Clin Endosc.  2024 Jul;57(4):424-433. 10.5946/ce.2023.138.

Colon stenting as a bridge to surgery in obstructive colorectal cancer management

• Kim DH
• Lee HH

• KMID: 2558096
• DOI: http://doi.org/10.5946/ce.2023.138

Abstract

Colonic stent placement is a commonly used bridging strategy for surgery in patients with obstructive colorectal cancer. The procedure involves the placement of a self-expandable metallic stent (SEMS) across the obstructive lesion to restore intestinal patency and alleviate the symptoms of obstruction. By allowing patients to receive surgery in a planned and staged manner with time for preoperative optimization and bowel preparation, stent placement may reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes. This review focuses on the role of colon stenting as a bridge to surgery in the management of obstructive colorectal cancer. SEMS as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful; however, further research is needed for its application in cases of right-sided colon cancer. Colon stent placement also has limitations and potential complications including stent migration, re-obstruction, and perforation. However, the timing of curative surgery after SEMS placement remains inconclusive. Considering the literature to date, performing surgery at an interval of approximately 2 weeks is considered appropriate. Therefore, colonic stent placement may be an effective strategy as a bridge to surgery in patients with obstructive colorectal cancer.

Keyword

Colonic neoplasms; Intestinal obstruction; Self-expandable metallic stent; Surgery

Reference

1. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin. 2011; 61:69–90.

2. Jullumstrø E, Wibe A, Lydersen S, et al. Colon cancer incidence, presentation, treatment and outcomes over 25 years. Colorectal Dis. 2011; 13:512–518.

3. Cheynel N, Cortet M, Lepage C, et al. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum. 2007; 50:1568–1575.

4. Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg. 2014; 207:127–138.

5. Kim JS, Hur H, Min BS, et al. Oncologic outcomes of self-expanding metallic stent insertion as a bridge to surgery in the management of left-sided colon cancer obstruction: comparison with nonobstructing elective surgery. World J Surg. 2009; 33:1281–1286.

6. Zhang Y, Shi J, Shi B, et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc. 2012; 26:110–119.

7. Tekkis PP, Kinsman R, Thompson MR, et al. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004; 240:76–81.

8. Leitman IM, Sullivan JD, Brams D, et al. Multivariate analysis of morbidity and mortality from the initial surgical management of obstructing carcinoma of the colon. Surg Gynecol Obstet. 1992; 174:513–518.

9. Deans GT, Krukowski ZH, Irwin ST. Malignant obstruction of the left colon. Br J Surg. 1994; 81:1270–1276.

10. Martinez-Santos C, Lobato RF, Fradejas JM, et al. Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum. 2002; 45:401–406.

11. Nugent KP, Daniels P, Stewart B, et al. Quality of life in stoma patients. Dis Colon Rectum. 1999; 42:1569–1574.

12. Park JJ, Del Pino A, Orsay CP, et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum. 1999; 42:1575–1580.

13. Iversen LH, Bülow S, Christensen IJ, et al. Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg. 2008; 95:1012–1019.

14. Cuffy M, Abir F, Audisio RA, et al. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 2004; 13:149–157.

15. McArdle CS, Hole DJ. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg. 2004; 91:605–609.

16. Dohmoto M. New method-endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva. 1991; 3:1507–1512.

17. Tilney HS, Lovegrove RE, Purkayastha S, et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc. 2007; 21:225–233.

18. Tejero E, Mainar A, Fernández L, et al. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum. 1994; 37:1158–1159.

19. Khot UP, Lang AW, Murali K, et al. Systematic review of the efficacy and safety of colorectal stents. Br J Surg. 2002; 89:1096–1102.

20. Cennamo V, Luigiano C, Coccolini F, et al. Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction. Int J Colorectal Dis. 2013; 28:855–863.

21. Cirocchi R, Farinella E, Trastulli S, et al. Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis. Surg Oncol. 2013; 22:14–21.

22. van Hooft JE, Veld JV, Arnold D, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline: update 2020. Endoscopy. 2020; 52:389–407.

