this clinical presentation often results in emergency operations that are associated with high rates of morbidity and mortality . many centers use an alternative to this approach that involves placement of a preoperative colonic stent . the stent serves as a temporizing measure for colonic decompression and provides a bridge to elective surgical resection . some data suggest a significantly lower incidence of postoperative complications in patients who undergo elective resection after stenting . in a randomized controlled trial , cheung et al demonstrated a significant decrease in rates of blood loss , pain , and infection in patients with stents . in a meta - analysis of randomized and retrospective studies , zhang et al report a decreased risk of postoperative complication in patients with stents , including intensive care unit stay ( rr = 0.42 ) and anastomotic leak ( rr = 0.31 ) . one study reported that 83% fewer patients underwent stoma formation if they had preoperative stenting , and 2 meta - analyses similarly demonstrated lower stoma rates in these patients . the evidence translates into fewer procedures in patients with stents , and fewer procedures are associated with lower costs and shorter hospital stays . a 1-stage procedure may be associated with a significantly lower mortality rate versus a 2- or 3-stage procedure . preoperative decompression results in a less dilated bowel that is more amenable to a 1-stage procedure , as there may be an association between colonic diameter and risk to the anastomosis . in addition , conversion to an elective procedure allows for bowel preparation , which is standard for elective procedures at many institutions . colonic stenting is a technology that is not available in all centers , and the procedure has a learning curve for those who perform it . the process of stent placement involves passing a self - expanding stent across a lesion under fluoroscopic guidance . the success of placement may be limited by tight strictures , complicated anatomy , and incomplete preparation , especially in critically ill patients . in a prospective , multicenter , clinical cohort study , meisner et al cited complication rates comparable to those at other large multicenter studies , including perforations ( 3.9% ) , migration ( 1.8% ) , pain ( 1.8% ) , and bleeding ( 0.5% ) , with a procedural success rate of 94.8% and a clinical success rate of 90.5% . for colonic stenting in malignant obstruction , the standard practice patterns of surgeons in the united states are unknown . our goals were to define the rate of colonic stenting for malignant obstruction in the united states and to compare the morbidity , mortality , and colostomy rates associated with this approach . we also sought to investigate which demographic variables might influence whether a patient is a candidate for a colonic stent . the nationwide inpatient sample ( nis ) database , a healthcare and utilization project ( hcup ) initiative , is the largest all - payer database in the united states . the collected data represent approximately 20% of all hospital admissions , and each data point is weighted to produce national estimates . for the study dates january 1 , 2010 , through december 31 , 2011 , patients with a diagnosis of sigmoid , rectosigmoid , or rectal cancer and obstruction were identified according to international classification of diseases , ninth revision ( icd-9 ) codes ( table 1 ) . partial resection was defined as left colectomy , sigmoidectomy , lower anterior resection , or abdominal perineal resection . icd-9 procedure codes lar = lower abdominal resection ; apr = abdominal perineal resection ; nos = not otherwise specified ; chf = congestive heart failure ; copd = chronic obstructive pulmonary disease . patients who underwent primary resection or stoma creation were compared to those who underwent preoperative colonic stenting . our primary outcome measures included the rate of stoma creation , total postoperative complications , and deaths . we also compared these groups for use of laparoscopy , rate of conversion to an open procedure , blood transfusion requirement , total parenteral nutrition , and variables related to cost . we performed our analysis with the statistical package for the social sciences ( spss ) , version 22.0 ( spss , chicago , illinois ) . weighting according to hospital characteristics was applied to all analyses , to produce national estimates . the nationwide inpatient sample ( nis ) database , a healthcare and utilization project ( hcup ) initiative , is the largest all - payer database in the united states . the collected data represent approximately 20% of all hospital admissions , and each data point is weighted to produce national estimates . for the study dates january 1 , 2010 , through december 31 , 2011 , patients with a diagnosis of sigmoid , rectosigmoid , or rectal cancer and obstruction were identified according to international classification of diseases , ninth revision ( icd-9 ) codes ( table 