Perforation in colorectal stenting: a meta-analysis and a search for risk factors

Background: Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.

Objective: To identify risk factors for perforation from colonic stenting.

Design: A meta-analysis of 86 studies published between 2005 and 2011.

Setting: Multicenter review.

Patients: All patients who underwent colorectal stent placement.

Intervention: Colorectal stent placement.

Main outcome measurements: The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.

Results: A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).

Limitations: Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.

Conclusions: The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.