From the Guidelines
Colonic stenting plays a significant role in the management of colorectal cancer (CRC), particularly in palliating obstructing left colon cancer and potentially as a bridge to elective surgery.
Key Points
- Palliation of obstructing left colon cancer: Self-expanding metallic stents (SEMS) are preferred to colostomy due to similar mortality/morbidity rates and shorter hospital stays 1.
- Bridge to elective surgery: SEMS can be a valid option in selected cases, offering better short-term outcomes with lower stoma rates, although long-term oncological evidence is still insufficient 1.
- Technical challenges and limitations: Right colon stenting is considered technically challenging, and future comparative studies are needed to develop evidence-based recommendations 1.
- Alternative treatments and considerations: Alternative treatments to SEMS should be considered in patients eligible for bevacizumab-based therapy, and involvement of the oncologist in decision-making is strongly recommended 1.
- Guideline recommendations: There is no consensus on whether stents should be inserted endoscopically, radiologically, or by using a combination of the two techniques, and limited guidance on the proximal limit of stenting 1.
Evidence Summary
The use of SEMS in CRC management is supported by several studies, including randomized controlled trials (RCTs) and meta-analyses 1. However, the evidence is not uniform, and some studies have reported conflicting results, such as the Dutch Stent-in I multicenter RCT, which was terminated prematurely due to a high incidence of stent-related perforations 1.
Clinical Implications
In clinical practice, the decision to use SEMS in CRC management should be made on a case-by-case basis, taking into account the patient's overall condition, the location and severity of the obstruction, and the availability of expertise and resources.
Important Considerations
The correlation between chemotherapy with bevacizumab and stent-related perforation is a significant concern, and alternative treatments should be considered in patients who are being treated with or are expected to be commenced on antiangiogenic drugs 1.
From the Research
Role of Colonic Stenting in Colorectal Cancer (CRC)
- Colonic stenting is used as a bridge to surgery in malignant large bowel obstruction, reducing initial morbidity and mortality rate associated with emergency surgery 2.
- The technical success rate for stenting as a bridge to surgery is high, with a rate of 92% reported in one study 2.
- Colonic stenting allows for full staging of the neoplastic process and optimization of the patient for surgery, with a 5-year overall survival of 53.5% reported in one study 2.
- The use of self-expandable metallic stents (SEMS) as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful, but further research is needed for its application in cases of right-sided colon cancer 3.
Benefits and Risks of Colonic Stenting
- Colonic stenting can reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes 3.
- The procedure can also reduce the rate of stoma formation and increase the rate of laparoscopic resections with low complication rates 2.
- However, colonic stenting also has limitations and potential complications, including stent migration, re-obstruction, and perforation 3, 4.
- The risk of technical or clinical failure is significant, at around 25% 4.
Outcomes and Survival
- The median overall survival rate of patients with stage 2-3 colorectal cancer who underwent colonic stenting as a bridge to surgery was 53.1 months, and 37.1 months for those with stage 4 disease 5.
- Colonic stenting can improve quality of life, shorten hospital stays, and decrease healthcare costs, especially in the palliative setting 6, 4.
- However, perforations may raise local recurrence and mortality rates, and the timing of curative surgery after SEMS placement remains inconclusive 3, 4.