1 ) . partial resection was defined as left colectomy , sigmoidectomy , lower anterior resection , or abdominal perineal resection . icd-9 procedure codes lar = lower abdominal resection ; apr = abdominal perineal resection ; nos = not otherwise specified ; chf = congestive heart failure ; copd = chronic obstructive pulmonary disease . patients who underwent primary resection or stoma creation were compared to those who underwent preoperative colonic stenting . our primary outcome measures included the rate of stoma creation , total postoperative complications , and deaths . we also compared these groups for use of laparoscopy , rate of conversion to an open procedure , blood transfusion requirement , total parenteral nutrition , and variables related to cost . we performed our analysis with the statistical package for the social sciences ( spss ) , version 22.0 ( spss , chicago , illinois ) . weighting according to hospital characteristics during the study years 2010 to 2011 , an estimated 7891 patients presented with sigmoid , rectosigmoid , or rectal obstruction , and underwent either colonic stent placement ( 12.1% ; n = 956 ) or colon resection or stoma creation without stent placement ( 87.9% ; n = 6935 ) . the patients who underwent placement of a stent were younger , less likely to be white , less likely to be in the lowest income quartile , and slightly less likely to have arrhythmia , malnutrition , or diabetes ( table 2a ) . there were no significant differences between the stented and nonstented groups in the other demographic and comorbidity variables . demographic and comorbidity comparisons a. stent versus no stent data are the percentage of patients in the total study group . significant at   .05 . based on median household income by zip code ( 2010 : < $ 41 000 ; 2011 : < $ 39 000 ) . of those patients who had placement of a colonic stent , 19.9% went on to have resection or stoma creation . compared with patients with stents who did not have surgery during the same admission , those who underwent preoperative stenting represented an older population with a higher incidence of cardiac arrhythmia ( table 2b ) . they had a significantly lower incidence of cardiac disease , pneumonia , and diabetes mellitus . patients in the lowest income quartile were underrepresented in the group that underwent preoperative stenting followed by surgery during the same admission . b. stent and surgery versus stent without surgery data are the percentage of patients in the total study group . significant at   0.05 . based on median household income by zip code ( 2010 : < $ 41 000 ; 2011 : < $ 39 000 ) . when all surgical patients were compared , those who underwent preoperative stenting represented an older population ( table 2c ) . those in the lowest income quartile were again underrepresented in the preoperative group with stenting compared with those in the operative group without stenting . surgical patients who underwent preoperative stenting had a lower incidence of cardiac disease , pneumonia , and diabetes when compared with those who received no stent . c. stent and surgery versus no stent and surgery data are the percentage of patients in the total study group . copd = chronic obstructive pulmonary disease . includes patients with stents who eventually underwent resection or colostomy . by univariate analysis . significant at   .05 . based on median household income by zip code ( 2010 : < $ 41 000 ; 2011 : < $ 39 000).41 00039 000 . as shown in table 3 , patients with preoperative colonic stenting were less likely to undergo colostomy formation ( 19.5% vs 42.5% ; p < .01 ) . these patients were also more likely to undergo primary partial resection , rather than total colectomy or stoma formation without colectomy ( 86.8% vs 80.0% ; p = .02 ) . use of laparoscopy was significantly higher in the stent group ( 32.6% vs 9.7% ; p < .01 ) ; and , in the patients who underwent laparoscopy , the rate of conversion to an open procedure was significantly lower ( 13.9% vs 33.9% ; p < .01 ) . there was no significant difference in the rate of total colectomy or of ileostomy creation . placement of a preoperative colonic stent was associated with a delayed median operative day ( day 6 vs day 1 , p < .01 ) . operative management for the stent versus no stent groups data are the percentage of patients in the total study group . lar = lower abdominal resection ; apr = abdominal perineal resection . includes patients with stents who eventually underwent resection or colostomy . patients who had preoperative placement of a colonic stent had a significantly lower rate of total postoperative complications ( 10.5% vs 21.7% ; p < .01 ) ( table 4 ) . this finding remained true when comorbidities were taken into account on multivariate regression analysis ( table 5 ) . preoperative colonic stenting was associated with a lower requirement for blood transfusion ( 8.9% vs 25.0% ; p < .01 ) . there was no difference in mortality , iatrogenic injury , or requirement for total