Endoscopy 2016; 48(02): 200
DOI: 10.1055/s-0034-1393638
Letters to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Reply to Kim

Emo E. van Halsema
,
Jeanin E. van Hooft
,
Cesare Hassan
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Publikationsverlauf

Publikationsdatum:
28. Januar 2016 (online)

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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].