Abstract
Background: The current use of endoscopic stenting as a bridge to surgery is not always accepted in standard clinical practice to treat neoplastic colonic obstructions. Objectives: The role of colonic self-expandable metal stent (SEMS) positioning as a bridge to resective surgery versus emergency surgery (ES) for malignant obstruction, using all new data and available variables, was studied and we focused on short- and long-term results. Materials and Methods: A systematic review with meta-analysis was performed. PubMed, SCOPUS and Web of Science databases were included. The search comprised only randomized controlled trials (RCTs) investigating the interventions that included SEMS positioning versus ES. The primary outcomes were the rates of overall postoperative mortality, clinical and technical success. The secondary outcomes were the short- and long-term results. Results: A total of 12 studies were eligible for further analyses. A laparoscopic colectomy was the most common operation performed in the SEMS group, whereas the traditional open approach was commonly used in the ES group. Intraoperative colonic lavage was seldomly performed during ES. There were no differences in mortality rates between the two groups (RR 1.06, 95% CI 0.55 to 2.04; I2 = 0%). In the SEMS group, the rate of successful primary anastomosis was significantly higher in of SEMS (69.75%) than in the ES (55.07%) (RR 1.26, 95% 245 CI 1.01 to 1.57; I2 = 86%). Conversely, the upfront Hartmann procedure was performed more frequently in the ES (39.1%) as compared to the SEMS group (23.4%) (RR 0.61, 95% CI 0.45 to 0.85; I2 = 23%). The overall postoperative complications rate was significantly lower in the SEMS group (32.74%) than in the ES group (48.25%) (RR 0.61, 95% CI 0.41 to 0.91; I2 = 65%). Conclusions: In the presence of malignant colorectal obstruction, SEMS is safe and associated with the same mortality and significantly lower morbidity than the ES group. The rate of successful primary anastomosis was significantly higher than the ES group. Nevertheless, recurrence and survival outcomes are not significantly different between the two groups. The analysis of short- and long-term results can suggest the use of SEMS as a bridge to resective surgery when it is performed by an endoscopist with adequate expertise in both colonoscopy and fluoroscopic techniques and who performed commonly colonic stenting.
Highlights
While the self-expandable metal stent (SEMS) is commonly accepted in a palliative setting for obstructive colorectal cancer, deciding whether to proceed with endoscopic stent as a bridge to curative surgery or upfront emergency surgery (ES) in case of symptomatic left-sided malignant colonic obstruction is still under debate
The PRISMA flow chart for systematic review schematically reported (Figure 1). After this screening for relevance, 20 articles remained for further assessment of eligibility
Eight of them were successively excluded [12,13,14,15,16,17,18,19] and a total of 12 articles were eligible for further analyses (Table 1) [6,7,20,21,22,23,24,25,26,27,28,29]
Summary
While the self-expandable metal stent (SEMS) is commonly accepted in a palliative setting for obstructive colorectal cancer, deciding whether to proceed with endoscopic stent as a bridge to curative surgery or upfront emergency surgery (ES) in case of symptomatic left-sided malignant colonic obstruction is still under debate. Several authors [1,2] do not recommend the use of SEMS before surgery in resectable patients because it may harm long-term outcomes. The 2017 Guidelines of the World Society of Emergency. Surgery [3] recognize “interesting advantages” offered by the use of the SEMS, but they highlighted that its use for surgically treatable cases may expose some long-term oncologic issues. Guideline [4] recommended the use of SEMS because it is associated with lower mortality rate, shorter hospital stay and a lower rate of related colostomy. The last systematic review including only RCTs was published three years ago [5], and the authors did not report a pooled analysis on the survival variables. An additional RCT was published by Elwan et al [6] in 2020 adding data for future analysis
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