Xiao H, Ma HC. Outcomes of colonic stent as a bridge to surgery vs emergency surgery for acute obstructive left-sided colon cancer. World J Gastrointest Surg 2025; 17(7): 104118 [DOI: 10.4240/wjgs.v17.i7.104118]
Corresponding Author of This Article
Hua-Chong Ma, MD, PhD, Professor, Department of Acute Abdominal Surgery, Capital Medical University, No. 8 Gongti South Road, Beijing 100020, China. xh1988@foxmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Xiao H contributed to the writing and editing of the manuscript, literature search, and discussion and design of the manuscript; Ma HC designed the overall concept and outline of the manuscript.
Institutional review board statement: The study was approved by the Ethics Committee of the Beijing Chaoyang Hospital.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hua-Chong Ma, MD, PhD, Professor, Department of Acute Abdominal Surgery, Capital Medical University, No. 8 Gongti South Road, Beijing 100020, China. xh1988@foxmail.com
Received: December 12, 2024 Revised: March 26, 2025 Accepted: May 20, 2025 Published online: July 27, 2025 Processing time: 225 Days and 4.1 Hours
Abstract
BACKGROUND
Self-expandable metal stent (SEMS) as a bridge to surgery (BTS) has become a popular alternative to emergency surgery in the management of acute left-sided malignant colonic obstruction (MCO). However, it remains controversial for colonic stent as a BTS due to a lack of consensus and insufficient data.
AIM
To assess the clinical and oncological safety of SEMS insertion followed by elective resection for acute left-sided MCO.
METHODS
The data from 96 patients with acute left-sided MCO in our institution from January 2018 to May 2020 were analyzed retrospectively. They underwent colonic stenting as a bridge to elective surgery (BTS group: n = 40) or emergency resection (ER group: n = 56). Demographic characteristics, stoma rate, laparoscopy rate, postoperative complications, and oncological outcomes were compared between the two groups.
RESULTS
The two groups were comparable with regard to the demographics and tumor characteristics. The stoma rate was 7.5% in the BTS group vs 48.2% in the ER group (P < 0.05). Primary anastomosis was performed in all patients in the BTS group, and only three patients underwent protective stoma in the BTS group. The BTS group had a significantly higher rate of laparoscopic surgery than the ER group (90% vs 57.1%, P < 0.05), and the major postoperative complication rate was significantly higher in the ER group than in the BTS group (33.9% vs 15%, P = 0.04). According to the Kaplan-Meier survival analysis and log rank test, no significant differences existed in the two groups with regard to the overall survival and disease-free survival.
CONCLUSION
The utilization of SEMS as a BTS is a useful alternative to emergency surgery in the treatment of acute left-sided MCO. SEMS insertion as a BTS can provide an effective and safe therapeutic option compared to emergency surgery.
Core Tip: Enrolling a total of 96 patient, this study demonstrated that the utilization of self-expandable metal stent as a bridge to surgery seems to be a useful alternative to emergency surgery in the management of acute left-sided malignant colonic obstruction. Self-expandable metal stent insertion as a bridge to surgery can provide an effective and safe therapeutic option compared to emergency surgery. The current focus of this field is on acute left-sided malignant colonic obstruction, oncological prognosis, and perioperative management.
Citation: Xiao H, Ma HC. Outcomes of colonic stent as a bridge to surgery vs emergency surgery for acute obstructive left-sided colon cancer. World J Gastrointest Surg 2025; 17(7): 104118
Colorectal cancer (CRC) has become the third most common malignancy and the fourth leading cause of cancer death[1]. In 2018, the number of CRC cases was estimated to be more than 1.8 million, with 800000 deaths, accounting for approximately 10% of cancer cases and deaths globally[2]. Acute malignant colonic obstruction (MCO) occurs in approximately 8%-29% of CRC patients and accounts for 85% of emergencies associated with CRC in spite of the effectiveness of screening strategies. MCO always needs urgent surgery, and there are several strategies for urgent surgery: Emergent colostomy with/without tumor resection, or tumor resection with one-stage anastomosis[3]. The optimal approach for patients with acute MCO has not yet been established. Emergency surgery is threatened by high morbimortality rates due to patients’ poor condition related with elderly age, advanced malignant disease, physiologic status with dehydration, anemia, metabolic disorders, malnutrition, and acid-base imbalance, abdominal sepsis, and inadequate bowel preparation[4]. It is worth to be noted that emergent surgery is an important risk factor for morbidity and mortality, and two thirds of patients with MCO who underwent emergent colostomy would develop into permanent stoma inevitably[5-7].
