What are the indications for rectal tube placement?

Indications for Rectal Tube Placement

Rectal tubes should be used primarily for gastrointestinal decompression in cases of bowel obstruction, excessive bowel motions in critically ill patients, and as a protective measure following certain colorectal surgeries to reduce anastomotic leakage risk.

Primary Indications

1. Gastrointestinal Decompression

• Colonic obstruction: Rectal tubes can provide direct small bowel decompression, which has shown improved clinical results compared to gastric decompression tubes 1
• Excessive bowel motions: Most common indication in critically ill patients 2
• Chronic colonic pseudo-obstruction: Decompressive cecostomy tubes can be placed surgically or percutaneously with endoscopic or image guidance 1

2. Post-Surgical Protection

• Following ileo-anal or colonic pouch surgery: 73% of surgeons using rectal tubes reported this as their primary indication 3
• After anterior resection: Used by 36% of surgeons, with 16% reserving them specifically for low anterior resections 3
• In the rectal stump after total/subtotal colectomy for acute colitis: Used by 11% of surgeons 3
• Alternative to diverting stoma: 23% of surgeons reported using rectal tubes as an alternative to a diverting stoma in selected patients, particularly following ileo-anal pouch surgery 3

3. Bleeding Anorectal Varices Management

• Temporary measure: Endorectal placement of a compression tube can serve as a bridging maneuver to help stabilize patients with bleeding anorectal varices or to allow transfer to a tertiary hospital 1

Technical Considerations

Tube Selection and Placement

• Tube type: Foley catheter is the most commonly used (70% of surgeons) 3
• Positioning: Usually placed above the anastomosis (80% of cases) 3
• Duration: Median of 5 days (range 1-13 days) 3
• Placement technique: Transanal insertion with positioning proximal to the anastomotic site 4

Efficacy and Evidence

• A prospective study showed that rectal tubes may be more effective than protective ileostomy in reducing anastomotic leak in lower pelvic intestinal anastomosis by reducing intraluminal pressure and lowering tension at the anastomosis site 4
• Rectal tubes appear to be frequently inserted in critically ill patients, with usage documented at 3% of ICU admissions in one study 2

Complications and Risks

Major Complications

• Bleeding: Major adverse events observed in 3% of ICU patients (0.5 events per 100 device days) 2
• Perforation: Rare but serious complications include tube perforation of the bowel or anastomosis (reported in 2.6% of cases) 3
• Need for intervention: Some patients may require laparotomy, sigmoidoscopy, or blood transfusions due to complications 2

Patient Selection Considerations

• Contraindications: Similar to other enteral access procedures, absolute contraindications include active peritonitis, uncorrectable coagulopathy, and bowel ischemia 1
• Higher risk patients: Patients requiring rectal tubes typically have longer ICU stays (mean 14 days vs 2.8 days) and higher mortality (15% vs 7.7%) compared to those not requiring tubes 2

Practice Patterns and Evolution

• Rectal tube placement is used by approximately one-third of colorectal surgeons in the UK and Ireland 3
• More commonly used by surgeons with less than 10 years of consultant practice 3
• Given their simplicity and potential benefits, further evaluation within randomized controlled trials is warranted 3

Clinical Pearls

• The mechanism of action is primarily to decompress the rectum and/or pouch, reducing pressure on anastomotic sites
• Proper fixation of the tube is essential to prevent dislodgement
• Regular assessment for complications is necessary, particularly for signs of bleeding or perforation
• Consider removing the tube if there are any signs of complications

While rectal tubes are widely used in clinical practice, their use should be guided by specific indications rather than routine placement, as they carry risks of serious complications despite their apparent simplicity.