Decompression stent, stoma, transanal tube or immediate surgery: Systematic review and Bayesian network meta-analysis for left-sided malignant colonic obstruction.

Abstract

The optimal initial management of left-sided malignant colonic obstruction (LMCO) remains debated, as previous studies have reported inconsistent results. To address this uncertainty, we conducted a systematic review and Bayesian network meta-analysis comparing various initial management strategies for potentially curable LMCO. The objective was to evaluate and compare short-term and long-term outcomes among bridge-to-surgery (BTS) approaches and immediate surgery. PubMed, Embase and the Cochrane Library were systematically searched until the end of September 2025. Eligible randomized controlled trials (RCTs) or propensity score (PS)-based comparative studies reported outcomes of immediate surgery or BTS using self-expandable metallic stents (SEMS), decompression stoma or transanal decompression tube (TDT). A Bayesian network meta-analysis was performed to assess survival outcomes, postoperative morbidity and stoma-related outcomes. Nine RCTs and 14 PS-based studies comprising 5164 patients were included. Procedure-related perforation occurred in 6.8% of SEMS (100/1467) and 7.5% of TDT (13/173) cases. No significant differences were observed among groups regarding survival outcomes or postoperative morbidity. The SEMS group was associated with a significantly lower overall stoma formation rate than immediate surgery (RR: 0.56, 95% CrI: 0.44-0.73) and TDT (RR: 0.44, 95% CrI: 0.23-0.82). Although decompression stoma required temporary stoma formation in all cases, it was associated with the lowest risk of permanent stoma formation. All strategies showed comparable survival and morbidity outcomes. The use of SEMS as a BTS approach was associated with a lower overall stoma formation rate. Decompression stoma as a BTS approach was associated with a lower risk of permanent stoma formation and may represent a reasonable alternative when SEMS is unsuitable and temporary stoma is acceptable.