title: Palliative treatment for incurable malignant colorectal obstructions: a meta-analysis.
abstract: OBJECTIVE
  To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.
  
  
  METHODS
  The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ² method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I² statistics, where P < 0.10 and I² < 25% indicated heterogeneity), a random-effects model was used.
  
  
  RESULTS
  Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).
  
  
  CONCLUSIONS
  SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.
authors.affiliation: Xiao-Dan Zhao, Ri-Sheng Cao, Rui-Hua Shi, Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China.
authors.forename: Xiao-Dan
authors.initials: XD
authors.lastname: Zhao
authors.forename: Bao-Bao
authors.initials: BB
authors.lastname: Cai
authors.forename: Ri-Sheng
authors.initials: RS
authors.lastname: Cao
authors.forename: Rui-Hua
authors.initials: RH
authors.lastname: Shi
mesh_terms: D015179:Colorectal Neoplasms / Q000150:complications*; D013505:Digestive System Surgical Procedures; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology / Q000601:surgery*; D010166:Palliative Care; D019919:Prosthesis Implantation; D017594:Publication Bias; D018570:Risk Assessment; D015607:Stents / Q000009:adverse effects; D016896:Treatment Outcome
keywords: Incurable malignant colorectal obstruction; Large-bowel obstruction; Palliative surgery; Self-expandable metal stents; Treatment outcomes
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