Acute Left-sided Malignant Colonic Obstruction Research Articles

Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis.

This study aimed to determine the best treatment for acute left-sided malignant colonic obstruction (ALMCO) among emergency surgery (ES), self-expanding metallic stent (SEMS), transanal drainage tube (TD), and decompressive stoma (DS). Articles that compared two or more treatments of ALMCO were searched from PubMed, Cochrane Library, and Embase. Network meta-analyses were performed to calculate the outcomes of primary anastomosis, stoma creation, morbidity, mortality, and 5-year survival. Fifty-one articles met inclusion criteria. TD was the optimal treatment in performing primary anastomosis [probability of ranking first (Pro-1) 0.96], while ES was the worst [probability of ranking fourth (Pro-4) 0.99]. More permanent stoma was formed in ES and TD groups than in SEMS and DS groups [OR (95%CI): TD vs SEMS: 4.12 (1.89, 9.45); TD vs DS: 3.39 (1.46, 8.75); ES vs DS: 2.55 (1.73, 4.17); SEMS vs ES: 0.33 (0.24, 0.42)]. More morbidity occurred in ES group than in SEMS group [OR (95%CI): ES vs SEMS: 1.44 (1.14, 1.82)]. Besides, SEMS was ranked first in avoiding infection (Pro-4 0.95). For in-hospital mortality, ES was ranked first (Pro-1 0.93). TD was ranked first in recurrence (Pro-1 0.97) and metastasis (Pro-1 0.98). There was no discrepancy in 5-year overall and disease-free survival among all strategies. SEMS as a bridge to surgery reduces stoma formation, and morbidity especially the infection rate with relatively great oncological outcomes. Therefore, SEMS should be recommended first for ALMCO in the medical center with experience and conditions.

Acute left-sided malignant colonic obstruction: Is there a role for endoscopic stenting?

The therapy of left-sided malignant colonic obstruction continues to be one of the largest problems in clinical practice. Numerous studies on colonic stenting for neoplastic colonic obstruction have been reported in the last decades. Thereby the role of self-expandable metal stents (SEMS) in the treatment of malignant colonic obstruction has become better defined. However, numerous prospective and retrospective investigations have highlighted serious concerns about a possible worse outcome after endoscopic colorectal stenting as a bridge to surgery, particularly in case of perforation. This review analyzes the most recent evidence in order to highlight pros and cons of SEMS placement in left-sided malignant colonic obstruction.

Impact of endoscopic metallic stent placement and emergency surgery on detection of viable circulating tumor cells for acute malignant left-sided colonic obstruction

BackgroundSelf-expanding metal stents (SEMS) served as a bridge to surgery (BTS). However, this method may be associated with worse long-term prognosis and relapse of CRC patients. Therefore, we attempted to clarify this in the angle of circulating tumor cells (CTCs).MethodsA multicenter study was performed from March 2018 to January 2021. Thirty-two colorectal cancer patients with obstruction were selected, of which 21 patients were performed SEMS as a BTS while 11 patients were performed emergency surgery. Bloods samples were collected in two groups of patients for further detecting CTCs. In the SEMS group, the samples were collected before and after stent insert and after radical surgery performed. In the ES group, the samples were collected before stent insert and after emergency surgery performed.ResultsThe number of CTCs did not show statistically significant differences before and after stent placement (34.90 vs 38.33, p=0.90), neither between the SEMS group and ES group in initial CTC levels (34.90 vs 58.09, p=0.394). No significant differences (38.33 vs 58.09, p=0.632) were observed after stent insert in the SMES group and the initial CTC levels in the ES group. Moreover, no major differences (24.17 vs 42.27, p=0.225) were observed after radical operation performed in both groups.ConclusionThe treatment of SEMS does not cause an increase in the number of CTC after stent insertion. Furthermore, there are may be other factors besides CTC to cause these poorer oncologic outcomes after SEMS placement.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

It has been found that 8%-29% of colorectal cancers are obstructive. The use of "stent as bridge to surgery" is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

Comparison of long-term outcomes of colonic stenting as a "bridge to surgery" and emergency surgery in patients with left-sided malignant colonic obstruction.