parenteral nutrition . perforation or peritonitis was associated with stent placement in 2.6% of cases and may reflect stent - related complications ( table 4 ) . morbidity and mortality for stent and surgery versus surgery without stent data are the percentage of patients in the total study group . includes shock , hemorrhage , wound infection , hematoma , seroma , internal infections ( e.g. , abscess ) , and respiratory , cardiac , renal problems ( table 1 ) . this icd-9 code is nonspecific ( table 1 ) and was not included in the total postoperative complications . multivariate analysis : association of stenting , age , and comorbidities with postoperative complications variables compared to stenting were significant on univariate analysis ( table 2c ) . or = odds ratio ; ci = confidence interval . the median total hospital charge for patients who underwent preoperative stenting was higher ( $ 108 530 vs $ 72 423 ; p < .01 ) , and the median hospital length of stay was longer ( 12 days vs 10 days ; p < .01 ) . the median postoperative length of stay , however , was shorter in the stent group ( 6 days vs 8 days , p = .02 ) . in addition , when all patients with stents were considered , including those who did not undergo an operation , their median total hospital charge and median hospital length of stay were both lower ( table 6 ) . there is no information available through the nis database after hospital discharge , and we therefore could not analyze rates of neoadjuvant therapy , delayed resection , morbidity and mortality after discharge , and long - term oncologic outcomes . during the study years 2010 to 2011 , an estimated 7891 patients presented with sigmoid , rectosigmoid , or rectal obstruction , and underwent either colonic stent placement ( 12.1% ; n = 956 ) or colon resection or stoma creation without stent placement ( 87.9% ; n = 6935 ) . the patients who underwent placement of a stent were younger , less likely to be white , less likely to be in the lowest income quartile , and slightly less likely to have arrhythmia , malnutrition , or diabetes ( table 2a ) . there were no significant differences between the stented and nonstented groups in the other demographic and comorbidity variables . demographic and comorbidity comparisons a. stent versus no stent data are the percentage of patients in the total study group . significant at   .05 . based on median household income by zip code ( 2010 : < $ 41 000 ; 2011 : < $ 39 000 ) . of those patients who had placement of a colonic stent , 19.9% went on to have resection or stoma creation . compared with patients with stents who did not have surgery during the same admission , those who underwent preoperative stenting represented an older population with a higher incidence of cardiac arrhythmia ( table 2b ) . they had a significantly lower incidence of cardiac disease , pneumonia , and diabetes mellitus . patients in the lowest income quartile were underrepresented in the group that underwent preoperative stenting followed by surgery during the same admission . b. stent and surgery versus stent without surgery data are the percentage of patients in the total study group . significant at   0.05 . based on median household income by zip code ( 2010 : < $ 41 000 ; 2011 : < $ 39 000 ) . when all surgical patients were compared , those who underwent preoperative stenting represented an older population ( table 2c ) . those in the lowest income quartile were again underrepresented in the preoperative group with stenting compared with those in the operative group without stenting . surgical patients who underwent preoperative stenting had a lower incidence of cardiac disease , pneumonia , and diabetes when compared with those who received no stent . c. stent and surgery versus no stent and surgery data are the percentage of patients in the total study group . copd = chronic obstructive pulmonary disease . includes patients with stents who eventually underwent resection or colostomy . by univariate analysis . significant at   .05 . based on median household income by zip code ( 2010 : as shown in table 3 , patients with preoperative colonic stenting were less likely to undergo colostomy formation ( 19.5% vs 42.5% ; p < .01 ) . these patients were also more likely to undergo primary partial resection , rather than total colectomy or stoma formation without colectomy ( 86.8% vs 80.0% ; p = .02 ) . use of laparoscopy was significantly higher in the stent group ( 32.6% vs 9.7% ; p < .01 ) ; and , in the patients who underwent laparoscopy , the rate of conversion to an open procedure was significantly lower ( 13.9% vs 33.9% ; p < .01 ) . there was no significant difference in the rate of total colectomy or of ileostomy creation . placement of a preoperative colonic stent was associated with a delayed median operative day ( day 6 vs day 1 , p < .01 ) . operative management for the stent versus no stent groups data are the percentage of patients in the total study group . lar = lower abdominal resection ; apr = abdominal perineal resection . includes patients with stents who eventually underwent resection or colostomy . patients who had preoperative placement of a colonic stent had a significantly lower rate of total postoperative complications ( 10.5% vs 21.7% ; p < .01 ) ( table 4 ) . this finding remained true when comorbidities were taken into account on multivariate regression analysis ( table 5 ) . preoperative colonic stenting was associated with a lower requirement for blood transfusion ( 8.9% vs 25.0% ; p < .01 ) . there was no difference in mortality , iatrogenic injury , or requirement for total parenteral nutrition . perforation or peritonitis was associated with stent placement in 2.6% of cases and may reflect stent - related complications ( table 4 ) . morbidity and mortality for stent and surgery versus surgery without stent data are the percentage of patients in the total study group . includes shock , hemorrhage , wound infection , hematoma , seroma , internal infections ( e.g. , abscess ) , and respiratory , cardiac , renal problems ( table 1 ) . this icd-9 code is nonspecific ( table 1 ) and was not included in the total postoperative complications . multivariate analysis : association of stenting , age , and comorbidities with postoperative complications variables compared to stenting were significant on univariate analysis ( table 2c ) . or = odds ratio ; ci = confidence interval . the median total hospital charge for patients who underwent preoperative stenting was higher ( $ 108 530 vs $ 72 423 ; p < .01 ) , and the median hospital length of stay was longer ( 12 days vs 10 days ; p < .01 ) . the median postoperative length of stay , however , was shorter in the stent group ( 6 days vs 8 days , p = .02 ) . in addition , when all patients with stents were considered , including those who did not undergo an operation , their median total hospital charge and median hospital length of stay were both lower ( table 6 ) . there is no information available through the nis database after hospital discharge , and we therefore could not analyze rates of neoadjuvant therapy , delayed resection , morbidity and mortality after discharge , and long - term oncologic outcomes . colonic stenting is a generally accepted method for palliation of obstructing colon cancer , although its use as a preoperative bridge to surgery is controversial , and data in the literature have been conflicting . in this study , we used a national database to define nationwide trends in management of malignant sigmoid , rectosigmoid , or rectal obstruction and analyzed the short - term outcomes . the results demonstrated no difference in mortality in patients who received a stent , which is consistent with the findings in 3 meta - analyses . our data do suggest , however , a clinical advantage to preoperative placement of a stent . in addition , the postoperative length of stay was shorter for them , perhaps because of the conversion of an emergent procedure into an elective one . this period of decompression is represented in our data by the significant difference in the median operative day ; patients with stents were in the hospital 6 days before resection or stoma , whereas patients without stents underwent surgery on hospital day 1 . those with stents had a lower rate of diabetes mellitus , pneumonia , and cardiac disease . patients with these comorbidities , as well as elderly patients , were more likely to have postoperative complications . preoperative stenting , however , still had a lower risk of postoperative complication when these factors were taken into account in multivariate logistic regression ( table 5 ) . there are theoretical benefits to having several days of bowel decompression before resection , and these benefits are reflected in our data . it is likely that patients without stents who undergo emergent surgery are experiencing systemic disturbances that may later manifest as postoperative complications . in addition , the decision to create a stoma rather than restore continuity is also related to the patient 's overall stability , and , in our study , the colostomy formation rate was significantly higher in patients without preoperative stenting . . the lower rate of colostomy formation in patients undergoing preoperative stenting is most likely related to the physical state of the bowel . many surgeons perform a mechanical or antibiotic bowel preparation before surgery , and this process is facilitated by stenting . preoperative decompression will result in a bowel that is less inflamed and of more normal caliber . a grossly dilated colon proximally and the presence of fecal bulk can preclude anastomosis or require more extensive resection . in this study , we were unable to determine whether preoperative stenting protects the anastomosis ; rates of anastomotic leak could not be accurately determined , as the code for this diagnosis is nonspecific ( table 4 ) . third , decompressing the large bowel before surgery has the potential benefit of facilitating