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• W1972420029 abstract "Dear Sir, We thank Dr Bugiantella and colleagues for their interest in our article recently published in Colorectal Disease 1. Concerning their first point about preoperative bowel preparation, this procedure remains controversial. Elective colonic resection without mechanical bowel preparation (MBP) has been demonstrated 2, 3. However, data on MBP in rectal cancer surgery are insufficient. A randomized controlled trial showed that rectal cancer surgery without MBP was associated with a higher risk of overall and infectious morbidity but with no significant increase of anastomotic leakage 4. We felt that no MBP regimen could be an additive risk factor for the postoperative morbidity in surgery of the mid and low rectum. Therefore, we washed the colon before rectal resection, or performed on-table colonic irrigation when the bowel preparation was poor. Regarding the postoperative diet, all patients with completely diverted tube ileostomy (CDTI) were instructed to have a low-residue diet, such as an elemental diet, milk, eggs, gruel, rice, noodles, bread, cake, bean curd, fish, shrimp, meat paste, mashed vegetables and fruit juice, in an attempt to maintain tube patency. Consequently, stoma tube irrigation was seldom required. We do agree with the diagnostic protocol for anastomotic leakage suggested previously 5-8. In our study, symptoms of anastomotic leakage were evaluated by digital rectal examination (DRE) and proctoscopy followed by plain abdominal CT scan. CT-enema was performed in patients to with suspected postoperative anastomotic leakage if anastomotic dehiscence was not detectable by DRE. We did assess the duration of the complete faecal diversion, measured as the interval between stoma creation and the first bowel action through the anus, when patients with CDTI presented with leakage. In our pilot study, the patients with leakage recovered within this period. Before removal of the catheter, CT-enema was performed to exclude persistent leakage. The tube used for CDTI was a rigid endotracheal tube with an inner diameter of 7 mm, and its balloon was inflated with about 10 ml of water to occupy the ileal lumen without impairing the blood supply of the intestinal wall. Once the bowel regained motility, there was a possibility that the ileal lumen around the balloon could dilate owing to the intestinal peristalsis; thus, it would be impossible to cause ischaemia of the ileal wall even if the tube was left in the ileum for about 30 days. So far, no ischaemia of the terminal ileum has been observed. Harries et al. used a rigid endotracheal tube to create a tube stoma 9. We felt that the dimension (i.e. inner diameter of 7 mm) and the rigidity of the catheter were necessary for tube patency. Additionally, we cut the catheter short, with only about 2 cm remaining above the abdominal wall, and used a stoma appliance for faecal collection (Fig. 1), which might also contribute to tube patency. As tube irrigation was seldom required, patients with an indwelling catheter could be discharged earlier, with planned removal of the catheter as an outpatient. The discomfort caused by the catheter was no worse than that of a conventional abdomen drainage tube. No patient reported severe pain and no patient asked for earlier removal of the catheter. The site of insertion closed spontaneously in an average of 12 days. Any discharge of small bowel contents from the wound after removal of the catheter resolved spontaneously within 1 month. We did not remove the tube within 3 weeks after creating the tube stoma, aiming to allow for sufficient adhesion formation around the catheter to prevent leakage. To date, we have not had a single case of leakage. In the CDTI technique, the staple line was located 10 cm distal to the tube stoma. Therefore, the volume of faecal contents entering the distal ileum was insufficient to cause abdominal distension before recanalization of the intestine. To date, there is no evidence that faecal transit into the distal ileum before the staple line becomes disrupted leads to abdominal pain. None." @default.
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• W1972420029 date "2014-12-23" @default.
• W1972420029 modified "2023-10-04" @default.
• W1972420029 title "Reply to Bugiantella<i>et al</i>." @default.
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• W1972420029 doi "https://doi.org/10.1111/codi.12801" @default.
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