Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis
Wang et al. World Journal of Surgical Oncology
Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis
Shuanhu Wang 0
Zongbing Zhang 0
Mulin Liu 0
Shiqing Li 0
Congqiao Jiang 0
0 Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College , Bengbu, Anhui Province , China
Background: Anastomotic leakage is a serious complication that can occur after anterior resection of the rectum. There is a question regarding whether the placement of a transanal tube can decrease the rate of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the efficacy of transanal tube placement after anterior resection. Methods: We searched three major databases (PubMed, Embase, and the Cochrane Library) up until January 2015 for studies evaluating the benefit of transanal tubes after anterior resection for rectal cancer. The primary outcome measure was the rate of clinical anastomotic leakage. Secondary outcome was the rate of reoperation. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were obtained using random effects models. Results: One randomized controlled trial and three observational studies involving 909 patients met inclusion criteria. Clinical anastomotic leakage occurred in 3.49 % (14 of 401) of patients with transanal tubes and 12.01 % (61 of 508) of patients without transanal tubes. Meta-analysis of the studies showed a lower risk of anastomotic leakage (RR, 0.32; 95 % CI 0.18-0.58) and reoperation related to leakage (RR, 0.19; 95 % CI 0.08-0.46) when the transanal tube was placed. Conclusions: While studies are few and mostly observational, the data to date indicate that placement of a transanal tube decreases the rate of clinical anastomotic leakage and reoperation related to leakage. More studies are needed to confirm these findings.
Rectal cancer; Transanal tube; Anastomotic leakage
In 1908, William Ernest Miles introduced the basis of
modern rectal cancer surgery in a study published in
Lancet. As late as the past few decades, his
abdominoperineal resection has been the gold standard of rectal
cancer treatment. In 1948, CF Dixon proposed another
technique, one that allowed for sphincter preservation
]. With the popularization of the concept of total
mesorectal excision (TME) and improvements in surgical
instruments, low anterior resection has become more
commonly performed than permanent stoma. With the
increase of anus-preserving operations, anastomotic
leakage has drawn the attention of surgeons.
Anastomotic leakage is defined as a defect of the
intestinal wall at the site of anastomosis (including suture
and staple lines in neorectal reservoirs) leading to a
communication between the intra- and extraluminal
]. Anastomotic leakage after anterior
resection of the rectum can be serious. The overall
frequency of this complication has been reported at
8.58 % [
]. Patients suffering from anastomotic leakage
not only remain hospitalized longer but also have a
lower survival rate [
]. Low anastomosis and male
gender are considered independent risk factors for
symptomatic anastomotic leakage [
]. For this reason,
surgeons have explored ways of reducing the incidence of
anastomotic leakage. Some systematic reviews and
metaanalyses have indicated that proximal fecal diversion can
reduce the rate of anastomotic leakage and reoperation
related to leakage [
]. Proximal fecal diversion by loop
ileostomy or colostomy requires another surgery to close
the stoma. This increases hospital costs and the rate of
stoma-related complications . While some surgeons
place a defunctioning transanal tube in an attempt to
reduce anastomotic leakage [
], others believe that
transanal tube placement is ineffective in preventing leakage
]. Thus, although defunctioning transanal tube
placement is widely used in anterior resection for rectal cancer,
it remains unclear whether this measure is useful to
patients. We conducted this systematic review and
metaanalysis of available data to determine whether a transanal
tube reduces postoperative complications in patients
undergoing anterior resection for rectal cancer.
The electronic databases Pubmed, Embase, and the
Cochrane Library were searched by two authors (S.W.
and Z.Z.) up till January 2015. The search strategy
included the following keywords in various
combinations: “transanal tube,” “transanal drainage,” “transanal
drainage tube,” “transanal catheter,” “anterior resection,”
“rectal cancer,” and “anastomotic leakage.” Free text
searches and MeSH searches were performed. Of the
articles included here, references were read to identify
any related articles. No language restrictions were applied.
The inclusion criteria were biopsy-proven rectal
cancer before operation, laparotomy or laparoscopy, radical
resection, use of stapler anastomosis, and comparison of
anterior resection with a transanal tube to anterior
resection without a transanal tube. The exclusion criteria were
defunctioning stoma, defunctioning stoma and transanal
tube placement at the same time, emergency operation,
and palliative operation.