Long-term oncologic outcomes of colonic stenting as a "bridge to surgery" in patients with left-sided malignant colonic obstruction (LMCO) are unclear. This study was performed to compare long-term outcomes of self-expandable metal stent (SEMS) insertion as a bridge to surgery and emergency surgery in patients with acute LMCO. This retrospective cohort study included patients with acute LMCO who underwent SEMS insertion as a bridge to surgery or emergency surgery. The primary outcomes were 5-year disease-free survival (DFS), overall survival (OS), and recurrence rate. Survival outcomes were determined using the Kaplan-Meier method and compared using log-rank tests. There was a trend of worsening 5-year OS rate in the SEMS group compared with emergency surgery group (45% vs. 57%, P=0.07). In stage-wise subgroup analyses, a trend of deteriorating 5-year OS rate in the SEMS group with stage III (43% vs. 59%, P=0.06) was observed. The 5-year DFS and recurrence rate were not different between groups. The overall median follow-up time was 58 months. On multivariate analysis, age of ≥65 years and American Joint Committee on Cancer stage of ≥III, and synchronous metastasis were significant poor prognostic factors for OS (hazard ratio [HR], 1.709; 95% confidence interval [CI], 1.007-2.900; P=0.05/HR, 1.988; 95% CI, 1.038-3.809; P=0.04/HR, 2.146; 95% CI, 1.191-3.866; P=0.01; respectively). SEMS as a bridge to surgery may have adverse oncologic outcomes. Patients in the SEMS group had a trend of worsening 5-year OS rate without higher recurrence.

Effectiveness and early postoperative outcomes of palliative endoluminal stenting versus Hartmann's procedure in acute malignant bowel obstruction in high-risk patients.

PurposeThe emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery.MethodsAn observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age > 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann’s procedure, HP), and 35 patients underwent SEMS insertion.ResultsAll cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 days vs. 3.5 ± 0.6 days, retrospectively; P < 0.001), the interval before regaining oral feeding (41.8 ± 26.8 hours vs. 27.6 ± 18.5 hours, retrospectively; P = 0.015), and the duration of intensive care unit (ICU) admission (5.0 ± 1.7 days vs. 1.5 ± 0.7 days, retrospectively; P = 0.035). Six patients (20.7%) in the HP group and 2 patients (5.7%) in the SEMS group required postoperative ICU admission.ConclusionSEMS placement provides comparable efficacy and safety to HP in managing acute malignant obstruction of the rectosigmoid region in high-risk individuals, with faster recovery and less hospital and ICU admission time.

Effectiveness and Early Postoperative Outcomes of Palliative Endoluminal Stenting Versus Hartmann’s Procedure in Acute Malignant Bowel Obstruction in High-risk Patients

The emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery. An observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age > 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann's procedure, HP), and 35 patients underwent SEMS insertion. All cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 days vs. 3.5 ± 0.6 days, retrospectively; P < 0.001), the interval before regaining oral feeding (41.8 ± 26.8 hours vs. 27.6 ± 18.5 hours, retrospectively; P = 0.015), and the duration of intensive care unit (ICU) admission (5.0 ± 1.7 days vs. 1.5 ± 0.7 days, retrospectively; P = 0.035). Six patients (20.7%) in the HP group and 2 patients (5.7%) in the SEMS group required postoperative ICU admission. SEMS placement provides comparable efficacy and safety to HP in managing acute malignant obstruction of the rectosigmoid region in high-risk individuals, with faster recovery and less hospital and ICU admission time.

Propensity score\u2010matched comparison of stenting as a bridge to surgery and emergency surgery for acute malignant left\u2010sided colonic obstruction

BackgroundBridge to elective surgery (BTS) using self-expanding metal stents (SEMSs) is a common alternative to emergency surgery (ES) for acute malignant left-sided colonic obstruction (AMLCO). However, studies regarding the long-term impact of BTS are limited and have reported unclear results.MethodsA multicenter observational study was performed at three hospitals from April 2012 to December 2019. Propensity score matching (PSM) was introduced to minimize selection bias. The primary endpoint was overall survival. The secondary endpoints included surgical approaches, primary resection types, total stent-related adverse effects (AEs), surgical AEs, length of hospital stay, 30-day mortality and tumor recurrence.ResultsForty-nine patients in both the BTS and ES groups were matched. Patients in the BTS group more often underwent laparoscopic resection [31 (63.3%) vs. 8 (16.3%), p < 0.001], were less likely to have a primary stoma [13 (26.5%) vs. 26 (53.1%), p = 0.007] and more often had perineural invasion [25 (51.0 %) vs. 13 (26.5 %), p = 0.013]. The median overall survival was significantly lower in patients with stent insertion (41 vs. 65 months, p = 0.041). The 3-year overall survival (53.0 vs. 77.2%, p = 0.039) and 5-year overall survival (30.6 vs. 55.0%, p = 0.025) were significantly less favorable in the BTS group. In multivariate Cox regression analysis, stenting (hazard ratio(HR) = 2.309(1.052–5.066), p = 0.037), surgical AEs (HR = 1.394 (1.053–1.845), p = 0.020) and pTNM stage (HR = 1.706 (1.116–2.607), p = 0.014) were positively correlated with overall survival in matched patients.ConclusionsSelf-expanding metal stents as “a bridge to surgery” are associated with more perineural invasion, a higher recurrence rate and worse overall survival in patients with acute malignant left-sided colonic obstruction compared with emergency surgery.

