Initial management strategies for right-sided malignant colonic obstruction: a systematic review and bayesian network meta-analysis

Right-sided malignant colonic obstruction (RMCO) remains challenging, as the evidence is more limited than for left-sided disease. Although primary resection is the standard approach, emergency surgery carries higher perioperative risks, increasing interest in bridge-to-surgery (BTS) strategies. However, their optimal role remains uncertain. We conducted a systematic review and Bayesian network meta-analysis to compare initial management strategies for RMCO and evaluate short- and long-term outcomes. A comprehensive search of PubMed, Embase, and the Cochrane Library was performed, with a last update in October 2025. Comparative studies including patients with potentially curable RMCO who underwent either immediate surgery or a BTS approach (stent, decompression stoma, or decompression tube) were eligible. A Bayesian random-effects network meta-analysis was conducted. The primary outcome was overall postoperative morbidity; secondary outcomes included postoperative mortality, stoma formation after resection, and overall survival (OS) rate. A total of 18 retrospective non-randomized cohort studies including 7,205 patients met the inclusion criteria. Stenting was associated with a significantly lower postoperative mortality as compared to immediate surgery (6.6 vs. 0.9%; RR: 0.33; 95% CrI: 0.10–0.75) and with a significantly lower rate of stoma formation after resection (11.8 vs. 2.3%; RR: 0.41; 95% CrI: 0.21–0.78). No significant differences were observed among treatment strategies in overall postoperative morbidity or OS rate. Stenting as a bridge to surgery (BTS) was associated with a lower postoperative mortality and a lower rate of stoma formation as compared to immediate surgery. These findings suggest that stenting may serve as a viable alternative for patients at high risk of postoperative mortality.