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ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 12-15

Intraluminal bypass tube across colorectal anastomosis: An alternative to stomas


Department of General Surgery, LN Medical College and JK Hospital, Bhopal, Madhya Pradesh, India

Date of Submission17-Jul-2020
Date of Decision10-Aug-2020
Date of Acceptance20-Sep-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. Sakshi Goyal
L.N. Medical College & J.K. Hospital, JK Campus, Kolar Road, Bhopal (462042), (M.P.)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_23_20

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  Abstract 

Introduction: Colorectal anastomotic leakage is a serious complication of colorectal surgery with high morbidity and mortality rates. Anastomotic leakage accounts for prolonged hospital stay and compromised postoperative quality of life, with aided psychological and economical burden to one's life. Currently, the most commonly used method to prevent leakage is by diversion ileostomy procedure, which has its own complications and morbidities. In recent decades, various studies that aimed at lowering the incidence of anastomotic leakage have been tried including the use of intraluminal bypass tube. In our study, we have introduced an intraluminal bypass tube through the anal canal reaching upto the proximal colon across the anastomotic site.The distal end of the tube was fixed with perianal skin to prevent the dislodging of the tube, thereby reducing intraluminal pressure as flatus follows the path of least resistance. Furthermore, it helps to prevent gush of the fecal stream coming in contact with the anastomotic site to some extent. Thus, we found this method as potentially simple and effective in reducing anastomotic leakage. Background: Currently, the only clinically valid method to prevent morbidity and mortality related to colorectal anastomotic leak (AL) is by construction of protecting ileostomy. The intraluminal bypass tube might also be a possible way to protect the anastomosis. Aims: The study aims to evaluate the usage of intraluminal bypass tube for the reduction of anastomosis-related morbidity and stoma creation in colorectal surgeries. Design: This was a prospective and observational study. Materials and Methods: The present study was conducted between January 2019 and December 2019. Twenty patients who underwent colorectal surgeries were studied. After completion of anastomosis, the latex tube was implanted and removed after 5 ± 1 days. Patients were followed for 10 days. Information about adverse events, ALs, and tolerance was collected. Results: In our study, there were twenty patients who underwent colorectal surgery and most of them were operated on due to colorectal malignancy 16 (80%). The postoperative period was uneventful. No anastomotic complications (hematoma, stricture, or abscess) or any adverse effects of the tube (ulceration of colon) were observed. Moreover, patients were discharged after 11–16 days of the surgery. Conclusions: Intraluminal bypass tube may provide a safe alternative for fecal diversion over a newly created anastomosis without the complications related to stoma creation and closure. However, larger randomized prospective studies should be performed in the future to confirm these findings.

Keywords: Anastomotic leakage, colorectal surgery, complication, intraluminal bypass tube


How to cite this article:
Mishra N, Goyal S, Bansal V. Intraluminal bypass tube across colorectal anastomosis: An alternative to stomas. Indian J Colo-Rectal Surg 2020;3:12-5

How to cite this URL:
Mishra N, Goyal S, Bansal V. Intraluminal bypass tube across colorectal anastomosis: An alternative to stomas. Indian J Colo-Rectal Surg [serial online] 2020 [cited 2020 Oct 21];3:12-5. Available from: https://www.ijcrsonweb.org/text.asp?2020/3/1/12/297100


  Introduction Top


Anastomotic leak (AL) refers to the communication between the hollow viscera lumen and the peritoneal cavity at the anastomotic level.[1] The etiology of AL is known to be multifactorial having serious consequences and the incidence varies between 2.5% and 20%.[2],[3],[4],[5],[6] In colonic resection, anastomotic leakage has increased morbidity and mortality rate, particularly in unprepared bowel and in emergency settings. To prevent this, the ileostomy is often created. Unfortunately, this solution exposes the patient to a new set of complications related to the ileostomy, and the additional surgery required to close the ileostomy after the anastomosis has been healed.[7]

To maintain the benefits of fecal diversion without the complications of a primary ileostomy, various studies have been done aimed at lowering the incidence of anastomotic leakage by the use of an intraluminal bypass tube.[8] Problems associated with both anastomosis and stoma can be prevented with the use of an internal bypass tube. Therefore, we have investigated the usage of this tube in patient who underwent colorectal surgery. The tube was introduced transanally in the proximal colon across the anastomosis and the distal end was fixed with perianal skin to prevent dislodging. This study revealed that it prevents the anastomotic dehiscence and leakage mainly by reducing the intraluminal pressure. Furthermore, it prevents, to some extent, gush of the fecal stream from coming in contact with anastomotic sites more safely and expeditiously.

