Colorectal cancer is the second most common malignant disease in developed countries, with about a million new cases and 500,000 deaths worldwide each year. Up to 30% of colorectal cancers present as an emergency with large bowel obstruction. Emergency surgery for obstructing colorectal cancer is associated with high morbidity and mortality, prolonged hospital stay and a high frequency of stoma formation, compromising the patient's quality of life. Patients treated in the emergency setting are also compromised in their subsequent care, notably because they are frequently unable to tolerate adjuvant chemotherapy.
Stenting of large bowel obstructions provides the potential to avoid emergency surgery, allow full assessment and preparation of the patient for surgery, with the potential to reduce operative morbidity and improve quality of life and survival. However, stenting can sometimes perforate the bowel wall and may increase the risk of tumour dissemination. The balance of benefits and risks has not yet been reliably assessed. CReST (ColoRectal Stenting Trial) is a randomised controlled trial to investigate whether endoluminal colonic stenting for obstructing colorectal cancer will result in reduced operative morbidity, reduced length of hospital stay, a reduced rate of stoma formation and improved quality of life and survival compared to conventional treatment.
Patients presenting in the emergency setting with left-sided colonic obstruction and radiological features consistent with a carcinoma who are considered to require urgent decompression are randomised to either endoluminal stenting or to surgical decompression with or without resection of the primary tumour.
CReST is a multi-centre Phase III randomised controlled trial with the following objectives:
To determine if endoluminal stenting for obstructing colonic cancers can result in:
Reduced perioperative morbidity as assessed by length of hospital stay
Reduced 30-day mortality
To determine if endoluminal stenting for obstructing colonic cancers:
Reduces stoma formation
Improves quality of life
Increases ability to tolerate adjuvant chemotherapy
Has demonstrable benefits in the palliative and attempted curative settings
Improves overall survival