23. Vogel JD, Felder SI, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the management of colon cancer. Dis Colon Rectum. 2022; 65:148–177.

24. Argilés G, Tabernero J, Labianca R, et al. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2020; 31:1291–1305.

25. Benson AB, Venook AP, Al-Hawary MM, et al. Colon cancer, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2021; 19:329–359.

26. van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Gastrointest Endosc. 2014; 80:747–761.

27. Spannenburg L, Sanchez Gonzalez M, Brooks A, et al. Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: a systematic review and meta-analysis of high quality prospective and randomised controlled trials. Eur J Surg Oncol. 2020; 46:1404–1414.

28. Arezzo A, Forcignanò E, Bonino MA, et al. Long-term oncologic results after stenting as a bridge to surgery versus emergency surgery for malignant left-sided colonic obstruction: a multicenter randomized controlled trial (ESCO Trial). Ann Surg. 2020; 272:703–708.

29. CReST Collaborative Group. Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial. Br J Surg. 2022; 109:1073–1080.

30. Sloothaak DA, van den Berg MW, Dijkgraaf MG, et al. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg. 2014; 101:1751–1757.

31. van Hooft JE, Bemelman WA, Oldenburg B, et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol. 2011; 12:344–352.

32. van Hooft JE, Fockens P, Marinelli AW, et al. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy. 2008; 40:184–191.

33. Yoon JY, Jung YS, Hong SP, et al. Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc. 2011; 74:858–868.

34. Cho YK, Kim SW, Lee BI, et al. Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction. Gut Liver. 2011; 5:165–170.

35. Kuwai T, Yamaguchi T, Imagawa H, et al. Factors related to difficult self-expandable metallic stent placement for malignant colonic obstruction: a post-hoc analysis of a multicenter study across Japan. Dig Endosc. 2019; 31:51–58.

36. Morita S, Ikeda K, Komori T, et al. Outcomes in colorectal surgeon-driven management of obstructing colorectal cancers. Dis Colon Rectum. 2016; 59:1028–1033.

37. Amelung FJ, Consten ECJ, Siersema PD, et al. A population-based analysis of three treatment modalities for malignant obstruction of the proximal colon: acute resection versus stent or stoma as a bridge to surgery. Ann Surg Oncol. 2016; 23:3660–3668.

38. Sakamoto T, Fujiogi M, Lefor AK, et al. Stent as a bridge to surgery or immediate colectomy for malignant right colonic obstruction: propensity-scored, national database study. Br J Surg. 2020; 107:1354–1362.

39. Amelung FJ, de Beaufort HW, Siersema PD, et al. Emergency resection versus bridge to surgery with stenting in patients with acute right-sided colonic obstruction: a systematic review focusing on mortality and morbidity rates. Int J Colorectal Dis. 2015; 30:1147–1155.

40. Boeding JRE, Ramphal W, Rijken AM, et al. A systematic review comparing emergency resection and staged treatment for curable obstructing right-sided colon cancer. Ann Surg Oncol. 2021; 28:3545–3555.

41. Kim SY, Kwon SH, Oh JH. Radiologic placement of uncovered stents for the treatment of malignant colorectal obstruction. J Vasc Interv Radiol. 2010; 21:1244–1249.

42. Kim H, Kim SH, Choi SY, et al. Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts in the treatment of acute malignant colorectal obstruction. J Vasc Interv Radiol. 2008; 19:1709–1716.

43. Shrivastava V, Tariq O, Tiam R, et al. Palliation of obstructing malignant colonic lesions using self-expanding metal stents: a single-center experience. Cardiovasc Intervent Radiol. 2008; 31:931–936.

44. Kim JH, Song HY, Li YD, et al. Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends. AJR Am J Roentgenol. 2009; 193:248–254.

45. Alcantara M, Serra X, Bombardó J, et al. Colorectal stenting as an effective therapy for preoperative and palliative treatment of large bowel obstruction: 9 years’ experience. Tech Coloproctol. 2007; 11:316–322.