The Surgical Infection Study Group (1991) categorized anastomotic leakage into clinical and subclinical leakage.[9] In 2001, Bruce et al.[10] recommended the three groups: radiological (no clinical signs), clinical minor (no intervention subdivision of anastomotic leakage into needed), and clinical major (intervention required) leakage. This grading of AL resembles the grading of AL proposed by the International Study Group of Rectal Cancer.[11] The extent or severity of AL should be graded according to the impact on clinical management. Grade A does not require active therapeutic intervention; Grade B requires active therapeutic intervention but is manageable without relaparotomy; and Grade C requires relaparotomy. In the present study, we focus on the use and potential success of the intraluminal bypass tube that may protect a colonic anastomosis against leakage.


  Materials and Methods Top


The present study was conducted between January 2019 and December 2019. Twenty patients who underwent colorectal surgeries with an anastomosis 20 cm or less from the anal verge were studied. Maximum patients were operated on due to colorectal malignancy (16, 80%). No patients had received any preoperative radiotherapy in case of colorectal malignancy and all were operable. After completion of the anastomosis, a No. 32–34 French latex tube was introduced through the anal canal and directed through the anastomosis to a distance of approximately 10 cm above the anastomotic site and was fixed to perianal skin distally. In none of the patients, any ileostomy was made. The tube was irrigated with normal saline on alternate days to confirm the tubal patency. After 5–6 days, the tube was removed. Enteral feeding was started 3 days postoperatively in all patients and were followed for 10 days to look for the leak.

Intra operative technique

The abdomen was opened through mid-line incision followed by colonic resection and anastomosis in two-layer handsewn technique. Before the completion of the anastomosis, the intraluminal bypass tube was inserted as described earlier. This allowed free passage of accumulated flatus in the postoperative period, as it provides path of least resistance. Thus, preventing the intraluminal pressure to rise and so the anastomotic dehiscence or leakage. Probably, fecal matter is also diverted through the lumen of the tube, having minimal contact with the anastomotic site. Stapled anastomoses can also be performed according to surgeons' preferences. Furthermore, an intrabdominal drain was placed which was removed after 24 h of removal of the intraluminal tube.


  Results Top


In our study, there were twenty patients who underwent colorectal surgery and anastomosis followed by intraluminal bypass tube insertion [Table 1]. Indications for the surgery included colorectal cancer in 16 patients (80%), traumatic perforation in 3 (15%), and postendoscopic retrograde cholangiopancreatography colocutaneous fistula in 1 (5%). The mean age was 48.8 (range 31–61) years. Baseline characteristics are summarized in [Table 2]. All patients had planned for open approach. The postoperative period was uneventful. Enteral feeding was started 3 days postoperatively. The tube was removed after 5 ± 1 days. The average hospital stay was 12.9 (11–16) days. All patients were followed for 10 days to look for the leak. No anastomotic complications (hematoma, stricture, or abscess) or any adverse effects of the tube (ulceration of colon) were observed.
Table 1: Details of patient studied and their clinical course

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Table 2: Baseline characteristics of patients studied

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  Discussion Top


AL still constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The incidence rate of anastomotic complications remains high.[12],[13] To alleviate the risk of AL, fecal diversion through a primary protective ileostomy is the most widely accepted method.

Unfortunately, a diverting stoma requires additional surgery of closure and introduces responsible for additional morbidity,[14],[15],[16] such as acute kidney injury due to high stoma output, parastomal and internal hernias, stoma-handling difficulties, electrolyte imbalance, and skin excoriation. The concept of an intraluminal bypass technique to avoid the use of a temporary diverting stoma after a low colorectal anastomosis was introduced by Ger and Ravo[17] during the 1980s. Clinical and experimental data have shown that the concept of an intraluminal bypass is safe with only a few complications.[18],[19] This intraluminal device functions by keeping the anal sphincter open, thereby decreasing the intraluminal pressure, as well as the pressure on the anastomosis. In this way, the device serves as a protective vent and prevents anastomotic dehiscence. However, they may also prevent the gush of fecal stream from contacting the anastomotic site to some extent.

