Paper read at the Annual Clinical Meeting of the Association of Surgeons and Physicians of Malta in December 1971. Defunctioning of the proximal colon after resection of the distal colon and anastomosis is a well-recognised procedure. It is not always carried out after pelvic colectomy or anterior resection of the rectum. There is, however, another method of producing decompression of the proximal colon that is rarely described. It has been used on eight consecutive patients with carcinoma of the pelvic colon or recto-sigmoid junction over a twelve month period: October 1970-October 1971. A short summary of the eight cases is presented. Decompression by rectal tube after distal colectomy appears to work satisfactorily and should reduce, at least, if it does not abolish, the practice of a transverse colostomy.peer-reviewe

Attard, Raphael

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GURDON, J.B. (1968): Scientific American, 219, December issue, p. 24. JONES, R.C. (1971): J. Reprod. Fertil., Suppl. 13, 5L KENNEDY, J.F., and DONAHUE, R.P. (1969): Science, N.Y., 164, 1292. MAsTROIANNI, L., and NORIEGA, C. (1970): Amer. J. Obstet. Gynec., 107, 682. NANCE, W.E. (1969): Nature, 224, 373. NORIEGA, C., and MASTROIANNI, L. (1969): Fertil. Steril., 20, 799. PATTON, GW., and VILLEE, C.A. (1968): Amer. J. Obstet. Gynec., 101, 424. RONDELL, P. (1970):Biol. Reprod., Suppl. 2, 64. STAMBAUGH, R., NORIEGA, C., and MASTROIANNI, L. (1969): J. Reprod. Fertil., 18, 5L TEICHMAN, R.J., and BERN STEIN, M.H. (1971): J. Reprod. FerUI., 27, 243. WEGMANN, T.G., and GILMAN, J.G. (1970): Dev. BioI., 21, 28L WHITTINGHAM, D.G.: (1971): Nature, 233, 125. YANAGIMOCHI. R., and NODA, Y.D. (1nO): J. ultrastruc. Res., 31 465 and 486. TUBE DECOMPRESSION AFTER DISTAL COLECTOMY R.ATTARD M.D., B.Sc., F.R.C.S. Paper read at the Annual Clinical Meeting of the Association of Surgeons and Physicians of Malta in December 1971. Defunctioning of the proximal colon after resection of ,the distal colon and ana-stomosis is a well-reGognised procedure. It as not always carried out after pelvic colectomy or anterior resection of the rec-tum. The indications vary with the pre-ferences of the surgeon, hut most surgeons would agree that the more distal the ana-stomosis the more essential it is to carry out defunctioning. Hence, it is most often used in low anterior resections and less often in high anterior resections. Even with pelvic colectomy, however, it is car-ried out if for technica:l reasons the sur-geon is not too happy with the anastomo-sis or H there is much loading of the pro-ximal colon wi,th faeces - to mention just two indications. The form of defunc-tioning is most often a transverse colo-stomy, but a caecostomy may be preferred by others. Defunctioning obviously pro-tects the anastomosis during the initial all important healing phase. There is, however, another method of producing decompression of the proximal colon that is rarely described. It has been used on 8 consecutive patients with car-cinoma of the pelvic colon or recto-s,ig-moid junction over a twelve month period: October 1970-0ctober 1971. After the pel-vic colectomy or anterior resection has been carried out and continuity of the large bowel has been restored by end-to-end anastomosis ,in two layers followed by re-peritonealisation of the raw areas in mesentery or pelvic floor, i.e. just be-fore closing the abdomen, a rubber rectal tube, 30Fr, 30 :inches long and ! inch in external diameter is passed by an assist-ant through the anus into the rectum and is guided by the surgeon through ,the ana-stomosis and up the descending colon near to the region of the splenic flexure or even into the distal transverse colon. Once the surgeon is s,atisfied that it is ly:ing snugly in place, the tube, which now protrudes from the anus for only about 6 inches, is sutured firmly to the skin around the anus so that there is no possibHity of Lts slip-ping out or its being pulled out. The abdo-men is then closed in layers in the usual way, after inserting a tube drain down to the site of the anastomosis through a sepa-rate stab wound out in the left flank. All / the patients have been able to get up and walk around or sit down in spite of hav-ing 6 inches or so of tube protruding from the anus. The tube was not specially at-tended to in any way until it was com-pletely removed from 5 to 7 days after operation. A short summary of the eight cases now follows. There were six male and two females with ages ranging from 50 to 74: 3 in age group 50-59; 2 in age group 60-69; 3 ,in age group 70-79. A mass was palp-able per rectum in 3 of the cases and :in another 2 some blood was found on the withdrawn fingerstall. Barium enema showed the new growth in 6 of the cases while the other 2 cases were r,adiologicaHy diagnosed as diverticular disease and nor-mal respectively. Sigmoidoscopy revealed a growth in 3 out of 6 cases, and an ,in-flamed colon in a fourth. A pelvic colec-tomy was carried out in 4 cases and an anterior resection in the other 4 cases. The adenocarcinoma was limited to the colon in 4 patients, had invaded the me-senteric lymphnodes ;in another 2 and in-vaded the ileum and its mesentery and the extracolonic fat in the remaining two. Pyrexia was the most common post-operative complication, occurring in 6 pa-tients: .low grade, below lOO°F. ;in 4 and above lOO°F. in the other 2 who developed a postope,rative "chest". Abdominal disten-tion occurred in 3 patients but gave rise to some anxiety only in one, where despite the passage of flatus and faeces by tube, the distension continued for several days after remova,lof the tube. This patient