Bowel preparation is associated with spillage of bowel contents in colorectal surgery

Colectomy without mechanical bowel preparation in the private practice setting

BACKGROUND

Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting.

METHODS

This prospective observational study included elective abdominal colorectal operations from one surgeon's practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year.

RESULTS

A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14).

CONCLUSIONS

Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis

PURPOSE

Mechanical bowel preparation (MBP) for elective colorectal surgery has been practiced as a clinical routine for many decades. However, earlier randomized clinical trials (RCTs) and meta-analyses suggest that MBP should be abandoned before colorectal surgery because of the futility in reducing postoperative complications and motility. The new published results from three RCTs comparing MBP with no MBP in colorectal surgery in 2010 make the updating of systemic review and meta-analysis necessary. The aim of this study was to estimate efficacy of MBP in prevention of postoperative complications for elective colorectal surgery.

METHOD

A literature search was performed mainly in electronic database including Cochrane Library, EMBASE, and MEDLINE. The inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. Septic complications, reoperation, and death were recorded as primary and secondary outcomes. The meta-analysis was conducted according to the QUOROM statement.

RESULTS

Fourteen RCTs were included in our analysis with a total number of 5,373 patients: 2,682 with MBP and 2,691 without. Comparing with no MBP for elective colorectal surgery, our study showed that MBP had not reduce any postoperative complications when concerning anastomotic leak [odds ratio (OR) 95% confidence interval (CI), 1.08 (0.82-1.43); P = 0.56]; overall SSI [OR 95% CI, 1.26 (0.94-1.68); P = 0.12]; extra-abdominal septic complications [OR 95% CI, 0.98 (0.81-1.18); P = 0.81]; wound infections [OR 95% CI, 1.21 (1.00-1.46); P = 0.05]; reoperation or second intervention rate [OR 95% CI, 1.11 (0.86-1.45); P = 0.42]; and death [OR 95% CI, 0.97(0.63-1.48); P = 0.88].

CONCLUSION

No evidence was noted supporting the use of MBP in patients undergoing elective colorectal surgery. MBP should be omitted in routine clinical practice.

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

The presence of bowel contents during colorectal surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.An enema before the rectal surgery to clean the rectum and facilitate the manipulation for the mechanical anastomosis is used for many surgeons. This is analysed separately

OBJECTIVES

To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.

SEARCH STRATEGY

Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, IBECS and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.Searches were performed December 1, 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).

MAIN RESULTS

At this update six trials and a new comparison (Mechanical bowel preparation versus enema) were added. Altogether eighteen trials were analysed, with 5805 participants; 2906 allocated to MBP (Group A), and 2899 to no preparation (Group B), before elective colorectal surgery.For the comparison Mechanical Bowel Preparation Versus No Mechanical Bowel Preparation results were:1. Anastomotic leakage for low anterior resection: 8.8% (38/431) of Group A, compared with 10.3% (43/415) of Group B; Peto OR 0.88 [0.55, 1.40].2. Anastomotic leakage for colonic surgery: 3.0% (47/1559) of Group A, compared with 3.5% (56/1588) of Group B; Peto OR 0.85 [0.58, 1.26].3. Overall anastomotic leakage: 4.4% (101/2275) of Group A, compared with 4.5% (103/2258) of Group B; Peto OR 0.99 [0.74, 1.31].4. Wound infection: 9.6% (223/2305) of Group A, compared with 8.5% (196/2290) of Group B; Peto OR 1.16 [0.95, 1.42].Sensitivity analyses did not produce any differences in overall results.For the comparison Mechanical Bowel Preparation (A) Versus Rectal Enema (B) results were:1. Anastomotic leakage after rectal surgery: 7.4% (8/107) of Group A, compared with 7.9% (7/88) of Group B; Peto OR 0.93 [0.34, 2.52].2. Anastomotic leakage after colonic surgery: 4.0% (11/269) of Group A, compared with 2.0% (6/299) of Group B; Peto OR 2.15 [0.79, 5.84].3. Overall anastomotic leakage: 4.4% (27/601) of Group A, compared with 3.4% (21/609) of Group B; Peto OR 1.32 [0.74, 2.36].4. Wound infection: 9.9% (60/601) of Group A, compared with 8.0% (49/609) of Group B; Peto OR 1.26 [0.85, 1.88].

AUTHORS' CONCLUSIONS

Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found. Further research on patients submitted for elective rectal surgery, below the peritoneal verge, in whom bowel continuity is restored, and studies with patients submitted to laparoscopic surgeries are still warranted.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

The presence of bowel contents during colorectal surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.An enema before the rectal surgery to clean the rectum and facilitate the manipulation for the mechanical anastomosis is used for many surgeons. This is analysed separately

OBJECTIVES

To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.

