Short- and long-term outcomes of self-expanding metallic stent placement vs. emergency surgery for malignant colorectal obstruction

Abstract

The European Society of Gastrointestinal Endoscopy does not recommend self-expanding metal stent (SEMS) placement as a bridge to surgery (BTS) for malignant colorectal obstruction (MCRO). However, no universally accepted consensus has been determined. The present study aimed to evaluate the short- and long-term outcomes of SEMS placement vs. emergency surgery (ES) for MCRO. Surgical resection of colorectal cancer was performed in 3,840 patients between April 2001 and June 2016. Of these, 93 patients had MCRO requiring emergency decompression. Only patients in whom the colorectal lesion was ultimately resected were included; thus, the present study included 62 patients treated with MCRO via SEMS placement as a BTS (n=25) or via ES (n=37). The rates of laparoscopic surgery, primary anastomosis, stoma formation, lymph node dissection, adverse events, 30-day mortality and disease-free survival were evaluated. The clinical success rate of SEMS placement was 92.0% (23/25). Compared with the ES group, the SEMS group had higher rates of laparoscopic surgery (68.0 vs. 2.7%; P<0.001) and primary anastomosis (88.0 vs. 51.4%; P=0.003), a greater number of dissected lymph nodes (30 vs. 18; P=0.001), and lower incidences of stoma formation (24.0 vs. 67.6%; P=0.002) and overall adverse events (24.0 vs. 62.2%; P=0.004). The 30-day mortality and disease-free survival of the SEMS group were not significantly different to that of the ES group (0 vs. 2.7%; P=1.000; log-rank test; P=0.10). In conclusion, as long as adverse events such as perforation are minimized, SEMS placement as a BTS could be a first treatment option for MCRO. The present study is registered in the University Hospital Medical Network Clinical Trials Registry (UMIN R000034868).

Keywords: colorectal cancer; emergency surgery; malignant colorectal obstruction; self-expanding metallic stent.

Figure 1

Flow diagram of the study selection process. CRC, colorectal cancer; SEMS, Self-expanding metal stent; MCRO, malignant colorectal obstruction.

Figure 2

SEMS placement procedure (Case 1). (A and B) Malignant colorectal obstruction due to a sigmoid colon lesion was diagnosed using abdominal CT (axial and coronal sections). Arrows indicate the beginning of the stricture. (C) The obstructive lesion was confirmed endoscopically, and marked by a clip on the anal side. (D) An endoscopic retrograde cholangiopancreatography catheter about to be inserted across the stricture. (E) The guidewire passed the stricture through the endoscopic retrograde cholangiopancreatography catheter, and reached the oral side. (F) The length and degree of the stricture was measured fluoroscopically. The double arrows indicate the distance of the stricture. (G and H) The guidewire was changed to a 0.035-inch guidewire, and the SEMS delivery system passed the stricture using the through-the-scope technique. (I) The SEMS just after being deployed from the delivery system. (J) Stools flowed through the SEMS from the oral side. (K) Biopsy was performed from the side of the tumor just after SEMS placement. (L) The surgical specimen resected 12 days after SEMS placement as a bridge to surgery. SEMS, Self-expanding metal stent.

Figure 3

Self-expanding metal stent placement procedure (Case 2). (A) MCRO was diagnosed using radiography. (B) Abdominal CT (axial section) showing MCRO due to a sigmoid colon lesion. Arrows indicate the beginning of the stricture. (C) The obstructive lesion was confirmed endoscopically. (D) The obstructive lesion marked by a clip on the anal side. (E) The length and degree of the stricture were measured fluoroscopically. The double arrows indicate the distance of the stricture. (F) The guidewire was changed to a 0.035-inch guidewire, and the SEMS delivery system passed the stricture using the through-the-scope technique. (G) The SEMS was deployed from the delivery system. (H) The SEMS just after being deployed. (I) The SEMS position was confirmed as appropriate on a radiographic image. (J) Radiography performed the day after SEMS placement showed that the gas pattern was improved. (K) The obstructive lesion 5 days after SEMS placement. The colonoscope passed through the stricture and reached the cecum. (L) The surgical specimen resected 14 days after SEMS placement as a bridge to surgery. SEMS, Self-expanding metal stent; MCRO, malignant colorectal obstruction.

Figure 4

Kaplan-Meier curves of disease-free survival in the SEMS group and the ES group excluding stage IV. SEMS, Self-expanding metal stent; ES, emergency surgery.