Colonic stenting as bridge to surgery versus emergency surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study).
BACKGROUND
Acute left-sided colonic obstruction is most often caused by malignancy and the surgical treatment is associated with a high mortality and morbidity rate. Moreover, these operated patients end up with a temporary or permanent stoma. Initial insertion of an enteral stent to decompress the obstructed colon, allowing for surgery to be performed electively, is gaining popularity. In uncontrolled studies stent placement before elective surgery has been suggested to decrease mortality, morbidity and number of colostomies. However stent perforation can lead to peritoneal tumor spill, changing a potentially curable disease in an incurable one. Therefore it is of paramount importance to compare the outcomes of colonic stenting followed by elective surgery with emergency surgery for the management of acute left-sided malignant colonic obstruction in a randomized multicenter fashion.


METHODS
Patients with acute left-sided malignant colonic obstruction eligible for this study will be randomized to either emergency surgery (current standard treatment) or colonic stenting as bridge to elective surgery. Outcome measurements are effectiveness and costs of both strategies. Effectiveness will be evaluated in terms of quality of life, morbidity and mortality. Quality of life will be measured with standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-CR38, EQ-5D and EQ-VAS). Morbidity is defined as every event leading to hospital admission or prolonging hospital stay. Mortality will be analyzed as total mortality as well as procedure-related mortality. The total costs of treatment will be evaluated by counting volumes and calculating unit prices. Including 120 patients on a 1:1 basis will have 80% power to detect an effect size of 0.5 on the EORTC QLQ-C30 global health scale, using a two group t-test with a 0.05 two-sided significance level. Differences in quality of life and morbidity will be analyzed using mixed-models repeated measures analysis of variance. Mortality will be compared using Kaplan-Meier curves and log-rank statistics.


CONCLUSIONS
The Stent-in 2 study is a randomized controlled multicenter trial that will provide evidence whether or not colonic stenting as bridge to surgery is to be performed in patients with acute left-sided colonic obstruction.


BACKGROUND
Current Controlled Trials ISRCTN46462267.
van Hooft
Jeanin E
JE
Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands. j.e.vanhooft@amc.nl
Bemelman
Willem A
WA
Breumelhof
Ronald
R
Siersema
Peter D
PD
Kruyt
Philip M
PM
van der Linde
Klaas
K
Veenendaal
Roeland A
RA
Verhulst
Marie-Louise
ML
Marinelli
Andreas W
AW
Gerritsen
Josephus J G M
JJ
van Berkel
Anne-Marie
AM
Timmer
Robin
R
Grubben
Marina J A L
MJ
Scholten
Pieter
P
Geraedts
Alfons A M
AA
Oldenburg
Bas
B
Sprangers
Mirjam A G
MA
Bossuyt
Patrick M M
PM
Fockens
Paul
P
D003108:Colonic Diseases / Q000209:etiology* / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000150:complications*; D013505:Digestive System Surgical Procedures / Q000379:methods; D004638:Emergency Treatment; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology* / Q000601:surgery*; D011446:Prospective Studies; D015607:Stents