Since its initial application for palliative treatment of colonic obstruction in patients with CRC[8], SEMS was subsequently described in 1994 as a novel alternative approach for managing malignant colorectal obstruction as a bridge to surgery (BTS)[9]. With the development of endoscopic technique, the utilization of colonic stents has become more and more widespread. BTS may reduce the above-mentioned risk factors and converts an emergency surgery into an elective surgery, which not only decreases postoperative morbidity but also lowers the rates of stoma creation[10,11]. However, due to a lack of consensus and insufficient data, the oncological outcomes after colonic SEMS placement remain unclear. There are raising concerns that stent insertion might result in potential tumor cell dissemination and colon perforation, thus facilitating tumor progression and local recurrence eventually. Consequently, European guidance[12] did not recommend SEMS placement as a bridge to elective surgery for patients with potentially curative left-sided MCO. Therefore, this study aimed to elucidate the clinical and oncological safety of elective resection after SEMS insertion for acute left-sided MCO by comparing with emergency surgery.
MATERIALS AND METHODS
Patients
A retrospective study was performed in Beijing Chaoyang Hospital, Capital Medical University. The study was approved by the Ethics Committee of the hospital. The data from 96 patients who underwent surgery for stage II-III CRC from January 2018 to May 2020 in our institution were retrospectively reviewed.
Inclusion and exclusion criteria
All patients with left-sided obstructive colon cancer with curative intent between January 2018 and May 2020 were considered for inclusion. The localization of left-sided obstructive CRC was defined as the distal third transverse colon to rectosigmoid junction. The exclusion criteria were colonic obstruction due to benign disease, the site of obstruction localized in the proximal colon and rectum, hereditary diseases such as familial adenomatous polyposis, and being combined with other organ malignancies. Finally, 96 patients with left-sided malignant colon obstruction for curative resection were enrolled in the study. Patients who underwent colonic stent insertion as a BTS followed by elective surgery were classified into BTS group, while those patients who underwent emergency resection (ER) were categorized into ER group. The flowchart depicting patients selection is shown in Figure 1.
Figure 1 Flowchart depicting patient selection.
ASA: American Society of Anesthesiologists; FAP: Familial adenomatous polyposis.
Definitions
Bowel obstruction was ascertained according to the clinical manifestation, including abdominal distention, discomfort, and constipation, as well as radiological findings such as abdominal computed tomography (Figure 2A). We defined the left-sided colon as the segment between the distal third transverse colon to rectosigmoid junction. The technical success of SEMS insertion was defined as the proper placement of a stent in the obstructed bowel lumen, and the stent expanded successfully by radiological verification (Figure 2B), allowing the smooth passage of bowel contents. The clinical success of SEMS insertion encompassed spontaneous evacuation of flatus and fecal matter with complete resolution of obstruction-related clinical manifestations within the designated 48-hour period, in the absence of subsequent endoscopic or surgical management. An emergency surgery was conducted if the patient had aggravated clinical signs, such as peritonitis and sepsis, along with bowel obstruction symptoms.
Figure 2 Imaging examination.
A: Computed tomography image showing proximal colonic dilation with a transition point and distal collapse. The orange arrow shows the tumor location; B: Abdominal radiography showed that the stent expanded successfully and the relief of the bowel obstruction; C: The colonic stent was deployed endoscopically.
SEMS procedure and surgical technique
The colonic stent was deployed endoscopically by an experienced endoscopist (Figure 2C). The SEMS was inserted under fluoroscopic guidance as described previously[13]. Pathological biopsies were obtained during the procedure of SEMS insertion. Stent position and expansion were confirmed by abdominal radiography. Either laparoscopic or open surgical procedure was conducted. The procedure mainly includes intestinal mobilization, vascular division, and lymphadenectomy, which were performed as conventional methods. The digestive tract was reconstructed extracorporeally by using the functional end-to-end method with a linear stapler. The procedure for the ER group included Hartmann procedure, anterior resection, and sigmoidectomy/left hemicolectomy with or without one-stage anastomosis depending on the clinical status of the patient and intraoperative conditions. Even for patients with primary anastomosis, a protective ileostomy might also be performed according to the surgeon's experiences.
