Original article
12666
Long-term outcome of stenting as a bridge to surgery for
acute left-sided malignant colonic obstruction
F. A. Quereshy*, J. T. C. Poon† and W. L. Law†
*Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada and †Department of Surgery, University
of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
Received 12 January 2014; accepted 6 April 2014; Accepted Article online 19 May 2014
Abstract
Aim This study aimed to evaluate both the short- and
long-term outcomes associated with colonic stenting as
a bridge to surgery in patients with obstructing adeno-
carcinoma of the colon.
Method Patients with potentially curable acute left-
sided colonic obstruction treated with stenting as a
bridge to surgery (n = 28) or with emergency surgical
resection (n = 39) from January 1998 to December
2008 were identified from a prospectively maintained
database. Short-term data on postoperative mortality,
morbidity, necessity of intensive care and length of hos-
pital stay were compared. Overall survival and disease-
free survival were also analysed.
Results Patients in the two study arms had similar
demographic profiles. Those receiving preoperative
stenting had a higher likelihood of a laparoscopic resec-
tion (P < 0.001). The emergency surgery group had a
higher rate of postoperative complications (P = 0.024),
rate of intensive care unit admission (P = 0.013) and
longer total length of hospital stay (9 vs 12 days,
Introduction
Several studies have demonstrated that 10–47% of
patients with colorectal cancer will present with colonic
obstruction [1–4] necessitating emergency intervention.
Given that constricting left-sided colonic neoplasms are
responsible for nearly 70% of acute large bowel
obstructions [5], traditional management has involved
either a Hartmann’s resection with the creation of an
end-colostomy or a subtotal colectomy with ileo-sig-
moid anastomosis. While the prognostic significance of
preoperative obstruction in colorectal cancer remains
controversial [6–9], its acute pathophysiological
Correspondence to: Wai Lun Law, Department of Surgery, University of Hong
Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, Hong Kong.
E-mail: lawwl@hkucc.hku.hk
788 Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
doi:10.1111/codi.
P = 0.001). With a median follow-up of 26.5 and
31.3 months for the stenting and surgical resection
groups, there was no difference in overall and disease-
free survival (overall survival 30 vs 31 months,
P = 0.858; disease-free survival 13 vs 12 months,
P = 0.989). There was no difference in the rate of sys-
temic recurrence (8 vs 13, P = 0.991).
Conclusion Stenting as a bridge to surgery is a safe
strategy for acute left-sided colonic obstruction with
improved short-term outcome and comparable long-
term oncological results.
Keywords Metallic stents, bridge to surgery, colorectal
obstruction, outcomes
What does this paper add to the literature?
The study provides data on the oncological outcome of
patients who underwent stenting for obstructing colo-
rectal cancer as a bridge to surgery and shows that
stenting is a safe strategy compared with immediate
emergency surgery.
sequelae result in significant patient morbidity and
mortality [10,11]. Furthermore, emergency surgery has
been linked to a high permanent colostomy rate [12],
thereby impacting overall quality of life and long-term
function [13,14].
With the advent of self-expanding metallic stents
(SEMS) in 1991 [15], the management options for
acute colonic obstruction have significantly evolved.
Several studies have validated the use of SEMS as a pal-
liative procedure for colonic obstruction as a result of
unresectable primary, recurrent or metastatic disease
[16–18]. Theoretically, the use of SEMS as a bridge to
surgery enables preoperative patient optimization before
definitive surgical resection. Several retrospective studies
have demonstrated the safety and efficacy of this
approach with a higher rate of primary anastomosis,
F. A. Quereshy et al.
fewer peri-operative complications and shorter hospital
stay [19]. Recently published randomized controlled
trials, however, have challenged the value of preopera-
tive colonic stenting [20,21]. Specifically, van Hooft
et al. [20] found a statistically significant increase in 30-
day morbidity in the stenting group mostly related to
colonic perforation. In addition to acute septic
complications, colonic perforation may result in poorer
long-term oncological outcome and overall survival.
Furthermore Maruthachalam et al. [22] found that the
use of colonic stenting was associated with an increase