SEARCH STRATEGY

Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, IBECS and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.Searches were performed December 1, 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).

MAIN RESULTS

At this update six trials and a new comparison (Mechanical bowel preparation versus enema) were added. Altogether eighteen trials were analysed, with 5805 participants; 2906 allocated to MBP (Group A), and 2899 to no preparation (Group B), before elective colorectal surgery.For the comparison Mechanical Bowel Preparation Versus No Mechanical Bowel Preparation results were:1. Anastomotic leakage for low anterior resection: 8.8% (38/431) of Group A, compared with 10.3% (43/415) of Group B; Peto OR 0.88 [0.55, 1.40].2. Anastomotic leakage for colonic surgery: 3.0% (47/1559) of Group A, compared with 3.5% (56/1588) of Group B; Peto OR 0.85 [0.58, 1.26].3. Overall anastomotic leakage: 4.4% (101/2275) of Group A, compared with 4.5% (103/2258) of Group B; Peto OR 0.99 [0.74, 1.31].4. Wound infection: 9.6% (223/2305) of Group A, compared with 8.5% (196/2290) of Group B; Peto OR 1.16 [0.95, 1.42].Sensitivity analyses did not produce any differences in overall results.For the comparison Mechanical Bowel Preparation (A) Versus Rectal Enema (B) results were:1. Anastomotic leakage after rectal surgery: 7.4% (8/107) of Group A, compared with 7.9% (7/88) of Group B; Peto OR 0.93 [0.34, 2.52].2. Anastomotic leakage after colonic surgery: 4.0% (11/269) of Group A, compared with 2.0% (6/299) of Group B; Peto OR 2.15 [0.79, 5.84].3. Overall anastomotic leakage: 4.4% (27/601) of Group A, compared with 3.4% (21/609) of Group B; Peto OR 1.32 [0.74, 2.36].4. Wound infection: 9.9% (60/601) of Group A, compared with 8.0% (49/609) of Group B; Peto OR 1.26 [0.85, 1.88].

AUTHORS' CONCLUSIONS

Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found. Further research on patients submitted for elective rectal surgery, below the peritoneal verge, in whom bowel continuity is restored, and studies with patients submitted to laparoscopic surgeries are still warranted.

Rectal cancer surgery with or without bowel preparation: The French GRECCAR III multicenter single-blinded randomized trial

OBJECTIVE

To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP).

BACKGROUND

The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP.

METHODS

From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay.

RESULTS

A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups.

CONCLUSIONS

This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer.

Complications in colorectal surgery: risk factors and preventive strategies

BACKGROUND

Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital.

METHODS

A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library.

RESULTS

This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications.

CONCLUSION

This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications.

Incidence of Anastomotic Leak in Patients Undergoing Elective Colon Resection without Mechanical Bowel Preparation: Our Updated Experience and Two-year Review

Mechanical bowel preparation before elective colon resection has recently been questioned in the literature. We report a prospective study evaluating the anastomotic leak rate in patients undergoing elective colorectal surgery without preoperative mechanical bowel preparation. One hundred fifty-three patients undergoing elective colon resection from July 2006 to June 2008 were enrolled into this Institutional Review Board-approved study. All patients were operated on by a single surgeon at a single institution. No patients received mechanical bowel preparation. Of the 153 patients enrolled, 51.6 per cent had a colorectostomy, 32 per cent had an ileocolostomy, 10.4 per cent had a colocolostomy 5.2 per cent had an ileoanal anastomosis, and 0.6 per cent had an ileorectostomy performed. A total of eight patients (5.2%) developed an anastomotic leak. Of these patients, four required reoperation, three were managed with percutaneous drainage, and one was managed with antibiotics alone. Five of the eight patients who developed an anastomotic leak had significant preoperative comorbidities, including neoadjuvant radiation therapy, diabetes mellitus, end-stage renal disease, prior anastomotic leak, and tobacco use. Elective colon resection can be performed safely without preoperative mechanical bowel preparation. Vigilance for anastomotic leak must be maintained at all times, especially in patients with comorbidities that predispose to anastomotic leak.

[A prospective, randomised, controlled study on the need to mechanically prepare the colon in scheduled colorectal surgery]

INTRODUCTION

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

MATERIAL AND METHOD

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The "Preparation" group (MPC) received MPC and the "non-preparation" group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

RESULTS

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of "no preparation" as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

CONCLUSIONS

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.

