Safety of Colonic Stenting in Malignant Obstruction: A Meta-Analysis

Abstract

Purpose: Placement of colonic stents for malignant obstruction especially for palliation has recently gained popularity due to reported low morbidity and mortality and avoidance of surgery. Morbidity of colonic stent placement is reported to be ˜15%; however, most data is derived from retrospective studies and case reports. Recent termination of randomized controlled trial (RCT) for colonic stent placement has opened a debate on safety of colonic stents. Therefore, a meta-analysis was performed comparing stent placement versus surgery for malignant colonic obstruction in terms of medical complications, mortality, and all complications. Methods: Medical literature search included PubMed, OVID Medline, CINAHL, Cochran reviews, and abstracts from gastroenterological meetings DDW and ACG (May 2009). Pooled estimates of adverse outcomes between stent placement or surgery for malignant colonic obstruction were studied. Separate analyses were performed for each outcome by using the fixed and random effects models. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Statistical analysis was performed with RevMan 5.0. Results: 159 articles were identified. Of these, six studies (N=217) met the inclusion criteria. Colonic stent placement demonstrated no statistically significant difference as compared to surgery for adverse outcomes without death (OR 0.50; 95% CI: 0.09-2.71, p=0.42), mortality (OR 0.45; 95% CI: 0.19-1.05, p=0.06), or adverse outcomes including death (OR 0.88; 95% CI: 0.11-6.78, p=0.90). However, a subgroup analysis of only RCTs demonstrated that surgical intervention resulted in a statistically significant decrease in adverse outcomes including death (OR 13.60; 95% CI: 0.25-736, p=0.02). Significant heterogeneity was noted for most outcomes resulting in the use of a random effects model. No publication bias was noted. Conclusion: Subgroup analysis of only RTCs demonstrated statistically significant decrease in adverse outcomes including death when surgery was used to palliate malignant obstruction of the colon. While colonic stenting is practiced widely, most data comes from case reports and retrospective studies. Given these results, further studies are needed to fully evaluate the efficacy and safety of colonic stenting.