as a bridge to surgery are still inconclusive. Nevertheless, the guideline development group felt that, based on the available evidence, a conservative recommendation was justified and we still think that one should be reticent about the use of SEMS as a bridge to surgery in young and fit patients with a potentially curable, left-sided, malignant, colonic obstruction.

First, the randomized controlled trials showed no benefit in postoperative mortality for patients treated with SEMS as a bridge to surgery compared with emergency resection [2]. Second, there is evidence that SEMSs are associated with an increased risk of tumor recurrence, especially after a stent-related perforation [3]. In addition, a recently published, population-based cohort study showed an almost significant trend toward an increased risk of recurrence for SEMS as a bridge to surgery compared with urgent resection (adjusted incidence rate ratio of 1.12; 95 % confidence interval 0.99 – 1.28) [4].

We acknowledge the meta-analysis by Matsuda et al. [5] on the long-term oncological outcomes of SEMS as a bridge to surgery compared with emergency surgery, which adds valuable data to the field of colorectal stenting. However, only 2 of the 11 included studies were randomized trials [5]. Those two trials reported increased recurrence rates in the SEMS group – 53 % (8/15) vs. 15 % (2/13) [6] and 50 % (11/22) vs. 23 % (3/13) [7] – although the sample sizes were insufficient to detect a statistically significant difference.

We realize that the long-term oncological data are limited and conflicting, but we feel that the oncological uncertainty of SEMS as a bridge to surgery outweighs the short-term benefits demonstrated by the meta-analysis of Huang et al. [2]: the higher primary anastomosis rate, lower stoma rate, and fewer postoperative complications. Furthermore, an acute resection is very feasible in young (age < 70 years) and fit (American Society of Anesthesiologists [ASA] status ≤ 2) patients with a potentially curable, left-sided, malignant, colonic obstruction, which is demonstrated by the postoperative mortality rate of far below 10 % in this subset of patients [8] [9] [10].

In summary, SEMS placement as a bridge to surgery is not recommended as standard treatment because: 1) it does not reduce the postoperative mortality in the general population, 2) SEMS may be associated with an increased risk of tumor recurrence, and 3) acute resection is feasible in young and fit patients, with an acceptable postoperative mortality rate. However, SEMS placement should be considered in patients with a potentially curable, left-sided, malignant, colonic obstruction who have an increased risk of postoperative mortality (age > 70 years and/or ASA status ≥ 3) [1].

• 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 Huang X, Lv B, Zhang S et al. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg 2014; 18: 584-591
• 3 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
• 4 Erichsen R, Horvath-Puho E, Jacobsen JB et al. Long-term mortality and recurrence after colorectal cancer surgery with preoperative stenting: a Danish nationwide cohort study. Endoscopy 2015; 47: 517-524
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• 8 Tanis PJ, Paulino Pereira NR, van Hooft JE et al. Resection of obstructive left-sided colon cancer at a national level: a prospective analysis of short-term outcomes in 1816 patients. Dig Surg 2015; 32: 317-324
• 9 Cheynel N, Cortet M, Lepage C et al. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum 2007; 50: 1568-1575
• 10 Tekkis PP, Kinsman R, Thompson MR et al. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg 2004; 240: 76-81