in circulating tumour cells and therefore may increase
the risk of systemic disease.
Despite the controversies surrounding the oncological
safety of preoperative colonic stenting, there is little infor-
mation on the long-term outcome associated with this
treatment. For this reason we conducted the present
study involving a retrospective analysis of prospectively
collected data to compare the disease-free and overall sur-
vival of patients treated with SEMS as a bridge to surgery
relative to surgery relative to emergency surgical resection.
Method
Using a prospectively maintained colorectal cancer data-
base, all patients presenting with acute left-sided colonic
obstruction from 1998 to 2008 were identified. This
study period was selected to enable survival analysis with
a follow-up period of at least 3 years. Patients with
incurable disease (radiographic evidence of peritoneal or
extrahepatic metastases at the time of presentation)
were excluded. During the study period 130 patients
were treated with SEMS for a malignant obstruction at
the Queen Mary Hospital. Of these, 28 were treated
with colonic stenting as a bridge to curative surgery
(treatment arm) and 39 by emergency resection (con-
trol arm). Each patient was confirmed to have acute
colonic obstruction on the basis of clinical and radio-
graphic evaluation. In the treatment arm, insertion of a
SEMS was performed on an urgent basis by an experi-
enced colorectal surgeon using both endoscopic and
fluoroscopic guidance. The senior author has previously
described the specific technical details related to stent
placement [19]. The success of the procedure was doc-
umented by clinical return of normal bowel function
and radiological resolution of the obstruction. At
2 weeks after SEMS insertion, patients had either stan-
dard or laparoscopic resection with curative intent. In
the control arm, patients had emergency segmental
resection or subtotal colectomy according to the same
oncological principles. All patients in both arms received
no bowel preparation. Length of stay was defined as the
total hospitalization, including the time associated with
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
Outcome of stent as bridge to surgery
the stenting procedure for patients in the treatment
arm. This is not a randomized trial and the choice of
management was decided by the preferences of the
patient and surgeon. After surgery, all patients were
referred to a medical oncologist for consideration of
adjuvant chemotherapy.
Statistical analysis
Statistical analysis was conducted using SPSS version 21.0
(SPSS, Chicago, Illinois, USA). Comparisons of baseline
characteristics and the short-term postoperative out-
comes were performed using the Mann–Whitney U test
for continuous variables and the chi-squared test for
categorical variables. Disease-free and overall survival
probabilities were estimated using the Kaplan–Meier
method and differences were compared using the log-
rank test. Chemotherapy completion rate and the likeli-
hood of a permanent colostomy were used as secondary
outcome measures and evaluated using the chi-squared
test. A two-sided P value of less than 0.05 was consid-
ered statistically significant.
Results
Demographic data and baseline patient characteristics
Demographic variables are summarized in Table 1. The
median age of patients within the treatment and control
arms was 73.5 (45–88) years and 74 (42–88) years
respectively. While only 24% of all patients were female,
there was no significant difference in gender distribu-
tion between the two cohorts (P = 0.327). Twenty-four
(61.5%) patients in the control group had at least one
pre-existing comorbidity (coronary artery disease,
chronic obstructive pulmonary disease, type II diabetes
and/or a cerebral vascular accident) compared with only
nine (32.1%) patients in the treatment arm (P = 0.018).
Despite this difference, the American Society of Anes-
thesiologists (ASA) score was not significantly different
between the two groups (P = 0.121), implying a com-
parable peri-operative risk profile between each study
arm. 83.5% of all patients had a T3 tumour on final
pathology with a comparable American Joint Commit-
tee on Cancer (AJCC) stage distribution between the
two groups (P = 0.176).
Operative characteristics and peri-operative course
All patients undergoing preoperative colonic stenting as
a bridge to curative surgery underwent definitive seg-
mental resection. In this cohort, 43% of operations were
performed laparoscopically while all patients in the con-
789
Outcome of stent as bridge to surgery F. A. Quereshy et al.

