Gastrointestinal Intervention

Colonic cancer: The current role of stent insertion

Katherine Newton, James Hill

Additional article information


Acute colonic obstruction secondary to left-colonic malignancy remains a common emergency condition. Traditional management is emergency surgery and has high morbidity and mortality. Self expandable metallic stents (SEMS) promised to improve morbidity and mortality, stoma rates and hospital stay. SEMS use in the potentially curative setting, as a bridge to surgery, is associated with an improved stoma rate and morbidity, but has no mortality benefit. There are concerns about oncological safety with higher local recurrence rates, thus SEMS is not recommended in this setting unless the patient has increased surgical risk and would benefit from a period of recovery prior to surgery. SEMS has a definite role in the palliative setting, for both patients with incurable disease or those with a high surgical risk. SEMS is associated with improved morbidity, mortality, and stoma rates. The technique for SEMS insertion is now well established but it is still unclear whether covered or uncovered stents are better.

Keywords: Colonic neoplasms, Intestinal obstruction, Stents


Colorectal cancer is the third most common cancer in men and second most common in women; it accounts for 8% of all cancer deaths globally.1 Eight to thirteen percent of all colonic cancers present with large bowel obstruction.2,3 Of these obstructing cancers 75% are distal to the splenic flexure; the sigmoid colon being the most common location.4 The traditional management of malignant colonic obstruction is surgical resection (with primary anastomosis or stoma formation) which has both high morbidity (40%–50%) and mortality (15%–20%).5,6 In patients unfit for surgical resection, a defunctioning stoma only was typically performed. Endoscopically placed self expandable metallic stents (SEMS) have been increasingly used to relieve malignant enteral obstruction (oesophageal, biliary). SEMS have been used in colonic obstruction since the early 1990s, as both a bridge to elective surgery and as palliation. Early cohort studies suggested that SEMS use was associated with reduced mortality, morbidity and colostomy rates when compared with emergency surgery.710

Randomized controlled trials (RCTs), and meta-analyses have demonstrated convincing benefits for the use of SEMS in the palliative setting, but not where the SEMS has been used as a bridge to surgery in potentially curative cases.11 Importantly, in the latter scenario, concern has been raised following analysis of RCT follow-up data regarding the oncological impact of SEMS use.1214 It is only recently that there has been some clarity as to the most appropriate clinical indications for SEMS in malignant colonic obstruction.15

Proximal obstructing cancers (proximal to splenic flexure) are generally treated with resectional surgery.4,16 Although there are no RCTs to support this practice, surgery for right-sided colonic obstruction has lower morbidity and mortality than that for left sided obstruction, and SEMS placement is more challenging.15 Rectal cancers have been excluded from all but one of the published RCTs on stenting. Stenting for low rectal cancer is associated with stent migration, tenesmus, pain and incontinence. Thus, much of the evidence applies to left sided colonic (distal to splenic flexure) cancers only.

The European Society of Gastrointestinal Endoscopy (ESGE) has published a clinical guideline on the use of SEMS in malignant colonic obstruction.15 This guideline is based on evidence and consensus opinion. General considerations based on clinical consensus rather than robust evidence are also included.

General Considerations and Technique

Contrast enhanced computed tomography (CT) scan is advised to diagnose malignant colonic obstruction (sensitivity 96%, specificity 93%).15 CT is also useful for accurately defining the level (94%) and aetiology (81%) of the obstruction, as well as local and distant disease staging in the majority of patients.1517 CT scanning will also reliably demonstrate if there is perforation at the site of tumour or caecum when stenting would be inappropriate. The diameter of the caecum also provides an indication of the urgency of decompression; caecal perforation is much more likely if there is a closed loop obstruction and when the diameter of the caecum is 14 cm or greater.

ESGE advise bowel preparation with an enema in order to clean the colon and rectum distal to the stricture prior to colonic SEMS insertion.15 Oral bowel preparation is relatively contraindicated with symptomatic bowel obstruction.

