Transforming outcomes: the pivotal role of self-expanding metal stents in right- and left-sided malignant colorectal obstructions-bridge to surgery: a comprehensive review and meta-analysis

Colon stents as a bridge to emergency surgery

Article information

Clin Endosc. 2025;.ce.2024.120

Publication date (electronic) : 2025 February 3

doi : https://doi.org/10.5946/ce.2024.120

Sheza Malik ¹

, Priyadarshini Loganathan ²

, Hajra Khan ³

, Abul Hasan Shadali ⁴

, Pradeep Yarra ⁵

, Saurabh Chandan ⁶

, Babu P. Mohan^,⁷

, Douglas G. Adler ⁸

, Shivangi Kothari ⁹

¹Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA

²Department of Internal Medicine, UT Health, San Antonio, TX, USA

³Department of Internal Medicine, Rawalpindi Medical College, Rawalpindi, Pakistan

⁴Department of Internal Medicine, Government Kilpauk Medical College, Chennai, India

⁵Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA

⁶Department of Gastroenterology and Hepatology, CHI Creighton Medical Center, Omaha, NE, USA

⁷Department of Gastroenterology and Hepatology, Orlando Gastroenterology PA, Orlando, FL, USA

⁸Department of Gastroenterology and Hepatology, Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA

⁹Department of Gastroenterology and Hepatology, University of Rochester, Rochester, NY, USA

Correspondence: Babu P. Mohan Department of Gastroenterology and Hepatology, Orlando Gastroenterology PA, 1507 S Hiawassee Rd, STE 105, Orlando, FL 32835, USA E-mail: dr.babu.pm@gmail.com

Received 2024 May 10; Revised 2024 June 25; Accepted 2024 July 10.

Abstract

Background/Aims

Self-expanding metallic stents (SEMS) are an alternative to emergency surgery (ES) for malignant colorectal obstruction. This study aimed to compare surgical outcomes between SEMS as a bridge to surgery (BTS) and ES in patients with malignant colorectal obstruction.

Methods

A comprehensive database search was conducted until October 2023 to compare outcomes between SEMS as a BTS and ES. A subgroup analysis of results by malignancy site was performed.

Results

We analyzed 57 studies, including 7,223 patients over a mean duration of 35.4 months. SEMS as a BTS showed clinical and technical success rates of 88.0% (95% confidence interval [CI], 86.1%–90.1%; I²=68%) and 91.6% (95% CI, 89.7%–93.7%; I²=66%), respectively. SEMS as a BTS revealed reduced postoperative adverse events (odds ratio [OR], 0.51; 95% CI, 0.41–0.63; I²=70%; p<0.001) and 30-day mortality (OR, 0.52; 95% CI, 0.37–0.72; I²=10%; p<0.001) compared to ES. Subgroup analysis showed postoperative mortality of 5% and 1.5% for left- and right-sided malignancies, respectively. Adverse events were 15% and 33% for the right and left colon, respectively.

Conclusions

SEMS as a BTS demonstrated a higher success rate, fewer postoperative adverse events, and a reduced 30-day mortality rate than ES, supporting its use as the preferred initial intervention for right- and left-sided obstructions and indicating broader clinical adoption.

Keywords: Bridge to surgery; Colorectal neoplasm; Intestinal obstruction; Self-expanding metallic stents; Treatment outcomes

Graphical abstract

INTRODUCTION

Colon cancer is the fifth most common cancer responsible for malignancy-associated deaths.1 Approximately 8% to 29% of individuals with colorectal cancer (CRC) are diagnosed after presenting with acute bowel obstruction.2 Tumors located distal to the splenic flexure are usually implicated as a cause of acute obstruction, with the sigmoid colon being the most common location of obstruction.3 Up until a few years ago, emergency resection was the primary treatment method for patients presenting with acute malignant colonic obstruction; however, in the recent past, self-expanding metallic stents (SEMS) as a bridge to surgery (BTS) have emerged as a safer alternative with lower postoperative mortality and morbidity.4

Many individual studies have been published since 1990, when SEMS were introduced as a BTS for the palliative treatment of incurable colonic malignancies.5 For treatment with curative intent, stenting as a BTS is considered an alternative rather than the standard of care by both the European Society of Gastrointestinal Endoscopy and the American Society of Colon and Rectal Surgeons.6

Despite the recognized benefits of SEMS as a BTS over emergency surgery (ES), such as lower postoperative mortality, reduced permanent stoma rates, quicker recovery, and decreased need for maximally invasive surgery,1,2,4,6,7 the literature has largely overlooked comparing the success rate of primary anastomosis when SEMS is used as a BTS versus ES across the entire colorectal tract. Previous studies often focused on specific obstruction sites without a comprehensive analysis or omitted to specify the location altogether, leaving a critical gap in understanding the broader efficacy of SEMS across different colorectal obstruction sites. This study aimed to fill this notable gap by evaluating the impact of obstruction sites on surgical outcomes and, particularly, the success rate of primary anastomosis, offering a more nuanced understanding of SEMS as a pre-surgical intervention for right- and left-sided malignant colorectal obstructions.