Diversion, resection, or stenting as a bridge to surgery for acute neoplastic left-sided colonic obstruction: a systematic review and network meta-analysis of studies with curative intent.

The debate on the best surgical management strategy for acute malignant left-sided colonic obstruction is ongoing. Decompressing colostomy (DC) and stenting as a bridge to surgery (SBTS) are the currently proposed alternative approaches to emergency colectomy (EC). However, the results of a traditional meta-analysis were inconclusive. Therefore, a network meta-analysis (NMA) was conducted to compare the three approaches for acute left-sided colonic obstruction. A systematic literature search of Embase, PubMed, Google Scholar and the Cochrane library was performed. A traditional meta-analysis and subsequent NMA were conducted. A significantly greater number of primary anastomoses were performed in the DC cohort than in the EC and SBTS cohorts. The 90-day mortality rate was significantly lower in the DC cohort than in the EC and SBTS cohorts. Higher costs were associated with the SBTS cohort (by US$2,000) than with the EC cohort. The locoregional recurrence rate was higher for the SBTS cohort than for the EC cohort. Evidence from the first NMA suggests there may be some clinical advantages associated with DC as an alternative approach to the EC and SBTS approaches for adequately selected patients with malignant large bowel obstruction.

Transtumoral decompression in acute left-sided colonic obstruction

To prove an effectiveness of transtumoral decompression in patients with acute malignant left-sided colonic obstruction. 154 patients with acute left-side colonic obstruction were enrolled. Patients were divided into 4 groups. In groups 1-3 (n=120) patients underwent surgery at the moment of colonic obstruction, in 34 patients obstruction was managed with transtumoral decompression followed by radical surgery. Self-expanding metallic stents (SEMS) were used in these patients. Radical and palliative procedures at the moment of colonic obstruction are associated with high rate of postoperative complications and mortality. Transtumoral decompression in malignant colonic obstruction resolves the main objectives of complicated colonic cancer management: absence of surgical trauma, endotracheal narcosis, reduced risk of abdominal infection, possible multidisciplinary assessment of patient's status and preparation for radical surgery.

Preoperative colonic stentsvsemergency surgery for acute left-sided malignant colonic obstruction: Meta-analysis with systematic review of the literature

Preoperative colonic stents vs emergency surgery for acute left-sided malignant colonic obstruction: Meta-analysis with systematic review of the literature

Colonic Stenting in the Management of Acute Left-sided Malignant Colonic Obstruction is Oncologically Safe?

The management of patients presenting with acute large bowel obstructioncaused by left sided colorectal cancer is still debated.Colonic stenting (CS) seems to be a good therapeutical option toemergency surgery: it is able to convert an urgent situation in anelective one. Lately conflicting results were published about thistechnique used as bridge to surgery in comparison with the emergencysurgery in terms of oncologic safety and recurrence rate.Actually self expandable metallic stents (SEMS) are not “allowed”to treat potentially curable patients. Data reported in literatureshow that colonic stenting improves primary anastomosis ratewith a low stoma creation in comparison with emergency surgery,enhancing patients’ quality of life, without differences in terms ofmortality and morbidity rate. According to available data, at oneyear follow up time, the recurrence rate is higher in patients treatedwith stent, with no statistical difference in terms of disease freesurvival and overall survival.Endoscopist’s experience, type of colic obstruction (partial or total),type of stent, insertion technique and timing of surgery arefundamental to reach CS technical and clinical success.Oncologic (un)-safety of colonic stenting has to be still investigatedand confirmed by medium and long term follow up of largeprospective studies and randomized controlled trials comparingSEMS and ES.

Reevaluation of Self-Expanding Metal Stents as a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction: Six Years Experience

IntroductionSelf-expanding metal stents (SEMS) as a bridge to surgery have been used as an alternative for acute malignant left-sided colonic obstruction. However, the benefits are uncertain. The European Society of Gastrointestinal Endoscopy no longer recommends their use in patients with low surgical risk because of the risk of tumor recurrence. MethodsPatients admitted for acute malignant left-sided colonic obstruction who underwent SEMS as a bridge to elective surgery or urgent surgery were retrospectively evaluated. Postoperative morbidity/mortality, stent complications and survival were recorded. Our aim was to compare the outcome between preoperative SEMS and direct emergent surgery in acute left-sided malignant colonic obstruction. Results42 patients were included (SEMS group: 27 and surgery group: 15). There were no differences between groups in relation to age, ASA classification and tumor stage. The technical success of SEMS was 88.9% and the clinical success was 85.2%. There were three SEMS related perforations. In the surgery group, the stoma rate was higher (86.7% vs 25.9%, p<0.001) and there was a trend for a lower length of hospital stay (18.9 days vs 26.3 days, p=0.051).SEMS verses surgery group: There were no differences in the rate of temporary stoma (57.1% vs 61.5%, p=0.84), definitive stoma (42.8% vs 38.5%, p=0.84), success of primary anastomosis (86.7% vs 66.7%, p=0.22) and Clavien–Dindo classification (≥III: 36% vs 58.2% p=0.24). Overall survival at 1/5 years was identical in the two groups 100%/56% in the SEMS group vs 93%/43% in the surgery group, p=0.14), as well as tumor recurrence at 3/5 years (24%/50% vs 20%/36% respectively, p=0.68). ConclusionsSEMS are associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival and recurrence between the groups.