Colonic SEMS can be inserted using either through-the-scope (TTS) or the over-the-guidewire (OTW) technique. The TTS technique utilizes combined endoscopy (usually a double-channel gastroscope) and fluoroscopy to locate and cannulate the stricture. OTW technique uses fluoroscopic guidance and can be performed with additional endoscopic visualization or purely radiologically (uses a stiff guide-wire). Comparable success rates of combined endoscopic and fluoroscopic guidance and purely fluoroscopy have been demonstrated by retrospective studies.1820 However there is a trend towards better success rates with the combined technique hence ESGE recommend colonic SEMS placement with combined endoscopy and fluoroscopy.15

ESGE discourage dilatation of malignant colonic stricture, either before or after SEMS placement.15 It is suggested that dilatation may adversely affect patient outcomes following SEMS.2123 Systematic review and meta-analysis of retrospective data suggests an increased risk of perforation colonic perforation with stricture dilatation.24,25

Enteral SEMS may be covered or uncovered. In the setting of malignant colonic obstruction; the two designs are equally safe and effective. Two recent meta-analyses26,27 found similar technical success rate, clinical success and complication rates. Covered SEMS suffer higher slippage rates (21.3% vs 5.5%), but significantly lower tumour ingrowth (0.9% vs 11.4%).26,27

The size of the stent is important. Stent diameter of less than 24 mm increases the risk of stent related complications (perforation, re-obstruction and migration), especially stent migration.21,22 Whilst stent length per se does not seem to be important, the ESGE guidance is that the stent should traverse the stricture such that it extends 20 mm either side (after deployment).15

As with all technical procedures, there is a learning curve for colonic SEMS placement. Retrospective series22,28 and non-comparative studies29,30 have shown that stent outcome is affected by operator experience. Technical success rate (and use of fewer stents) significantly improves after 20 procedures.29,30 Thus colonic SEMS insertion should be performed or supervised by an operator with experience of 20 or more cases.15

Synchronous colorectal cancers occur in 3% to 4% of patients,31,32 thus expedient (within three months) visualization of the remaining colon after potentially curative resection for malignant obstruction is recommended.15 Preoperative CT colonography and colonoscopy through the stent both appear to be safe and feasible.3335

SEMS as a Bridge to Elective Surgery

The European Guidelines state that colonic SEMS placement is not recommended for routine use in the treatment of left-sided colonic malignant obstruction as a bridge to elective surgery.15 This guideline is based on the evidence from eight systematic reviews with meta-analysis comparing preoperative stenting with emergency resection for left-sided colonic malignant obstruction,11,3642 with assimilated data from up to seven RCTs.4349 Three of those RCTs were closed early due to adverse outcomes in the SEMS group (higher 30-day morbidity related to stent perforation),43,44 or high anastomotic leak rate in the emergency surgery group.48 The most recently published meta-analysis found that SEMS as a bridge to surgery (n = 195) compared to emergency surgery (n = 187) had a lower overall morbidity (33.1% vs 53.9%, P = 0.03), a higher successful primary anastomosis rate (67.2% vs 55.1%, P < 0.01), and a lower permanent stoma rate (9% vs 27.4%, P < 0.01); however, there was no statistical difference in post-operative mortality (10.7% vs 12.4%). This data suggests some advantages of SEMS use over emergency surgery, although with no difference in short-term mortality, the benefit of SEMS placement in this setting is less clear.

Importantly, there is some limited evidence that there may be worse long-term oncological outcomes after SEMS use. Early studies suggested an oncological compromise associated with tumour perforation or tumour cell dislodgement during SEMS insertion resulting in seeding of malignant cells.13 Manipulation of the tumour by the shearing forces of endoscopy and colonic insufflation is thought to disseminate tumour cells locally and into the circulation.43 Three RCTs have investigated long-term oncological outcome, all the sample sizes were small (15–26 patients in the SEMS groups), and found increased disease recurrence in the SEMS groups.12,46,48 Sloothaak et al12 reanalyzed the largest data set (from the Stent-In-2 trial in 2014). They excluded the benign cases and those with advanced disease (palliative). Median follow-up was 36 months. Loco-regional recurrence was reported in 9/32 (28%) in the surgery group and 13/26 (50%) in the SEMS group (8/20 unperforated SEMS [40%] and 5/6 perforated SEMS [83%]). Five-year recurrence was 25% in the surgery group and 42% in the SEMS group (P < 0.01). Cumulative incidence of overall disease recurrence was 26% in the surgery group, 34% in the unperforated SEMS group and 83% in the perforated SEMS group (P < 0.01).12 The concern therefore is that short-term gains would be negated by poorer long-term outcomes. If true, this would be an inappropriate trade off in patients fit enough to undergo surgery in whom the intent is curative. None of the studies have thus far, shown a reduced survival associated with increased disease recurrence.