METHODS

This study adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.8

Search strategy

We conducted a comprehensive search of several databases and conference proceedings, including PubMed, Ovid, Cochrane, and CINHAL databases (from earliest inception to October 2023). An experienced medical librarian, using inputs from the study authors, helped with the literature search to identify studies reporting SEMS as a BTS in patients with malignant colorectal obstruction. The detailed literature search strategy is provided in Supplementary Material 1. Three authors (HK, AHS, and PY) independently reviewed the title and abstract of studies identified in the primary search and excluded studies that did not address the research question based on pre-specified exclusion and inclusion criteria. The full text of the remaining articles was reviewed to determine whether they contained relevant information. Any discrepancy in article selection was resolved by consensus or through discussion with a co-author (BPM). The bibliographic section of the selected articles, as well as the systematic and narrative articles on the topic, were manually searched for additional relevant articles.

Study selection

In this meta-analysis, we included studies that focused on the outcomes of SEMS as a BTS in patients with malignant colorectal obstruction. All the studies, irrespective of malignancy site, reporting technical and clinical success, postoperative adverse events, mortality, and anastomotic insufficiency rate were included. We considered studies from all geographic locations and in any publication status (abstract or manuscript) as long as they contributed necessary data for our analysis. Studies lacking adequate data for outcome estimation were excluded. Comparative analysis was conducted against ES, including procedures such as emergency resection. For cases of multiple reports from the same patient cohort, we included data from the most recent and comprehensive publication.

Data abstraction and quality assessment

Data on study-related outcomes in the individual studies were abstracted independently into a standardized form by three authors (HK, AHS, and PY). The risk of bias was assessed in the included studies using the Newcastle Ottawa Scale for observational studies and the Jaded scale for randomized control trials (RCTs).

Outcomes assessed

The outcomes of interest were pooled rates of technical success, clinical success, postoperative adverse events, and 30-day mortality for SEMS as a BTS. Additionally, the pooled odds ratio (OR) of postoperative adverse events, 30-day mortality, and successful primary anastomosis with SEMS as a BTS versus ES were calculated. A subgroup analysis was planned based on the site of obstruction of the malignancy (right colon, left colon, unspecified).

Statistical analysis

We used meta-analysis techniques to calculate the pooled estimate in each case, following the methods suggested by DerSimonian and Laird9 using the random effects model; our application can be considered to align with their general approach, where the effect is measured by risk probability. When the incidence of an outcome was zero in a study, a correction of 0.01 was added to the number of incident cases before statistical analysis.10 We assessed heterogeneity between study-specific estimates using Cochran’s Q and I² statistics.11,12 In heterogeneity assessment, values of <30%, 30% to 60%, 61% to 75%, and >75% were suggestive of low, moderate, substantial, and considerable heterogeneity, respectively.13 Additionally, we calculated the 95% prediction interval, which deals with the dispersion of the effects. Publication bias was ascertained qualitatively by visual inspection of the funnel plot and quantitatively by the Egger test.14 All analyses were performed using the Comprehensive Meta-Analysis software ver. 4 (BioStat).

RESULTS

Search results and population characteristics

Of the 3,899 citations identified by our literature search, 1,935 titles were screened, and 351 full-length articles were assessed for eligibility. The final meta-analysis included 57 studies (47 observational and 10 RCTs). The schematic diagram of the study selection is illustrated in Supplementary Fig. 1.

Characteristics and quality of included studies

The meta-analysis included 57 studies, with a total of 7,223 patients, and 58% of them were female. Forty-seven studies were observational, and 10 were RCTs. Four, 31, and 22 studies assessed outcomes of SEMS as a BTS in patients with right, left, and right and left combined (unspecified site) malignant colorectal obstructions, respectively.

