CReST trial: addressing surgical management of emergency oncology admissions and the role of randomised trials

James Hill1

1Manchester Royal Infirmary, Manchester, UK,2Manchester Academic Health Science Center, Manchester, UK

Abstract

Changes in the provision of both elective cancer surgery and emergency laparotomy care (being pioneered as part of the Healthier Together initiative in Greater Manchester) should provide more speciality specific care for emergency oncology admissions.

A significant proportion of patients with colorectal cancer present as an emergency with large bowel obstruction and require emergency surgery.  This is associated with increased mortality rate, prolonged stay in hospital, increased need for stoma formation and greatly reduced patient quality of life. This surgery should be provided by specialist colorectal surgeons.

Colonic stenting is an alternative to surgery for malignant large bowel obstruction as it allows relief of the obstruction while avoiding stoma formation in palliative cases. It can also facilitate bowel decompression (acting as a ‘bridge to surgery’) for those with resectable disease, avoiding the need for emergency surgery.

Previously published studies have reported small numbers with conflicting results and stenting in the potentially curative setting is still not recommended. Recent NICE guidance on this topic considered only evidence from randomised clinical trials. Significant challenges to completion of the CReST study included quality assurance and randomisation in the emergency setting.

Stent design will be the subject of a further randomised study. The potential complications associated with stenting include perforation, stent obstruction and stent migration. A recent systematic review concluded that tumour ingrowth was more common with uncovered stents, but that late migration occurred more frequently with covered stents, and expulsion causes significant morbidity.  The evidence relating to stent design is very limited and  further large scale randomised controlled trials are recommended to compare covered and uncovered stents to assess their clinical and cost-effectiveness.