ArticlesColonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial
Introduction
Colorectal cancer is a common cancer, with 412 900 new cases and 207 400 deaths in Europe in 2006.1 7–29% of patients with colorectal cancer present with a bowel obstruction.2, 3 Conventionally, these patients receive emergency surgery to restore luminal patency. Emergency operations are associated with mortality in 15–34% of patients and morbidity in 32–64%, despite advances in perioperative care.3, 4, 5, 6, 7 Several surgical techniques can be used to treat this disorder. Usually, an ostomy is created with the intention of secondary closure, but in many patients, these ostomies will not be closed.2, 5 Patients with a permanent stoma frequently report complications and poorer health-related quality of life than do patients without colostomy.8, 9, 10, 11
In the early 1990s, colonic stenting was introduced to restore luminal patency in patients with malignant obstruction of the left side of the colon. Stent placement before elective surgery, also known as a bridge to surgery, improved the clinical condition of the patient and seemed to decrease mortality, morbidity, and number of colostomies in uncontrolled studies.5, 6, 12, 13 Additionally, this temporary procedure enables accurate tumour staging and prevents the need for surgery in patients with disseminated disease or unacceptable surgical risk. In these patients, the colonic stent can serve as permanent palliation. In a systematic review of 54 uncontrolled trials and case reports, self-expandable metal stents were technically successful in 91·9% of patients and clinically successful in 71·7% of patients when used as a bridge to surgery.14 Major stent-procedure and stent-related complications were perforation (3·8%), stent migration (11·8%) and reobstruction (7·3%). The stent-procedure related mortality was less than 1%.14 Perforation is a particular threat because it can lead to subsequent peritoneal tumour spill, changing a potentially curable disease into an incurable one.
Until now, colonic stenting has mainly been undertaken by experts in tertiary centres and published results are often retrospective or uncontrolled. Stent insertion needs to be properly assessed in randomised controlled trials.15 We did a randomised assessment of colonic stenting versus emergency surgery, with respect to global health status, mortality, morbidity, other quality-of-life dimensions, and stoma rates.
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Patients
Patients presenting with an acute left-sided colorectal obstruction presumed to be caused by a colonic malignancy were enrolled consecutively from 25 participating Dutch hospitals (four university and 21 non-university teaching hospitals). Eligible patients were aged 18 years or older, had clinical signs of severe colonic obstruction that had existed for less than 1 week, and had dilation of the colon on either plain abdominal radiograph, with typical abnormalities on a gastrografin enema
Results
Between March 9, 2007, and Aug 27, 2009, 98 patients (mean age 71·0 years [SD 10·8]) were enrolled from 25 centres and randomly assigned to receive colonic stenting or emergency surgery (figure 1). Demographic and clinical characteristics were balanced between treatment groups at baseline (table 1). Two protocol violations occurred. One patient refused emergency surgery and was treated with a colonic stent followed by uneventful elective surgery. One endoscopist refused to do endoscopy because
Discussion
In this multicentre randomised trial, colonic stenting or emergency surgery did not have any distinct benefits for global health status, mortality, morbidity, other quality-of-life dimensions, and stoma rates. These results are less favourable than are previous data obtained from comparative non-randomised,4, 5, 13 matched controlled,6, 12 and non-comparative studies14, 25 (panel).
We might have selected a population at increased risk for complications: 70% of patients presented with a complete
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