The mean follow-up duration for SEMS as BTS was approximately 29.04 months, whereas it was 33.23 months for ES. Supplementary Table 1 describes the baseline characteristics of the included studies.1-6,15-63 Supplementary Tables 2 and 3 provide a detailed quality assessment of the included studies.1-6,15-27,29-52,54-63

Meta-analysis outcomes

1) Cumulative pooled rates for SEMS as a BTS

The overall pooled clinical and technical success rates for SEMS as a BTS were 88.0% (95% confidence interval [CI], 86.1%–90.1%; I²=68%) and 91.6% (95% CI, 89.7%–93.7%; I²=66%), respectively (forest plot, Figs. 1, 2). Postoperative adverse events (i.e., surgical site infection, intra-abdominal abscess, sepsis, postoperative bleeding, postoperative ileus, urinary tract infection, thrombosis, intensive care unit admission, stent migration, stent occlusion, fistula formation, perforation, anastomotic dehiscence, anastomotic leakage, anastomotic stenosis, incisional hernia, cardiopulmonary complications [e.g., pneumonia and cardiac arrhythmia], tenesmus, abdominal-rectal pain, and stoma prolapse) and mortality rates for SEMS as a BTS were 21.6% (95% CI, 18.7%–24.9%; I²=89%) and 4.6% (95% CI, 3.7%–5.9%; I²=33%), respectively (forest plot, Figs. 3, 4). The anastomotic insufficiency rate (calculated from a number of non-successful anastomoses following SEMS/total number of anastomoses performed following SEMS) was 4.9% (95% CI, 3.9%–6.2%; I²=29%) for SEMS as a BTS (forest plot, Fig. 5).

Fig. 1.

Forest plot, pooled clinical success rate for self-expanding metallic stents as a bridge to surgery. CI, confidence interval.

Fig. 2.

Forest plot, pooled technical success rate for self-expanding metallic stents as a bridge to surgery. CI, confidence interval.

Fig. 3.

Forest plot, pooled postoperative adverse events rate for self-expanding metallic stents as a bridge to surgery. CI, confidence interval.

Fig. 4.

Forest plot, pooled 30-day postoperative mortality rate for self-expanding metallic stents as a bridge to surgery. CI, confidence interval.

Fig. 5.

Forest plot, pooled anastomotic insufficiency rate for self-expanding metallic stents as a bridge to surgery. CI, confidence interval.

2) Cumulative pooled OR

The pooled OR of postoperative adverse events favored SEMS as a BTS (OR, 0.51; 95% CI, 0.41–0.63; I²=70%; p<0.001) (forest plot, Fig. 6). Similarly, the OR for 30-day mortality was 0.52 (95% CI, 0.37–0.72; I²=10%; p<0.001) (forest plot, Fig. 7), and successful primary anastomosis favored stent placement as a BTS (OR, 3.31; 95% CI, 2.09–5.25; I²=67%; p<0.001) (forest plot, Fig. 8).

Fig. 6.

Forest plot, pooled odd ratio for postoperative adverse events. CI, confidence interval.

Fig. 7.

Forest plot, pooled odd ratio for 30-day mortality. CI, confidence interval.

Fig. 8.

Forest plot, pooled odd ratio for successful primary anastomosis. CI, confidence interval.

3) Subgroup analysis based on the site of obstruction

Subgroup analysis demonstrated high technical and clinical success pooled rates for SEMS as a BTS regardless of the site of obstruction. The pooled clinical success rate for SEMS as a BTS for right colon obstruction was 95.2% (95% CI, 90.3%–97.8%; I²=0%) compared to 89.0% (95% CI, 80.9%–89.9%; I²=73%) for left-sided colon obstruction. The technical success rate for SEMS as a BTS for the right- and left-sided colon obstruction was 95.2% (95% CI, 86.1%–98.4%; I²=35%) and 89.9% (95% CI, 85.8%–92.9%; I²=73%), respectively (Forest plot, Figs. 1, 2). Postoperative mortality rates for SEMS as a BTS were 5% (95% CI, 3%–6%; I²=34%) and 1.5% (95% CI, 0.4%–5%; I²=0%) for left- and right-sided malignancy, respectively (forest plot, Fig. 4). Postoperative adverse events for SEMS as a BTS were 15% (95% CI, 10%–21%; I²=0%) for the right colon and 33% (95% CI, 30%–35%; I²=91%) for the left colon (forest plot, Fig. 3). Comparing postoperative adverse events between SEMS as a BTS and ES, OR favored SEMS across all subgroups with OR, 0.28 (95% CI, 0.14–0.55; I²=0%; p<0.001) for right-sided vs. OR, 0.55 (95% CI, 0.41–0.74; I²=65%; p<0.001) for left-sided obstruction (forest plot, Fig. 6).

