A comparison of self-expandable metal stent (SEMS) vs decompressing stoma (DS) as a bridge to surgery (BTS) for advanced left-sided obstructive colon cancer showed advantages and disadvantages for each, with oncologic outcomes that slightly favor DS, according to a study published in JAMA Surgery.
This cohort study of patients having surgery for non-locally advanced left-sided obstructive colon cancer was designed to compare outcomes with use of DS or SEMS as a bridge to surgery for obstructive colon cancer. Study outcomes and measures included disease-free survival, overall survival, locoregional recurrence, post-resection presence of a stoma, permanent stoma, primary anastomosis rate, complications, and additional interventions. One-to-one propensity score matching was performed to provide an optimal balance between the techniques; participants were matched on sex, age, body mass index, prior abdominal surgery, American Society of Anesthesiologists score, tumor location, length of stenosis, cM stage, pN stage, and year of resection.
After exclusions were applied to 4216 patients from 75 hospitals in the Netherlands who were eligible for the study, 443 participants were included and underwent bridge to surgery (240 DS and 203 SEMS). Outcome comparison analyses were based on the propensity-score–matched groups, which resulted in 2 groups of 121 participants each. Median hospital stay for the BTS interval for DS was 7 days (interquartile range [IQR], 5-12 days) compared with 4 days (IQR, 2-6 days) for SEMS (corrected odds ratio [cOR], 0.86; 95% CI, 0.79-0.92; P <.001). No differences were observed in BTS-related complications (cOR, 0.78; 95% CI, 0.29-2.09; P =.62; hazard ratio [HR], 0.80; 95%CI, 0.32-2.04; P =.64).
Compared with participants undergoing DS, participants undergoing SEMS had fewer post-resection stomas (34/117 [29.1%] vs 81/121 [66.9%]; cOR, 0.15; 95%CI, 0.07-0.32; P <.001), and less primary anastomoses (90/120 [75.0%] vs 104/121 [86.0%]; cOR, 0.41; 95%CI, 0.19-0.89; P =.02). Although there was no significant between-group difference for 90-day complication rate, participants undergoing SEMS had more major resection–related complications (18/118 [15.3%] vs 7/121 [5.8%]; cOR, 3.20; 95% CI, 1.17-8.74; P =.02). The 90-day mortality rates were 5.0% for SEMS and 1.7% for DS.
The median follow-up was 36 months (IQR, 15-59 months) for DS and 31 months (IQR, 15-56 months) for SEMS (cOR for follow-up time, 1.00; 95% CI, 0.99-1.01; P =.59)
After DS, the 3-year locoregional recurrence rate was 11.7% compared with 18.8% for SEMS, the 3-year disease-free survival rate for DS was 64.0% compared with 56.9% for SEMS, and the 3-year overall survival rate for DS was 78.0% compared with 71.8% for SEMS; however, these differences did not reach statistical significance. Permanent stoma rate also did not differ significantly between the groups (28.9% for DS vs 19.2% for SEMS; cOR, 0.63, 95% CI, 0.36-1.13; P =.12).
More subsequent interventions were seen for DS compared with SEMS (57.5% vs 28.2%; cOR, 0.28; 95% CI, 0.15-0.53; P <.001), but this did not remain significant after stoma reversals were excluded. Participants undergoing DS had a higher number of interventions, with a median of 3.0 interventions (IQR, 2.0-3.0) for SEMS compared with 2.0 (IQR, 2.0-3.0) for DS (cOR, 0.42; 95% CI, 0.25-0.72; P =.002). The total median hospital stay was longer for DS at 15 days (IQR, 11-23 days) compared with 13 days (IQR, 9-20 days) for SEMS.
Study investigators concluded, “This nationwide, propensity score-matched study comparing DS and SEMS for nonlocally advanced LSOCC revealed advantages and disadvantages of the 2 bridging techniques. Oncologic outcome was slightly in favor of DS, but statistical significance was not reached and follow-up was relatively short. Randomized clinical trials are indicated to determine the best BTS strategy considering the equipoise.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Veld JV, Amelung FJ, Borstlap WAA, et al. Comparison of decompressing stoma vs stent as a bridge to surgery for left-sided obstructive colon cancer [published online January 8, 2020]. JAMA Surg. doi: 10.1001/jamasurg.2019.5466