Endoscopy plays an essential role in managing malignant obstruction of the colon and an important part in treating benign colonic strictures related to Crohn’s disease, postsurgical anastomosis, and diverticulitis. 

In light of that, the American Society for Gastrointestinal Endoscopy (ASGE)’s Standards of Practice Committee, chaired by Narav C. Thosani, MD, MHA, of the Center for Interventional Gastroenterology at UTHealth, McGovern Medical School in Houston, has issued a broad-ranging update on stricture management in Gastrointestinal Endoscopy after conducting a meta-analysis of recent evidence. Evidence was weighed for certainty using the Grading of Recommendations Assessment, Development and Evaluation system.

The last time the society directly addressed this topic was in 2010, Thosani told Medscape Medical News,and over the intervening 15 years, the evidence landscape has changed considerably. “We now have eight randomized trials of stenting as a bridge to surgery, including the large CReST trial published in 2022. We felt strongly that endoscopists needed an updated, GRADE-based framework covering both malignant and benign disease, so we conducted new meta-analyses across six Population, Intervention, Comparison, and Outcome questions rather than simply refreshing the old document.”

On the benign side, he added, a useful order has been established, with balloon dilation remaining first-line treatment and stricturotomy and lumen-apposing metal stents (LAMS) clearly positioned as options for short, refractory strictures rather than competing first-line therapies.

Thosani cautioned that nearly every recommendation is conditional and based on low- to very-low-certainty evidence. “That’s not a weakness of the guideline so much as an honest reflection of the field, and it means these recommendations are a scaffold for multidisciplinary, patient-centered decision-making — not a protocol.”

The overall direction is greater confidence in colonic stenting for malignant obstruction, both as a bridge to surgery (BTS) and in the palliative setting, compared with the more cautious posture of the 2010 era. “What’s genuinely new is the explicit carve-out for the antiangiogenic bevacizumab. We recommend shared decision-making with the surgeon, oncologist, and patient rather than a blanket endorsement of stenting, given the perforation concern, while acknowledging that more recent observational data have questioned the older risk assessments.”

Among specific 2026 recommendations:

• For colonic obstruction from suspected or confirmed colorectal cancer (CRC) that appears surgically resectable, the ASGE recommends endoscopic placement of a colonic stent as a BTS over emergency surgery without stent placement.
• For CRC obstruction deemed not curable by surgical resection, endoscopic placement of a palliative colonic stent is recommended over palliative surgery. In patients who receive or may receive bevacizumab, shared decision-making with surgeons, oncologists, and patients deciding between a colonic stent or palliative surgery.
• For obstruction from extracolonic malignancy, the choice between stent placement or surgery should be based on specific tumor biology and multidisciplinary discussion. Stent placement in this setting has a higher risk for clinical and technical failure than in intraluminal malignancy, and this risk should be openly discussed with patients for shared decision-making.
• In patients undergoing endoscopic stent placement, the ASGE suggests using uncovered self-expandable metal stents over covered.
• In those with symptomatic benign noninflammatory colonic stricture, endoscopic balloon dilation (EBD) is recommended over endoscopic stent placement as first-line therapy. After multidisciplinary evaluation, endoscopic stent placement with fully covered metal stents may be considered for patients who fail EBD.
• In patients with anastomotic colonic strictures of < 15 mm in length and refractory to EBD, the ASGE suggests using LAMS.
• For those with symptomatic benign noninflammatory strictures, EBD is recommended over endoscopic stricturotomy (ES) as first-line therapy. ES can be considered for short (< 3 cm) benign strictures refractory to EBD when technical expertise is available.

As to reaction in the GI community, Thosani said, some colleagues, particularly in surgical oncology, may feel that any statistically significant recurrence signal with BTS stenting deserves more weight than the guideline gives it.

“Our response is that the evidence for that outcome was of very low certainty and fragile, with no survival penalty, whereas the stoma benefit was the most robust finding in the entire analysis,” he explained. “Proponents of stricturotomy may feel the guideline undersold the technique given its lower recurrence rates in unadjusted analyses, but the time-adjusted analysis eliminated that difference, and the 14-fold increase in bleeding was difficult to ignore. We see stricturotomy as promising but needing standardization and training before first-line use.”

Offering Medscape Medical News his perspective on the guideline, Mohit Girotra, MD, chief of endoscopy at Banner Health in Chandler, Arizona, near Phoenix, and an associate professor of medicine at the Elson S. Floyd College of Medicine at Washington State University in Spokane, Washington, called it a major update and clinically relevant for many reasons.

“First, there is no dedicated guideline on this subject from any other GI society in the US, and second, the only non-US influential document in this regard is the 2020 European Society for Gastrointestinal Endoscopy (ESGE) update on colonic stenting, which does not provide detailed benign-stricture recommendations,” said Girotra, who was not involved in developing the 2026 guideline. In addition, the new guideline is a comprehensive endoscopic management document, going above and beyond the standard EBD and colonic stenting approaches, and providing an in-depth overview of endoscopic ultrasound-guided LAMS placement, as well as bypass for nonsurgical patients.

“For these reasons, I believe, clinicians and readers in the US, as well as other parts of the world, will heavily lean on this document in their clinical practice, Girotra said. “For practicing therapeutic endoscopists and trainees, the 2026 ASGE and the 2020 ESGE stenting guidelines are complementary documents, highlighting essentially all major evidence-based recommendations currently used in Western practice.”

Ultimately, Thosani added, the 2026 recommendations are a scaffold for multidisciplinary, patient-centered decision-making and are not a protocol. “Surgical consultation should be part of every case of significant colonic obstruction. I’d encourage readers not to skip the best-practice sections. Advice such as advancing the scope with water-jet irrigation rather than insufflation to avoid pressurizing a closed loop, mandatory photo documentation, and proper tattoo technique may be the most immediately practice-changing content for general endoscopists.”

Future Directions

Among many questions still to be answered is the risk for recurrent cancer from stents as BTS in patients with CRC. In addition, longer follow-up data on disease-specific survival would clarify the prevalence of recurrent malignancy and the effect on patient outcomes.

“Because patients survive longer with new therapies, a confirmed increased risk of recurrent cancer would affect the recommendations we make for colonic stent placement as BTS,” the authors stated. Furthermore, improved stent design of dedicated uncovered metal stents in the right-sided colon or extracolonic malignancy may reduce the risk for migration.

High-quality studies are needed to clarify whether bevacizumab substantially increases the risk for perforation during stent placement, for short benign strictures, larger studies are needed to see whether a lumen-apposing metal stent is superior to EBD in reducing stricture resolution procedures and adverse events.

The ASGE guideline received no outside funding. Thosani reported consulting for PENTAX Medical, Boston Scientific Corporation, and Ambu; receiving royalties from UpToDate, as well as ownership in ROSEAId. Numerous coauthors disclosed various financial ties to multiple private-sector companies. Girotra disclosed having no conflicts of interest relevant to his comments.