spent 26 days in hospital postoperatively. There was a slight puruletlt discharge from the lower end of the main incision in 3 of the cases but this 'soon cleared up. It is per-tinent to point out that floss nylon was used to repair the wounds of all 8 patients. One patient developed p'ersIstent diarrhoea, , 'lving his bowels open five or six times a day. He had had, in addition to a colec tomy, a resection of a long segment of the ileum the mesentery of which was in-volved by the carcinoma. The attempt to control his diarrhoea, with some success in ,the end, accounted for his staying in hospital for 29 days after his operation. Another patient developed a coron-53 ary thrombosis on the 14th day after ope-ration when he was due to be discharged - he was hence discharged on the 29th day after operation. The other 5 patients were discharged 15 to 19 days after ope-ration. The average postoperative stay in hospital for all 8 patients was 20 days. Goligher et al. (1970) stated that the aver-age postoperative stay in hospital of a large Goligher et aI. (1970) stated that the average postoperative stay in hospital of a large ser,ies of patients who had high anterior resection without dehi-scence was seventeen days, while if dehi-scence occurred the stay lenghtened to 35 days. None oJ the 8 patients had difficulty in passing flatus per rectal tube which also allowed the passage of faeces in some cases. None of the patients, with the ex-ception of the one already mentioned, had difficulty in having his or her bowels open after removal of the reotal tube. None of the few complications mentioned can be ascribed to the use of the rectal tube. All 8 patients are at present alive and well. The 4 patients who had an anterior resection and at least one of those who had a pelvic colectomy would have had a transverse colostomy carried out as a de-functioning procedure in the norma.} course of events. Butler (1971) states he performed a protective transverse colo-stomy on 38% of patients undergoing pri-mary colectomy and on 56% of patients undergoing anterior resection for cancer. In a large series of anterior resections, Goligher et al. (1970) performed simulta-neous colostomy on 41% ,though most of these were for low resections. However, they were unable to determine the influ-ence of the transverse colostomy on the incidence of postoperative anastomotic dehiscence on account of the unfavourable nature of the patients, though they would have expected an even higher incidence of faecal fistula without a transverse colo-stomy. Goligher et al. (1970) also stated after a careful study of their series that 40% of patients undergoing high anterior resection and fully 69% of those under-going low anter,ior resection develop ana-stomotic dehiscence whether of minimal or major degree. Though a transverse colostomy (or cae-54 costomy) has undoubted advantages, it has a number of definite disadvantages. For obvious reasons, patients do not relish th:s ectopic anus, no matter how tempo-rary. In fact, it was the pleadings in this respect of the first patient in this series, a deaf woman of 50 years, that induced me to give the tube decompression method a try. A colostomy increases a patient's length of stay in hospital qu:te consider-ably. Eventual closure of the colostomy has i,ts own particular morbidity and mor-taiity. Breakdown and leakage, i.e. faecal fistula, occurred in 23% of a series of colostomy closures studied by Knox et al. (1971). Hence, a method of decompressing the proximal colon, that protects the dis-tal anastomosis after pelvic colectomy or anterior resection, which obviates the dis-advantages of a colostomy and is at the same time safe, would appear to be a very satisfactory one to attain. Such is the tube method used in this admittedly small se-ries. Wangensteen (1945) advocated the use of a no. 22 rectal tube though he pass-ed it just beyond the anastomosis and with-drew it gradually over several days. On the other hand, Mayo (l952) simply pre-ferred stretching the anus widely. Jack-man and Beahrs (1968) dismiss the rectal tube as a plug that traumatises the ana-stomosis. Goligher (1967) has given up both the rectal tube and stretching the anus with, he states, no apparent altera-tion in results and goes on to say that his present practice of establishing a tempo-rary colostomy in (low) anterior resec-tions reduces their relevance. On the other hand, Drobni and Ineze (1969) use the rec-tal tube for six to seven days after anterior resection to prevent distension of the suture line with success. In conclusion, decompression by rec-tal tube after distal colectomy appears to work safsfactorily and should reduce, at least, if it does not abolish, the practice of a transverse colostomy. References BUTLER, E.C.B. (1971), Br. J. SUI·9., 58, 29. DROBNI, S. and INEZE, F. (1969), Surgery of Rectal Cancer, Budapest: Akadem:ai I<iado. GOLIGHER, J.C. (1967), Surgery of the Anus, Rectum and Colon, 2nd. Ed. London: Bailliere, Tindall & Cassell. GOLIGHER, J.C., GRAHAM, N.G., and DE DOMBAL, F.T. (1970), Br. J. Surg., 57, 109. (1971yysd ETAOiN SHRDLU SHRDLU SHRDLU NIDAT JACI<MAN, R.J. and BEAHRS, O.H. (1968), Tumours of the Large Bowel, Ph:ladelphia: W.B. Saunders Company. I<NOX, A.J.S., BIRJ<ETT, F.D.H. and COLLINS, C.D. (1971), Br. J. Surg. 58, 669 MAYO, C.w. (1952), personal communication quoted by Goli-gher, J.C. (1967) above. WANGENSTEEN, O.H. (1945), Surg. Gynec. Obstet., 81, 1. 

Tube decompression after distal colectomy

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Tube decompression after distal colectomy

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