Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis

Abstract

Background and study aims Colorectal cancer (CRC) is the third most common malignancy and the third leading cause of cancer death worldwide. Malignant colonic obstruction (MCO) due to CRC occurs in 8% to 29% of patients. The aim of this study was to perform a systematic review and meta-analysis of RCTs comparing colonic SEMS versus emergency surgery (ES) for MCO in palliative patients. This was the first systematic review that included only randomized controlled trials in the palliative setting. Methods A literature search was performed according to the PRISMA method using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Primary outcomes were: mean survival, 30-day adverse events, 30-day mortality and length of hospital stay. Stoma formation, length of stay on intensive care unit (ICU), technical success and clinical success were recorded for secondary outcomes. Technical success (TS) was defined as successful stent placement across the stricture and its deployment. Clinical success (CS) was defined as adequate bowel decompression within 48 h of stent insertion without need for re-intervention. Results We analyzed data from four RCT studies totaling 125 patients. The 30-day mortality was 6.3% for SEMS-treated patients and 6.4% for ES-treated patients, with no difference between groups (RD: -0.00, 95% CI [-0.10, 0.10], I-2: 0 %). Mean survival was 279 days for SEMS and 244 days for ES, with no significant difference between groups (RD: 20.14, 95% CI: [-42.92, 83.21], I-2: 44%). Clinical success was 96% in the ES group and 86.1% in the SEMS group (RD: -0.13, 95% CI [-0.23, -0.02], I-2: 51%). Permanent stoma rate was 84% in the ES group and 14.3% in the SEMS group (RR: 0.19, 95% CI: [0.11, 0.33], I-2: 28%). Length of hospital stay was shorter in SEMS group (RD: -5.16, 95% CI: [-6.71, -3.61], I-2: 56%). There was no significant difference between groups regarding adverse events (RD 0.18, 95% CI: [-0.19, 0.54;]) neither regarding ICU stay. (RD: -0.01, 95% CI: [-0.08, 0.05], I-2: 7%). The most common stent-related complication was perforation (42.8% of all AE). Conclusion Mortality, mean survival, length of stay in the ICU and early complications of both methods were similar. SEMS may be an alternative to surgery with the advantage of early hospital discharge and lower risk of permanent stoma.