Comparison of Clinical Outcomes and Pathological Characteristics of Self-Expandable Stent Bridge to Surgery and Emergency Surgery in Obstructive Colon Cancer

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

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.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

It has been found that 8%-29% of colorectal cancers are obstructive. The use of “stent as bridge to surgery” is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

Serum Chemokine CXCL7 as a Potential Novel Biomarker for Obstructive Colorectal Cancer

Due to the lack of typical symptoms and signs and sensitive indicators for early diagnosis of obstructive colorectal cancer (OCRC), it is critically needed to find new novel biomarkers to ameliorate the management of OCRC patients. In this study, 472 blood samples were collected and measured by enzyme-linked immunosorbent assay (ELISA) to investigate the value of serum chemokine ligand 7 (CXCL7) in diagnosis and prognosis for OCRC patients. The median concentrations of CXCL7 in non-OCRC and OCRC were both higher than that in controls (both P < 0.05). Importantly, the median serum concentration of CXCL7 in OCRC was also higher than that in non-OCRC (P < 0.001). In all OCRC patients, the area under the curve (AUC) of CXCL7 was 0.918 with a sensitivity of 86.54% and a specificity of 81.87%. Similarly, the AUC of CXCL7 was 0.684 when the diagnostic test was performed between OCRC and CRC patients. CXCL7 had a higher AUC than other markers. The concentration of CXCL7 in 40 postoperative OCRC patients was higher than normal people and lower than preoperative patients. The median survival time was 62.00 months and the 5-year overall survival (OS) rate of the patients was 51.80% in all 155 OCRC patients. Multivariate Cox proportional hazard regression model analysis showed that high CXCL7 in serum was independent factors associated with poor OS of OCRC patients (HR = 2.216, P = 0.032). These results demonstrate that serum CXCL7 may be a potential biomarker both in diagnosis and prognosis for OCRC patients.

Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction

BACKGROUND

The use of a self-expandable metallic stent (SEMS) as a bridge to surgery has increased for patients with obstructing colorectal cancer. However, relatively few reports have compared SEMS as a bridge to elective surgery for acute malignant obstruction of the right-sided colon (MORC) vs. emergency surgery (ES). This study aimed to evaluate the benefits of elective surgery after SEMS placement vs. ES for patients (including stage IV cases) with acute MORC.

METHODS

Patients with acute MORC who underwent radical resection for a primary tumour from July 2008 to November 2016 at Zhongshan Hospital of Fudan University were retrospectively enrolled. Postoperative short-term outcomes, progression-free survival (PFS), and overall survival (OS) were compared between the SEMS and ES groups.

RESULTS

In total, 107 patients with acute MORC (35 in the SEMS group and 72 in the ES group) were included for analysis. The Intensive Care Unit admission rate was lower (11.4% vs. 34.7%, P = 0.011), the incidence of complications was reduced (11.4% vs. 29.2%, P = 0.042), and the postoperative length of hospitalisation was significantly shorter (8.23 ± 6.50 vs. 11.18 ± 6.71 days, P = 0.033) for the SEMS group. Survival curves showed no significant difference in PFS (P = 0.506) or OS (P = 0.989) between groups. Also, there was no significant difference in PFS and OS rates between patients with stage II and III colon cancer. After colectomy for synchronous liver metastases among stage IV patients, the hepatectomy rates for the SEMS and ES groups were 85.7% and 14.3%, respectively (P = 0.029). The hazard ratio for colectomy alone vs. combined resection was 3.258 (95% CI 0.858-12.370; P = 0.041).

CONCLUSION

Stent placement offers significant advantages in terms of short-term outcomes and comparable prognoses for acute MORC patients. For synchronous liver metastases, SEMS placement better prepares the patient for resection of the primary tumour and liver metastasis, which contribute to improved survival.

Perineural invasion is increased in patients receiving colonic stenting as a bridge to surgery: a systematic review and meta-analysis

BACKGROUND

In recent years, there has been growing concern about the potential association of stent placement as a bridge to surgery in malignant colon obstruction and some anatomopathological findings that could lead to worsening long-term cancer outcomes, such as perineural, vascular and lymphatic invasion. The aim of the present review was to assess the pathological changes found in surgical specimens after stent placement for obstructing colon cancer vs. emergency surgery, and the impact of perineural invasion on survival rates METHODS: MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed four meta-analyses to estimate the pooled effect sizes using a random effect model. The outcomes were perineural, vascular and lymphatic invasion rates, and 5-year overall survival rate in patients with obstructive colon cancer, depending on the presence or absence of perineural invasion.

RESULTS

Ten studies with a total of 1273 patients were included in the meta-analysis. We found that patients in the stent group had a significantly higher risk of perineural (OR 1.98, 95% CI 1.22-3.21; p = 0.006) and lymphatic invasion (OR 1.45, 95% CI 1.10-1.90; p = 0.008). Furthermore, patients with positive perineural invasion had almost twice the risk of dying compared to those with no perineural invasion (HR 1.92, 95% CI 1.22-3.02; p = 0.005).

CONCLUSIONS

Stent placement as a bridge to surgery in colorectal cancer patients modifies the pathological characteristics such as perineural and lymphatic invasion, and this may worsen the long-term prognosis of patients. The presence of perineural infiltration in obstructed colon cancer decreases the long-term survival of patients.

Evaluation of Postoperative Serum MACC1 in the Prognosis of Laparoscopic Complete Mesocolic Excision for Colon Cancer

BACKGROUND

To investigate the correlation between postoperative serum metastasis-associated in colon cancer-1 (MACC1) and prognosis of colon cancer patients after laparoscopic complete mesocolic excision (CME).

MATERIALS AND METHODS

A total of 280 colon cancer patients undergoing laparoscopic CME were included. The 40-month disease-free survival, progression-free survival, and overall survival were calculated.

RESULTS

Immunohistochemical staining, western blotting, and quantitative real-time polymerase chain reaction results showed that the MACC1 expression in cancer tissues was significantly higher than adjacent tissues (P<0.05). Compared with the small interfering RNA-negative control group, the tumor weight, tumor volume, and tumor number were all significantly decreased after treatment with small interfering RNA-MACC1 (P<0.05). Survival analysis showed that compared with the low MACC1 group, the disease-free survival (χ2=30.095, P<0.001), progression-free survival (χ2=50.027, P<0.001), and overall survival (χ2=53.861, P<0.001) in the high MACC1 group all decreased significantly.

CONCLUSION

Postoperative serum MACC1 has a potential value for evaluating the prognosis of patients undergoing laparoscopic CME.