Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion

• Published in: Diseases of the colon & rectum Vol. 58; no. 9; pp. 838 - 849
• Main Authors: Young, Christopher J, De-loyde, Katie J, Young, Jane M, Solomon, Michael J, Chew, Emily H, Byrne, Chris M, Salkeld, Glenn, Faragher, Ian G
• Format: Journal Article
• Language: English
• Published: United States The American Society of Colon and Rectal Surgeons 01-09-2015
• Subjects: Adult; Aged; Aged, 80 and over; Colonic Diseases - etiology; Colonic Diseases - mortality; Colonic Diseases - therapy; Colorectal Neoplasms - complications; Decompression, Surgical; Female; Follow-Up Studies; Humans; Intestinal Obstruction - etiology; Intestinal Obstruction - mortality; Intestinal Obstruction - therapy; Kaplan-Meier Estimate; Male; Middle Aged; Palliative Care - methods; Prospective Studies; Quality of Life; Stents; Treatment Outcome
• ISSN: 0012-3706; 1530-0358
• DOI: 10.1097/DCR.0000000000000431

BACKGROUND:Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents.
OBJECTIVE:The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression.
DESIGN:This study reports on a randomized control trial (registry number ACTRN012606000199516).
SETTING:This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne.
PATIENTS AND INTERVENTION:Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion.
MAIN OUTCOME MEASURES:The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions.
RESULTS:Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022).
LIMITATIONS:This study was limited by the lack of an EQ-5D Australian-based population set.
CONCLUSIONS:Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.