Endoscopic stenting for colorectal cancer obstruction as a bridge-to-surgery strategy.

Abstract

Acute obstructive colorectal cancer requires prompt decompression commonly by emergency surgery (ES). However, self-expanding metal stents (SEMS) have been increasingly used as a bridge-to-surgery (BTS) strategy. In an 8-year period, consecutive patients with acute left-sided colonic obstruction, due to locally advanced colorectal cancer, underwent ES or SEMS implantation. We evaluated technical/clinical success of SEMS, adverse events, and overall (OS) and disease-free survival (DFS) of the two therapeutic options. Forty-five patients underwent ES (n=23) or SEMS (n=22). The two groups were comparable for sex, age, ASA score and cancer site/stage. Technical and clinical successes of SEMS were 100% and 72.7%, respectively. Clinical success correlated with neutrophil-lymphocyte ratio (NLR) at baseline (OR=0.65, 95% CI 0.43-0.98, P=.04). SEMS allowed primary anastomosis in the 45.5% of cases (0% in ES). SEMS implantation allowed a higher rate of surgery carried out by a laparoscopic approach: 36.4% vs 13.0% in ES. Performance of a definitive stoma and complications were similar. Median OS (34 in SEMS; 45 in ES, P=.33) and DFS (36 in SEMS; 35 in ES, P=.35) did not differ between the two groups. At univariate analysis, DFS was positively associated with primary anastomosis (HR=2.44, 95% CI 1.4-16.6, P=.04) and laparoscopic surgery (HR=8.33, 95% CI 1.08-50, P=.04), and inversely associated with a NLR>3.6 (HR=0.59, 95% CI 0.16-0.92, P=.03). At multivariate analysis, no feature retained an independent predictive power. SEMS is an effective and safe procedure, equivalent to emergency surgery in terms of complications, OS and DFS, providing the chance of a primary anastomosis in the majority of patients.