Palliative therapy of colorectal carcinoma: stent or surgery?

"Surgical" palliation of obstructing colorectal carcinomas may involve resection with or without stoma formation, formation of a stoma alone, a colonic bypass procedure, or no procedure at all. Palliative surgical procedures confer a significant morbidity and mortality. Factors associated with increased mortality for colorectal cancer include advancing age of patient, advancing stage of the disease and the necessity for an emergency procedure. Advanced obstructing malignant lesions pose a clinical dilemma as the risks and time of recovery from surgery have to be balanced against providing a dignified quality of remaining life. Self expanding metal stents (SEMS) for acutely obstructing advanced colorectal carcinomas provide a cost effective option that avoids surgery in a usually frail group of patients. They can be inserted under sedation, rapidly decompress the colon and lead to an early return of colonic function. The procedure is carried out endoscopically with radiological assistance to determine a lumen and to confirm adequate stent placement. SEMS are not suitable for low rectal lesions and are more difficult to place in those that traverse colonic flexures. Complications from successful SEMS placement include migration and stent occlusion. The morbidity associated with SEMS is associated with migration or perforation of the colon during placement, pain and less commonly haemorrhage. Despite these problems most patients can be successfully decompressed without further endoscopic or surgical reintervention and allow satisfactory palliation.