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Background Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. Methods Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1–4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. Results Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11–34) versus 18 (10–28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. Conclusion Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

The aim of this study was to compare non-enhanced spiral CT (NECT) and intravenous pyelography (IVP) in patients with suspected acute renal colic. Two-hundred patients presenting to the Emergency Department with suspected acute renal colic were randomized into groups undergoing NECT or IVP. The main outcome measures were diagnostic utility, incidence of alternative diagnoses, requirement for further imaging, length of hospital stay, urological intervention rates, radiation dosage and costs. Non-enhanced spiral CT was better than IVP in making a definitive diagnosis of ureteric calculus or of recent calculus passage (65/102 or 66% vs 42/98 or 41%; P = 0.003). Calculi were missed in two patients in the IVP group. Two patients in each group had alternative diagnoses by initial imaging. There was no difference in the length of hospital stay or intervention rate. More plain X-rays during admission and more IVPs during follow up were performed in the NECT group. Effective radiation dosages were 2.97 mSv (IVP) and up to 5 mSv (NECT). Non-enhanced spiral CT provided greater diagnostic utility in this randomized comparison but no difference in measured outcomes. The incidence of alternative diagnoses was low, probably due to patient selection. Financial costs for each modality are comparable in a public tertiary hospital. Radiation dosages are higher for NECT and, for this reason, it might be appropriate to consider limiting NECT use to patients who have do not have classical symptoms of renal colic, to older patients and those with a contraindication to the administration of intravenous contrast media.