[A prospective, randomised, controlled study on the need to mechanically prepare the colon in scheduled colorectal surgery]

INTRODUCTION

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

MATERIAL AND METHOD

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The "Preparation" group (MPC) received MPC and the "non-preparation" group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

RESULTS

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of "no preparation" as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

CONCLUSIONS

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

The presence of bowel contents during surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.

OBJECTIVES

To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.

SEARCH STRATEGY

Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.Searches were performed March 13, 2008.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).

MAIN RESULTS

Four new trials were included at this update (total 13 RCTs with 4777 participants; 2390 allocated to MBP (Group A), and 2387 to no preparation (Group B), before elective colorectal surgery) .Anastomotic leakage occurred:(i) in 10.0% (14/139) of Group A, compared with 6.6% (9/136) of Group B for low anterior resection; Peto OR 1.73 (95% confidence interval (CI): 0.73 to 4.10).(ii) in 2.9% (32/1226) of Group A, compared with 2.5% (31/1228) of Group B for colonic surgery; Peto OR 1.13 (95% CI: 0.69 to 1.85). Overall anastomotic leakage occurred in 4.2% (102/2398) of Group A, compared with 3.4% (82/2378) of Group B; Peto OR 1.26 (95% CI: 0.941 to 1.69). Wound infection occurred in 9.6% (232/2417) of Group A, compared with 8.3% (200/2404) of Group B; Peto OR 1.19 (95% CI: 0.98 to 1.45). Sensitivity analyses did not produce any differences in overall results.

AUTHORS' CONCLUSIONS

There is no statistically significant evidence that patients benefit from MBP. The belief that MBP is necessary before elective colorectal surgery should be reconsidered. Further research on patients submitted for elective colorectal surgery in whom bowel continuity is restored, with stratification for colonic and rectal surgery, is still warranted.

Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons

OBJECTIVE

Antibiotic prophylaxis (AP) and mechanical bowel preparation (MBP) previous to surgery have classically been regarded as important in colorectal surgery. The latter has recently been questioned. We evaluated opinion of Spanish surgeons about the use of these measures.

METHOD

E-mail survey among all members of Spanish Coloproctologic Associations.

RESULTS

Of 413 participants in the survey, 131 (31.7%) responded; 87% of surgeons used cathartics (70%), enemas (2%) or both (28%) for MBP. MBP was used 60% in right colon surgery, 90% in left colon and 99% in rectal surgery. Surgeons with more case load or those who specialized in colorectal surgery used significantly less MBP; 60% of the surgeons thought that MBP made surgery easier and reduced contamination; 35% thought that it decreased wound infection (WI) and 17% thought that it prevented anastomotic leaks. For 77%, it was regarded as useful or very useful. AP was used by 99.3% of surgeons including systemic alone in 86.2% and combined with oral in 16.8%. The first dose was given 2 h before surgery by 20.2% of the surgeons, at the anaesthetic induction by 78.3% and postoperatively by 1.5%; 43% used single dose only, 44.5% extended to 24 h and 12.5% for two or more days; 95% thought that AP reduced WI and 96% considered that it was useful.

CONCLUSION

There is general agreement on AP. MBP remained a common practice among Spanish colorectal surgeons except for right colonic resection. Surgeons with more case load and specialization used it significantly less.

Mechanical bowel preparation for colorectal surgery: a meta-analysis on abdominal and systemic complications on almost 5,000 patients

BACKGROUND

Several studies concluded that mechanical bowel preparation (MBP) does not confer any advantage on reducing the anastomotic leak rate or wound infections. The aim of this meta-analysis was to review all prospective randomised controlled trials on the use of MBP before colorectal surgery in order to find differences in the rates of abdominal and systemic complications in view of recent published articles.

METHODS

Review of all randomised prospective trials compare MBP vs. non-MBP. Primary outcome measures were anastomotic leakages, abdomino-pelvic abscesses and postoperative ileus. Secondary outcomes were wound infections, extra-abdominal complications (urinary infections, pulmonary infections, deep venous thrombosis or pulmonary embolism, cardiac events), sepsis and mortality.

RESULTS

Twelve articles met the inclusion criteria with 4,919 patients. The non-MBP group showed no significant increase of the anastomotic leakages (3.4% vs. 4.1%; p = NS) and wound infections (8.7% vs. 9.6%; p = NS) but had a lower rate of postoperative cardiac events (2.5% vs. 4.0%; p = 0.04).

CONCLUSION

The evidence from recent studies, combined with previous ones, further suggests that the dogma of the necessity of mechanical bowel preparation before elective colorectal surgery should be reconsidered.

Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature

INTRODUCTION

Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery.

METHODS

We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio.