Objective measurements and follow-up
The primary outcomes were the technical and clinical success rates of SEMS insertion, stent-related complications in the BTS group, postoperative complications, 30-day mortality, and the rate of stoma creation in both groups. Colonic stent-associated complications included, but were not limited to, failure to deploy the stent, bowel perforation, stent migration, and re-obstruction. The postoperative complications were categorized according to the Clavien-Dindo system[14]. The secondary outcomes were the oncological results in the two groups, such as overall survival (OS) and 3-year disease-free survival (DFS). OS was defined as the time from admission to the time of death or last follow-up. DFS was defined as the time from the date of surgery to any recurrence including local recurrence or distant metastasis. Elective surgery was conducted few days to weeks after SEMS placement in the BTS group. Patients who underwent surgery were followed regularly, initially at 3-month intervals for 3 years and then at 6-month intervals for the next 2 years. The contents of follow-up included clinical history, physical examination, carcinoembryonic antigen and carbohydrate antigen 19-9 levels, computed tomography, and colonoscopy.
Statistical analysis
GraphPad Prism for Windows (version 10.0) was utilized to conducted the statistical analyses. Continuous variables are described as the mean with standard deviations, while categorical variables are presented as frequencies with percentages. χ2-tests or Fisher exact test were adopted to compare the categorical variables between the two groups. The continuous variables between the two groups were compared by t-tests. OS and DFS were estimated by using the Kaplan-Meier method, and the log-rank test was used to compare the differences between the curves. P < 0.05 was considered to be statistically significant.
RESULTS
Characteristics of the two groups
A total of 96 patients with obstructive left-sided colon cancer were enrolled in the study, of whom 56 received emergency surgery and 40 underwent SEMS placement as a BTS. The characteristic of the patients are summarized in Table 1. There were no significant differences in age, sex, tumor location, American Society of Anesthesiologists class, tumor-node-metastasis stage, or other clinicopathologic characteristics between the two groups.
Table 1 Baseline characteristics of patients in the two groups.
Characteristic
BTS group (n = 40)
ER group (n = 56)
P value
Age, years
57 (38-79)
71 (31-88)
0.41
BMI, kg/m2
21.8 ± 3.21
22.4 ± 4.34
0.23
Sex, male/female
23/17
29/27
0.68
ASA-PS score
0.44
I/II
30
38
III
10
18
Tumor site
0.96
Splenic flexure
7
8
Descending colon
12
19
Sigmoid colon
13
17
Recto-sigmoid
8
12
Preoperative CEA
0.58
Normal
11
22
Elevated
29
34
Preoperative TNM stage
0.59
II/III
25
32
IVa
15
24
SEMS-related outcomes of the BTS group
Colonic stent was allocated in 50 patients. The technical success rate of SEMS placement was 100%, and the clinical success rate was 97.5%. Patients who did not have relief of obstruction after SEMS insertion underwent emergency surgery. The median interval to surgery after SEMS placement was 15.5 (range, 7-30) days. All patients were administered an enema prior to stent insertion, and 16 were given an oral bowel preparation. Stent-related complications occurred in one patient, who experienced re-obstruction after stent insertion for 2 weeks. Colonic stent-related outcomes are shown in Table 2.
Table 2 Outcomes of self-expanding metal stent placement, n (%).
Characteristic (n = 40)
P value
Technical success
40 (100)
Clinical success
39 (97.5)
Stent-related complications
0
Migration
0
Re-obstruction
1 (0.25)
Perforation
0
Median interval from stenting to surgery, days
15.5 (7-30)
Surgical characteristics of the two groups
The surgical characteristics of the two groups are summarized in Table 3. All patients achieved R0 resection in the two groups. The BTS group had a significantly higher rate of laparoscopic surgery than the ER group (90% vs 57.1%, P < 0.05). The operation time in the BTS group was slightly longer than that of the ER group (257.2 ± 71.3 minutes vs 220.6 ± 65.9 minutes, P = 0.14), and the amount of blood loss in the BTS group was slightly more than that of the ER group (212.4 ± 71.2 mL vs 157.4 ± 45.8 mL, P = 0.32). The postoperative hospital stay in the BTS group (7.4 ± 3.5 days) and ER group (8.6 ± 3.1 days) was similar (P = 0.57). Primary anastomosis was performed in all patients in the BTS group, and only three patients underwent protective stoma in the BTS group. The rate of stoma creation (including colostomies and ileostomies, temporary and permanent) was significantly higher in the ER group compared with the BTS group (48.2% vs 7.5%, P < 0.05). The utilization of protective stoma mainly depended on the clinical status of patients and intraoperative conditions, such as severe comorbidities and highly advanced tumors. According to the Clavien-Dindo classification, the overall postoperative complication rate was 33.9% in the ER group and 15% in the BTS group (P < 0.05).
Table 3 Surgical characteristics and postoperative outcomes in the two groups, n (%).
