Experience with ambulatory preoperative bowel preparation at the Johns Hopkins Hospital

Comparação entre as soluções orais de manitol a 10% e bifosfato de sódio no preparo mecânico do cólon

OBJETIVO: Comparar o uso das soluções orais de manitol a 10% e de bifosfato de sódio no preparo mecânico do cólon quanto a qualidade da limpeza, a tolerabilidade e as alterações hidroeletrolíticas e da osmolaridade plasmática. MÉTODO: Foram analisados 60 pacientes de modo randomizado, duplo-cego e prospectivo, com indicação de colonoscopia. A qualidade da limpeza intestinal foi analisada pelo examinador através da classificação de Beck. A tolerabilidade à ingestão baseou-se na pesquisa do gosto, presença ou não de desconforto, aparecimento de efeitos adversos e a quantidade da solução ingerida. Foram dosados o sódio, potássio, cálcio, magnésio, fósforo, uréia, creatinina, glicose, hematócrito, hemoglobina e calculado a osmolaridade plasmática, antes e após a ingestão da solução oral de preparo inestinal. RESULTADOS: Ambas as soluções atingiram qualidade de preparo classificado como bom ou superior em mais de 80% dos pacientes. O uso do bifosfato de sódio determinou menor desconforto e melhor tolerância, apesar de não ter sido superior ao manitol quanto à análise do gosto e presença de efeitos adversos. O bifosfato induziu ao aumento e o manitol a uma redução da osmolaridade, reflexo do que ocorreu com o sódio plasmático nos dois grupos respectivamente. O bifosfato ainda determinou alteração significativa dos níveis séricos de fósforo, cálcio, magnésio e potássio, sem repercussões clínicas. CONCLUSÃO: Ambos os tipos de preparo intestinal determinaram qualidade de limpeza adequada. O bifosfato de sódio, apesar de melhor tolerado, determina maior quantidade de alterações hidroeletrolíticas.

Mechanical and Antibacterial Bowel Preparation in Colon and Rectal Surgery

Colorectal surgery performed prior to 1970 was fraught with postoperative infectious complications which occurred in more than 30-50% of all operations. Diversion of the fecal stream appeared mandatory when operating on an urgent or emergent basis, thereby requiring the performance of multiple, staged operations instead of a single surgery encompassing resection and primary anastomosis as is performed commonly today. Multiple studies conducted in the early 1970s determined that anaerobic colonic microflora were causative agents in postoperative infections in colon and rectal surgery, and these studies initiated the development of effective oral preoperative antibiotic prophylaxis in combination with preoperative mechanical bowel preparation. This dual-tier regimen significantly reduced the incidence of postoperative infectious complications, thus allowing most uncomplicated colon and rectal surgeries to be performed in a single stage without the need for the diversion of the fecal stream and multiple operations. Therefore, a preoperative mechanical and antibacterial bowel regimen serves as the cornerstone of modern elective colorectal surgery, and these regimens now comprise three therapeutic directives. The first step is preoperative mechanical cleansing of the bowel, which is then followed by preoperative oral antibiotic prophylaxis. Finally, perioperative parenteral antibiotics directed against aerobic and anaerobic colonic microflora are utilized.

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions

AIM

The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery.

METHODS

All eligible patients were prospectively randomized to receive either 4 l of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxon's rank-sum test and Fisher's exact test.

RESULTS

Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P < 0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17 vs. 32 percent; P < 0.0002), less abdominal pain (12 vs. 22 percent; P = 0.004), less bloating (7 vs. 28 percent), and less fatigue (8 vs. 17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P < 0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P < 0.0001). For quality of cleansing, surgeons scored NaP as "excellent" or "good" in 87 compared with 76 percent after PEG (P = not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P = not significant).

CONCLUSION

Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Inpatient vs. outpatient bowel preparation for elective colorectal surgery

BACKGROUND

Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP).

METHODS

Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993.

RESULTS

The two groups, 90 patients who underwent OBP and 98 patients who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7 vs. 9 days; P < 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP group vs. 18 percent in the IBP group), including infectious complications (10 percent in the OBP group vs. 7 percent in the IBP group). Although operating time was similar (mean, 199 vs. 213 minutes) and estimated blood loss (mean, 528 vs. 536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300 vs. 3700 ml; P < 0.05; Student's t-test), intraoperative colloid administration (48 vs. 29 percent; P < 0.0002; chi-squared), 24-hour postoperative fluids (3224 vs. 2700 ml; P < 0.0001; Student's t-test), and postoperative fluid challenges (50 vs. 20 percent; P < 0.0001; chi-squared analysis).

CONCLUSION

Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.