Morbidity and mortality of emergency colonic resection remains high5,6 thus it is important to balance the long-term oncological risks of SEMS against the risks of surgery. In patients in whom the risk of surgery is higher than average (for example American Association of Anesthesiologists classification [ASA] III, or age > 70 years),50,51 SEMS as a bridge to elective surgery may still be appropriate management.15 It can convert an emergency into an elective operation and provide time for preoperative optimization of comorbidities and improvement in physiology. There is minimal data to suggest what the ideal time interval is between SEMS placement and elective surgery. The balance between allowing adequate recovery from the episode of bowel obstruction and improving nutritional status must be weighed against the increasing risk of stent complications with time. The ESGE guidelines suggest 5 to 10 days.15 An interval of 10 to 28 days is usual, but longer periods may be considered if the obstruction has coincided with serious medical complications, such as myocardial infarction.

Palliative SEMS

ESGE state that colonic SEMS placement is recommended in the palliation of malignant left-sided colonic obstruction.15

In the palliative setting, the clinical priorities for managing malignant colonic obstruction are clearly different to the potentially curative setting. The objectives of SEMS placement are shorter hospital stay, reduced morbidity and mortality and an improved quality of life. SEMS should be an ideal management option for obstructed patients who are unfit for surgery and those with either an unresectable primary tumour, and/or incurable metastatic disease and therefore reduced life-expectancy. An early RCT published in 2008 reported early and late stent related colonic perforation as up to 18% and 36% respectively raising concerns about SEMS use on this group.52

More recently two meta-analyses have assessed SEMS versus surgery in the setting of palliation of malignant left-sided colonic obstruction, in terms of short-term and long-term complications, hospital stay, 30-day mortality, and stoma rate.53,54 The larger study included data from 13 studies (n = 837; SEMS group n = 404, surgery group n = 433).54 Successful relief of obstruction was high in both groups, but lower in the SEMS group (99.8% vs 93.1%, P < 0.001). In SEMS treated patients, hospital stay was significantly shorter (18.8 days vs 9.6 days, P < 0.00001), and 30-day mortality was significantly lower (4.2% vs 10.5%, P = 0.01). Stoma formation rate is an important consideration in the palliative setting due to impact on quality of life. Permanent stoma rate was significantly lower in the SEMS group (13.0% vs 54.0%, P < 0.001). Stent related complications were common and included perforation (10.1%), migration (9.2%), and re-obstruction (18.3%). Surgery related complications included anastomotic leak (4.7%) and wound infection (5%). The overall complication rate was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the stent-related complications occurred later than the surgery-related complications (early complications: 13.7% vs 33.7%, P = 0.03; late complications: 12.7% vs 32.3%, P < 0.0001). Overall survival time of SEMS- and surgery-treated patients was similar (7.6 months vs 7.8 months).54 The evidence is sufficiently strong for the benefit of stenting in this situation that this service should be available to patients at the time of need.

Colonic SEMS placement in the palliative setting is associated with some important adverse events which can be divided into early and late complications. Early complications include perforation (range 0%–12.8%), stent failure (range 0%–11.7%), stent migration (range 0%–4.9%), re-obstruction (range 0%–4.9%), pain (range 0%–7.4%), and bleeding (range 0%–3.7%).15 Late complications include perforation (range 0%–4.0%), re-obstruction (range 4.0%–22.9%), and stent migration (range 1.0%–12.5%).15 Perforation may be associated with guide-wire or catheter positioning, dilatation of the malignant stricture during stent placement, stent induced direct or local perforation, or proximal colonic perforation due to excessive insufflation or inadequate decompression.15,55 Early perforation necessitates emergency surgery and may be associated with high mortality (reported as 50% in prospective and retrospective studies.56,57 Stent migration and re-obstruction (caused by either tumour in-growth or inadequate stent expansion) can usually be managed endoscopically. Stent-in-stent placement has reported success rates of 75% to 86% but there is a lack of data on long-term outcomes.21