Two authors independently assessed all titles and
abstracts for relevance (S.W. and S.L.). Disagreements
were resolved through discussion. In cases where no
consensus could be reached, a third specialist was
consulted (C.J.). If a study covered both handsewn
and stapler anastomosis, it was included only if a
breakdown of data by level of anastomosis was
available. Studies were excluded if all anterior resections
(both curative and palliative) were included, without
any breakdown by level of anastomosis.
Two outcome variables were evaluated: clinical
anastomotic leakage (primary outcome) and reoperation related
to leakage (secondary outcome). Clinical anastomotic
leakage was defined as the presence of clinical symptoms
such as peritonitis, fever, or septicemia combined with
the occurrence of pelvic abscess, discharge of feces,
pus, or gas from the drainage tube, and formation of
a rectovaginal fistula [
]. Radiologically confirmed
anastomotic leakage with no clinical signs was not
included. When the required information could not be
obtained from the article, e-mails were sent to the authors
requesting it. If there was no reply from the author, the
data were considered missing.
Two authors (S.W. and M.L.) assessed the quality of
the included articles. The Jadad scoring system was used
to assess the quality of RCT [
]. The quality of the
observational studies was assessed using the
NewcastleOttawa quality assessment scale [
Statistical analysis was performed using Review Manager
(RevMan, version 5.3, The Nordic Cochrane Centre, the
Cochrane Collaboration, Copenhagen, Denmark).
Statistical heterogeneity was assessed using I2 and χ2 statistics.
Fig. 1 Flow chart of study screening and selection
We estimated pooled risk ratio (RR) and 95 % confidence
interval (CI) for each outcome. Heterogeneity was
considered significant if the P value (χ2) was <0.1 or
I2 was >50 %. A random effects model was used even
if no significant heterogeneity statistical heterogeneity
was noted. This takes into account the low statistical
power of tests of heterogeneity and the likelihood
that clinical heterogeneity may exist even if statistical
heterogeneity cannot be demonstrated. Sensitivity
analysis was conducted by omitting each study one at a
time in order to assess the influence of each single
study on the overall risk estimate. Because of the
limited number (below 10) of studies included in each
analysis, publication bias was not assessed.
The initial search retrieved 79 studies. After removal of 11
repeated studies, 68 articles remained. After reading the
titles and abstracts of the studies, 51 studies were excluded
because 1 was a systematic review (Poster Abstracts in
Colorectal Disease) and another 50 were not relevant.
Upon further review, 13 studies were excluded because
the data regarded the placement of a transanal tube and
nothing else. Finally, four articles were included (Fig. 1).
The included studies were published between 2011
and 2014. Sample size of studies varied from 158 to
370 patients. One randomized controlled trial [
and three observational studies [
] involved 909
patients, 401 of whom had a transanal tube and 508
did not. All studies reported clinical anastomotic leakage
and reoperation related to leakage. Characteristics of the
studies included are given in Table 1.
Three items (randomization, blinding, withdrawals,
and dropouts) in the Jadad scoring system were used to
There is one star for each point, a study can be given a maximum of nine stars
assess the quality of the study. Eight elements in
Newcastle-Ottawa quality assessment scale were used to
assess patient population and selection, study
comparability, follow-up, and outcome of interest. High-quality
elements are awarded by adding a star, and then the
stars are added up to compare the study quality.
Assessment of the methodologic quality of studies using the
three items in the Jadad scoring system for randomized
trials and eight items in the Ottawa quality assessment
scale for observational studies are shown in Table 2.
Four studies reported on clinical anastomotic leakage
and reoperation. The pooled results from the three
observational studies showed that transanal tubes was
associated with a lower risk of both anastomotic leakage
(pooled RR 0.32, 95 % CI 0.18–0.58, P = 0.0002, Fig. 2)
and reoperation (0.19, 95 % CI 0.08–0.46, P = 0.0003,
Fig. 3). There was no significant heterogeneity for either
outcome. The pooled RR for the three observational
studies was similar to the RR in the randomized trial for
both anastomotic leakage (0.27, 95 % CI 0.12–0.60
versus 0.40, 95 % CI 0.17–0.94) and reoperation (0.23,
95 % CI 0.07–0.70 versus 0.14, 95 % CI 0.03–0.60).
