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

Abstract

Background and aims: Twenty years after the first description of the technique, the debate is still open on the role of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery for symptomatic left-sided malignant colonic obstruction. The aim was to compare morbidity rates after colonic stenting bridge to surgery (SBTS) versus emergency surgery (ES) for left-sided malignant obstruction.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) on SBTS or ES for acute symptomatic malignant left-sided large bowel obstruction. The primary outcome was overall morbidity within 60 days after surgery.

Results: The meta-analysis included 8 RCTs and 497 patients. Overall mortality within 60 days after surgery was 9.6% in SBTS-treated patients and 9.9% in ES-treated patients (relative risk [RR], 0.99; P = .97). Overall morbidity within 60 days after surgery was 33.9% in SBTS-treated patients and 51.2% in ES-treated patients (RR, 0.59; P = .023). The temporary stoma rate was 33.9% after SBTS and 51.4% after ES (RR, 0.67; P < .001). The permanent stoma rate was 22.2% after SBTS and 35.2% after ES (RR, 0.66; P = .003). Primary anastomosis was successful in 70.0% of SBTS-treated patients and 54.1% of ES-treated patients (RR, 1.29; P = .043).

Conclusions: SBTS was associated with lower short-term overall morbidity and lower rates of temporary and permanent stoma. Depending on multiple factors such as local expertise, 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.