Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction: a meta-analysis of randomized control trials

Abstract

Background:Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, is still a concern. Aim: The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS). Methods: Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to March 2017, were retrieved from the Pubmed and Embase database. The primary endpoints were the safety parameters: overall morbidities, 30-day mortality and recurrence rates. The secondary endpoints were the disease-free and overall survival rates and the permanent stoma rates. Results: There were nine eligible publications from seven RCTs, involving a total of 448 patients. Two publications reported on the follow-up results of RCTs. Compared to EmS, BTS stent had a significantly less risk of overall complications, RR=0.605, 95% CI 0.382-0.958, p=0.032. The 30 day mortality rate was comparable between the two interventions. However, the overall recurrence rate was higher in the BTS stent group, 37.0% compared to 25.9%, RR =1.425, 95% CI 1.002-2.028, p=0.049. Subgroup analysis showed that BTS stent increased the risk of systemic recurrence, RR =1.627, 95% CI 1.009-2.621, p=0.046. The locoregional recurrence rates were comparable. This did not translate into significant difference in terms of three-years disease free survival and three-years overall survival. BTS stent had an advantage of lower risk of permanent stoma, RR=0.740, 95% CI 0.555-0.985, p=0.039. Conclusion: BTS stent has the advantage of lower overall morbidities and lower risk of permanent stoma. However, it was associated with higher chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor the best option for patients suffering from left-sided obstructing cancer of colon.