Sensitivity analysis was performed by excluding each
single study at a time. The effect on anastomotic leakage
did not materially alter the pooled RR, which ranged
from 0.27 (95 % CI 0.12–0.60, P = 0.001) to 0.34 (95 %
CI 0.19–0.63, P = 0.0006). The pooled RR for reoperation
ranged from 0.16 (95 % CI 0.05–0.47, P = 0.001) to 0.23
(95 % CI 0.07–0.70, P = 0.01).
Anastomotic leakage is a serious complication following
surgery for rectal cancer. With the development of
surgical instruments and surgical techniques,
sphincterNewcastle-Ottawa quality assessment scale cohort studies
Selection (0–4) Comparability (0–2) Outcome (0–3)
2 (1.1) 14 (7.7)
preserving procedures have become more prevalent [
However, the risk of anastomotic leakage is increasing
], and placement of a transanal tube for its
prevention is controversial.
The present meta-analysis was conducted to evaluate
existing data to help clarify the role of transanal tube
placement in the prevention of anastomotic leakage and
reoperation. Results of both the meta-analysis of the
three observational studies and the one randomized
trials indicate that placement of a transanal tube
significantly decreases the risk of leakage and reoperation.
While the mechanism of action of the transanal tube is
unclear, it may be related to reduction in endoluminal
pressure in the anastomotic portion of the intestine
which may be an important factor in anastomotic
]. This is supported by the observation that rectal
resting pressure was lower in the transanal tube group
than in the tube-free group in one study [
transanal tube may also directly drainage on the proximal
side of the anastomosis [
]. If anastomotic leakage
occurs, a large amount of stool will leak to the peritoneal
cavity in the tube-free group. Reoperation for
anastomotic leakage will be inevitable. The rate of reoperation
for anastomotic leakage was 8.3 % (42 of 508) in the
tube-free group. In contrast, stool could be drained from
the rectum through the transanal tube. A small amount
of stool might leak to the peritoneal cavity resulting in
localized peritonitis. The localized peritonitis was cured
conservatively by the placement of abdominal drainage
tube. So the rate of reoperation for anastomotic leakage
was only 1.3 % (5 of 401) in the tube group.
These results are similar to those published in an earlier
meta-analysis by Shigeta and co-workers [
that study was published only in a poster abstract. No
further details were made available. The purpose of the
present article is to fill this gap.
This meta-analysis followed clear methodology with
clearly predefined inclusion and exclusion criteria,
outcome measures, study quality appraisal, and statistical
methods a priori. However, there are limitations that
should be considered. First, there was only one RCT and
three observational studies available for inclusion.
Second, among the included studies, some patients
underwent laparotomy and others underwent laparoscopy. But
the rate of anastomotic leakage was not significant
differences between laparotomy and laparoscopy group
]. The outer diameters of the transanal tube also
varied from 24 to 28 Fr. These differences constitute
clinical heterogeneity even though statistical
heterogeneity was not demonstrated. Finally, the sample size of all
studies was relatively small. However, the sensitivity of
the analysis indicated that the results were robust.
Although transanal tube may reduce the risk of
anastomotic leakage and reoperation, its placement increases
patients’ discomfort and inconvenience. There have also
been reports of tubes perforating bowel especially in the
region anterior to the sacrum [
]. However, compared
with the reoperations required for anastomotic leakage in
the absence of a transanal tube, complications associated
with a transanal tube are relatively minor.
This systematic review and meta-analysis indicates that
placement of transanal tubes after anterior resection
reduces the risk of anastomotic leakage and reoperation.
However, the studies are few and mostly observational. A
well-powered, multicenter, randomized, controlled trial is
needed to confirm these findings. If confirmed, the use of
this intervention will improve outcomes and reduce
complications in patients undergoing anterior resection.
NTT: non-transanal tube; TME: total mesorectal excision; TT: transanal tube.
The authors declare that they have no competing interests.
