Self-Expanding Metal Stents as an Alternative to Palliative Surgery in Advanced Obstructive Colorectal Cancer—A Systematic Review and Meta-Analysis

TL;DR

Self-expanding metal stents (SEMSs) offer a less invasive alternative to surgery for relieving bowel blockage in advanced colorectal cancer, but may lead to worse long-term outcomes.

Contribution

A systematic review and meta-analysis comparing SEMS placement with palliative surgery in obstructive colorectal cancer.

Findings

SEMS placement had lower early complications and shorter hospital stays compared to surgery.

Surgery was associated with higher clinical success and lower late complications.

Surgery improved overall survival, suggesting SEMS may be less favorable for patients with longer life expectancy.

Abstract

The diagnosis of colorectal cancer in more advanced stages, especially in younger patients where the diagnosis usually occurs because of obstructive complications, has prompted the development of less invasive, more rapid and well tolerated methods of decompression as an alternative to the standard surgical approach. As such, self-expanding metal stents (SEMSs) have gained wide acceptance for the palliative alleviation of obstructive symptoms in patients with advanced colorectal cancer. The purpose of this study was to evaluate SEMS placement against various forms of palliative surgical procedures in terms of effectiveness, morbidity, mortality and oncologic results. We conducted a systematic search of PubMed, Web of Science, Cochrane Library and Medline for articles describing patients with incurable locally advanced obstructive colorectal cancer who underwent surgery or self-expanding metal stent placement as a palliative procedure for the alleviation of symptoms. Eighteen studies (1606 patients) were included in a pooled meta-analysis. In the surgery group the clinical success was slightly higher (98.62% vs. 94.92%; OR = 0.35, 95%CI [0.16–0.73], p = 0.005) and the late complications rate was lower (13.9% vs. 24.0%; OR = 3.01, 95%CI [2.06–4.39], p < 0.00001). The SEMS placement was associated with a lower early complication (11.3% vs. 28.1%; OR = 0.34, 95%CI [0.19–0.58], p = 0.0001) and a shorter length of hospital stay (SMD = −1.94, 95%CI [−2.76, −1.12], p < 0.00001). In terms of the oncologic results, surgery was significantly associated with an increased overall survival regardless of the type of procedure (OR = 1.24, 95%CI [1.08–1.42], p = 0.002). Although having lower early morbidity and mortality rates, SEMS placement was associated with an increased chance of late complications and a worse overall survival, thus making them avoidable when patients have longer life expectancies. Due to the lower early complications rates, SEMSs might still have a place in the management of selected cases with bowel obstruction.

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