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Original Investigation
January 8, 2020

Comparison of Decompressing Stoma vs Stent as a Bridge to Surgery for Left-Sided Obstructive Colon Cancer

Author Affiliations
  • 1Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
  • 2Cancer Center Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 3Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
  • 4Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
  • 5Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
  • 6Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
  • 7Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
  • 8Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
JAMA Surg. Published online January 8, 2020. doi:10.1001/jamasurg.2019.5466
Key Points

Question  Is a decompressing stoma better than self-expandable metal stent as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer?

Findings  In this cohort study of 443 patients with left-sided obstructive colon cancer, after propensity score matching, patients treated with a decompressing stoma had a longer hospital stay during the bridging interval, more primary anastomoses, more stomas after resection, fewer major resection–related complications, and more subsequent interventions. No significant differences in locoregional recurrence, disease-free survival, and overall survival were found.

Meaning  The findings suggest that equipoise still exists in the management of left-sided obstructive colon cancer.

Abstract

Importance  Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce.

Objective  To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching.

Design, Setting, and Participants  This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019.

Exposures  Decompressing stoma vs SEMS as a bridge to surgery.

Main Outcomes and Measures  Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection.

Results  A total of 3153 of the eligible 4216 patients were included in the study (mean [SD] age, 69.7 [11.8] years; 1741 [55.2%] male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing SEMS had more primary anastomoses (104 of 121 [86.0%] vs 90 of 120 [75.0%], P = .02), more postresection stomas (81 of 121 [66.9%] vs 34 of 117 [29.1%], P < .001), fewer major complications (7 of 121 [5.8%] vs 18 of 118 [15.3%], P = .02), and more subsequent interventions, including stoma reversal (65 of 113 [57.5%] vs 33 of 117 [28.2%], P < .001). After DS and SEMS, the 3-year locoregional recurrence rates were 11.7% for DS and 18.8% for SEMS (hazard ratio [HR], 0.62; 95% CI, 0.30-1.28; P = .20), the 3-year disease-free survival rates were 64.0% for DS and 56.9% for SEMS (HR, 0.90; 95% CI, 0.61-1.33; P = .60), and the 3-year overall survival rates were 78.0% for DS and 71.8% for SEMS (HR, 0.77; 95% CI, 0.48-1.22; P = .26).

Conclusions and Relevance  The findings suggest that DS as bridge to resection of left-sided obstructive colon cancer is associated with advantages and disadvantages compared with SEMS, with similar intermediate-term oncologic outcomes. The existing equipoise indicates the need for a randomized clinical trial that compares the 2 bridging techniques.

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