46. Selinger CP, Ramesh J, Martin DF. Long-term success of colonic stent insertion is influenced by indication but not by length of stent or site of obstruction. Int J Colorectal Dis. 2011; 26:215–218.

47. Yoon J, Kwon SH, Lee CK, et al. Radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon. Cardiovasc Intervent Radiol. 2017; 40:99–105.

48. Sebastian S, Johnston S, Geoghegan T, et al. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol. 2004; 99:2051–2057.

49. Little MW, Oakley T, Briggs JH, et al. Technical and clinical outcomes following colonic stenting: a seven-year analysis of 268 procedures. Cardiovasc Intervent Radiol. 2016; 39:1471–1478.

50. Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents: a multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014; 16:476–483.

51. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc. 2010; 71:560–572.

52. Saito S, Yoshida S, Isayama H, et al. A prospective multicenter study on self-expandable metallic stents as a bridge to surgery for malignant colorectal obstruction in Japan: efficacy and safety in 312 patients. Surg Endosc. 2016; 30:3976–3986.

53. Kim JS, Lee WS, Chung CY, et al. Clinical impact of prophylactic antibiotic treatment for self-expandable metallic stent insertion in patients with malignant colorectal obstruction. Gastroenterol Res Pract. 2015; 2015:416142.

54. Baron TH, Song LM, Repici A. Role of self-expandable stents for patients with colon cancer (with videos). Gastrointest Endosc. 2012; 75:653–662.

55. Han SH, Lee JH. Colonic stent-related complications and their management. Clin Endosc. 2014; 47:415–419.

56. Lee YJ, Yoon JY, Park JJ, et al. Clinical outcomes and factors related to colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc. 2018; 87:1548–1557.

57. Boyle DJ, Thorn C, Saini A, et al. Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis. Dis Colon Rectum. 2015; 58:358–362.

58. Jiménez-Pérez J, Casellas J, García-Cano J, et al. Colonic stenting as a bridge to surgery in malignant large-bowel obstruction: a report from two large multinational registries. Am J Gastroenterol. 2011; 106:2174–2180.

59. Meisner S, González-Huix F, Vandervoort JG, et al. Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients. Gastrointest Endosc. 2011; 74:876–884.

60. Watt AM, Faragher IG, Griffin TT, et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg. 2007; 246:24–30.

61. Pirlet IA, Slim K, Kwiatkowski F, et al. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc. 2011; 25:1814–1821.

62. van Halsema EE, van Hooft JE, Small AJ, et al. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc. 2014; 79:970–982.

63. Tomita M, Saito S, Makimoto S, et al. Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series. Surg Endosc. 2019; 33:499–509.

64. Verstockt B, Van Driessche A, De Man M, et al. Ten-year survival after endoscopic stent placement as a bridge to surgery in obstructing colon cancer. Gastrointest Endosc. 2018; 87:705–713.

65. Balciscueta I, Balciscueta Z, Uribe N, et al. Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis. Int J Colorectal Dis. 2020; 35:1439–1451.

66. Manes G, de Bellis M, Fuccio L, et al. Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: analysis of results and predictors of outcomes in a large multicenter series. Arch Surg. 2011; 146:1157–1162.

67. Park YE, Park Y, Park SJ, et al. Outcomes of stent insertion and mortality in obstructive stage IV colorectal cancer patients through 10 year duration. Surg Endosc. 2019; 33:1225–1234.

68. Athreya S, Moss J, Urquhart G, et al. Colorectal stenting for colonic obstruction: the indications, complications, effectiveness and outcome: 5 year review. Eur J Radiol. 2006; 60:91–94.

69. Clark JS, Buchanan GN, Khawaja AR, et al. Use of the Bard Memotherm self-expanding metal stent in the palliation of colonic obstruction. Abdom Imaging. 2003; 28:518–524.

70. Currie A, Christmas C, Aldean H, et al. Systematic review of self-expanding stents in the management of benign colorectal obstruction. Colorectal Dis. 2014; 16:239–245.