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PurposeThe aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. MethodsFrom January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7–9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. ResultsTwenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). ConclusionDecompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes.

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking. This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting. A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed. From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen. Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.

Meta-Analysis of Complications of Colonic Stenting Versus Emergency Surgery for Acute Left-sided Malignant Colonic Obstruction

Left-sided malignant colonic obstruction is one of the most difficult clinical problems, whereas both emergency operations and colonic stenting may have their own advantages and disadvantages. The purpose of this study was to evaluate the complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. Medline, Embase, and the Cochrane Library were searched. Only prospective randomized controlled trials that compared the 2 methods were included. Evaluation indexes in our study involved hospital death rates and complications. No significant difference in either hospital death rates or the overall complications between the 2 groups was found. Heterogeneity analysis found that there was no significant heterogeneity. Removing individual studies from the data editor did not substantially change the RR or the level of heterogeneity of significance for our 2 outcome measures. Testing for publication bias showed that hospital death rates and the overall complications had no serious publication bias. Colonic stenting was no better than emergency surgery, and should be only used as an alternative to emergency surgery carefully.

Surgical failure after colonic stenting as a bridge to surgery.

To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction. The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patients were included in our study when they had undergone stent placement as a bridge to surgery in acute left-sided malignant colonic obstruction due to primary colon cancer. Out of 68 patients, forty-eight (70.6%) were male, and the mean age was 64.9 (range, 38-89) years. The technical and clinical success rates were 97.1% (66/68) and 88.2% (60/68), respectively. Overall, 85.3% (58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9% (53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d (range, 0-26 d). The mean hospital stay after surgery was 12.5 d (range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents (OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4% (3/68) and 1.5% (1/68), respectively. The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.

Preoperative Colonic Stents Versus Emergency Surgery for Acute Left-Sided Malignant Colonic Obstruction: A Meta-analysis

PurposeThe purpose of this paper is to evaluate the efficacy and safety of colonic stenting as a bridge to surgery versus emergency surgery for acute left-sided malignant colonic obstruction. MethodsRandomized clinical trials (RCT) that compared the efficacy or safety of preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction were searched in medical databases, including PubMed, OVID, EMBASE, and the Cochrane Library. Statistical heterogeneity between trials was evaluated by Revman 5.1 and was considered to exist at I2 > 50 %. ResultsSeven RCTs were identified. There was a total of 382 patients, 195 who received a colonic stent and 187 who received emergency surgery. Compared with the emergency surgery group, the colonic stent group achieved significantly more favorable rates of permanent stoma, primary anastomosis, wound infection, and overall complications. There was no significant difference between the two groups in anastomotic leakage, mortality, or intra-abdominal infection. Inspection of funnel plots for all outcome measures did not reveal evidence of publication bias. ConclusionsSelf-expanding metal stents serve as a safe and effective bridge to subsequent surgery in patients with obstructing left-sided colon cancer. They can significantly improve one-stage surgery rates, and decrease the rates of permanent stoma and wound infection.

Invited commentary: left-sided malignant colonic obstruction: a systematic review

Acute colonic obstruction is frequently caused by colorectal cancer and is a common emergent clinical issue for the surgeon. The appropriate management of the patient will depend on his/her overall condition and the pathologic stage of the tumor. The availability of qualified specialists to offer a full range of options is also an important issue. Traditionally, the surgical issues have resolved around whether to perform a 3-stage approach with an initial proximal diversion followed by resection and then reconstruction, a 2-stage approach such as the Hartmann procedure, or primary resection and anastomosis in appropriately selected patients. There are a number of controversies around when and how to perform a primary resection, the issue of intraoperative bowel preparation, segmental versus total colonic resection, whether or not to use proximal diversion, and, more recently, the role of laparoscopy. The ability to stent colonic strictures via colonoscopy has been present for 20 years. This would appear to be a very useful procedure for acute left-sided malignant colonic obstruction. It would palliate patients with unresectable disease. Stent placement could also serve as a bridge to convert an emergent procedure into an elective one. This would permit optimization of the patient’s medical condition, completion of oncologic staging including the evaluation of synchronous colon lesions, decreased need for a stoma, and avoidance of multistage operations. This approach may also facilitate laparoscopic resection. Stenting presumably would decrease morbidity and mortality.