title: Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial).
abstract: The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction.
  
  
  
  This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery.
  
  
  
  Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far.
  
  
  
  Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.
authors.affiliation: Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy. alberto.arezzo@unito.it.
authors.forename: Alberto
authors.identifier: 0000-0002-2110-4082
authors.initials: A
authors.lastname: Arezzo
authors.affiliation: Hospital de la Sta Creu i St Pau, Barcelona, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Balague
authors.affiliation: Hospital de la Sta Creu i St Pau, Barcelona, Spain.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Targarona
authors.affiliation: ASO Santa Croce e Carle, Cuneo, Italy.
authors.forename: Felice
authors.initials: F
authors.lastname: Borghi
authors.affiliation: ASO Santa Croce e Carle, Cuneo, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Giraudo
authors.affiliation: ASO Santa Croce e Carle, Cuneo, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Ghezzo
authors.affiliation: Hospital General Universitario, Elche, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Arroyo
authors.affiliation: Hospital General Universitario, Elche, Italy.
authors.forename: Javier
authors.initials: J
authors.lastname: Sola-Vera
authors.affiliation: Humanitas Gradenigo Hospital, Turin, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: De Paolis
authors.affiliation: Humanitas Gradenigo Hospital, Turin, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Bossotti
authors.affiliation: Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Bannone
authors.affiliation: Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Forcignanò
authors.affiliation: Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy.
authors.forename: Marco Augusto
authors.initials: MA
authors.lastname: Bonino
authors.affiliation: Division of Nuclear Medicine, University of Torino, Turin, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Passera
authors.affiliation: Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Morino
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003106:Colon / Q000601:surgery*; D003110:Colonic Neoplasms / Q000150:complications / Q000601:surgery*; D018572:Disease-Free Survival; D004630:Emergencies; D005260:Female; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D000069322:Self Expandable Metallic Stents / Q000009:adverse effects
keywords: Bridge to surgery; Emergency colorectal surgery; Endoscopic stenting; Large bowel obstruction; Randomized controlled trial