S.W. conceived the study, extracted and analyzed the data, and drafted the
manuscript. Z.Z. collected the data and helped to draft the manuscript. S.L.
extracted the data. M.L. analyzed the data. C.J. participated in the study
design. All authors read and approved the final manuscript.
The authors thank LetPub (www.letpub.com) for its linguistic assistance
during the preparation of this manuscript.
1. Dixon CF . Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid . Ann Surg . 1948 ; 128 ( 3 ): 425 - 42 .
2. Rahbari NN , Weitz J , Hohenberger W , Heald RJ , Moran B , Ulrich A , et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer . Surgery . 2010 ; 147 ( 3 ): 339 - 51 . doi: 10 .1016/j.surg. 2009 . 10 .012.
3. Cong ZJ , Hu LH , Bian ZQ , Ye GY , Yu MH , Gao YH , et al. Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer . PLoS One . 2013 ; 8 ( 9 ), e75519 . doi: 10 .1371/journal.pone. 0075519 .
4. Kulu Y , Tarantio I , Warschkow R , Kny S , Schneider M , Schmied BM , et al. Anastomotic leakage is associated with impaired overall and disease-free survival after curative rectal cancer resection: a propensity score analysis . Ann Surg Oncol . 2015 ; 22 ( 6 ): 2059 - 67 . doi: 10 .1245/s10434-014-4187-3.
5. Law WL , Choi HK , Lee YM , Ho JW , Seto CL . Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy . J Gastrointest Surg . 2007 ; 11 ( 1 ): 8 - 15 . doi: 10 .1007/s11605-006-0049-z.
6. Kang CY , Halabi WJ , Chaudhry OO , Nguyen V , Pigazzi A , Carmichael JC , et al. Risk factors for anastomotic leakage after anterior resection for rectal cancer . JAMA Surg . 2013 ; 148 ( 1 ): 65 - 71 . doi: 10 .1001/ 2013 .jamasurg.2.
7. Matthiessen P , Hallbook O , Andersson M , Rutegard J , Sjodahl R . Risk factors for anastomotic leakage after anterior resection of the rectum . Colorectal Dis . 2004 ; 6 ( 6 ): 462 - 9 . doi: 10 .1111/j.1463- 1318 . 2004 . 00657 .x.
8. Chen J , Wang DR , Yu HF , Zhao ZK , Wang LH , Li YK . Defunctioning stoma in low anterior resection for rectal cancer: a meta-analysis of five recent studies . Hepatogastroenterology . 2012 ; 59 ( 118 ): 1828 - 31 . doi: 10 .5754/hge11786.
9. Gu WL , Wu SW . Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies . World J Surg Oncol . 2015 ; 13 :9. doi: 10 .1186/ s12957-014-0417-1.
10. Huser N , Michalski CW , Erkan M , Schuster T , Rosenberg R , Kleeff J , et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery . Ann Surg . 2008 ; 248 ( 1 ): 52 - 60 . doi: 10 .1097/SLA. 0b013e318176bf65.
11. Tan WS , Tang CL , Shi L , Eu KW . Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer . Br J Surg . 2009 ; 96 ( 5 ): 462 - 72 . doi: 10 .1002/bjs.6594.
12. Thoker M , Wani I , Parray FQ , Khan N , Mir SA , Thoker P. Role of diversion ileostomy in low rectal cancer: a randomized controlled trial . Int J Surg . 2014 ; 12 ( 9 ): 945 - 51 . doi: 10 .1016/j.ijsu. 2014 . 07 .012.
13. Patrascu T , Doran H , Musat O . Protective transanal tube in colo-rectal anastomosis . Chirurgia (Bucur) . 2004 ; 99 ( 1 ): 75 - 8 .
14. Cong ZJ , Fu CG , Wang HT , Liu LJ , Zhang W , Wang H . Influencing factors of symptomatic anastomotic leakage after anterior resection of the rectum for cancer . World J Surg . 2009 ; 33 ( 6 ): 1292 - 7 . doi: 10 .1007/s00268-009-0008-4.
15. Eckmann C , Kujath P , Schiedeck TH , Shekarriz H , Bruch HP . Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach . Int J Colorectal Dis . 2004 ; 19 ( 2 ): 128 - 33 . doi: 10 .1007/s00384-003-0498-8.
