Zhao, W.T., Hu, F.L., Li, Y.Y., Li, H.J., Luo, W.M., & Sun, F. (2013). Use of a transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer. World Journal of Surgery, 37, 227–232. 

To determine if postoperative use of a transanal drainage tube after anterior resection surgery for rectal cancer would prevent anastomotic leakage and bleeding

In this study, patients were divided into either a transanal drainage tube (TDT) or the non-transanal drainage tube (NTDT) group. A 26 Fr tube was placed during surgery proximal to the anastomosis site. Then, an air leakage test and anastomotic bleeding test were performed. If either test were positive, then corrective surgical measures were employed prior to completion of the surgery. The tube was secured to the patient with a skin suture and connected to draining. The tube was removed approximately five to six days postoperatively. The study accepted patients from January 2007 through May 2011.

• N = 158
• AGE RANGE = < 60 years (66 patients); > 60 years (92 participants)
• MALES: 56.9%, FEMALES: 43.1%
• KEY DISEASE CHARACTERISTICS: Tumor characteristics including tumor diameter, distance of tumor from anal verge, tumor location, histopathological grade, TNM stage, tumor stage, regional lymph node involvement, and distant metastasis were matched and did not reach statistical significance (p < 0.05). 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients in both the TDT and NTDT groups were also matched as to other comorbid illnesses. These included hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, colorectal adenomatous polyps, breast cancer, and anal fistula.  

• SITE: Not stated/unknown  
• SETTING TYPE: Inpatient  
• LOCATION: The First Affiliated Hospital, Guangzhou University of Traditional Chinese medicine, Guangzhou, People’s Republic of China

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

The study design was a nonrandomized, prospective trial.

A functional definition of anastomotic leakage and anastomotic bleeding were used. The anastomotic leakage definition addressed the drainage of stool, exudate, and gas from the abdominal and rectal drains or a rectovaginal fistula. Leakage was also considered present if peritonitis was present. Leaks were confirmed by CT scan, sigmoidoscopy, rectal examination, or laparotomy. Anastomotic bleeding was defined as continuous rectal bleeding from the rectal drain with a hemoglobin drop that no other cause could explain. Bleeding was confirmed by sigmoidoscopy, rectal examination, or laparotomy.

The use of a transanal tube to reduce bleeding in patients undergoing an anterior resection was not clinically significant. The study findings did not reach statistical significance, possibly due to the small population. However, the TDT group had 0% bleeding occur while the NTDT group experienced a 2.6% bleeding rate (p = 0.236). Of note, when anastomotic leakage was also considered, the TDT complication rate was 2.5% and the NTDT rate was 11.7%, which was clinically significant (p = 0.029).

Anastomotic bleeding is considered a complication of anterior resections. Physiological changes that occur postoperatively include a tight contraction of the anal sphincter, inflammation, pain, and trauma from the surgery. Placement of a transanal tube may be considered a mechanism for addressing some of these changes occurring postoperatively, therefore reducing bleeding.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable

Educational opportunities exist for nurses to instruct patients preoperatively regarding the possible placement of a transanal tube postoperatively, with the rationale for its use to ease the postoperative recovery. Standardization of instruction for nursing staff regarding \"normal\" versus abnormal amounts and types of bleeding/drainage from tubes is necessary.