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 (DAOH90) and 90-day unplanned readmission. Propensity score matching and multilevel multivariable regression were used. RESULTS: Of 516 patients that presented acutely with obstructing left-sided colon cancer (median age 69 years; 44% female; 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 (9.3%) patients had immediate complications, and a further 4 (7.4%) patients 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 DAOH90 (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 hazard ratio [HR] 0.34, 95% CI: 0.08-1.36). LIMITATIONS: These were observational data, subject to selection bias. In addition, confidence intervals 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. See Video Abstract. ClinicalTrials.gov No: NCT05641129.