Table 1 Demographic data and baseline patient characteristics. Table 2 Peri-operative course and short-term outcome.

Stenting Control Stenting Control

(n = 28) (n = 39) P value (n = 28) (n = 39) P value

Median age 73.5 (45–88) 74 (42–88) 0.665 Operative details

Gender 5 F; 23 M 11 F; 28 M 0.327 Laparoscopic resection 12 9 < 0.001*
Comorbidity† 9 (32.1%)‡ 24 (61.5%)‡ 0.018* Primary anastomosis 26 29 0.051
ASA status Surgical resection
I 5 2 0.121 Subtotal 0 21 < 0.001*
II 15 14 Segmental 28 19
III 3 10 Creation of stoma 10 13 0.840
IV 0 1 Postoperative course
Unknown 5 12 Postoperative 8 22 0.024*
Tumour stage complication
T2 0 1 0.329 ICU admission 6 20 0.013*
T3 22 34 30-day mortality 1 5 0.191
T4 6 4 Median length of stay† 9 (3–76) 12 (8–49) 0.001*
AJCC stage
II 5 15 0.176 ICU, intensive care unit.
III 14 16 †Length of stay was defined as the total hospitalization, includ-
IV 9 8 ing the time associated with the stenting procedure for patients
in the treatment arm.
ASA, American Society of Anesthesiologists; AJCC, American *P < 0.05 was considered statistically significant.
Joint Committee on Cancer.
†Comorbidity includes coronary artery disease, chronic
Postoperatively patients in the treatment arm had
obstructive pulmonary disease, type II diabetes and/or a cere-
bral vascular accident. significantly fewer complications (treatment arm 8; con-
‡This represents the number (percentage) of patients who had trol arm 22; P = 0.024). Only six patients in the preop-
at least one pre-existing comorbidity. There were 13 total com- erative stenting group required intensive care unit
orbidities seen in nine patients in the stenting group and 31 (ICU) admission while 20 in the surgery-first cohort
total comorbidities seen in 24 patients in the control group. did so (P = 0.013). There was a significant reduction in
*P < 0.05 was considered statistically significant. median length of stay in the stenting group relative to
the control group [9 days (3–76) vs 12 days (8–49);
trol arm underwent open resection (P < 0.001). In the P < 0.001], but there was no difference in 30-day mor-
treatment arm, there were no stent-associated perfora- tality with one and five deaths in the treatment and
tions and successful stent deployment was achieved in control arms (P = 0.191). Details of the peri-operative
all patients. The rate of primary anastomosis was not course are summarized in Table 2.
significantly different between the two study cohorts
(26 patients in the treatment arm vs 29 patients in the
Survival analysis and long-term outcome
control arm; P = 0.051). However, there was a discern-
able trend favouring preoperative colonic stenting and Patients were followed for a median of 26.5 and
further patient accrual would be necessary to define this 31.3 months in the treatment and control arms. In the
difference. With regard to surgical procedure, 21 entire study cohort there were a total of 26 cancer
(53.8%) patients in the control arm underwent subtotal recurrences, 81% of which were systemic. In the treat-
colectomy with ileo-sigmoid anastomosis while all ment arm there were 10 recurrences including eight dis-
patients in the stented arm received a standard segmen- tant and two local. In the control arm, there were 16
tal resection (P < 0.001). The rate of stoma creation recurrences including 13 (81.3%) distant disease and
(temporary or permanent) was comparable between the three local. The incidence of local and distant recur-
two groups (treatment arm 10; control arm 13; rence was not significantly different in the groups
P = 0.840). While other centres have reported a reduc- (P = 0.944). The 3-year disease-free survival and overall
tion in stoma creation following preoperative colonic survival were not statistically different between the two
stenting, the routine practice at the Queen Mary Hospi- groups (3-year disease-free survival, treatment arm
tal is to protect a primary anastomosis fashioned in the 27.0%; control arm 33.3%, P = 0.875; 3-year overall
emergency setting based on surgeon discretion. Opera- survival, treatment arm 35.7%, control arm 43.6%,
tive details are summarized in Table 2. P = 0.859). The median disease-free survival was 13

