title: Long-term outcomes of palliative colonic stenting versus emergency surgery for acute proximal malignant colonic obstruction: a multicenter trial.
abstract: Background and study aimsLong-term data are limited regarding clinical outcomes of self-expanding metal stents as an alternative for surgery in the treatment of acute proximal MBO. The aim of this study was to compare the long-term outcomes of stenting to surgery for palliation in patients with incurable obstructive CRC for lesions proximal to the splenic flexure.Patients and methodsRetrospective multicenter cohort study of obstructing proximal CRC patients with who underwent insertion of a SEMS (n = 69) or surgery (n = 36) from 1999 to 2014. The primary endpoint was relief of obstruction. Secondary endpoints included technical success, duration of hospital stay, early and late adverse events (AEs) and survival.ResultsTechnical success was achieved in 62/69 (89.8 %) patients in the SEMS group and in 36 /36 (100 %) patients who underwent surgery (P= 0.09). In the SEMS group, 10 patients underwent stenting as a bridge to surgery and 59 underwent stent placement for palliation. Clinical relief was achieved in 78 % of patients with stenting and in 100 % of patients who underwent surgery (P< 0.001). Patients with SEMS had significantly less acute AEs compared to the surgery group (7.2 % vs. 30.5 %,P= 0.003). Hospital mortality for the SEMS group was 0 % compared to 5.6 % in the surgery group (P= 0.11). Patients in the SEMS group had a significantly shorter median hospital stay (4 days) as compared to the surgery group (8 days) (P< 0.01). Maintenance of decompression without the recurrence of bowel obstruction until death or last follow-up was lower in the SEMS group (73.9 %) than the surgery group (97.3 %;P= 0.003). SEMS placement was associated with higher long-term complication rates compared to surgery (21 % and 11 %P= 0.27). Late SEMS AEs included occlusion (10 %), migration (5 %), and colonic ulcer (6 %). At 120 weeks, survival in the SEMS group was 5.6 % vs. 0 % in the surgery group (P= 0.8).ConclusionsTechnical and clinical success associated with proximal colonic obstruction are higher with surgery when compared to SEMS, but surgery is associated with longer hospital stays and more early AEs. SEMS should be considered the initial mode of therapy in patients with acute proximal MBO and surgery should be reserved for SEMS failure, as surgery involves a high morbidity and mortality.
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Ali
authors.initials: A
authors.lastname: Siddiqui
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Natalie
authors.initials: N
authors.lastname: Cosgrove
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Linda H
authors.initials: LH
authors.lastname: Yan
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Daniel
authors.initials: D
authors.lastname: Brandt
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Raymond
authors.initials: R
authors.lastname: Janowski
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Ankush
authors.initials: A
authors.lastname: Kalra
authors.affiliation: Jefferson University School of Medicine, Gastroenterology and Hepatology, Philadelphia, Pennsylvania, United States.
authors.forename: Tingting
authors.initials: T
authors.lastname: Zhan
authors.affiliation: University of North Carolina, Gastroenterology and Hepatology, Chapel Hill, North Carolina, United States.
authors.forename: Todd H
authors.initials: TH
authors.lastname: Baron
authors.affiliation: Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy.
authors.forename: Allesandro
authors.initials: A
authors.lastname: Repici
authors.affiliation: University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States.
authors.forename: Linda Jo
authors.initials: LJ
authors.lastname: Taylor
authors.affiliation: University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, United States.
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Adler