Prospective randomized study of preoperative bowel cleansing for patients undergoing colorectal surgery

[Role of Mechanical Bowel Preparation for Elective Colorectal Surgery]

The presence of bowel contents during colorectal surgery has been related to surgical site infections (SSI), anastomotic leakage (AL) and postoperative complications theologically. Mechanical bowel preparation (MBP) for elective colorectal surgery aims to reduce fecal materials and bacterial count with the objective to decrease SSI rate, including AL. Based on many observational data, meta-analysis and multicenter randomized control trials (RTC), non-MBP did not increase AL rates or SSI and other complications in colon and even rectal surgery. In 2011 Cochrane review, there is no significant benefit MBP compared with non-MBP in colon surgery and also no better benefit MBP compared with rectal enemas in rectal surgery. However, in surgeon's perspectives, MBP is still in widespread surgical practice, despite the discomfort caused in patients, and general targeting of the colon microflora with antibiotics continues to gain popularity despite the lack of understanding of the role of the microbiome in anastomotic healing. Recently, there are many evidence suggesting that MBP+oral antibiotics (OA) should be the growing gold standard for colorectal surgery. However, there are rare RCT studies and still no solid evidences in OA preparation, so further studies need results in both MBP and OA and only OA for colorectal surgery. Also, MBP studies in patients with having minimally invasive surgery (MIS; laparoscopic or robotics) colorectal surgery are still warranted. Further RCT on patients having elective left side colon and rectal surgery with primary anastomosis in whom sphincter saving surgery without MBP in these MIS and microbiome era.

Effectiveness of Minimal Bowel Preparation With Oral Bisacodyl Before Laparoscopic Radical Proctectomy: Case-Control Comparison of Bisacodyl and Polyethylene Glycol as Oral Laxative Agents

The aim of this study was to evaluate the usefulness of minimal mechanical bowel preparation (MBP) using oral bisacodyl before laparoscopic rectal cancer surgery. Preoperative MBP using conventional oral laxatives in laparoscopic proctectomy may detrimentally affect morbidity and surgical outcomes. Between March 2010 and December 2014, 272 rectal cancer patients who underwent laparoscopic proctectomy were included in the current study. A total of 85 patients undergoing bowel preparation with oral bisacodyl (bisacodyl group) were individually matched to patients receiving polyethylene glycol (PEG group) using propensity score matching. Operative outcomes, morbidity, and mortality were compared between the matched groups. The quality of bowel cleansing was much poorer in the bisacodyl group than in the PEG group (excellent, 43.5% versus 68.2%; fair, 41.2% versus 16.5%; and poor, 15.3% versus 15.3%; P < 0.001). The degree of small bowel distension (collapsed, 56.4% versus 52.9%; mildly distended, 41.2% versus 40.0%; and severely distended, 2.4% versus 7.1%; P = 0.452) and postoperative outcomes, including time to first flatus (3.0 versus 3.0 days, P = 0.426); hospital stay (16.0 versus 15.0 days, P = 0.215); anastomotic leakage rate (8.2% versus 5.9%, P = 0.549); and mortality (0 versus 1.2%, P = 1.000), were similar between the bisacodyl group and the PEG group, respectively. MBP using oral bisacodyl before laparoscopic proctectomy was feasible and safe with respect to morbidity and surgical outcomes. Minimal bowel preparation with bisacodyl seems to be a useful preparation method for laparoscopic proctectomy.

