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A Case-Matched Comparative Study of Self-Expandable Metal Stent Placement and Acute Resection in the Management of Right-Sided Colonic Obstructions Femke J. Amelung*1,2, Werner Draaisma2, Esther Consten2, Peter D. Siersema1, Frank ter Borg3 1Gastroenterology, Academic Medical Centre Utrecht, Utrecht, Netherlands; 2Surgery, Meander Medical Centre, Amersfoort, Netherlands; 3Deventer Hospital, Deventer, Netherlands Background: Acute primary resection is the standard of care in all patients presenting with acute right-sided colonic obstruction (RSCO), but recent data suggest that a bridge to surgery approach using Self Expanding Metallic Stent (SEMS) placement may lead to lower mortality and morbidity rates. However, data regarding the safety of SEMS placement for RSCO is limited. Aim: To retrospectively compare outcomes of SEMS placement versus acute resection in patients with malignant RSCO. Methods: All consecutive patients that underwent SEMS placement for malignant RSCO were reviewed. SEMS placement is the standard of care at our institution in these patients and primary resection is only performed when a colonic perforation is suspected. All included SEMS patients were matched on a 1:4 basis according to age (±5), gender, ASA score, tumor location, surgical approach (open/laparoscopic) and pTNM-stage with patients treated with acute resection for RSCO. Controls were selected from a national database that prospectively registers all patients undergoing surgery for colorectal cancer. Results: In total, 41 patients received SEMS placement for RSCO. In 19 patients SEMS was initially placed as a palliative procedure, in 22 patients SEMS was placed as a bridge to elective resection. (Figure 1) Technical and clinical success rates following SEMS placement were 90.5% and 88.1%, respectively. When comparing the SEMS group to their matched controls undergoing primary resection for RSCO, no significant difference in morbidity and mortality rates, number of radical resections and number of primary anastomoses was found. However, in both the palliative and curative groups, patients treated with a SEMS were less likely to have a stoma constructed (p=0.04). No SEMS-related complications occurred in patients in whom SEMS was placed as bridge to surgery, whereas one stent-related perforation, three stent migrations and five stent re-obstructions were observed in the palliative group;. Three re-obstructions were treated with re-stenting, but all other patients with long-term complications required additional surgical interventions. Long-term SEMS success rate, defined as successful relief of obstructive symptoms by a SEMS until death, was therefore 52.6% (10/19 patients). Conclusion: SEMS placement for RSCO appears to be a relatively feasible and safe alternative for acute primary resection in both the curative and palliative setting. Stent placement provides rapid relief of obstruction and avoids stoma construction, which could positively influence quality of life. However, these benefits should be weighed against SEMS related morbidity and mortality, and the uncertainty about long-term oncologic risks of SEMS in curative patients.
Table 1| Study outcomes of SEMS compared to primary resection for acute right-sided colonic obstructions. Patients are subdivided based on treatment intend; palliative and curative since treatment algorithms differ between these two groups.
# Minor and major morbidity in the SEMS group include complictions after SEMS placement as well as the elective resection if conducted. Abbreviations: RSCO: right-sided colonic obstruction, SEMS: self-expanding metallic stent, DSCA: Dutch Surgical Colorectal Audit Figure 1| Flowchart of the patients in whom SEMS was placed Back to 2016 Annual Meeting |
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