RESULTS

Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899-1.64, P = 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946-1.413, P = 0.155).

DISCUSSION

This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery.

CONCLUSION

In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet "standard of care."

Oral colorectal cleansing preparations in adults

Bowel preparation has been a much-debated issue for both colonoscopy and for colorectal surgery. While bowel preparation for colonoscopy is clearly mandatory for optimal intraluminal visualization, bowel preparation for surgery has recently been challenged. This review evaluates oral bowel preparation, based on evidence in the literature, in order to provide a practical guide for physicians and practitioners about oral bowel cleansing preparations in current use for both colonoscopy and for colorectal surgery.A MEDLINE search, limited to publications in English language, was done through Ovid including articles published from 1966 to 2007 about bowel preparation using terms 'pre-operative care' and 'colonoscopy' or 'surgical procedure' associated with 'polyethylene glycol' and 'sodium phosphate'. The references lists from the identified articles were also included in the review. No bowel preparation method meets the ideal criteria for bowel cleansing prior to colonoscopy. However, polyethylene glycol-electrolyte lavage solution (PEG-ELS) and sodium phosphate are the most commonly used bowel preparations before colonoscopy and colon surgery. Both preparations are safely used and effective; however, some precautions should be considered, particularly with sodium phosphate. In addition, the efficacy of low-volume PEG-ELS can be improved by the addition of preparation adjuncts. Timing and dose are important considerations regardless of the method used. Mechanical bowel preparation for surgery has been questioned, and shown to have no extra benefits and possibly the association with increased morbidity. Regardless of the evidence, there are many randomized controlled trials showing the lack of benefit of mechanical bowel preparation.

Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial

BACKGROUND

Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation.

METHODS

We did a multicentre randomised non-inferiority study at 13 hospitals. We randomly assigned 1431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496.

FINDINGS

77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups: 32/670 (4.8%) patients who had mechanical bowel preparation and 37/684 (5.4%) in those who did not (difference 0.6%, 95% CI -1.7% to 2.9%, p=0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3%] vs 17/684 [2.5%], p=0.001). Other septic complications, fascia dehiscence, and mortality did not differ between groups.

INTERPRETATION

We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.

Rectal cancer surgery without mechanical bowel preparation

BACKGROUND

: Eight randomized clinical trials and two meta-analyses recently questioned the value of preoperative mechanical bowel preparation (MBP) in colorectal surgery. However, very few patients having rectal surgery were included in these studies. The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP.

METHODS

The postoperative course was assessed in 52 consecutive unselected patients who underwent rectal cancer resection and sphincter preservation without MBP. This group was compared with a group of 61 matched patients in whom MBP was performed before surgery.

RESULTS

The overall morbidity rate after rectal resection was higher in patients who had MBP than in those who did not (51 versus 31 per cent; P = 0.036). The incidence of symptomatic anastomotic leakage was similar in the two groups (8 versus 10 per cent respectively; P = 1.000). Although not significant, peritonitis occurred more frequently in the absence of MBP (2 versus 6 per cent; P = 0.294). A trend towards a higher rate of infectious complications was noted in patients who had MBP (23 versus 12 per cent; P = 0.141), but MBP was associated with a significantly higher rate of infectious extra-abdominal complications (11 versus 0 per cent; P = 0.014). Mean hospital stay was significantly longer in the MBP group (12 versus 10 days; P = 0.022).

CONCLUSION

Elective rectal surgery for cancer without MBP may be associated with reduced postoperative morbidity.

Mechanical bowel preparation for elective colorectal surgery with primary intraperitoneal anastomosis by a single surgeon: interim analysis of a prospective single-blinded randomized trial

We report an interim analysis of a prospective single-blinded randomized trial designed to investigate whether preoperative mechanical bowel preparation influences the rate of surgical-site infection and anastomotic failure after elective colorectal surgery with primary intraperitoneal anastomosis performed by a single surgeon. Patients scheduled to undergo an elective colorectal procedure with a primary intraperitoneal anastomosis were randomized to receive either oral polyethylene glycol lavage solution and enemas (group A) or no preparation (group B). Surgical-site infection and anastomotic failure were investigated. Of 97 patients included, 48 were assigned to group A and 49 to group B. Twelve (12.4%) developed wound infections, six in each group (12.5 vs. 12.2%; NS). Intra-abdominal sepsis was only seen in group A (n = 3, 6.3%). Anastomotic failure occurred in four patients in group A (8.3%) vs. two patients in group B (4.1%) (NS). The overall complication rate in group A was 27.1%, vs. 16.3% in group B. The number needed to harm was 9.3. Our interim analysis of a prospective single-blinded randomized trial suggests that a surgeon may have the same or even worse outcomes when mechanical bowel preparation is routinely used for colorectal surgery with primary intraperitoneal anastomosis.

Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición?

Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.

Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery

BACKGROUND

The type of mechanical bowel preparation (MBP) used before elective colorectal surgery remains controversial.

METHODS

This post hoc analysis of a prospective randomized controlled antibiotic prophylaxis trial (ertapenem vs. cefotetan) evaluated the effect of polyethylene glycol (PEG) and sodium phosphate (SP) MBPs on the rates of postoperative surgical site infections (SSI).

RESULTS

Good to excellent MBPs were observed in 281 of 303 (93%) evaluable patients for the PEG and 336 of 367 (92%) for the SP types. A higher rate of SSI was observed in the PEG (34%) than SP (24%) group (difference, 10%; 95% confidence interval, 3.4-17.2). The MBP type was a significant risk factor for SSI, with SP favored over PEG (odds ratio, .6; 95% confidence interval, .43-.85) in univariate analysis; multivariate analysis favored SP, but was not significant (odds ratio, .69; 95% confidence interval, .46-1.02). SSI was lowest with SP and ertapenem (19%) and highest with PEG and cefotetan (44%).

CONCLUSIONS

SP, coupled with ertapenem antibiotic prophylaxis, may improve outcomes and reduce SSIs in patients undergoing elective colorectal surgery when compared with PEG coupled with cefotetan antibiotic prophylaxis.

Is Bowel Preparation Required Before Cystoplasty in Children?

PURPOSE

We evaluated whether bowel preparation is required before augmentation cystoplasty in children.

MATERIALS AND METHODS

A total of 46 consecutive children underwent cystoplasty using detubularized ileum between 1998 and 2004. Group 1 (24 patients) underwent standard mechanical bowel preparation with sodium picosulfate, a bowel enema (sodium phosphate) if required and clear fluids for 24 hours preoperatively. Group 2 (22 patients) received no bowel preparation and was on a normal diet preoperatively. One dose of parenteral triple antibiotics was administered at induction of anesthesia in both groups. The surgical technique was similar in both groups. Postoperatively, group 1 had a nasogastric tube in situ, while group 2 had no nasogastric tube. The main outcome measures were hospital stay (days), time to commencing fluids postoperatively (hours), incidence of urinary tract infection during hospitalization and incidence of wound infection.

RESULTS

Median postoperative stay was 5 days (range 4 to 7) in group 1 and 4 days (3 to 6) in group 2. Median time to intake of oral fluids was 48 hours (range 24 to 72) in group 1 and 24 hours (12 to 48) in group 2. Three patients in group 1 and 2 in group 2 had a symptomatic urinary tract infection during the postoperative course. One patient in each group had a superficial wound infection.

CONCLUSIONS

There were no significant differences in hospital stay or postoperative complications between the 2 groups. This series suggests that bowel preparation is unnecessary for children undergoing cystoplasty.

Mechanical Bowel Preparation for Colorectal Surgery

BACKGROUND

Nosocomial infections are the most frequent complications of surgical patients. Most surgical site infections (SSI) are acquired intraoperatively and arise from the flora of the patient's skin, gastrointestinal tract, or mucous membranes. Although preoperative mechanical cleansing of the bowel is considered by many surgeons a cornerstone of modern elective colorectal surgery and, in association with antibiotic prophylaxis, a fundamental component of an intestinal antisepsis program, many surgeons do not perform preoperative mechanical preparation routinely.

METHODS

Review of the pertinent literature.

RESULTS

Some recent randomized trials and a Cochrane review found no proof that mechanical bowel preparation reduces the risk of complications after elective colorectal surgery. Indeed, there is some evidence that this intervention is associated with a higher rate of anastomotic leakage and wound complications.

CONCLUSIONS

The dogma that mechanical bowel preparation is necessary before elective colorectal surgery may need to be reconsidered. On the other hand, such preparation decreases operating time by improving bowel handling during construction of the anastomosis. Moreover, it is helpful when intestinal palpation will be necessary for identification of a lesion.

Preoperative evaluation of colorectal cancer

Surgery is a primary modality for the treatment of patients with colorectal cancer. Before any surgical therapy, patients diagnosed with colorectal cancer require an evaluation. This preoperative evaluation can be used to assess the patient's risk associated with surgery, plan the surgical resection, and stage the patient's cancer. Staging of the cancer preoperatively is primarily of concern in rectal cancer patients. This article focuses on the elective surgical setting and the recommended preoperative evaluation of patients who have been diagnosed with colorectal cancer.