the use of minimally invasive modalities . although this increase may be due in part to physician preference at institutions where colonic stenting is available , the higher conversion rate for patients without stents suggests that preoperative stenting enables a minimally invasive approach . finally , we expect that the patient whose bowel is decompressed and optimized before surgery would have a shorter recovery . the postoperative hospital length of stay was indeed shorter for patients with stents . the hospital charge associated with stenting was lower when considering all patients with stents , although the cost includes many patients who may return at a later date for resection . similarly , the cost associated with colostomy takedown during a subsequent admission is not included for any patients undergoing colostomy formation , and the cost is higher in the nonstented group . nonetheless , patients who undergo preoperative stenting as a bridge to surgery have a longer stay on average and higher associated hospital charges . the patient group that received a colonic stent differed from the nonstented group ( table 2c ) . the difference may be related to the availability of colonic stenting at centers that provide care to low - income patients . of interest , patients in the lowest income bracket who received a stent were more likely to be discharged without surgery ; however , it is unknown how many of these patients returned for surgery after the initial discharge ( table 2b ) . elderly patients who received a stent were more likely to have surgery during the same admission than to be discharged without surgery ( table 2b ) . a possible explanation for this difference is the decreased likelihood that an elderly patient would undergo neoadjuvant therapy with a stent in place . it is also possible , however , that the clinical success rate of stenting is lower in elderly patients ; thus , surgery is necessary during the same admission . we addressed this possibility by comparing the demographic and comorbidity variables of our 2 groups . there may , however , be important covariates not considered , and more important , there may be inaccurate or incomplete coding of some of these variables in the nis database . we analyzed operative outcomes , including the likelihood of stoma creation , but we were unable to access records and operative notes to determine the actual decision - making that accounted for the operative variations between our groups . these data would be helpful in reconciling the higher rate of abdominal perineal resection in patients who underwent preoperative stenting . the higher rate of stoma creation may be due to the emergent nature of the operation , which is mitigated by stent placement , but there could be other operative or patient variables that warranted stoma creation , independent of the factors related to emergent surgery . in addition , we were unable to ascertain the rate of stoma reversal in this sample of patients . in this study , we were not able to directly measure the rate of perforation from stent placement . we indirectly assessed this complication by measuring the percentage of patients with stents who also had a diagnosis of peritonitis or bowel perforation during the same hospital stay . it is safe to assume that these conditions were not present before stent placement or on admission . our estimated rate of 2.6% , however , is lower than the rate of 5.9% that is reported by sagar in a cochrane database meta - analysis of 5 randomized controlled trials . despite this limitation , the negative sequelae of a clinically significant perforation would be reflected in the rate of postoperative complications , which still favors patients with stents . the nis database collects only information during a patient 's hospital stay ; any events after discharge are lost . first , our patients who received a preoperative stent had a shorter postoperative length of stay . complications that occurred after discharge were missed , and this falsely depressed the rate of postoperative complication in patients with stents . the observed lower complication rate in patients with stents may nevertheless be real , as it most likely accounts for the shorter postoperative length of stay . we also can not draw conclusions regarding the proportion of stomas that were permanent , nor can we determine the clinical success rate of stents for palliation or as a bridge to surgery . finally , concern has been raised in the literature that patients who undergo preoperative placement of a colonic stent for obstructing cancer may have a higher cancer - related mortality . the blood transfusion requirement was lower in the stented group  a notable finding , in that blood transfusion has been associated with poorer oncologic outcome in patients who undergo colectomy . we addressed this possibility by comparing the demographic and comorbidity variables of our 2 groups . there may , however , be important covariates not considered , and more