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Stenting or Not Stenting Before Operating Malignant Colonic Obstruction? That Is the Question—Reply

Hester Y. S. Cheung, FRACS; Cliff C. C. Chung, FRCSEd; Michael K. W. Li, FRCS, FRCSEd
Arch Surg. 2010;145(6):601-602. doi:10.1001/archsurg.2010.87.
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We greatly appreciate Slim and colleagues' interest in our article.1 We also congratulate them on their multicenter randomized controlled trial. They rightly pointed out that there may be possible tumor dissemination following colonic stenting in theory, but there are no oncological consequences reported in the literature so far.2 On the other hand, systemic reviews have demonstrated the safety and efficacy of endoluminal stenting for patients with colorectal cancer, with low stent-related mortality of less than 1%. The median perforation and stent migration rates were only 4% and 11%,3 respectively.4 In our earlier reported series, in which colonic stenting was used in 68 patients with distal colorectal tumors from February 2002 to August 2008—including emergency stenting in 53 patients with acute intestinal obstruction, palliative stenting for endoscopically obstructed cancer in 12 patients, as well as preemptive stenting in 3 patients with locally advanced stenotic rectal cancer intended for neoadjuvant chemoirradiation—the technical success and clinical success rates were 81% and 65%, respectively.5 Our experience showed that colonic stenting is a useful adjunct in the management of distal colorectal cancer. Apart from being an alternative measure for palliation, it is an effective and noninvasive way for relieving obstruction in patients with obstructed tumors, allowing them to undergo subsequent 1-stage laparoscopic tumor resection. It is also useful in patients with locally advanced rectal cancer, in whom neoadjuvant chemoirradiation is planned. Nonetheless, as the current evidence on the benefits of colonic stenting as a bridge to surgery in patients with malignant colonic obstruction is inconclusive because of methodological weakness in the trials or small sample size,3 a properly conducted multicenter randomized controlled trial with a larger sample size and longer follow-up is warranted to establish its role and to investigate the long-term oncological outcomes of this approach.

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June 1, 2010
Karem Slim, MD; Isabelle Pirlet, MD; Bertrand Millat, MD, PhD
Arch Surg. 2010;145(6):601. doi:10.1001/archsurg.2010.86.
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