Long-term Oncologic Results After Stenting as a Bridge to Surgery Versus Emergency Surgery for Malignant Left-sided Colonic Obstruction: A Multicenter Randomized Controlled Trial (ESCO Trial)

Objective: To assess overall (OS), time to progression (TTP), and diseasefree survival (DFS) at 3 years after treatment, comparing stenting as bridge-tosurgery (SBTS) versus emergency surgery (ES) in neoplastic left colon obstruction, secondary endpoints of the previously published randomized controlled trial. Background: While SBTS in neoplastic colon obstruction may reduce morbidity and need for a stoma compared with ES, concern has been raised, about long-term survival. Methods: Individuals affected by left-sided malignant large-bowel obstruction were enrolled from 5 European hospitals and randomly assigned (1:1 ratio) to receive SBTS or ES. The computer-generated randomization sequence was stratified by center on cT and concealed by the use of a web-based application. Investigators and participants were unmasked to treatment assignment. The secondary outcomes analyzed here were OS, TTP, and DFS. Analysis was by intention to treat. This study is registered, ID-code NCT00591695. Results: Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 115 (SBTS n ¼ 56, ES n ¼ 59) were eligible for analysis, while 20 participants were excluded for a benign disease, 1 for unavailability of the endoscopist while 8 withdrew from the trial. With a median follow-up of 37 months (range 1–62), no difference was observed in the SBTS group compared with ES in terms of OS (HR 0.93 (95% CI 0.49–1.76), P ¼ 0.822), TTP (HR 0.81 (95% CI 0.42–1.54), P ¼ 0.512), and DFS (HR 1.01 (95% CI 0.56–1.81), P ¼ 0.972). Planned subgroup analysis showed no difference in respect to age, sex, American Society for Anesthesiology score, body mass index, and pT between SBTS and ES groups. Those participants randomized for the SBTS group whose obstruction was located in the descending colon had a better TTP compared with ES group (HR 0.44 (95% CI 0.20–0.97), P ¼ 0.042), but no difference was observed in terms of OS (HR 0.73 (95% CI 0.33–1.63), P ¼ 0.442) and DFS (HR 0.68 (95% CI 0.34–1.34), P ¼ 0.261) in the same individuals. Conclusions: This randomized controlled trial shows that, although not powered for these seconday outcomes, OS, TTP, and DFS did not differ between groups at a minimum follow-up of 36 months. Keywords: bridge to surgery, emergency colorectal surgery, endoscopic stenting, large bowel obstruction, randomized controlled trial