16. Matthiessen P , Hallbook O , Rutegard J , Simert G , Sjodahl R . Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial . Ann Surg . 2007 ; 246 ( 2 ): 207 - 14 . doi: 10 .1097/SLA.0b013e3180603024.
17. Jadad AR , Moore RA , Carroll D , Jenkinson C , Reynolds DJ , Gavaghan DJ , et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials . 1996 ; 17 ( 1 ): 1 - 12 .
18. Lo CK , Mertz D , Loeb M . Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments . BMC Med Res Methodol . 2014 ; 14 : 45 . doi: 10 .1186/ 1471 -2288-14-45.
19. Xiao L , Zhang WB , Jiang PC , Bu XF , Yan Q , Li H , et al. Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study . World J Surg . 2011 ; 35 ( 6 ): 1367 - 77 . doi: 10 .1007/s00268-011-1053-3.
20. Nishigori H , Ito M , Nishizawa Y , Nishizawa Y , Kobayashi A , Sugito M , et al. Effectiveness of a transanal tube for the prevention of anastomotic leakage after rectal cancer surgery . World J Surg . 2014 ; 38 ( 7 ): 1843 - 51 . doi: 10 .1007/ s00268-013-2428-4.
21. Hidaka E , Ishida F , Mukai S , Nakahara K , Takayanagi D , Maeda C , et al. Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution . Surg Endosc . 2015 ; 29 ( 4 ): 863 - 7 . doi: 10 .1007/ s00464-014-3740-2.
22. Zhao WT , Hu FL , Li YY , Li HJ , Luo WM , Sun F . Use of a transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer . World J Surg . 2013 ; 37 ( 1 ): 227 - 32 . doi: 10 .1007/ s00268-012-1812-9.
23. Bordeianou L , Maguire LH , Alavi K , Sudan R , Wise PE , Kaiser AM . Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results . J Gastrointest Surg . 2014 ; 18 ( 7 ): 1358 - 72 . doi: 10 .1007/s11605-014-2528-y.
24. Moran BJ . Predicting the risk and diminishing the consequences of anastomotic leakage after anterior resection for rectal cancer . Acta Chir Iugosl . 2010 ; 57 ( 3 ): 47 - 50 .
25. Yang L , Huang XE , Zhou JN . Risk assessment on anastomotic leakage after rectal cancer surgery: an analysis of 753 patients . Asian Pac J Cancer Prev . 2013 ; 14 ( 7 ): 4447 - 53 .
26. Guenaga KF , Lustosa SA , Saad SS , Saconato H , Matos D. Ileostomy or colostomy for temporary decompression of colorectal anastomosis . Cochrane Database Syst Rev . 2007 ; 1, CD004647 . doi: 10 .1002/14651858. CD004647. pub2 .
27. Montemurro S , De Luca R , Caliandro C , Ruggieri E , Rucci A , Sciscio V , et al. Transanal tube NO COIL(R) after rectal cancer proctectomy . The “G. Paolo II ” Cancer Centre experience . Tumori . 2012 ; 98 ( 5 ): 607 - 14 . doi: 10 .1700/1190.13202.
28. Montemurro S , Caliandro C , Ruggeri E , Rucci A , Sciscio V . Endoluminal pressure: risk factor for anastomotic dehiscence in rectal carcinoma. Preliminary results . Chir Ital . 2001 ; 53 ( 4 ): 529 - 36 .
29. Shigeta K , Baba H , Yamafuji K , Kubochi K. A meta-analysis of use of transanal tube to prevent anastomotic leakage after anterior resection for rectal cancer . Colorectal Disease . 2014 ; 16 : 87 .
30. Zhao JK , Chen NZ , Zheng JB , He S , Sun XJ . Laparoscopic versus open surgery for rectal cancer: results of a systematic review and meta-analysis on clinical efficacy . Mol Clin Oncol . 2014 ; 2 ( 6 ): 1097 - 102 . doi: 10 .3892/ mco . 2014 . 345 .
31. Rickert A , Herrle F , Doyon F , Post S , Kienle P . Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection . Surg Endosc . 2013 ; 27 ( 12 ): 4675 - 83 . doi: 10 .1007/s00464-013-3108-z.