Validation of meta-analysis results

1) Heterogeneity and sensitivity analysis

To assess the possible dominant effect of individual studies on the meta-analysis, we excluded one study at a time and analyzed the resulting effect on the main summary estimate. No single study significantly affected the outcomes of interest or the heterogeneity. Table 1 shows the I²% values for all the studied pooled outcomes alongside the pooled rates. Subgroup sensitivity analyses based on the study design and geography are summarized in Tables 2 and 3.

Table 1.

Meta-analysis of colonic stent placement outcomes in malignant colorectal obstruction: pooled rates and comparisons

Table 2.

Subgroup analysis based on study design

Table 3.

Subgroup analysis based on location

2) Publication bias

Egger's regression output, with an intercept of –1.08405 and a two-tailed p=0.04, signifies the presence of publication bias in our meta-analysis, suggesting an under-representation of smaller or negative studies. The results are summarized in Table 4 and illustrated in Figure 9.

Table 4.

Eggers regression analysis including publication bias

Fig. 9.

Funnel plot for the postoperative adverse events between the emergency surgery vs. self-expanding metallic stents as a bridge to surgery for colorectal cancer obstruction.

DISCUSSION

Our systematic review and meta-analysis evaluated the efficacy of SEMS as a BTS for malignant colorectal obstruction. The pooled results demonstrated excellent clinical (89%) and technical success (91.6%) rates and reduced the likelihood of postoperative adverse events and 30-day mortality, regardless of the site of colonic obstruction. The successful primary anastomosis was significantly greater when a colonic stent was deployed preoperatively.

Addressing the paramount concern of postoperative adverse events, our meta-analysis showed a pooled OR of 0.51, favoring SEMS as a BTS over ES. This convincing result aligns with the conclusions of previous studies1,2,16 and emphasizes that patients who underwent SEMS placement experienced significantly fewer complications compared to those who underwent traditional surgery. For instance, a meta-analysis conducted by Arezzo et al.17 demonstrated lower short-term overall morbidity and reduced rates of temporary and permanent stoma formation with SEMS placement. Similarly, a study by Jiménez-Pérez et al.64 reported an overall complication rate of 7.8%, including perforation, stent migration, bleeding, persistent colonic obstruction, and stent occlusion due to fecal impaction in 3%, 1.2%, 0.6%, 1.8%, and 1.2%, respectively. Additionally, in line with previous analyses,65,66 our study also demonstrated a reduced risk of 30-day mortality. These findings emphasize that SEMS offer an effective BTS treatment with an acceptable complication rate for patients with acute malignant colonic obstruction.

Another critical parameter influencing the choice between SEMS as a BTS and ES is the feasibility of achieving a successful primary anastomosis. Our analysis showed a significant advantage for stent placement, with an OR of 3.31, confirming and extending the results of previous studies.4,18 This suggests that patients who undergo SEMS placement are more likely to receive a successful primary anastomosis, avoiding the need for ostomies and potentially improving their overall quality of life postoperatively.

Meta-analyses comparing SEMS as a BTS and ES, which include both left- and right-sided colonic tumors, are sparse in the literature. Two meta-analyses published within the last 2 years compared SEMS as a BTS and ES in only the right-sided colon and included less than 20 studies.67,68 A meta-analysis published in 2020 compared surgical outcomes in patients with colonic malignancies regardless of site specification.66 Our study extends the literature by confirming and extending that stent implantation is effective regardless of the site of obstruction.65-68 This finding is crucial as it implies that the benefits of SEMS placement are not limited to a specific site in the colorectal tract, making it a versatile option for a variety of clinical scenarios.

Our systematic review and meta-analysis investigating the utilization of SEMS as a BTS for malignant colorectal obstruction, including both right- and left-sided CRC lesions, represents a significant advancement compared to prior meta-analyses.65-68 Although previous meta-analyses have reported on the efficacy of SEMS, our analysis uniquely illuminates a higher success rate for primary anastomosis when SEMS was used as a BTS and provides a more comprehensive understanding of the benefit of SEMS at different anatomic sites, an aspect that has been relatively understudied in previous studies.4,18

However, similar to previous meta-analyses,65-68 our study has some limitations. We encountered common challenges associated with large-scale studies of this nature. The inclusion of observational studies and RCTs could introduce bias into the analysis. Additionally, the significant heterogeneity observed in certain outcomes might be due to variations in study design, patient populations, and stent placement techniques. The strengths of this study lie in the careful selection of a large number of studies, along with subgroup analysis based on the site of malignancy. We believe the results of this study establish the role of SEMS in surgical candidates with malignant obstruction of the colon.

