Long-term outcomes after stenting as a “bridge to surgery” for the management of acute obstruction secondary to colorectal cancer

Abstract

Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients (> 70 years) or with high surgical risk (ASA III/IV).

Keywords: Self-expanding metallic stent, Colorectal cancer, Obstructive colorectal cancer, Colorectal cancer chemotherapy, Colorectal cancer surgery

Core tip: Self-expanding metal stents placement as a bridge to surgery in patients with obstructive left-colon cancer is controversial. Stent insertion is beneficial regarding perioperative morbidity, being patients with advanced age or with important comorbidity the ones who could obtain more benefit of transforming emergency surgery into elective surgery. But, on the other hand, an increase of local recurrence rate has been shown after stent placement when compared with emergency surgery, compromising oncologic outcome of these patients. Without definitive data, it seems cautious to consider emergency surgery and assume a higher initial complication rate in young patients without relevant co-morbidities avoiding the risk of local recurrence and stenting, accepting the risk of local recurrence but with a lesser perioperative complications rate, in old patients with high surgical risk.