Post written by Alberto Arezzo, MD, from the Department of Surgical Sciences, University of Torino, Turin, Italy.

Twenty years after the first description of the technique, the debate is still open on the role of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery for symptomatic left-sided malignant colonic obstruction. The focus of our study was to assess, in a systematic review and meta-analysis of only randomized controlled trials (RCTs), the pros and cons of stent bridge to surgery (SBTS) versus emergency surgery (ES) in this peculiar but not rare clinical condition. So far, contradicting results have been presented by the different RCTs published. They even led to contradicting guidelines such as ESGE and WSES. We need to clarify, with objective data superior to single RCTs such as meta-analyses, in which conditions stents should be used and in which not. Analyzing data on 497 patients treated with either SBTS or ES for acute symptomatic malignant left-sided large bowel obstruction, we found a statistically significant reduction in overall morbidity within 60 days after surgery in temporary stoma rate and in permanent stoma rate, as well as statistically significant higher primary anastomosis success rates in SBTS-treated patients. These findings, together with enhanced quality of life and comparable oncologic outcomes, suggest that a SBTS strategy is preferable to ES for left-sided malignant obstruction, especially when sufficient endoscopic expertise is available.

Figure 4. Forest plot for the overall morbidity rate within 60 days.

The key issue for the oncologic patient is the cure of his/her oncologic disease; the other issues, including quality of life, are secondary for most of them. Therefore, any conclusions should first take into consideration disease-free survival. This is unfortunately very difficult to meta-analyze. Therefore, we have started an Individual Participant Data analysis based on the same 8 RCTs to finally address the key point of oncologic adequacy of the 2 techniques. Till then, when local expertise allows it, a SBTS strategy should be preferred as it provides a lower morbidity and a better quality of life.

Find the article abstract here.

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