Liam Davenport

June 10, 2016

CHICAGO — Using a stent to unblock the bowel in left-sided colorectal cancer patients before surgery, rather than proceeding directly to emergency surgery, could significantly reduce the number of patients requiring a stoma, researchers say.

Approximately one-fifth of all colorectal cancer cases present as an emergency, and four-fifths of these patients have a colonic obstruction. The majority of these patients will undergo emergency surgery to unblock the obstruction, often resulting in a stoma and the need for a colostomy bag.

But researchers from the United Kingdom have shown that using a stent to unblock the bowel, instead of proceeding straight to emergency surgery, reduced the number of patients needing a stoma by almost 25%.

Importantly, stenting followed by surgery 1 to 4 weeks later had no impact on 30-day or 1-year postoperative mortality or critical care utilization, or on quality of life.

"Traditionally, doctors have worried that unblocking the bowel in this way could increase the chance of cancer spreading, but our early results don't show this," said lead researcher James Hill, MD, consultant general and colorectal surgeon at Central Manchester University Hospitals in the United Kingdom.

"We're also pleased to see that this could be a way of reducing the risk of patients needing a colostomy bag after their surgery, which is a huge improvement to patients' day-to-day lives," he added.

Dr Hill presented the findings here at the American Society of Clinical Oncology 2016 Annual Meeting.

Discussing the findings after the presentation, Larissa K.F. Temple, MD, surgical oncologist and colorectal surgeon at the Memorial Sloan Kettering Cancer Center in New York City, described the trial as "incredibly important," saying that "it informs our decisions on how to manage these patients."

She praised the researchers for having done a "wonderful job," and for showing that smaller procedures might be better for the patients. This is an example in surgery of where less is more, she said.

Dr Temple added a note of caution, however, saying: "I do believe that we have much more to do. Clearly, the stent group should have had better outcomes." Although the stoma rate was 46%, which is much better than the 70% that has been reported in the past, it is still high, and she said she feels that "we can do better."

Comparison of Stent vs Emergency Surgery

Because there is a degree of uncertainty about the efficacy and safety of endoluminal stenting, the researchers randomized 249 patients from 39 units with left-sided colonic obstruction needing urgent decompression and radiologic signs of carcinoma to either endoluminal stenting as a bridge to surgery 1 to 4 weeks later or emergency surgical decompression.

The patients, who were treated from 2009 to 2014, were required to be fit for surgery and to have clinical or radiologic evidence of obstruction. Exclusion criteria included signs of peritonitis and/or perforation, right iliac fossa tenderness and features of incipient cecal perforation, and rectal obstruction potentially requiring neoadjuvant therapy.

Relief of obstruction was achieved in 82% of stent patients, compared with almost 100% of those who underwent emergency surgery.

Crucially, there was a significant reduction in stoma formation in the stenting group, at 45% vs 69% with emergency surgery (P < .001).

The team found that 30-day postoperative mortality was similar between the stent and emergency-surgery groups (5.3% vs 4.4%), as was the length of hospital stay (5.5 vs 16.0 days).

There were no significant differences in scores on postoperative quality-of-life measures at 3 or 12 months, or in the use of critical care, between the stenting and emergency-surgery groups. There was also no difference in 1-year mortality between the two groups among the 92% of patients who were treated with curative intent.

Dr Hill explained that patients undergoing emergency surgery have a very dilated bowel, requiring a large incision that can cause increased pain after surgery. The dilated bowel is also edematous, with a diameter different than that below the obstruction.

Because the patients often have fluid and electrolyte imbalances, they typically need to go to the critical care unit after emergency surgery.

Dr Hill told Medscape Medical News: "The combination of the technical issues in joining edematous bowel of different diameters and the fact that the patient is acutely unwell and that healing may be impaired makes surgeons more reluctant to join the bowel together and instead bring the bowel out to the surface of the abdomen to form a stoma."

He added that, if a join is made and that fails, with bowel contents leaking out into the abdominal cavity, the patient can develop peritonitis, which carries a very high risk for morbidity and mortality.

Although stenting followed by surgery 1 to 4 weeks later requires two procedures, this approach could still be cost-effective, compared with emergency surgery, "if it reduces the stay in hospital."

He added: "Stoma care and stoma appliances are also very expensive and there can be a substantial saving by avoiding stomas."

Eliminating a stoma would have "a huge impact" on patients' lives, said Martin Ledwick, head of cancer information nurses at Cancer Research UK, which funded the research.

He added: "If longer-term follow-up and larger studies confirm these results, it is great news for bowel cancer patients who come to accident and emergency with bowel blockages."

The research was funded by Cancer Research UK. The authors have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2016 Annual Meeting: Abstract 3507. Presented June 5, 2016.

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