Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?
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SIRC INVITED REVIEW
Obstructing Left‑Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere? Augusto Lauro1 · Margherita Binetti1 · Samuele Vaccari2 · Maurizio Cervellera1 · Valeria Tonini1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract For the 8–29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with welldemonstrated superiority. Keywords Colorectal cancer · Left-sided obstruction · Emergency surgery · SEMS · “Bridge to Surgery” · Short-term outcomes · Long-term outcomes · International guidelines Abbreviations CRC Colorectal cancer CT Computed tomography SEMS Self-expandable metallic stent ES Emergency surgery BTS Bridge to surgery MOF Multiorgan failure MRI Magnetic resonance imaging TS Technical success CS Clinical success ASGE American Society for Gastrointestinal Endoscopy ESGE European Society of Gastrointestinal Endoscopy * Samuele Vaccari [email protected] Augusto Lauro [email protected] 1
Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
Department of Surgical Sciences, Umberto I University Hospital - La Sapienza, Rome, Italy
2
PFS Progression-free survival OS Overall survival DFS Disease-free survival
Introduction CRC is one of the most frequent and deadly malignancies worldwide [1]. Despite screening efforts aimed at achieving an early diagnosis, > 33% of CRC initially manifests as a clinical complication, most frequently obstruction, perforation, and bleeding [2, 3]. Among CRC, 8–29% are initially complicated by obstruction [4] and manifest as bloating, pain, obstipation, and vomiting. Although emergency
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