- Design
- Cochrane systematic review and meta-analysis of 4 RCTs
- Population
- 1318 adults undergoing rectal cancer surgery
- Primary outcome
- Anastomotic leak within 30 days
- Effect
- RR 0.88 (95% CI 0.46 to 1.72); re-intervention for leak RR 0.32 (0.10 to 1.00)
An updated Cochrane review pooled four randomised trials of a transanal tube versus none after rectal cancer surgery, 1318 patients in total. Every trial carried some concerns for bias, and certainty ran from very low to low.
Overall, the tube made no clear difference to anastomotic leak (RR 0.88, 95% CI 0.46 to 1.72). It may reduce re-operation for leak (RR 0.32, 0.10 to 1.00; about 45 to 14 per 1000). The pooled figure hides a split: without a diverting stoma the leak RR was 0.72 (0.36 to 1.43), and re-intervention fell (RR 0.25, 0.07 to 0.94); with a stoma, leaks were more frequent in the tube arm (RR 2.38, 1.00 to 5.69), from two small trials.
In practice, the tube is a reasonable option in an unprotected low anastomosis where the aim is to avoid a return to theatre. It has no demonstrated role alongside a defunctioning stoma, and a quarter of patients reported tube-related discomfort.
- Decide on the tube after the stoma decision, not instead of it.
- If there is no stoma, a tube may reduce re-operation for leak — discuss it as low-certainty evidence.
- With a diverting stoma, do not add a tube routinely.
- Warn patients about discomfort: about one in four report tube-related complaints.
- Record tube type and duration so your own results can be audited.
Why it matters
The same device may help one patient and harm another depending on a decision made minutes earlier in the same operation.
Don't overread it
The harm signal with a stoma comes from two small trials and is low-certainty; it is a reason not to add a tube, not proof that tubes cause leaks.
The statistics, in plain English
An overall risk ratio of 0.88 with an interval from 0.46 to 1.72 means the data fit anything from halving leaks to nearly doubling them. The re-intervention interval ends exactly at 1.00, so even that benefit is at the edge of chance. The stoma subgroup rests on only 250 patients; a subgroup difference (P = 0.03) raises a question rather than settling it.
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