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Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial)

Surgical Endoscopy volume 31, pages 3297–3305 (2017)Cite this article

Abstract

Background

The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction.

Methods

This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery.

Results

Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far.

Conclusions

Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

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Acknowledgements

The present study received endorsement by the European Association for Endoscopic Surgery.

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Affiliations

  1. Department of Surgical Sciences, University of Torino, corso Dogliotti 14, 10126, Turin, Italy

    Alberto Arezzo, Elisa Bannone, Edoardo Forcignanò, Marco Augusto Bonino & Mario Morino

  2. Hospital de la Sta Creu i St Pau, Barcelona, Spain

    Carmen Balague & Eduardo Targarona

  3. ASO Santa Croce e Carle, Cuneo, Italy

    Felice Borghi, Giorgio Giraudo & Luigi Ghezzo

  4. Hospital General Universitario, Elche, Italy

    Antonio Arroyo & Javier Sola-Vera

  5. Humanitas Gradenigo Hospital, Turin, Italy

    Paolo De Paolis & Maurizio Bossotti

  6. Division of Nuclear Medicine, University of Torino, Turin, Italy

    Roberto Passera

Authors
  1. Alberto Arezzo
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  2. Carmen Balague
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  3. Eduardo Targarona
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  4. Felice Borghi
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  5. Giorgio Giraudo
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  6. Luigi Ghezzo
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  7. Antonio Arroyo
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  8. Javier Sola-Vera
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  9. Paolo De Paolis
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  10. Maurizio Bossotti
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  11. Elisa Bannone
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  12. Edoardo Forcignanò
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  13. Marco Augusto Bonino
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  14. Roberto Passera
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  15. Mario Morino
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Corresponding author

Correspondence to Alberto Arezzo.

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Disclosures

Drs. Alberto Arezzo, Carmen Balague, Eduardo Targarona, Felice Borghi, Giorgio Giraudo, Luigi Ghezzo, Antonio Arroyo, Javier Sola-Vera, Paolo De Paolis, Maurizio Bossotti, Elisa Bannone, Edoardo Forcignanò, Marco Augusto Bonino, Roberto Passera, and Mario Morino have no conflicts of interest or financial ties to disclose.

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Arezzo, A., Balague, C., Targarona, E. et al. Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial). Surg Endosc 31, 3297–3305 (2017). https://doi.org/10.1007/s00464-016-5362-3

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  • DOI: https://doi.org/10.1007/s00464-016-5362-3

Keywords

  • Large bowel obstruction
  • Endoscopic stenting
  • Bridge to surgery
  • Emergency colorectal surgery
  • Randomized controlled trial