Upfront Surgery Without Neoadjuvant Chemotherapy After Stenting for Malignant Colonic Obstruction May Increase Recurrence Rates

Dear Editor,

I read with great interest the article by Öçal and Torun¹ entitled “Endoscopic Stenting Followed by Laparoscopic Resection in Malignant Colonic Obstruction: Oncological Safety of the Bridge-to-Surgery Approach.” I congratulate the authors for presenting a large series of patients with malignant colonic obstruction treated by self-expandable metallic stent (SEMS) as a bridge to surgery followed by elective laparoscopic colectomy. To my knowledge, this represents one of the largest Turkish series on this subject, and the reported 100% technical success of stenting is noteworthy (Table 1).^2-7

The perioperative findings are clinically relevant. In acute malignant colonic obstruction, SEMS can shift treatment from emergency surgery to a planned setting, allowing staging, patient optimization, bowel preparation, and elective minimally invasive resection. Higher laparoscopic completion, greater chance of primary anastomosis, and reduced need for stoma are important short-term benefits. In this series, the laparoscopic completion rate of 84.2%, R0 resection rate of 93.7%, no 30-day mortality, and low stoma rate support the perioperative value of this strategy in experienced centers.¹

However, the main concern with SEMS as a bridge to surgery remains long-term oncological safety. Radial tumor compression, endoscopic manipulation, overt or occult perforation, and microscopic tumor dissemination have all been proposed as possible mechanisms. The absence of clinical perforation in this cohort is reassuring, but it does not fully exclude microscopic transmural injury or subclinical tumor spread. Therefore, the lack of a non-stented control group and the median follow-up of 31.8 months warrant cautious interpretation of the oncological conclusions.¹

The literature also remains unsettled. Recent systematic reviews and meta-analyses have reported signals of increased overall, systemic, or distant recurrence after stent placement compared with emergency surgery, although findings are heterogeneous and influenced by study design, perforation definitions, and patient selection.^{8, 9} These uncertainties are especially relevant in patients treated with curative intent.

In this context, one of the most important points in the present series is that neoadjuvant therapy was not used. After successful decompression, neoadjuvant chemotherapy before resection has increasingly been discussed for left-sided obstructive colon cancer. The rationale is that systemic treatment may counterbalance the potential risk of micrometastatic disease promoted by tumor manipulation or occult dissemination. Emerging analyses suggest that SEMS followed by neoadjuvant chemotherapy may improve survival outcomes compared with SEMS followed directly by surgery.¹⁰

The study by Öçal and Torun¹ shows that SEMS followed by laparoscopic colectomy is feasible and may improve perioperative comfort in experienced hands. Nevertheless, these results should not be interpreted as definitive proof of oncological safety for all curative candidates. Future multicenter Turkish studies should compare stented and non-stented patients by stage; report local, peritoneal, and distant recurrences separately; distinguish clinical from pathological or occult perforation; and analyze patients receiving post-stent neoadjuvant chemotherapy as a separate subgroup.

In conclusion, the authors’ work is a valuable contribution to the Turkish experience with malignant colonic obstruction. Its high technical success and favorable perioperative outcomes are commendable, but long-term oncological risk and the potential role of neoadjuvant chemotherapy after stenting should remain central considerations.

Sincerely,