A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction.
BACKGROUND
The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.


METHODS
Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.


RESULTS
Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.


CONCLUSIONS
In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.
Department of Surgery, University of Milano-Bicocca, San Gerardo Hospital, Via Pergolesi 33, 20900 Monza, Italy. luca.gianotti@unimib.it
Luca
L
Gianotti
Nicolò
N
Tamini
Luca
L
Nespoli
Matteo
M
Rota
Elisa
E
Bolzonaro
Roberto
R
Frego
Alessandro
A
Redaelli
Laura
L
Antolini
Antonella
A
Ardito
Angelo
A
Nespoli
Marco
M
Dinelli
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003108:Colonic Diseases / Q000401:mortality / Q000601:surgery*; D003113:Colonoscopy / Q000379:methods* / Q000401:mortality; D015179:Colorectal Neoplasms / Q000401:mortality / Q000601:surgery; D005260:Female; D006801:Humans; D007415:Intestinal Obstruction / Q000401:mortality / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D011351:Proctoscopy / Q000379:methods* / Q000401:mortality; D011446:Prospective Studies; D012002:Rectal Diseases / Q000401:mortality / Q000601:surgery*; D012810:Sigmoid Diseases / Q000401:mortality / Q000601:surgery; D015607:Stents; D013997:Time Factors