BTS group (n = 40)
ER group (n = 56)
P value
Surgical procedure
0.005
Laparoscopy
36
32
Open
4
24
Operation time, minutes
257.2 ± 71.3
220.6 ± 65.9
0.14
Blood loss, mL
212.4 ± 71.2
157.4 ± 45.8
0.32
Postoperative hospital stay, days
7.4 ± 3.5
8.6 ± 3.1
0.57
The rate of stoma creation
3 (7.5)
27 (48.2)
< 0.0001
Major postoperative complications
6 (15)
19 (33.9)
0.04
Leakage
1
3
0.64
Wound infection
3
11
0.09
Ileus
2
4
1.00
Bleeding
0
1
1.00
Postoperative TNM stage
0.71
II/III
32
43
IVa
8
13
Adjuvant chemotherapy
34 (85.0)
45 (80.4)
0.56
Oncological outcomes of the two groups
All patients should receive postoperative adjuvant chemotherapy theoretically due to the fact that obstruction was an independent risk factor for metastasis. Eventually, adjuvant chemotherapy was administered to 34 (85%) patients in the BTS group and 45 (80.4%) patients in the ER group (P = 0.56). The median follow-up period was 35 (24-45) months for the BTS group and 42 (24-48) months for the ER group (P = 0.32). According to the Kaplan-Meier survival analysis and log rank test, the OS rate (Figure 3A) and progression-free survival rate (Figure 3B) in the BTS group and ER group showed no significant difference (P > 0.05).
Figure 3 Kaplan-Meier curves.
A: Kaplan-Meier curves showing the overall survival in the bridge to surgery group and emergency resection group (P = 0.34); B: Kaplan-Meier curves showing the progression-free survival in the bridge to surgery group and emergency resection group (P = 0.21). BTS: Bridge to surgery; ER: Emergency resection.
DISCUSSION
Acute obstructive left-sided colon cancer is a relatively common surgical emergency. The mortality rate after emergency colorectal surgery varies from 6% to 16%, and the rate of complications ranges from 45%-81%[15-17]. Furthermore, the cohort undergoing emergent colorectal resection exhibits a statistically significant increase in ostomy creation incidence compared to patients managed with SEMS placement as a BTS strategy, and the stoma creation is sometimes permanent in patients who underwent emergency surgery. SEMS insertion has become a popular alternative to emergency surgery in the treatment of acute obstructive left-sided colon cancer since 1991. Although it has been established that SEMS as a BTS has short-term benefits, its prognostic impacts remains controversial.
The study indicated that an important advantage of SEMS insertion for obstructive left-sided colon cancer is one-stage resection and primary anastomosis without stoma creation. The rate of stoma creation (including colostomies and ileostomies, temporary and permanent) was significantly lower in the BTS group compared with the ER group (7.5% vs 48.2%, P < 0.05) in our study. Actually, there is no need for stoma creation if primary anastomosis is considered safe. Patients’ quality of life and psychosocial well-being would be burdened by the stoma creation, either permanent or temporary[18]. Primary anastomosis was performed in all patients in the BTS group, and only three patients underwent protective stoma in the BTS group. All patients in the BTS group had enough time to undergo full bowel preparation in preventing infectious complications, and the nutritional status of the patients was obviously improved prior to surgery, which may be due to the low rate of stoma creation in the BTS group.
Another significant finding of this study is that laparoscopic surgery was more common in the BTS group than in the ER group (90% vs 57.1%, P < 0.05). Minimally invasive colonic surgery has become a mainstream treatment for CRC worldwide. However, laparoscopy is difficult to conduct within the constricted working space for patients due to distended bowel. Hence, laparotomy is more common in emergency surgery for patients with acute obstructive left-sided colon cancer. The situation has begun to change with the utilization of colonic stents. Laparoscopic colectomy is possible after a successful decompression by using colonic stents.
Our study showed comparable operation time and blood loss between the two groups. SEMS placement is not an independent risk factor for both operation time and blood loss. Operation type and conversion to laparotomy are independent risk factors for operation time, while conversion to laparotomy is an independent risk factor for blood loss. The overall rate of postoperative complications (mainly Clavien-Dindo classification grade II) in the ER group was significantly higher than that of the BTS group. Abdominal incision requires longer time in emergency surgery due to the need of decompression. Patients in the emergency surgery group had a poor basic state without enough time for adjustment, as well as strong stress reaction and high incidence of various complications. The wound infection was more common in the ER group. In addition, no anastomotic leakage or grade III or higher complications (Clavien-Dindo classification) occurred in either group. These data suggest that colonic stent as a BTS was associated with less surgical complications, especially incision infection. Previous studies have also reported that SEMS placement was related to better short-term morbidity and mortality than emergency surgery, hence SEMS placement is considered a good alternative to emergency surgery[10].
