The Role of Stents as Bridge to Surgery for Acute Left-Sided Obstructive Colorectal Cancer: Meta-Analysis of Randomized Controlled Trials

Abstract

Background: The role of self-expanding metallic stents (SEMS) as a bridge to surgery for acute left-sided obstructive colorectal cancer has remained controversial. Objective: To study the efficacy of this approach, we performed a meta-analysis at the gastrointestinal surgery center of Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital (Eastern Hospital). Methods: Two PubMed and science-direct electronic databases were searched up to December 30, 2017. Eligible studies were randomized controlled trials (RCTs). Results: We selected 8 RCTs articles, which included 497 cases. The directly stoma rates were significantly lower in the stent group (odds ratio [OR] = 0.46, 95% confidence intervals [CIs] = 0.30-0.70, p = 0.0003). The successful primary anastomosis rates were significantly higher in the stent group (OR = 2.29, 95% CIs = 1.52-3.45, p < 0.0001). The post-procedural complication rates were significantly lower in the stent group (OR = 0.39, 95% CI = 0.18-0.82, p = 0.01). However, tumor recurrence rates were significantly higher in the stent group (OR = 1.79, 95% CI = 1.09-2.93, p = 0.02). Conclusions This meta-analysis confirms that SEMS placement could reduce direct stoma rate and increases the successful primary anastomosis rate; however, it was associated with a seemingly higher incidence of tumor recurrence.

Colorectal stenting for palliation and bridge to surgery of obstructing cancer

“…This metaanalysis highlighted that SEMS as BTS does not confer an advantage in short-term mortality [12] in contrast with previous meta-analyses [33À36]. The findings by Arezzo et al were recently confirmed by another 2 meta-analyses, respectively by Yang et al [37] and by Boland et al [38]. Colostomy is often maintained for life, due to comorbidities or willingness to avoid re-operation in elderly patients, carrying a significant deterioration in the quality of life.…”

Response:

“…Finally, the issue related to stomas. We, unlike Allievi et al 5 and Yang et al, 4 considered temporary and permanent stoma rates separately, rather than global stoma rates, which could be confounding. Nevertheless, whether one considers the global incidence of stomas, or the temporary and permanent stoma rates, whether one uses the odds ratio or the risk ratio, an advantage in favor of stent bridge to surgery is always demonstrated.…”

“…Nevertheless, our systematic review and meta-analysis appeared in the literature earlier than the other 4 meta-analyses cited. [3][4][5][6] Therefore, I would not be surprised if the reviews published later, such as that by Yang et al, 4 report similar results and conclusions, and no new relevant information.…”

“…We acknowledge that we did not include data about recurrence reported by Ghazal et al 8 This was clearly a mistake, but fortunately not so important, inasmuch as the new calculation including these data persists in showing a nonstatistically significant difference between groups. In fact, Yang et al, 4 who collected data correctly, surprisingly used fixed effects for the analysis, despite a reported heterogeneity I 2 Z 53%, therefore obtaining a statistically significant difference favoring emergency surgery. Correctly, owing to heterogeneity, random effects should be used.…”

Analysis of prognosis, genome, microbiome, and microbial metabolome in different sites of colorectal cancer

“…Most studies showed that the prognoses of patients with left-sided CRC were better than those of patients with right-sided CRC [5][6][7][8]. Intestinal obstruction is more likely to occur on the left-sided because the right-sided colon wall is thin and easy to expand [9][10][11]. The more abundant blood supply in the right-sided colon results in faster tumour growth, more prone to necrosis, bleeding, and secondary infection and leads to the more common clinical characteristics including anaemia, emaciation, fever, and dyscrasia [12,13].…”