American Journal of Gastroenterology ISSN 0002-9270 C  2004 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2004.40017.x Published by Blackwell Publishing Pooled Analysis of the Efficacy and Safety of Self-Expanding Metal Stenting in Malignant Colorectal Obstruction Shaji Sebastian, Sean Johnston, Tony Geoghegan, William Torreggiani, and Martin Buckley Departments of Gastroenterology; Gastrointestinal Surgery; and Interventional Radiology, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland BACKGROUND: Self-expanding metal stents have been used in the management of colorectal obstruction as an alternative to emergency surgery. Our aim was to systematically review the efficacy and safety of these stents in the setting of malignant colorectal obstruction. METHODS: Both English and foreign language reports were identified from Medline, Embase, Cancerlit, Science Citation Index, Cochrane Library, and proceedings of relevant meetings. Data were collected on technical success, clinical success, and safety parameters. RESULTS: Fifty-four studies reported the use of stents in a total of 1,198 patients. The median technical and clinical success rates were 94% (i.q.r. 90–100) and 91% (i.q.r. 84–94), respectively. The clinical success when used as a bridge to surgery was 71.7%. Major complications related to stent placement included perforation (3.76%), stent migration (11.81%), and reobstruction (7.34%). Factors related to an increased complication risk were identified. Stent-related mortality was 0.58%. Limited available data suggest that this approach may be cost effective in the preoperative setting. CONCLUSION: Placement of self-expanding metal stents is an effective and safe definitive procedure in the palliation of malignant colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating safer single-stage surgery. (Am J Gastroenterol 2004;99:2051–2057) INTRODUCTION There are over 300,000 new cases of colorectal cancers di- agnosed annually in the western world, of which 150,000 die each year (1, 2). It has been estimated that 7–29% of patients with colorectal cancer present with near or complete bowel obstruction and patients presenting with obstruction tend to have more advanced disease (3). Several studies have shown that bowel obstruction negatively influences the outcome of affected patients who survive the postoperative period, when compared to those who present without obstruction, even when those undergoing palliative surgery are excluded from the analysis (4). Although malignant obstruction of the large bowel is con- sidered a surgical emergency, there is ongoing controversy on the initial therapeutic approach to these patients. Mortality and morbidity figures for emergency surgical decompression in this context are 15–20% and 45–50%, respectively, as op- posed to a mortality rate of 0.9–6% for elective surgery (5, 6). These high figures are a reflection of, not only the ad- vanced stage of the neoplasm, but also of electrolyte im- balances, deficient nutritional status, and fecal loading of the unprepared colon (5). Despite the initial enthusiasm and acceptance by some of the techniques of intraopera- tive colonic lavage, resection, and primary anastomosis, high morbidity and mortality rates have been reported following primary resection and anastomosis in emergency conditions (7, 8). In addition, curative resection is not feasible in up to 30% of patients who present with malignant colonic ob- struction due to extensive local tumor infiltration, distant metastasis, and severe comorbidity (9). Consequently, a two- stage surgical procedure is often performed in these pa- tients and this involves creation of a temporary colostomy stoma. Colostomy is associated with significant complica- tions in malignant obstructions where patients are often el- derly, frail, and have significant comorbid conditions (10). There are data to conclude that the stoma has an adverse effect on the quality of life of these patients (11). More im- portantly, reversal of stoma is not performed in up to 50% of patients in the setting of malignant disease (12). Placement of self-expanding metal stents was described in the early 1990s by Dohmoto et al. (13). Over the last decade there has been increasing popularity of stenting, particularly with the availability of more sophisticated stents and stent- delivery systems (14). They have been used as a definitive palliative procedure and also as a bridge to surgery to allow a single-stage surgical procedure later (15). However, no ran- domized controlled trials have been performed yet and hence 2051