Chemotherapy is known to prolong survival in palliative colorectal cancer. Shorter hospitalization and better 30-day mortality rate in SEMS use allows earlier start of chemotherapy treatment. Early evidence regarding chemotherapy use in stented patients was contradictory21,58 but there was concern that chemotherapy use may increase perforation rate. Retrospective series suggested an increased perforation rate in those treated with bevacizumab (an angiogenesis inhibitor) (17% 50%).22,57,59 A recent meta-analysis investigated risk factors for increased perforation rate.25 Chemotherapy without bevacizumab was not associated with a significantly increased risk (7.0%), but use of bevacizumanb was (12.5%). Perforation rate in those who did not receive chemotherapy was 9.0%.25


The technique for colonic SEMS insertion in malignant colonic obstruction has been established, and technical and clinical success rates are high. There is now a well established role for SEMS use in patients with left sided malignant colonic obstruction treated with palliative intent with significant reductions in morbidity, mortality and stoma rates. Stenting related complications in this group are significant and are in the order of 30%. It is not known whether covered or bare metal stents are better in the palliative setting.

The evidence from RCTs has shown some benefit for SEMS as a bridge to surgery in patients with potentially curative disease, with a reduction in stoma rates, but there are concerns about the oncological safety. As such, current guidelines recommend that this treatment be used only when patients are considered to be a high surgical risk.

Article information

Gastrointestinal Intervention.Jul 31, 2017; 6(2): 118-121.
Published online 2017-07-31. doi:  10.18528/gii160013
Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
Department of General Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK. E-mail (K. Newton).
Received March 23, 2016; Accepted March 27, 2016.
Articles from Gastrointestinal Intervention are provided here courtesy of Gastrointestinal Intervention


  • Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65:87-108.
  • Cheynel N, Cortet M, Lepage C, Benoit L, Faivre J, Bouvier AM. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum. 2007;50:1568-75.
  • Jullumstrø E, Wibe A, Lydersen S, Edna TH. Colon cancer incidence, presentation, treatment and outcomes over 25 years. Colorectal Dis. 2011;13:512-8.
  • Kleespies A, Füessl KE, Seeliger H, Eichhorn ME, Müller MH, Rentsch M. Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis. 2009;24:1097-109.
  • Breitenstein S, Rickenbacher A, Berdajs D, Puhan M, Clavien PA, Demartines N. Systematic evaluation of surgical strategies for acute malignant left-sided colonic obstruction. Br J Surg. 2007;94:1451-60.
  • Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 2004;13:149-57.
  • Saida Y, Sumiyama Y, Nagao J, Uramatsu M. Long-term prognosis of preoperative “bridge to surgery” expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation. Dis Colon Rectum. 2003;46:S44-9.
  • Martinez-Santos C, Lobato RF, Fradejas JM, Pinto I, Ortega-Deballón P, Moreno-Azcoita M. Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum. 2002;45:401-6.
  • Ng KC, Law WL, Lee YM, Choi HK, Seto CL, Ho JW. Self-expanding metallic stent as a bridge to surgery versus emergency resection for obstructing left-sided colorectal cancer: a case-matched study. J Gastrointest Surg. 2006;10:798-803.
  • Park JS, Kim BG, Chang IT, Choi YS, Kwak BK, Shim HJ. Placement of stents in proximal colonic obstructions using a percutaneous retroperitoneal colostomy. Surg Laparosc Endosc Percutan Tech. 2009;19:e202-5.
  • Tan CJ, Dasari BV, Gardiner K. Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg. 2012;99:469-76.
  • Sloothaak DA, van den Berg MW, Dijkgraaf MG, Fockens P, Tanis PJ, van Hooft JE. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg. 2014;101:1751-7.
  • Maruthachalam K, Lash GE, Shenton BK, Horgan AF. Tumour cell dissemination following endoscopic stent insertion. Br J Surg. 2007;94:1151-4.
  • Sabbagh C, Browet F, Diouf M, Cosse C, Brehant O, Bartoli E. Is stenting as “a bridge to surgery” an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis. Ann Surg. 2013;258:107-15.
  • van Hooft JE, van Halsema EE, Vanbiervliet G, Beets-Tan RG, DeWitt JM, Donnellan F. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Gastrointest Endosc. 2014;80:747-61.e1–75.
  • Frago R, Ramirez E, Millan M, Kreisler E, del Valle E, Biondo S. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg. 2014;207:127-38.
  • Frager D, Rovno HD, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging. 1998;23:141-6.
  • Kim JW, Jeong JB, Lee KL, Kim BG, Jung YJ, Kim W. Comparison of clinical outcomes between endoscopic and radiologic placement of self-expandable metal stent in patients with malignant colorectal obstruction. Korean J Gastroenterol. 2013;61:22-9.
  • Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol. 2004;99:2051-7.
  • de Gregorio MA, Laborda A, Tejero E, Miguelena JM, Carnevale FC, de Blas I. Ten-year retrospective study of treatment of malignant colonic obstructions with self-expandable stents. J Vasc Interv Radiol. 2011;22:870-8.
  • Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Outcomes of secondary self-expandable metal stents versus surgery after delayed initial palliative stent failure in malignant colorectal obstruction. Digestion. 2013;88:46-55.
  • Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc. 2010;71:560-72.
  • Meisner S, González-Huix F, Vandervoort JG, Goldberg P, Casellas JA, Roncero O. Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients. Gastrointest Endosc. 2011;74:876-84.
  • Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg. 2002;89:1096-102.
  • van Halsema EE, van Hooft JE, Small AJ, Baron TH, García-Cano J, Cheon JH. Perforation in colorectal stenting: a meta-analysis and a search for risk factors. Gastrointest Endosc. 2014;79:970-82.e7.
  • Zhang Y, Shi J, Shi B, Song CY, Xie WF, Chen YX. Comparison of efficacy between uncovered and covered self-expanding metallic stents in malignant large bowel obstruction: a systematic review and meta-analysis. Colorectal Dis. 2012;14:e367-74.
  • Yang Z, Wu Q, Wang F, Ye X, Qi X, Fan D. A systematic review and meta-analysis of randomized trials and prospective studies comparing covered and bare self-expandable metal stents for the treatment of malignant obstruction in the digestive tract. Int J Med Sci. 2013;10:825-35.
  • Geraghty J, Sarkar S, Cox T, Lal S, Willert R, Ramesh J. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014;16:476-83.
  • Lee JH, Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH. The learning curve for colorectal stent insertion for the treatment of malignant colorectal obstruction. Gut Liver. 2012;6:328-33.