790 Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
F. A. Quereshy et al. Outcome of stent as bridge to surgery

[95% confidence interval (CI) 3, 23] months in the Table 3 Long-term outcome.
treatment group and 12 (95% CI 0, 25) months in the
Stenting Control
control group. The median overall survival was 30 (95%
(n = 28) (n = 39) P value
CI 21, 39) months in the treatment group and 31
(95% CI 5, 57) months in the control group (Figs 1
Median follow-up 26.5 (0–155) 31.3 (0–164) 0.638
and 2, Table 3). (months)
Stoma at last 7 14 0.343
Discussion follow-up
Disease failure
The study summarizes the results of colonic stenting as All recurrences 10 16 0.944
a bridge to surgery compared with emergency surgery Distant metastases 8 13 0.991
as curative treatment of malignant left-sided large bowel Survival outcomes
obstruction. There was no difference in 3-year disease- 3-year DFS 27.0% 33.3% 0.875
3-year OS 35.7% 43.6% 0.859

Disease-free survival (DFS) functions DFS, disease-free survival; OS, overall survival.

1.0
Stent Group free or overall survival between the two study arms.
Surgery-First Group
0.8 case-censored Given that the oncological outcomes are comparable
control-censored
between the study cohorts, this analysis supports the
Cum DFS survival

use of preoperative colonic stents in centres with exper-

0.6
tise in endoluminal stenting and the non-operative
management of acute malignant obstructions. With an
0.4 estimated 30% of newly diagnosed colorectal cancers
presenting with obstruction [2–5], emergency manage-
0.2 ment must balance the acute care needs of the patient
with oncological principles. Traditionally, definitive sur-
gical management with a Hartmann’s resection has been
0.0 the cornerstone of treatment, but this is associated with
0.00 50.00 100.00 150.00 200.00 a high rate of peri-operative morbidity, mortality and
DFS in months
impaired quality of life [11–14]. The introduction of
Figure 1 Comparison of disease free survival of the stent SEMS has increased the available management options
group and the surgery first group. for acute colonic obstruction. While the use of SEMS
has been validated in palliative care of locally advanced,
recurrent and/or metastatic disease [17–19], their role
Overall survival (OS) functions
as a bridge to definitive surgery is controversial.
1.0
In a recent multicentre randomized controlled trial,
Stent Group van Hooft et al. concluded that preoperative stenting
Surgery-First Group
0.8 case-censored was associated with an increase in 30-day morbidity
control-censored with a 13% perforation rate [20]. These authors there-
Cum DFS survival

fore suggested that colonic stenting as a bridge to sur-

0.6
gery failed to improve the short-term peri-operative
outcome and should be reserved for highly selected
0.4 patients. A recent meta-analysis of eight studies with
over 600 patients, however, reported a perforation rate
0.2
of only 1.2% and a better peri-operative outcome for
patients having stenting [23–25]. The disparity between
these results may be related to the relative expertise of
0.0 the participating institutions. In the randomized trial
0 50 100 150 200 reported by van Hooft et al., the endoscopists who
OS in months inserted the stents needed to have performed only 10
Figure 2 Comparison of overall survival of the stent group such procedures as a condition for participation in the
and the surgery first group. study. In contrast, many of the series included within