important , there may be inaccurate or incomplete coding of some of these variables in the nis database . we analyzed operative outcomes , including the likelihood of stoma creation , but we were unable to access records and operative notes to determine the actual decision - making that accounted for the operative variations between our groups . these data would be helpful in reconciling the higher rate of abdominal perineal resection in patients who underwent preoperative stenting . the higher rate of stoma creation may be due to the emergent nature of the operation , which is mitigated by stent placement , but there could be other operative or patient variables that warranted stoma creation , independent of the factors related to emergent surgery . in addition , we were unable to ascertain the rate of stoma reversal in this sample of patients . in this study , we were not able to directly measure the rate of perforation from stent placement . we indirectly assessed this complication by measuring the percentage of patients with stents who also had a diagnosis of peritonitis or bowel perforation during the same hospital stay . it is safe to assume that these conditions were not present before stent placement or on admission . our estimated rate of 2.6% , however , is lower than the rate of 5.9% that is reported by sagar in a cochrane database meta - analysis of 5 randomized controlled trials . despite this limitation , the negative sequelae of a clinically significant perforation would be reflected in the rate of postoperative complications , which still favors patients with stents . the nis database collects only information during a patient 's hospital stay ; any events after discharge are lost . first , our patients who received a preoperative stent had a shorter postoperative length of stay . complications that occurred after discharge were missed , and this falsely depressed the rate of postoperative complication in patients with stents . the observed lower complication rate in patients with stents may nevertheless be real , as it most likely accounts for the shorter postoperative length of stay . we also can not draw conclusions regarding the proportion of stomas that were permanent , nor can we determine the clinical success rate of stents for palliation or as a bridge to surgery . finally , concern has been raised in the literature that patients who undergo preoperative placement of a colonic stent for obstructing cancer may have a higher cancer - related mortality . the blood transfusion requirement was lower in the stented group  a notable finding , in that blood transfusion has been associated with poorer oncologic outcome in patients who undergo colectomy . preoperative placement of a colonic stent is associated with lower postoperative complications , a lower rate of colostomy formation , and increased successful use of laparoscopy . as more data emerge regarding the long - term outcomes of patients who undergo stenting , the nis database can be used to follow national trends in management of patients with malignant obstruction .
background and objectives : colonic stenting has been used in the setting of malignant obstruction to avoid an emergent colectomy . 
 we sought to determine whether preoperative placement of a colonic stent decreases morbidity and the rate of colostomy formation.methods:cases of obstructing sigmoid , rectosigmoid , and rectal cancer from january 1 , 2010 , to december 31 , 2011 , were identified in the nationwide inpatient sample ( nis ) database . 
 all patients were treated at hospitals in the united states , and the database generated national estimates . 
 postoperative complications , mortality , and the rate of colostomy formation were analyzed.results:of the estimated 7891 patients who presented with obstructing sigmoid , rectosigmoid , or rectal cancer necessitating intervention , 12.1% ( n = 956 ) underwent placement of a colonic stent , and the remainder underwent surgery without stent placement . 
 of the patients who underwent stenting , 19.9% went on to have colon resection or stoma creation during the same admission . 
 patients who underwent preoperative colonic stent placement had a lower rate of total postoperative complications ( 10.5% vs 21.7% ; p < .01 ) . 
 there was no significant difference in mortality ( 4.7% vs 4.2% ; p = .69 ) . 
 the rate of colostomy formation was more than 2-fold higher in patients who did not undergo preoperative stenting ( 42.5% vs 19.5% ; p < .01 ) . 
 preoperative stenting was associated with increased use of laparoscopy ( 32.6% vs 9.7% ; p < .01).conclusions : our study characterizes the national incidence of preoperative placement of a colonic stent in the setting of malignant obstruction . 
 preoperative stent placement is associated with lower postoperative complications and a lower rate of colostomy formation . 
 the results support the hypothesis that stenting as a bridge to surgery may benefit patients by converting an emergent surgery into an elective one .