Impact of perioperative care on the post-operative recovery of women undergoing surgery for gynaecological tumours

To assess perioperative care in patients undergoing abdominal surgery for gynaecological tumours and how it relates to post-operative (PO) complications and oral PO feeding. Ninety-one women undergoing major abdominal surgery for gynaecological tumours were enrolled. Data included mechanical bowel preparation (MBP), prescribed diet, length of fast, start date of oral diet and progression of food consistency, anaesthetic technique, use of opioids and intravenous hydration (IH). Outcomes evaluated were nausea, vomiting and abdominal distension. The median pre-operative length of fast was 11.4 h. PO digestive complications occurred in 46.2% of the patients. Median intraoperative total IH and crystalloids were significantly higher in patients with abdominal distension during the first and second PO day. MBP with mannitol implied greater intraoperative IH and was significantly associated with a higher incidence of immediate PO nausea. Post-operative IH was also associated with gastrointestinal complications. The best cut-off point for the cumulative fluid load PO for determining a longer PO hospital stay was 4 L. Performing MBP before surgery and excessive IH are factors related to major digestive complications in our study population. Changes in pre-operative fasting time and PO refeeding should be considered to reduce the gastrointestinal complications and PO recovery time.

The impact of mechanical bowel preparation in elective colorectal surgery: a propensity score matching analysis

PURPOSE

To evaluate the influence of preoperative mechanical bowel preparation (MBP) based on the occurrence of anastomosis leakage, surgical site infection (SSI), and severity of surgical complication when performing elective colorectal surgery.

MATERIALS AND METHODS

MBP and non-MBP patients were matched using propensity score. The outcomes were evaluated according to tumor location such as right- (n=84) and left-sided colon (n=50) and rectum (n=100). In the non-MBP group, patients with right-sided colon cancer did not receive any preparation, and patients with both left-sided colon and rectal cancers were given one rectal enema before surgery.

RESULTS

In the right-sided colon surgery, there was no anastomosis leakage. SSI occurred in 2 (4.8%) and 4 patients (9.5%) in the non-MBP and MBP groups, respectively. In the left-sided colon cancer surgery, there was one anastomosis leakage (4.0%) in each group. SSI occurred in none in the rectal enema group and in 2 patients (8.0%) in the MBP group. In the rectal cancer surgery, there were 5 anastomosis leakages (10.0%) in the rectal enema group and 2 (4.0%) in the MBP group. SSI occurred in 3 patients (6.0%) in each groups. Severe surgical complications (Grade III, IV, or V) based on Dindo-Clavien classification, occurred in 7 patients (14.0%) in the rectal enema group and 1 patient (2.0%) in the MBP group (p=0.03).

CONCLUSION

Right- and left-sided colon cancer surgery can be performed safely without MBP. In rectal cancer surgery, rectal enema only before surgery seems to be dangerous because of the higher rate of severe postoperative complications.

Laparoscopy in the era of enhanced recovery

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives. Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake. With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes.

Early detection of anastomotic leakage after elective low anterior resection

BACKGROUND

Colorectal anastomotic leakage is a serious complication leading to major postoperative morbidity and mortality. In the present study, we investigated the early detection of anastomotic leakage before its clinical presentation.

METHOD

Fifty-six patients with rectal cancer were included prospectively in this study. All patients underwent elective low anterior resection. Peritoneal samples were collected from the abdominal drains at the first, third, and fifth days postoperatively for bacteriological study (quantitative cultures for both aerobes and anaerobes) and cytokines (IL-6, IL-10, TNF) measurement. Patients were divided into two groups: those without symptomatic or clinical evidence of anastomotic leakage (AL; group 1) and those with clinical evidence of AL (group 2). Study variables included hospital stay, wound infection, operative time, blood loss, height of anastomosis, intraperitoneal cytokines, and microbiological study of peritoneal fluid.

RESULT

Clinically evident AL occurred in eight patients (14.3%) and diagnosed postoperatively on median day 6. Intraperitoneal bacterial colonization and cytokine levels were significantly higher in patients with clinical evidence of AL. Wound infection was significantly higher in anastomotic leakage group. The hospital stay for the patients with anastomotic leakage was significantly longer than those without AL (14 ± 1.41 vs. 5.43 ± 0.89 days). A significant difference among two groups was observed regarding operative time, blood loss, blood transfusion, and height of the anastomosis.

CONCLUSION

The peritoneal cytokines levels and intraperitoneal bacterial colonization might be an additional diagnostic tool that can support the decision making of surgeons for early detection of anastomotic leak in colorectal surgery.

Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta-analysis

PURPOSE

The aim of this study was to estimate efficacy of mechanical bowel preparation with polyethylene glycol (PEG) in prevention of postoperative complications in elective colorectal surgery.

METHOD

A literature search of MEDLINE (PubMed), EMBASE, and the Cochrane Library was done to identify randomized controlled trials involving comparison of postoperative complications after mechanical bowel preparation with PEG (PEG group) and no preparation (control group). A meta-analysis was set up to distinguish overall difference between the two groups.

RESULTS

A total of five randomized controlled trials was identified according to our inclusion criteria. The use of PEG for mechanical bowel preparation did not significantly reduce the rate of surgical site infection (SSI; odds ratio (OR) 95% confidence interval (CI), 1.39 (0.85-2.25); P = 0.19) including incisional SSI (OR 95% CI, 1.44 (0.88-2.33); P = 0.15), organ/space SSI (OR 95% CI, 1.10 (0.43-2.78); P = 0.49), anastomotic leak (OR 95% CI,1.78 (0.95-3.33; P = 0.07), mortality (OR 95% CI, 1.24 (0.37-4.14; P = 0.73), infectious complications (OR 95% CI, 1.14 (0.62-2.08); P = 0.67), and hospital stay (weighted mean difference 95% CI, 2.17 (-2.90-7.25); P = 0.40) except main complications (OR 95% CI, 1.76 (1.09-2.85); P = 0.02), of which the rate increased significantly in the PEG group.

CONCLUSION

The use of mechanical bowel preparation with PEG does not significantly lower postoperative complications in elective colorectal surgery.

Colonic irrigation for defecation disorders after dynamic graciloplasty

BACKGROUND AND AIMS

Dynamic graciloplasty (DGP) improves anal continence and quality of life for most patients. However, in some patients, DGP fails and fecal incontinence is unsolved or only partially improved. Constipation is also a significant problem after DGP, occurring in 13-90%. Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated.

MATERIALS AND METHODS

Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol(R) Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation.

RESULTS

Forty-six patients were included in the study with a mean age of 59.3 +/- 12.4 years (80% female). On average, the patients started the irrigation 21.39 +/- 38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90 +/- 0.40 times per day. The mean amount of water used for the irrigation was 2.27 +/- 1.75 l with a mean duration of 39 +/- 23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation.

CONCLUSION

Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP.

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.

Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection

Background

Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery.

Methods

A total of 1505 patients, aged 18–85 years with American Society of Anesthesiologists grades I–III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days.

Results

A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5·1 and 4·6 per cent respectively, general infectious complications in 7·9 and 6·8 per cent, and surgical-site complications in 15·1 and 16·1 per cent. At least one complication was recorded in 24·5 per cent of patients who had MBP and 23·7 per cent who did not.

Conclusion

MBP does not lower the complication rate and can be omitted before elective colonic resection. Registration number: ISRCTN28535118 (http://www.controlled-trials.com).

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.

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

PURPOSE

Infectious complications pose a significant cause of morbidity in colon and rectal surgery. This study was designed to assess the effect of bowel preparation on spillage of bowel contents into the peritoneal cavity during colorectal surgery, and its potential effect on the rate of postoperative infectious complications.

METHODS

The quality of bowel preparation and the incidence of spillage of bowel contents were prospectively assessed in patients undergoing elective colon and rectal resection. The patients were followed for 30 days for postoperative infectious and noninfectious complications.

RESULTS

A total of 333 patients were included in this study, of which 181 did not receive mechanical bowel preparation. Intraoperative spillage of bowel contents occurred in 48 patients (14 percent), whereas in 285 patients (86 percent), spillage did not occur. There was a trend toward a higher rate of overall surgical infectious and noninfectious complications in patients who had spillage of bowel contents compared with patients without spillage; however, this difference was not statistically significant (18.7 vs. 11 percent, and 29 vs. 19 percent, respectively). Preoperative mechanical bowel preparation and colocolonic or colorectal anastomosis was associated with a higher rate of bowel contents spillage, although this difference did not reach statistical significance. Liquid colonic contents caused significantly higher rates of spillage.