Our data showed that the clinical success rate of SEMS placement in BTS patients was 97.5%, which is comparable to previous reports. Two patients did not have relief of obstructive symptoms even after successful stent insertion, then they underwent emergency surgery. Previous randomized controlled trials[19] reported that the clinical success rates of SEMS insertion range from 87.5%-98.8%, and from 55.1%-58.5%, respectively, suggesting that they varied in different institutions. However, some studies indicated that SEMS as a BTS has disadvantages of poor long-term oncologic outcomes such as more frequent locoregional recurrence, more frequent peritoneal metastases, and jeopardized OS. The therapeutic application of SEMS in BTS protocols remains a contentious clinical paradigm, particularly regarding potential long-term oncological safety compromises associated with tumor dissemination risks. The oncologic outcomes might be impaired by the SEMS-related perforation[20]. Yamashita et al[21] reported tumor cell dissemination into peripheral circulation after SEMS insertion, which might result in poor oncologic outcomes. The Dutch Stent-In 2 trial documented perforation-related recurrence in 83.3% (5/6) of cases post-SEMS deployment[22]. Notably, the comparative analysis by Ribeiro et al[15] revealed a fourfold elevation in locoregional recurrence rates among SEMS-treated cohorts vs emergent surgical cohorts (32% vs 8%, P = 0.04), with concurrent evidence of an 8% iatrogenic perforation incidence in stent-based interventions. SEMS insertion may impair oncological outcomes even without perforation. The SEMS procedure can induce mechanical stress on the tumor, which could result in the dissemination of cancer cells into the peritoneal cavity, lymphatic fluid, and bloodstream[23]. However, it remains controversial whether tumor dissemination has adverse effects on OS in the SEMS group because both locoregional and distant recurrences were not higher. Consequently, the 2014 European Society of Gastrointestinal Endoscopy clinical guidelines issued a non-recommendation for SEMS deployment in BTS strategies, based on emerging evidence demonstrating suboptimal clinical efficacy and elevated adverse event profiles in comparative cohort analyses[12].
However, we found that SEMS as a BTS did not jeopardize survival, and the OS and 3-year DFS rates were similar between the two groups in our study. Recently, the results of a randomized controlled trial study[24] shows no difference in DFS and OS, as well as 30-day postoperative mortality, length of hospital stay, and quality of life. Therefore, the European Society of Gastrointestinal Endoscopy revisited the role of SEMS as a BTS strategy in 2020, and suggested that in patients with potentially curable left-sided obstructing colon cancer, SEMS may be considered—within a shared decision-making framework—as an alternative to emergency resection, but should provide an interval of approximately two weeks preceding definitive surgery[25]. There are concerns that a delayed interval to surgery might result in worse oncological outcomes. A longer interval may result in local tumor infiltration and surrounding tissue fibrosis, making the procedure more difficult and thus increasing the incidence of postoperative ileus. In the present study, the median interval between SEMS insertion and surgery was 15.5 days (range, 7 to 30 days).
Some recent studies showed the high success rates of SEMS and good oncological outcomes[26-32], and demonstrated that colonic stent as a BTS has several advantages such as less surgical complications, low duration of hospital and intensive care unit stays, and reduced costs, as well as more primary anastomosis compared with emergency surgery. Hence, colonic stent as a BTS is safe and highly effective for the management of obstructive left-sided colon cancer with regard to the short-term clinical outcomes, and these data suggest that colonic stent as a BTS should be considered as an alternative to emergency surgery in the treatment of obstructive left-sided colon cancer. However, large prospective randomized studies with long-term follow-up should be conducted clinically to verify the role of colonic stent as a BTS. In addition, obstructive right-sided colon cancer was excluded from the study, hence the safety and efficacy of SEMS insertion for obstructive right-sided colon cancer need further validation.
CONCLUSION
Colonic stent as a BTS followed by elective surgery is feasible and effective in the treatment of acute obstructive left-sided colon cancer. Colonic stent as a BTS provides an alternative method to treat patients with acute obstructive left-sided colon cancer, which not only has several advantages such as lower stoma creation rate, higher rates of laparoscopic surgery, and fewer postoperative complications, but also has similar oncological outcomes to ER.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade D
Creativity or Innovation: Grade B, Grade D
Scientific Significance: Grade B, Grade C
P-Reviewer: Despalatovic BR; Hari Rajah K S-Editor: Wei YF L-Editor: Wang TQ P-Editor: Zhang L
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