71. Di Mitri R, Mocciaro F, Traina M, et al. Self-expandable metal stents for malignant colonic obstruction: data from a retrospective regional SIED-AIGO study. Dig Liver Dis. 2014; 46:279–282.

72. Rodrigues-Pinto E, Morais R, Coelho C, et al. Bridge-to-surgery versus emergency surgery in the management of left-sided acute malignant colorectal obstruction: efficacy, safety and long-term outcomes. Dig Liver Dis. 2019; 51:364–372.

73. Mashar M, Mashar R, Hajibandeh S. Uncovered versus covered stent in management of large bowel obstruction due to colorectal malignancy: a systematic review and meta-analysis. Int J Colorectal Dis. 2019; 34:773–785.

74. Zhang Y, Shi J, Shi B, et al. Comparison of efficacy between uncovered and covered self-expanding metallic stents in malignant large bowel obstruction: a systematic review and meta-analysis. Colorectal Dis. 2012; 14:e367–e374.

75. Rayhanabad J, Abbas MA. Long-term outcome of endoscopic colorectal stenting for malignant and benign disease. Am Surg. 2009; 75:897–900.

76. Lee HJ, Hong SP, Cheon JH, et al. Clinical outcomes of self-expandable metal stents for malignant rectal obstruction. Dis Colon Rectum. 2018; 61:43–50.

77. Park SJ, Lee KY, Kwon SH, et al. Stenting as a bridge to surgery for obstructive colon cancer: does it have surgical merit or oncologic demerit? Ann Surg Oncol. 2016; 23:842–848.

78. Fiori E, Lamazza A, Sterpetti AV, et al. Endoscopic stenting for colorectal cancer: lessons learned from a 15-year experience. J Clin Gastroenterol. 2018; 52:418–422.

79. Imai M, Kamimura K, Takahashi Y, et al. The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine. Int J Colorectal Dis. 2018; 33:189–197.

80. Sousa M, Pinho R, Proença L, et al. Predictors of complications and mortality in patients with self-expanding metallic stents for the palliation of malignant colonic obstruction. GE Port J Gastroenterol. 2017; 24:122–128.

81. Yang Z, Wu Q, Wang F, et al. A systematic review and meta-analysis of randomized trials and prospective studies comparing covered and bare self-expandable metal stents for the treatment of malignant obstruction in the digestive tract. Int J Med Sci. 2013; 10:825–835.

82. Yoon JY, Park SJ, Hong SP, et al. Outcomes of secondary self-expandable metal stents versus surgery after delayed initial palliative stent failure in malignant colorectal obstruction. Digestion. 2013; 88:46–55.

83. Yoon JY, Jung YS, Hong SP, et al. Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc. 2011; 74:625–633.

84. Broholm M, Kobborg M, Frostberg E, et al. Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence. Int J Colorectal Dis. 2017; 32:513–516.

85. Abdussamet Bozkurt M, Gonenc M, Kapan S, et al. Colonic stent as bridge to surgery in patients with obstructive left-sided colon cancer. JSLS. 2014; 18:e2014.00161.

86. Kye BH, Kim JH, Kim HJ, et al. The optimal time interval between the placement of self-expandable metallic stent and elective surgery in patients with obstructive colon cancer. Sci Rep. 2020; 10:9502.

87. Matsuda A, Miyashita M, Matsumoto S, et al. Optimal interval from placement of a self-expandable metallic stent to surgery in patients with malignant large bowel obstruction: a preliminary study. Surg Laparosc Endosc Percutan Tech. 2018; 28:239–244.

88. Lee GJ, Kim HJ, Baek JH, et al. Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer. Int J Surg. 2013; 11:442–446.

89. de Roos MA, Hugen N, Hazebroek EJ, et al. Delayed surgical resection of primary left-sided obstructing colon cancer is associated with improved short- and long-term outcomes. J Surg Oncol. 2021; 124:1146–1153.

90. Oh HH, Hong JY, Kim DH, et al. Differences in clinical outcomes according to the time interval between the bridge to surgery stenting and surgery for left-sided malignant colorectal obstruction. World J Surg Oncol. 2022; 20:178.