CONCLUSIONS

Spillage of bowel contents into the peritoneal cavity during colon and rectal surgery may increase the rate of postoperative infectious complications. In addition, inadequate mechanical bowel preparation, leading to liquid bowel contents, increases the rate of intraoperative spillage.

Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery

PURPOSE

Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted.

METHODS

During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak.

RESULTS

In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11).

CONCLUSION

In the present study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.

[Preoperative bowel preparation--is it useful?]

Mechanical cleansing of the colon prior to elective colorectal surgery is a dogmatically established belief in surgery. Polyethylene glycol was extensively used in the 1980's and 1990's but has been largely replaced by other laxative solutions such as sodium phosphate which are better tolerated by the patient. Evidence-based data in the surgical literature question the dogma of routine mechanical bowel cleansing (8 randomized controlled studies and 4 meta-analyses). These data show with a good level of evidence that mechanical bowel preparation is unnecessary and perhaps harmful.

Bowel Preparation before Microvascular Free Colon Transfer for Head and Neck Reconstruction: Is It Necessary?

Mechanical bowel preparation before any intestinal operation, especially when the large intestine is involved, is routine practice for most surgeons. This practice has been questioned by many colorectal surgeons, with convincing data showing the lack of benefit of preoperative mechanical bowel preparation. Free microvascular transfer of the large intestine is occasionally performed for reconstruction of the upper esophagus, as it provides a better size match for the oropharynx than other visceral organs. Nine patients underwent reconstruction of the cervical esophagus and voice tube using a segment of ileocolon. In all patients, the cervical esophagus was reconstructed using the ascending colon and the voice tube was reconstructed using the ileal segment. Both were transferred as one free flap. All patients underwent the procedure without any form of preoperative mechanical bowel preparation. The patients were able to tolerate a solid diet at the end of the mean follow-up period of 7 months, and all esophagograms showed no evidence of stricture formation. One patient developed a fistula at the recipient site that was treated with a regional flap, one patient developed a superficial wound infection of the abdominal wall, and one patient developed a postoperative abdominal wound dehiscence after several episodes of excessive coughing. Microvascular transfer of a large intestinal segment without preoperative mechanical bowel preparation for the reconstruction of the esophagus is a safe procedure. It can avoid the discomfort and complications associated with mechanical bowel preparation. If preoperative mechanical bowel preparation is preferred, the results of this study, which are based on nine patients, demonstrate the safety of this practice in cases where the patient did not follow proper instructions or in cases where the use of the colon was not anticipated preoperatively.

Bowel preparation comparison: flavored versus unflavored colyte

Patients undergoing colonoscopy who have poor bowel cleansing must undergo repeated colon lavage and procedure, resulting in the possibility of additional discomfort and risk. Patient compliance with the necessary 4 liters of colon lavage fluid is essential. At our facility, the current colon lavage solution is unflavored and most patients complain about the taste. These are the patients who are likely to have poorly cleansed bowels. Patient preference for flavor of lavage is not known. A randomized controlled trial of 130 patients was undertaken to learn whether Colyte flavor made a difference in bowel cleansing. Results showed flavor made no difference in bowel cleansing (chi2 = 0.064, p =.96, NS); successful cleansing occurred in 75% (n = 45) of patients who received flavored and 76% (n = 53) who received unflavored Colyte. Results suggest flavor is not a factor in patients' completion of the prep nor cleansing effectiveness. As unflavored Colyte costs less than flavored, cost savings can result from continuing use of unflavored Colyte. While this clinical trial did not answer the dilemma about how to improve colon preparation, the staff's process of conducting nursing research inspired critical thinking and innovative problem-solving. Patients who are undergoing a colonoscopy are required to do a bowel cleansing the day before the procedure. Without proper bowel cleansing, colonic lesions such as polyps, neoplasms, and arteriovenous malformations (AVMs) may go undetected by being covered with small particles of stool ( Cohen et al., 1994). Poor bowel cleansing results in the need for repeat colon preparation and repeat procedure, which pose risk and discomfort for the patient and cost for the staff and institution. Done under moderate sedation, colonoscopy poses potential cardiac risks and respiratory problems for the patient. In addition, the endoscopy procedure itself could cause perforation and bleeding. Avoiding repeat procedures because of failed colonic preparation is, therefore, essential for patient safety and organization cost. Optimally, completing the colon prep solution results in adequate bowel cleansing. Prep flavor was theorized to be a possible cause of noncompliance. The purposes of this study were to determine whether patients' preferred prep solution would yield better compliance with the colon lavage solution and whether the improved compliance results in an adequately prepared bowel.

