The largest randomised trial to examine the effectiveness of two surgical interventions for treating acute malignant bowel obstruction, a common symptom of patients with colorectal cancer, suggests that preoperative colonic stenting offers no clear benefit over emergency surgery. The findings, published Online First in The Lancet Oncology, also suggest that colonic stenting has the potential to worsen clinical outcome because of a higher rate of tumour perforations that might cause the cancer to spread.
Around 7% of patients with colorectal cancer present with a bowel obstruction. Emergency surgery is the standard treatment for these patients but is associated with high mortality and morbidity. A more recent technique called colonic stenting has been used as an alternative to emergency surgery to temporarily relieve the obstruction before elective surgery. Findings from non-randomised studies show that stenting can reduce mortality, morbidity, and the number of colostomies. However, it has been suggested that tumour perforation, a stent-related complication, could result in the spread of cancer cells with the potential to change a curable cancer into an incurable one.
Paul Fockens from the University of Amsterdam, Amsterdam, Netherlands and colleagues designed a randomised trial to compare the clinical effectiveness of preoperative colonic stenting with emergency surgery in patients with acute malignant left-sided colonic obstruction from 25 hospitals across the Netherlands.
Between 2007 and 2009, 98 patients were randomly assigned to receive colonic stenting (47) or emergency surgery (51) and their global health status assessed at regular intervals for up to 6 months using a quality of life questionnaire. Mortality, morbidity, and stoma rate were also recorded.
Two successive interim analyses showed an increased risk of death at 30 days in the stenting group, which led to the premature suspension of the study.
At 6 month follow-up, no differences were recorded between the treatment groups in global health status, quality of life, mortality and morbidity risk, or rates of colostomy.
Importantly, a high perforation rate of almost 20% (9 of 47 patients) was recorded in the colonic stenting group compared with an average perforation rate of 5% in previous published reports.
The authors conclude: "Colonic stenting can be used as an alternative to emergency surgery, but should be used with caution, mainly because of concerns of overt and silent perforations. Future studies need to further investigate oncological outcomes and establish whether specific groups of patients could have a greater benefit from either colonic stenting or emergency surgery."
In a Comment, Louis Wong Kee Song and Todd Baron from the Mayo Clinic, Rochester, USA, say: "The potential benefits of preoperative colonic stenting cannot be realised with a technical success rate of 70% and a perforation rate of 13%...Until these issues are addressed, endoscopic preoperative stenting might best be done in selected centres and in selected patients who are most likely to benefit. Such patients are probably those with the highest predicted preoperative morbidity and mortality, but further studies are needed to define the subgroup precisely."
Dr Paul Fockens, University of Amsterdam, Amsterdam, Netherlands. T) +31 20 5663534 E) p.fockens@amc.nl
Dr Todd Baron, Mayo Clinic, Rochester, USA. Via Mayo Clinic Public Affairs T) +1 507 284 5005 E) baron.todd@mayo.edu
For full Article and Comment see: http://press.thelancet.com/tlocolonic.pdf
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Journal
The Lancet Oncology