  • Williams D, Law R, Pullyblank AM. Colorectal stenting in malignant large bowel obstruction: the learning curve. Int J Surg Oncol. 2011;2011:917848.
  • Mulder SA, Kranse R, Damhuis RA, de Wilt JH, Ouwendijk RJ, Kuipers EJ. Prevalence and prognosis of synchronous colorectal cancer: a dutch population-based study. Cancer Epidemiol. 2011;35:442-7.
  • Kodeda K, Nathanaelsson L, Jung B, Olsson H, Jestin P, Sjövall A. Population-based data from the Swedish Colon Cancer Registry. Br J Surg. 2013;100:1100-7.
  • Park SH, Lee JH, Lee SS, Kim JC, Yu CS, Kim HC. CT colonography for detection and characterisation of synchronous proximal colonic lesions in patients with stenosing colorectal cancer. Gut. 2012;61:1716-22.
  • Cha EY, Park SH, Lee SS, Kim JC, Yu CS, Lim SB. CT colonography after metallic stent placement for acute malignant colonic obstruction. Radiology. 2010;254:774-82.
  • Lim SG, Lee KJ, Suh KW, Oh SY, Kim SS, Yoo JH. Preoperative colonoscopy for detection of synchronous neoplasms after insertion of self-expandable metal stents in occlusive colorectal cancer: comparison of covered and uncovered stents. Gut Liver. 2013;7:311-6.
  • Huang X, Lv B, Zhang S, Meng L. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg. 2014;18:584-91.
  • Cirocchi R, Farinella E, Trastulli S, Desiderio J, Listorti C, Boselli C. Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis. Surg Oncol. 2013;22:14-21.
  • Cennamo V, Luigiano C, Coccolini F, Fabbri C, Bassi M, De Caro G. Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction. Int J Colorectal Dis. 2013;28:855-63.
  • De Ceglie A, Filiberti R, Baron TH, Ceppi M, Conio M. A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction. Crit Rev Oncol Hematol. 2013;88:387-403.
  • Ye GY, Cui Z, Chen L, Zhong M. Colonic stenting vs emergent surgery for acute left-sided malignant colonic obstruction: a systematic review and meta-analysis. World J Gastroenterol. 2012;18:5608-15.
  • Zhang Y, Shi J, Shi B, Song CY, Xie WF, Chen YX. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc. 2012;26:110-9.
  • Sagar J. Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev. 2011:CD007378.
  • 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;25:1814-21.
  • van Hooft JE, Bemelman WA, Oldenburg B, Marinelli AW, Lutke Holzik MF, Grubben MJ. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol. 2011;12:344-52.
  • Ghazal AH, El-Shazly WG, Bessa SS, El-Riwini MT, Hussein AM. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg. 2013;17:1123-9.
  • Tung KL, Cheung HY, Ng LW, Chung CC, Li MK. Endo-laparoscopic approach versus conventional open surgery in the treatment of obstructing left-sided colon cancer: long-term follow-up of a randomized trial. Asian J Endosc Surg. 2013;6:78-81.
  • Ho KS, Quah HM, Lim JF, Tang CL, Eu KW. Endoscopic stenting and elective surgery versus emergency surgery for left-sided malignant colonic obstruction: a prospective randomized trial. Int J Colorectal Dis. 2012;27:355-62.
  • Alcántara M, Serra-Aracil X, Falcó J, Mora L, Bombardó J, Navarro S. Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer. World J Surg. 2011;35:1904-10.
  • Cheung HY, Chung CC, Tsang WW, Wong JC, Yau KK, Li MK. Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg. 2009;144:1127-32.
  • Biondo S, Parés D, Frago R, Martí-Ragué J, Kreisler E, De Oca J. Large bowel obstruction: predictive factors for postoperative mortality. Dis Colon Rectum. 2004;47:1889-97.
  • Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD, Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004;240:76-81.
  • van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy. 2008;40:184-91.
  • Liang TW, Sun Y, Wei YC, Yang DX. Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today. 2014;44:22-33.
  • Zhao XD, Cai BB, Cao RS, Shi RH. Palliative treatment for incurable malignant colorectal obstructions: a meta-analysis. World J Gastroenterol. 2013;19:5565-74.
  • Baron TH, Wong Kee Song LM, Repici A. Role of self-expandable stents for patients with colon cancer (with videos). Gastrointest Endosc. 2012;75:653-62.
  • Fernández-Esparrach G, Bordas JM, Giráldez MD, Ginès A, Pellisé M, Sendino O. Severe complications limit long-term clinical success of self-expanding metal stents in patients with obstructive colorectal cancer. Am J Gastroenterol. 2010;105:1087-93.
  • Manes G, de Bellis M, Fuccio L, Repici A, Masci E, Ardizzone S. Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: analysis of results and predictors of outcomes in a large multicenter series. Arch Surg. 2011;146:1157-62.
  • Abbott S, Eglinton TW, Ma Y, Stevenson C, Robertson GM, Frizelle FA. Predictors of outcome in palliative colonic stent placement for malignant obstruction. Br J Surg. 2014;101:121-6.
  • Cennamo V, Fuccio L, Mutri V, Minardi ME, Eusebi LH, Ceroni L. Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy?. Clin Gastroenterol Hepatol. 2009;7:1174-6.