Outcomes of colorectal stents when used as a bridge to curative resection in obstruction secondary to colorectal cancer

Abstract

Background Up to 25% of colorectal cancers present with bowel obstruction. Metal stents (MS) can provide a bridge to surgery by relieving obstruction and allowing the subject's condition to improve pre-operatively. Methods Hospital Episode Statistics (HES) is a database of all NHS funded secondary care episodes in England. Subjects admitted with bowel obstruction secondary to colorectal cancer without metastases were identified and subdivided into two groups: MS insertion prior to surgery and surgery only. Due to demographic differences between the groups, propensity score matching was used to analyse procedural outcomes, mortality and readmission within 30 days in left-sided cancers based upon age, sex and Charlson co-morbidity score. Results Over 10 years, 4571 subjects were identified; 401 received a MS and 4170 underwent surgery only. Median age of MS subjects was 71 (IQR 62-79) years; 226 (56.4%) were male. Median age of surgery-only subjects was 73 (64-81); 2165 (51.9%) were male. Following propensity matching 375 MS and 375 surgery-only subjects remained; MS had fewer readmissions within 30 days (28 (7.5%) versus 44 (11.7%), p = 0.047), fewer respiratory complications (< 6 (< 1.5%) versus 28 (7.5%), p < 0.001), lower stoma rates (49 (13.1%) versus 159 (42.4%), p < 0.001) and higher rates of laparoscopic surgery (154 (41.1%) versus 25 (6.7%), p < 0.001). Mortality was lower in the MS group at 30 days (7 (1.9%) versus 33 (8.8%), p < 0.001) and 1 year (37 (9.9%) versus 71 (19.0%), p < 0.001). Conclusions In subjects presenting with obstructing colorectal cancer outcomes including respiratory complications, readmission and mortality appear to be better in subjects undergoing MS as a bridge to surgery compared to surgery alone.

Risk of Bowel Obstruction in Patients Undergoing Neoadjuvant Chemotherapy for High-risk Colon Cancer

“…For patients developing progressive obstruction where there is a real concern for the resectability of the primary tumor, colonic defunctioning or stenting may be helpful to facilitate NAC. 16,17 This nested case-control study benefitted from highquality data monitoring, governance, and quality assurance within a randomized trial, and provides the best available evidence on this topic. Nonetheless, this study has several limitations.…”

“…A higher proportion of T4 tumors may also explain the increased pR1 rate in obstructed patients. For patients developing progressive obstruction where there is a real concern for the resectability of the primary tumor, colonic defunctioning or stenting may be helpful to facilitate NAC 16,17 …”

Benefit or bias: Using retrospective databases to evaluate efficacy of cancer treatments

“…Again, this database has limited patient and survival information. Studies published using this data and examining the effectiveness of treatment should be viewed with caution given the likely role that bias plays in the results [28][29][30]. Some may argue that using propensity scores can help mitigate this limitation inherent to retrospective databases, but propensity scores can only account for the patient variables that are actually available in the data set.…”

“…Again, this database has limited patient and survival information. Studies published using this data and examining the effectiveness of treatment should be viewed with caution given the likely role that bias plays in the results [28–30].…”

Obstructing colorectal cancer: a population-based review of colonic stenting in Queensland, Australia

“…A 2017 guideline update from Cancer Council Australia [8] recommended that stents as a bridge to surgery, in potentially curative CRC, should not be the standard of care in curative intent cases (grade D evidence), but remain a preferred management strategy in the palliative setting. This recommendation is primarily due to the risk of perforation and has resulted in the premature closure of 2 randomized controlled trials [9,10]. A recently published meta-analysis by Balciscueta et al [11] shows an increased risk of locoregional recurrence and overall recurrence when stenting malignant large bowel obstructions as a bridge to surgery.…”