This approach holds clinical promise to reduce or prevent early leakage of colorectal anastomoses and concomitant sequelae. It also has multiple advantages: easy application, minimally invasive, adds only a few minutes to surgery, and does not change the construction of anastomosis. It abolishes surgical dilemma between the risks and benefits of constructing a stoma and the dire consequences of an AL.


  Conclusions Top


This study emphasizes that the intraluminal bypass tube may provide a safe alternative to a primary diverting stoma in patients undergoing colorectal surgery. In our study, we found that it acts as a protective vent by decreasing intraluminal pressure, which is one of the important causes of anastomotic leakage. Furthermore, it reduces the considerable complication rate accompanying the construction and closure of the ileostomy. We believe that the use of intraluminal bypass tube in colorectal surgery is a simple and effective method of reducing the occurrence of anastomotic leakage. However, larger randomized prospective studies should be performed in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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;147:339-51.  Back to cited text no. 1
    
2.
Jung SH, Yu CS, Choi PW, Kim DD, Park IJ, Kim HC, et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 2008;51:902-8.  Back to cited text no. 2
    
3.
Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 2005;92:211-6.  Back to cited text no. 3
    
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Matthiessen P. Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 2006;8:366.  Back to cited text no. 4
    
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6.
Laxamana A, Solomon MJ, Cohen Z, Feinberg SM, Stern HS, McLeod RS. Long-term results of anterior resection using the double-stapling technique. Dis Colon Rectum 1995;38:1246-50.  Back to cited text no. 6
    
7.
Emmanuel A, Chohda E, Lapa C, Miles A, Haji A, Ellul J. Defunctioning stomas result in significantly more short-term complications following low anterior resection for rectal cancer. World J Surg 2018;42:3755-64.  Back to cited text no. 7
    
8.
Willenz U, Wasserberg N, Botero-Anug AM, Greenberg R. Feasibility of an intraluminal bypass device in low colorectal anastomosis: Preliminary results in a porcine model. Surg Innov 2016;23:298-304.  Back to cited text no. 8
    
9.
Peel AL, Taylor EW. Proposed definitions for the audit of postoperative infection: A discussion paper. Surgical Infection Study Group. Ann R Coll Surg Engl 1991;73:385-8.  Back to cited text no. 9
    
10.
Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001;88:1157-68.  Back to cited text no. 10
    
11.
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;147:339-51.  Back to cited text no. 11
    
12.
Alves A, Panis Y, Pocard M, Regimbeau JM, Valleur P. Management of anastomotic leakage after nondiverted large bowel resection. J Am Coll Surg 1999;189:554-9.  Back to cited text no. 12
    
13.
Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007;9:71-9.  Back to cited text no. 13
    
14.
Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis 2014;29:1131-5.  Back to cited text no. 14
    
15.
Ihnát P, Guňková P, Peteja M, Vávra P, Pelikán A, Zonča P. Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc. 2016 Nov;30(11):4809-4816. doi: 10.1007/s00464-016-4811-3. Epub 2016 Feb 22. PMID: 26902615.  Back to cited text no. 15
    
16.
Hallböök O, Matthiessen P, Leinsköld T, Nyström PO, Sjödahl R. Safety of the temporary loop ileostomy. Colorectal Dis 2002;4:361-4.5.  Back to cited text no. 16
    
17.
Ravo B, Ger R. A preliminary report on the intracolonic bypass as an alternative to a temporary colostomy. Surg Gynecol Obstet. 1984;159:541–545.  Back to cited text no. 17
    
18.
Ravo B, Mishrick A, Addei K, Castrini G, Pappalardo G, Gross E, et al. The treatment of perforated diverticulitis by one-stage intracolonic bypass procedure. Surgery 1987;102:771-6.  Back to cited text no. 18
    
19.
Rosati C, Smith L, Deitel M, Burul CJ, Baida M, Borowy ZJ, et al. Primary colorectal anastomosis with the intracolonic bypass tube. Surgery 1992;112:618-22.  Back to cited text no. 19
    



 
 
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