In conclusion, in our meta-analysis of 57 studies, including 7,223 patients, the use of SEMS as a BTS in patients with malignant colon obstruction was associated with excellent pooled clinical and technical success, with lesser chances of postoperative adverse events and 30-day mortality, regardless of the site of obstruction (right colon, left colon). Additionally, primary anastomosis was significantly better when SEMS was used preoperatively. In this day and age of healthcare, our study findings support that minimally invasive and clinically effective solutions to manage gastrointestinal conditions in a multidisciplinary manner are paramount for optimal patient outcomes.

Supplementary Material

Supplementary Material 1. Literature search strategy.

ce-2024-120-Supplementary-Material-1.pdf

Supplementary Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.

ce-2024-120-Supplementary-Fig-1.pdf

Supplementary Table 1. Baseline characteristics of the studies.

ce-2024-120-Supplementary-Table-1.pdf

Supplementary Table 2. Newcastle Ottawa scale for reporting observational studies.

ce-2024-120-Supplementary-Table-2.pdf

Supplementary Table 3. Jaded scale for reporting randomized control trials.

ce-2024-120-Supplementary-Table-3.pdf

Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2024.120.

Notes

Ethical Statements

Not applicable.

Conflicts of Interest

Douglas G. Adler is a consultant for Boston Scientific. The other authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: SM, BPM; Data curation: HK, AHS; Formal analysis: PL; Methodology: PL, BPM; Project administration: BPM; Resources: SM; Software: PL; Supervision: DGA, SK; Validation: BPM, SM; Visualization: DGA, SK, PY, SC; Writing–original draft: SM, PY, SC, SK; Writing–review & editing: all authors.

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Outcome	Pooled rate (95% CI)	Study (n)	p-value (for pooled ratio)	Heterogeneity (I² %)
Technical success (%)
Overall	91.6 (89.5–93.3)	50		66
Unspecified site	92.3 (89.6–94.3)	18		40
Right colon	95.2 (86.1–98.4)	5		35
Left colon	89.9 (64.2–97.8)	27		73
Clinical success (%)
Overall	88.9 (86–91.2)	21		68
Unspecified site	89.4 (84.9–92.7)	16		59
Right colon	95.3 (90.3–97.8)	5		0
Left colon	86 (80.9–89.9)	42		73
Postoperative adverse events (%)
Overall	29 (27–31)	48		89
Unspecified site	26 (24–28)	18		86
Right colon	15 (10–21)	4		0
Left colon	33 (30–35)	26		91
Complications: stent vs. surgery, OR (95% CI)
Overall	0.50 (0.40–0.623)	48	<0.001	70
Unspecified site	0.52 (0.37–0.73)	20	<0.001	70
Right colon	0.28 (0.14–0.55)	4	<0.001	0
Left colon	0.55 (0.41–0.74)	24	<0.001	65
Successful primary anastomosis, OR (95% CI)	3.31 (2.09–5.25)	30	<0.001	67
Postoperative mortality (%)
Overall	4.6 (3.7–5.9)	53		33
Unspecified site	4.5 (3.1–6.7)	16		37
Right colon	1.5 (0.4–5.1)	4		0
Left colon	5 (2.2–11.3)	23		34
30-Day mortality, OR (95% CI)	0.52 (0.37–0.72)	29	<0.001	10
Tumor recurrence rate, OR (95% CI)	1.04 (0.82–1.33)	21	0.69	42
Anastomotic insufficiency (%)	4.9 (3.9–6.2)	36		29

Study design	Clinical success rate (%, 95% CI)	I² (%)	Technical success rate (%, 95% CI)	I² (%)
Observational	89 (87–92)	54	92 (90–94)	63
RCTs	77 (59–89)	80	82 (70–90)	55

Location	Clinical success rate (%, 95% CI)	I² (%)	Technical success rate (%, 95% CI)	I² (%)
Asia	93 (91–96)	46	92 (88–94)	40
Europe	89 (85–92)	74	84 (78–88)	75
United States	88 (74–91)	68	87 (49–98)	82

Parameter	Value
Intercept	–1.08405
Standard Error	0.52233
95% lower limit (2-tailed)	–2.13544
95% upper limit (2-tailed)	–0.03265
t-value	2.07541
Degrees of freedom (df)	46
p-value (1-tailed)	0.02178
p-value (2-tailed)	0.04357