What is the optimal time interval between stent placement and surgery?

In patients with left-sided malignant colorectal obstruction (LMCO), deferring surgery for >4 weeks after placement of self-expanding metallic stent (SEMS) appears to yield better short-term clinical outcomes, according to a recent study.

“This study found that a time interval >4 weeks from SEMS placement to elective surgery not only accelerated postoperative recovery but also reduced postoperative complications,” the researchers said.

A total of 148 patients were included in the retrospective analysis, of whom 70.27 percent received surgery within 4 weeks after SEMS placement (group 1), while the procedure was delayed for >4 weeks in the remaining 29.73 percent (group 2). At baseline, both groups were comparable in terms of age, sex, body mass index, and American Society of Anesthesiologists (ASA) score.

The primary outcomes of the study were short-term clinical postoperative complications, as quantified by a Clavien-Dindo grade ≥II. Only one patient (2.3 percent) in group 1 developed such an outcome, as opposed to 15 (14.4 percent) in group 2. Conversely, a significantly higher proportion of group 2 vs group 1 patients were free of postoperative complications (97.7 percent vs 85.6 percent; p=0.04). [Front Gastroenterol 2022;doi:10.3389/fgstr.2022.1059916]

Moreover, postoperative bowel function time (p<0.001), postoperative hospital stay (p=0.028), and overall hospital stay (p=0.002) were all significantly better in group 2 patients.

These results were confirmed through multivariate logistic regression analysis. Deferring the surgery for >4 weeks was associated with a reduction in the likelihood of Clavien-Dindo grade ≥II complications (odds ratio [OR], 0.071, 95 percent confidence interval [CI], 0.006–0.847; p=0.036).

Significant improvements were also reported for postoperative bowel function time (OR, 0.527, 95 percent CI, 0.359–0.775; p=0.001), postoperative hospital stay (OR, 1.329, 95 percent CI, 1.118–1.584; p=0.001), and total hospital stay (OR, 0.762, 95 percent CI, 0.680–0.854; p<0.001).

“Our findings suggest that a longer interval between SEMS placement and surgery does not affect surgical difficulty but reduces postoperative complications, shortens hospital stay, and accelerates recovery of bowel function,” the researchers explained.

The researchers then looked at the specific postoperative complications that arose at different rates between groups 1 and 2. They found that the most common complications almost exclusively occurred in group 1.

For instance, all four postoperative cases of anastomotic leakage, the most frequently detected complication, were detected in group 1 participants. The same was true for all three cases of lung infection and two cases of abdominal wound infection. The only complication reported in group 2 was one case of postoperative intestinal complication; two such episodes were detected in group 1.

“Prolonging the interval between SEMS and elective surgeries allows intestinal patency and anti-infective therapy to better restore intestinal barrier function, which makes it difficult for bacteria to pass through the intestinal barrier,” the researchers explained. “Therefore, it can reduce the risk of perioperative infectious complications.”

Moreover, “the improvement of intestinal wall oedema and ischemia also favours the modification of destructive microbes, which would reduce the occurrence of anastomotic leakage,” they added.

Future studies are needed to verify the link between a longer wait to surgery and the incidence of postoperative complications, as well as to elucidate underlying mechanisms.