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793 791
Outcome of stent as bridge to surgery
the meta-analysis had developed specialized surgical
programmes with expertise in endoluminal stenting.
The relative difference in the results may therefore be a
reflection of the learning curve rather than a true
treatment failure. In this series, there were no stent-
associated perforations and successful stent deployment
was achieved in all patients, further affirming the impor-
tance of institutional expertise as a prerequisite for this
strategy.
The results of our study further support the meta-
analysis and emphasize the role of preoperative colonic
stenting in reducing postoperative complications. In
addition to institutional expertise, these findings are
likely to be related to improved optimization of the
patient’s general condition through the early involve-
ment of a multidisciplinary team and the correction of
fluid and electrolyte abnormalities. Furthermore,
patients in the stenting group were more likely to
undergo successful laparoscopic colectomy. The use of
minimally invasive techniques has been shown to reduce
length of stay and is accompanied by enhanced recovery
following surgery [26–28]. Preoperative bowel decom-
pression through colonic stenting enables the use of
minimally invasive techniques and, as a result, was asso-
ciated in the present study with a 3-day reduction in
median length of stay, fewer peri-operative complica-
tions and a lower ICU admission rate.
In a recent study conducted by Ghazal et al. [29],
patients were randomized to SEMS followed by elective
surgical resection vs subtotal/total colectomy for an
obstructing left-sided neoplasm. The authors concluded
that both strategies yielded similar long-term results but
with higher peri-operative complications and worse func-
tion in the emergency resection group. In our study,
patients treated with emergency surgery were more likely
to have a subtotal colectomy rather than a standard seg-
mental resection. While not included as a primary out-
come variable, changes in bowel function and quality of
life may be significantly preserved through a SEMS
approach. Further studies are necessary, however, to
define the utility of stenting as a bridge to surgery related
to quality of life and patient satisfaction.
According to Maruthachalam et al. [22], the use of
colonic stenting results in an increase in circulating
tumour cells and may therefore increase the risk of
systemic metastases, but the results of the present
study do not support this theoretical association. The
results of Maruthachalam et al. are limited by two
independent factors: first, the follow-up period may
not have been sufficient to identify all systemic recur-
rences, and second, with an adjuvant chemotherapy
completion rate of only 10.7% the majority of study
patients did not receive optimal systemic therapy. As a
792 Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 788–793
F. A. Quereshy et al.
result, it is difficult to define the true risk of develop-
ing distant metastases and further prospective studies
are necessary.
In a recent study by Gorissen et al. [30] SEMS was
associated with an increased risk of local recurrence.
This is in contrast to the results of our study which did
not show a significant difference in the rate of local
recurrence between the two groups. This difference may
be attributable to our smaller sample size, although the
median follow-up was comparable between the studies.
Despite the increased rate of local recurrence in younger
patients in the SEMS group observed by Gorissen et al.,
this did not translate into a statistically significant differ-
ence in overall survival. Our results further affirm this
finding with comparable 3-year disease-free and overall
survival between the SEMS and emergency surgery
groups. Furthermore, Gorissen et al. also demonstrated
that patients treated with colonic stenting were more
likely to undergo laparoscopic surgery without differ-
ences in the rate of primary anastomosis and stoma for-
mation, similar to our series.
The present study is limited by its retrospective
design, the small number of patients and the single
institutional experience. This will inevitably result in
selection bias of the distribution of patients to each
study arm. Although there was no difference in ASA
class, differences in presentation and acuteness may have
influenced the treatment decisions. The findings must
therefore be interpreted with caution. Nevertheless
despite recent concerns over the safety of SEMS and
poor short-term results, our study reinforces the need
for a multicentre randomized controlled trial to estab-
lish definitely the role of preoperative colonic stenting
as a bridge to surgery in patients with acute left-sided
malignant obstruction.
Author contributions
Study conception and design: Law. Acquisition of data:
Quereshy, Law, Poon. Analysis and interpretation of
data: Law, Poon, Quereshy. Writing the manuscript:
Quereshy, Law.
Conflicts of interest
Drs Quereshy, Poon and Law have no conflicts of inter-
est or financial ties to disclose.
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