April's 2023 'Paper of the Month' presents a randomized clinical trial on colorectal endoscopic stenting (CReST) for obstructing left-sided colorectal cancer.
Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial
CReST Collaborative Group
Br J Surg. 2022 Oct 14;109(11):1073-1080. doi: 10.1093/bjs/znac141.
What is known about the subject?
The optimal treatment approach for patients with obstructive colon cancer lacks evidence to make strong recommendations on whether the patients should undergo emergent stoma formation (with/without colectomy) versus stent placement as a bridge to definitive surgery. The NCCN guidelines [1] for resectable obstructing colon cancer recommend either resection with diversion, or diversion alone or stent (in selected cases) followed by colectomy, while the ESMO guidelines recommend stenting only in expert centres and especially in frail patients with greater risk of postoperative complications. [2]
What does the study add?
This was a multicentre randomized trial, involving 245 participants from 39 hospitals. Stenting was attempted in 119/123 allocated patients, achieving relief of obstruction in 98 of 119 (82.4%). Overall postoperative complications were similar in the two groups (32.5% in the stenting group vs 37.7% in the surgery group) as well as major complication (defined as Clavien-Dindo >III) rate (17.9% and 22.1%). There were no significant differences in length of stay and type of complications. Six-month mortality, overall mortality, as well as recurrence rates at three years did not differ significantly between groups. Recurrence rates were 47/110 and 36/107 in the stenting and surgical groups respectively. At one year of follow-up, 44.5% of patients in the stenting group and 66.4 % in the surgery group had stomas (P = 0.001).
Implications for colorectal practice
The use of stents for obstructing colon cancer as a bridge to definitive treatment reduces stoma rates at one year with no significant increase in morbidity, mortality, and recurrence rates compared to surgical intervention (either colectomy and diversion or diversion alone). Based on the results of two previous trials that were prematurely terminated due to low stent insertion success rates and high stent-related complication rates, there has been a certain reluctance to routinely recommend stenting for obstructing colon cancer. The authors of the CREST trial suggest that possible explanations for low failure rates in the stenting group were shared experience, stenting workshops, and protocol-driven procedures. Therefore, stenting can be considered in patients with obstructing colon cancer especially when there is doubt regarding whether the disease is resectable or a specialist colorectal surgeon is not available.
References
- NCCN Guidelines Version 1.2023, Colon Cancer, https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf, accessed on 10/4/2023
- Argilés G, Tabernero J, Labianca R, Hochhauser D, Salazar R, Iveson T, Laurent-Puig P, Quirke P, Yoshino T, Taieb J, Martinelli E, Arnold D; ESMO Guidelines Committee. Electronic address: This email address is being protected from spambots. You need JavaScript enabled to view it.. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2020 Oct;31(10):1291-1305. doi: 10.1016/j.annonc.2020.06.022. Epub 2020 Jul 20. PMID: 32702383.
- Pirlet IA, Slim K, Kwiatkowski F, Michot F, Millat BL. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc 2011;25:1814–1821
- van Hooft JE, Bemelman WA, Oldenburg B, Marinelli AW, Lutke Holzik MF, Grubben MJ et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol 2011;12:344–352