Global Use and Outcomes of Endoscopic Stenting in Acute Malignant Left-Sided Colonic Obstruction: A Secondary Analysis of APOLLO, An International, Prospective Cohort Study

BACKGROUND: Endoscopic colonic stents are an alternative to surgical decompression for obstructing colorectal cancer.

OBJECTIVE: To characterize the global use of endoscopic stents in the setting of acute left-sided colonic obstruction.

DESIGN: A prospective, international, multicenter cohort study.

SETTINGS: At 179 centers performing colorectal surgery across 37 countries.

PATIENTS: This study enrolled consecutive adult patients presenting acutely with colorectal cancer between January and June 2023 with malignant left-sided obstruction.

INTERVENTIONS: Patients were managed nonoperatively, with endoscopic stenting, or with surgery.

MAIN OUTCOME MEASURES: The primary outcome was 90-day mortality, and the secondary outcomes were days alive and out of hospital at 90 days and 90-day unplanned readmission. Propensity score matching and multilevel multivariable regression were used.

RESULTS: Of 516 patients who presented acutely with obstructing left-sided colon cancer (median age 69 years; 44% women; median Clinical Frailty Score 3.0), 47 (9.1%) were managed nonoperatively, 54 (10.5%) were managed with colonic stenting, and 415 (80.4%) were managed surgically. Stenting was predominantly performed in high-income countries (96.3%). After stenting, 5 patients (9.3%) had immediate complications, and an additional 4 patients (7.4%) had stent-related complications within 90 days (compared to a 20.5% major postoperative complications rate after surgery). On univariable analysis, there was no difference in 90-day mortality (14.8% after stenting vs 11.6% after surgery; difference: 3.25%, 95% CI, -4.7% to 15.4%), with clinically similar days alive and out of hospital at 90 days (median 82 vs 79 days). After propensity score matching and multilevel, multivariable adjustment, the stenting group had a statistically similar hazard of mortality compared to the surgery group (adjusted HR 0.34; 95% CI, 0.08-1.36).

LIMITATIONS: These were observational data, subject to selection bias. In addition, CIs around survival estimates were wide.

CONCLUSIONS: Endoscopic stenting is rarely used outside high-income countries but offers lower short-term morbidity and comparable 90-day outcomes to surgery.