Colonic stenting or emergency surgery for acute malignant
colonic obstruction: comparison of long-term outcomes in
two general hospitals.
M.W. van den Berg1,2, D.A.M. Sloothaak3,4, M.G.W. Dijkgraaf5, E. van der Zaag4, W.A.
Bemelmam3, P.J. Tanis3, R.J.I. Bosker6, P. Fockens1, F. ter Borg2, J.E. van Hooft1
1
Dept. of Gastroenterology & Hepatology, Academic Medical Center, University of
Amsterdam, Amsterdam, the Netherlands
2
Dept. of Gastroenterology & Hepatology, Deventer Hospital, Deventer, the Netherlands
3
Dept. of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the
Netherlands
4
Dept. of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
5
Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the
Netherlands
6
Dept. of Surgery, Deventer Hospital, Deventer, the Netherlands
Endoscopic stent placement is widely performed for the management of acute
malignant colonic obstruction (AMCO). It can serve both as a ‘bridge to elective
surgery’ (BTS) in a curative setting as well as definitive palliation in incurable or
inoperable patients. Recently published randomized studies revealed no superiority
of stent placement over acute surgery as well as a relatively high number of stentrelated perforations. These perforations raised concerns of potential tumor seeding,
which could influence oncologic outcomes. This study aimed to compare long-term
outcomes of the different treatment strategies in patients with AMCO.
A retrospective comparison of two prospectively collected patient cohorts (20052012) from two Dutch general teaching hospitals was performed. In the first hospital,
all consecutive patients presenting with AMCO were treated with emergency surgery,
while in the other hospital, patients were treated with endoscopic stent placement.
The cohorts were sub-divided in ‘palliative’ (PAL) and ‘curative’ (CUR) groups. The
following outcomes were compared: overall survival (OS), recurrence-free survival
(RFS), overall major complication rates (Clavien Dindo grade ≥3) and both initial and
long-term stoma-rates (end of follow-up).
Besides tumor stage in the CUR-group and tumor location in the PAL-group, patient
characteristics (age, gender, chemotherapy administration) did not significantly differ
between groups. No significant differences were found in the PAL-group regarding
OS (Log-Rank [L-R] 0.178, p=0.183), and the number of overall major complications
(p=0.445). In the PAL-group both the initial (12% vs. 48%, relative risk [RR] 1.68
[95% CI: 1.10-2.57]) and long-term stoma-rate (10% vs. 43%, RR 1.58 [95% CI: 1.08-
2.32]) were significantly less in stented patients. In the CUR group there were no
significant differences when stratified for tumor stage regarding OS (stage I&II L-R
0.046, p=0.831; stage III L-R 0.469, p=0.494; stage IV L-R 0.318, p=0.573) and RFS
(stage I&II p=0.84; stage III p=0.18; stage IV p=0.74). In the CUR-group there was no
difference in overall major complications (p=0.909). Initial stoma-rate was
significantly lower after stent placement (22% vs. 50%, RR 1.56 [95% CI: 1.13-2.15]),
while long-term stoma-rates did not differ (20% vs. 22%, RR 1.02 [95% CI: 0.831.24]).
Conclusion Despite concerns of potential tumor seeding after stent placement as
BTS, oncologic outcomes were not different from acute resection in this nonrandomized comparative study. Both treatment strategies are equal with regard to
major complications while stent placement does significantly reduce stoma-rates in a
palliative setting.