Complications after colorectal surgery without mechanical bowel preparation

BACKGROUND

The current practice of mechanical bowel preparation (MBP) before colorectal surgery is questionable. Mechanical bowel preparation is unpleasant for the patient, often distressful, and potentially harmful. The results are often less than desired, increasing the risk of contamination. Cleansing the colon and rectum before surgery has never been shown in clinical trials to benefit patients. In animal experiments MBP has a detrimental effect on colonic healing.

STUDY DESIGN

To investigate the outcomes of colorectal surgery without MBP, we prospectively evaluated a consecutive series of patients who underwent resection and primary anastomosis of the colon and upper rectum, including emergency operations. One surgeon performed all operations. Endpoints were wound infection, anastomotic failure, and death. Late signs and symptoms that might be secondary to leakage of the anastomosis were considered as an anastomotic failure as well, during a followup of 1 year.

RESULTS

Two hundred fifty operations were performed, of which 199 (79.6%) were elective. Colectomies were left-sided in 65.6%. Anastomoses were ileocolic in 32%, colocolic in 20.8%, colorectal intraperitoneal in 34.4%, and extraperitoneal in 12.8%. No patient suffered from fecal impaction. Followup was complete in 97.2%. Eight patients (3.3%; 95% confidence interval [CI]: 1.4-6.4) developed superficial wound infections. In three patients there was leakage from an extraperitoneal colorectal anastomosis, in two of them after hospital discharge. The overall anastomotic failure rate was 1.2% (95% CI: 0.3-3.6). The in-hospital mortality rate was 0.8% (95% CI: 0.1-2.9) and was not related to abdominal or septic complications.

CONCLUSION

Mechanical bowel preparation is not a sine qua non for safe colorectal surgery.

Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study

PURPOSE

Efficient mechanical bowel preparation has been regarded as essential in preventing postoperative complications of colorectal surgery, but the necessity of bowel cleansing has been disputed recently. The aim of this study was to evaluate the outcome of elective colorectal surgery in patients with or without bowel preparation.

METHODS

Altogether, 267 consecutive adult patients admitted for elective open colorectal surgery were randomly assigned either to the bowel preparation group with oral polyethylene glycol electrolyte solution (138 patients) or no preparation group (129 patients). Patients who were unable to drink polyethylene glycol electrolyte solution, those who had had bowel preparation within the previous week, and patients not needing opening of the bowel were excluded. Routine colorectal surgery was undertaken, and infectious and other complications were registered daily. Late complications were checked up one to two months after surgery.

RESULTS

No deaths were recorded, and 76 percent of the patients in the polyethylene glycol electrolyte solution group and 81 percent in the unprepared group recovered without complication. Anastomotic leaks occurred in 4 percent of the polyethylene glycol electrolyte solution patients and in 2 percent of the other cases, and other surgical site infections occurred in 6 and 5 percent, respectively. None of the differences was statistically significant. There was no difference in restoration of bowel function. The median postoperative stay was eight days in both groups.

CONCLUSIONS

Preoperative bowel preparation seems to offer no benefit in elective open colorectal surgery.

Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation

BACKGROUND

Although polyethylene glycol lavage solutions are widely used for colonoscopy preparation, evidence suggests that sodium phosphate is better tolerated and has similar efficacy. The purpose of this study was to compare compliance with and efficacy of polyethylene glycol and sodium phosphate using meta-analysis and to compare the cost of colonoscopy with both methods.

