The optimal time interval between the placement of self-expandable metallic stent and elective surgery in patients with obstructive colon cancer

Abstract

A bridge to surgery (BtS) after a colonic stent for obstructive colon cancer has not been accepted as a standard treatment strategy. Also, there is no consensus regarding the optimal time interval for BtS. We aimed to identify the optimal timing for BtS after stent placement to decrease the oncologic risk. We retrospectively collected data of 174 patients who underwent BTS after stent placement for stage II or III obstructive colon cancer from five hospitals. We divided the patients into three groups based on the time interval for BTS after stent placement: within 7 days (Group 1), from 8 to 14 days (Group 2), and after 14 days (Group 3). The primary outcome was to compare the oncologic outcomes including overall survival (OS), disease-free survival (DFS), and recurrence rate (RR) among the three groups. Groups 1, 2, and 3 involved 75, 56, and 43 patients, respectively. Postoperative morbidity rates were 17.3%, 10.8%, and 9.3% in Groups 1, 2, and 3, respectively (P = 0.337). RRs were 16.0%, 35.7%, and 30.2% in Groups 1, 2, and 3, respectively (P = 0.029). In multivariate analysis, the time interval for BTS was an independent risk factor for DfS (p < 0.001; HR, 14.463; 95% CI, 1.458-3.255) and OS (P = 0.027; HR, 4.917; 95% CI, 1.071-3.059). In conclusion, the perioperative short-term outcome was not affected by the time interval of BTS. However, elective surgery within 7 days after colonic stent might be suggested to balance the short-term benefits and long-term oncologic risks. About 8-29% of patients with colorectal cancer (CRC) are presented with symptoms of a malignant obstruction at the time of diagnosis, and 85% of emergency colorectal surgery result from obstructive symptoms 1-3. There are several therapeutic options in treating obstructing CRC, including single-stage radical colectomy which means colectomy with en bloc removal of regional lymph node and primary anastomosis are performed simultaneously, resection of primary lesion with diversion, or bridge to surgery (BTS) after diversion or stent. Colonic stent using self-expandable metal stent (SEMS) placement to an obstructive lesion can make a BTS possible therapeutic option by converting an emergency situation into an elective one in patients with operable obstructing cancer 4. Compared with emergency surgery, SEMS placement as BTS may have some advantages: less morbidity rate, increased primary anastomosis rate, and decreased permanent stoma rate 5. However, in long-term outcomes, the use of SEMS as a BTS may be related to an increased risk of colorectal cancer recurrences 6-8. According to the European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline, SEMS placement for BTS is not recommended as a standard treatment of symptomatic cancer obstruction in left-sided colon and may be acceptable as an alternative to emergency surgery in a group of patients at high risk of postoperative mortality 9 .

What are the factors predictive of postoperative complications in patients with colorectal cancer undergoing stenting as a bridge to surgery?

“…Some reports show that a shorter interval could induce severe postoperative complications such as anastomotic leakage, 13,37 and others note that a longer interval could lead to a higher risk of tumor recurrence 38 . A recent multicenter study ( N = 174) showed that perioperative short‐term outcomes are not affected by the interval, although a longer interval (>7 days) is an independent negative risk factor for long‐term outcomes 14 . As the ESGE guideline recommends a short interval of approximately 2 weeks, a reasonable strategy may be to perform elective surgery as soon as possible after stenting, to strike a fine balance between potential adverse events and long‐term oncologic outcomes.…”

“…Therefore, it is reasonable to recommend colonic stenting, both to avoid emergency surgery and to prevent postoperative complications in patients with CRC and obstruction. Accumulating evidence shows that greater experience with colonic stenting (≥40 procedures) and a shorter interval between stenting and surgery (≤15 days) are important factors for reducing postoperative complications and improving oncologic outcomes 12–14 . However, there are no studies that detail the predictors of postoperative complications in patients with CRC undergoing BTS.…”

“…Accumulating evidence shows that greater experience with colonic stenting (≥40 procedures) and a shorter interval between stenting and surgery (≤15 days) are important factors for reducing postoperative complications and improving oncologic outcomes. [12][13][14] However, there are no studies that detail the predictors of postoperative complications in patients with CRC undergoing BTS. If these factors are known, and a patient is not an appropriate candidate for BTS with colonic stenting based on the presence of these factors, surgeons could instead recommend a decompressing stoma and chemotherapy as better BTS options.…”

Management of obstructive colon cancer: Current status, obstacles, and future directions

“…Additionally, stent-related complications were most frequently observed in patients who underwent surgery after 17 d[ 63 ]. On the other hand, a multicenter retrospective study on the optimal timing of elective surgery after SEMS placement by Kye et al [ 62 ] supports the concept that early elective surgery within seven days after SEMS placement correlates with better oncological outcomes than elective surgery after seven days. Currently, the ESGE guidelines state only that the time interval for surgery after SEMS placement should balance stent-related adverse events and surgical outcomes[ 47 ].…”

“…At present, prospective comparative data on how the different intervals affect the short- and long-term outcomes are not available. Two retrospective studies have reported conflicting results regarding resection timing after decompression for postoperative morbidity and oncologic outcomes[ 62 , 63 ]. A retrospective study using the Dutch nationwide cohort demonstrated that surgery within 5–10 d resulted in a longer hospital stay, a lower rate of laparoscopic resection, and a higher rate of stoma creation than surgery after 11 d[ 63 ].…”