Association for Academic SurgeryColonic Stent Use by Indication and Patient Outcomes: A Nationwide Inpatient Sample Study
Introduction
Colonic stent placement for large bowel obstruction offers the potential to avoid a high-risk urgent operative intervention. Emergency surgery for large bowel obstruction is associated with high rates of morbidity, mortality, and stoma creation among survivors1,2. Following the introduction of colonic stents in the early 1990s, stent outcomes research has mostly focused on curative left-sided colon cancer (CC), and to a lesser extent on palliative stenting in metastatic CC, showing better outcomes with fewer stomas compared with emergency surgery1,3, 4, 5, 6. Stent outcomes among obstructions due to either extrinsic compression by extra-colonic malignancy (ECM) or benign disease (such as Crohn's, diverticular, ischemic, and radiation strictures) are poorly documented. Evidence regarding the benefits and harms of stenting for these indications remains uncertain, largely due to sporadic and small observational studies6,7. Study samples are small in benign obstruction and extracolonic malignancy;8, 9, 10, 11 a recent meta-analysis of benign obstructions was able to pool only 122 patients from 21 studies11. While professional guidelines have remained lukewarm or silent regarding ECM and benign obstructions, stent use continues among these groups6,7,12. Robust evidence based on larger samples is needed to provide guidance for practice.
Our study describes the nationwide trends in stent use using a population-based dataset, and reports the rates of ostomy procedures, perforation events, and in-hospital death among four diagnostic categories of patients: (1) colon cancer without metastatic disease, (2) metastatic colon cancer, (3) extrinsic compression by other abdominal or pelvic malignancies, and (4) benign obstruction. We further sought to identify the patient, disease and hospital characteristics associated with subsequent ostomy creation.
Section snippets
Methods
We conducted a retrospective cohort study of patients with colonic stent procedures in the National Inpatient Sample (NIS). Because these are de-identified data provided by the Health Care Utilization Project (HCUP) for research purposes, the study was determined exempt from IRB review by the University of South Carolina Institutional Review Board.
Results
We identified a total of 4257 patients with a code for colonic stent placement (mean age 64.6 years (SD 15.5), 52% male, 69.1% white and 12.8% black (Table 1). Patients were treated at 2,838 hospitals. Most procedures were performed at large (71%), and urban teaching hospitals (76%), and 111 high-volume hospitals (defined as >25 total stents placed over the study period) managed 28.3% of all stent patients. The remaining patients were managed by 1,727 low-volume hospitals (≤25 stent procedures).
Discussion
This retrospective, population-based observational study presents unique findings that demonstrate colonic stent practice patterns and outcomes beyond what is reported in single-center and multi-center studies. In contrast to the literature's current focus on bridge-to-surgery for CC obstruction, this analysis highlights the spectrum of patient populations who are stented.
Studies suggest that up to 60% of large bowel obstructions are due to colorectal cancer13. With much of the literature
Conclusion
Despite limitations, the key contributions of the study include estimates and recent trends of colonic stent procedure volumes by indication in the US population, and evidence on stent outcomes among the less frequently studied indications in the literature. It finds favorable outcomes among ECM patients, comparable or only slightly inferior to outcomes seen in the traditional “bridge-to-surgery” population. The findings regarding benign obstruction are concerning. Although the risk of
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