METHODS

We used Medline to identify all randomized controlled trials comparing the two preparations. Study methods were evaluated, and quantitative data were abstracted independently, including inability to complete the preparation and preparation quality, rated as adequate or excellent. A random effects model was used to calculate the pooled relative risk. Direct costs and literature-based probability estimates were used to compare costs.

RESULTS

Among 1286 subjects from eight colonoscopist-blinded trials, the pooled relative risk of inability to complete the preparation was 0.23 (95% CI [0.18-0.28]) in favor of sodium phosphate. Although the best estimate of the relative risk for an adequate quality preparation revealed therapeutic equivalence (relative risk = 1.06: 95% CI [0.95-1.19]), an excellent quality preparation was more likely with sodium phosphate (relative risk = 1.72: 95% CI [1.16-2.53]). Assuming reexamination rates from published literature of 3% and 8% for sodium phosphate and polyethylene glycol, respectively, direct costs of colonic examination were $465 and $503. There were no clinically important adverse effects with either method.

CONCLUSION

The results suggest that sodium phosphate is as effective and less costly, with a more easily completed preparation, compared with polyethylene glycol and is the preferred method of preparation for colonoscopy for certain patient subgroups.

What is the role of mechanical bowel preparation in patients undergoing colorectal surgery?

BACKGROUND

Most surgeons use mechanical bowel preparation before performing operations on the colon and rectum. The aim of this study is to determine if there is any published literature that supports this practice.

METHODS

We undertook a review of the literature on the benefits of mechanical bowel preparation in patients undergoing surgery on the colon and rectum. A meta-analysis was conducted on all available clinical trials addressing this issue.

RESULTS

A meta-analysis of three clinical trials revealed a significantly greater incidence of wound infection in patients who received a mechanical bowel preparation (10.8 vs. 7.4 percent; P < 0.002; 95 percent confidence interval of the difference, -1.6-8.4 percent). Patients who received mechanical bowel preparation had an incidence of anastomotic leakage that was twice that of control patients; however, this difference was not significant (8.1 vs. 4 percent; P < 0. 1 14; 95 percent confidence interval of the difference, -0.4-8.4 percent).

CONCLUSION

There is limited evidence in the literature to support the use of mechanical bowel preparation in patients undergoing colorectal surgery. Hence, there is a need for clinical trials comparing the more traditional, aggressive forms of bowel preparation (e.g., polyethylene glycol solutions, sodium phosphate) with either no preparation or simpler techniques, such as a single phosphate enema.

Improvements in mechanical bowel preparation for elective colorectal surgery

PURPOSE

This study was undertaken to determine whether a mechanical bowel preparation with 2 liters of polyethylene glycol solution combined with a laxative (Group A) increases the acceptability of bowel preparation and reduces discomfort compared with 4 liters of polyethylene glycol solution (Group B).

METHODS

One hundred patients undergoing an elective colorectal resection were included in a prospective, randomized study. Acceptability (nausea, vomiting, abdominal cramps, discomfort from insertion of the nasogastric tube, and anal discomfort) was assessed using visual analog scales. Efficacy of bowel lavage was scored intraoperatively by a blinded surgeon.

RESULTS

Overall acceptability was 5.1 +/- 2.8 in Group A patients and 5.6 +/- 2.6 in Group B patients (P = 0.5). The incidence and visual analog score for nausea, vomiting, anal discomfort, and cramps were not different between groups. Excellent efficacy of bowel preparation was shown in 94 percent of patients in Group A and 84 percent of patients in Group B (P = 0.5). The incidence of septic complications was 2 percent in Group A patients and 12 percent in Group B patients (P = 0.06).

CONCLUSION

Because the acceptability of both cleansing regimens were not different, 2 liters of polyethylene glycol plus Prepacol should be preferred because the amount of fluid administered to clean the bowel is reduced and the nasogastric tube can always be avoided.

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.