Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery

Bowel regimens before radical cystectomy: An analysis of a modern cohort

INTRODUCTION

Bowel regimens (BR) before radical cystectomy (RC) are currently not recommended by Enhanced Recovery After Surgery (ERAS) protocols, as prior studies have shown BRs lead to worsened outcomes. However, many of those studies have used historic literature before recent surgical advancements such as minimally invasive RC and have not investigated the impact BRs have by type of urinary diversion. Our goal is to determine the outcomes of preoperative BR in patients undergoing RC based on diversion type using a modern patient cohort.

METHODS

RCs performed between 2019 and 2020 with BR information available were identified in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP). Patients were grouped by type of BR received: no BR, both mechanical bowel preparation (MBP) and preoperative oral antibiotic BR (OABR), MBP only, and OABR only. We conducted propensity score matching based on factors influencing the operative approach. Baseline demographics and 30-day complication rates were compared between matched groups. We analyzed hospital length of stay (LOS) via multivariate regression with a Poisson distribution.

RESULTS

In total, 2054 RCs were identified with 2.4% receiving OABR, 21.3% receiving MBP, 5.3% receiving both, and 71.0% receiving no BR. For patients with ileal conduit diversions, outcomes with BRs appeared mixed, as OABR leads to increased LOS. For patients with neobladder diversions, BRs were not associated with any worsened outcomes and were associated with reduced length of stay.

CONCLUSIONS

BRs such as OABR may associated with improved outcomes in patients receiving RC with neobladder diversion, a finding that warrants further investigation.

Does luck always favor the prepared? Analysis of the NSQIP database shows benefits of combined bowel preparation on colostomy reversal outcomes

BACKGROUND

Bowel preparation has long been used to prevent infectious complications and facilitate easy colorectal surgery. Both mechanical and oral antibiotic bowel preparation have been thoroughly studied in the elective colorectal resection population, but no studies exist on their use before adult colostomy reversals. This study aims to evaluate the effect of preoperative bowel preparation on anastomotic leak and infectious complication rates after colostomy reversal surgery.

METHODS

Retrospective cohort analysis of the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program colorectal-specific database was performed. Adults who underwent elective colostomy reversal were stratified into 4 groups: no bowel preparation, oral antibiotic only, mechanical bowel preparation only, or combined oral antibiotic + mechanical bowel preparation. Outcomes measured were infectious complications, anastomotic leak, prolonged ileus, wound disruption, acute kidney injury, Clostridium difficile colitis, return to the operating room, survivor-only length of stay, mortality, and unplanned readmissions. Logistic regression analyses were performed to identify predictors of infectious complications and anastomotic leak.

RESULTS

A total of 793 patients who underwent colostomy takedown were identified (no bowel preparation: 37%; oral antibiotic only: 7%; mechanical bowel preparation only: 13%; combined oral antibiotic + mechanical bowel preparation: 42%). Patients who had oral antibiotic + mechanical bowel preparation had significantly lower 30-day rates of organ/space surgical site infection, sepsis, septic shock, anastomotic leak, prolonged ileus, wound disruption, and length of stay (P < .05). On multivariate analysis, combined oral antibiotic + mechanical bowel preparation was associated with lower adjusted odds of infectious complications (adjusted odds ratio: 0.52, P < .05) and anastomotic leak (adjusted odds ratio: 0.37, P < .05).

CONCLUSION

This is the first study specifically demonstrating that combined oral antibiotic and mechanical bowel preparation may reduce infectious complications and anastomotic leaks without increasing Clostridium difficile colitis and acute kidney injury after adult elective colostomy reversal. Granular, large-scale, prospective studies are warranted to replicate these findings and identify opportunities for quality improvement.

Pre-Operative Mechanical Bowel Preparation Does Not Affect the Impact of Anastomosis Leakage in Left-Side Colorectal Surgery-A Single Center Observational Study

Despite rapid advances in colorectal surgery, morbidity and mortality rates in elective gastrointestinal surgery play a significant role. For decades, there have been tempestuous discussions on preventative measures to minimize the risk of anastomotic dehiscence. When mechanical bowel preparation before an elective procedure, one of the key hypotheses, was introduced into practice, it was assumed that it would decrease the number of infectious complications and anastomotic dehiscence. The advancements in antibiotic treatment supported the concomitant administration of oral antibiotics and mechanical bowel preparation. In the prospective study conducted at our clinic, we performed left-side colorectal procedures without prior mechanical preparation. All patients enrolled in the study underwent the surgery and were observed in the 3rd Surgical Clinic, Faculty of Medicine, Comenius University in Bratislava, Slovakia, from January 2019 to January 2020. As a control group, we used a similar group of patients with MBP. Our observed group included 87 patients with tumors in the left part of their large intestine (lineal flexure, descendent colon, sigmoid colon, and rectum). Dixon laparoscopic resection was performed in 26 patients. Sigmoid laparoscopic resection was performed in 27 patients. In 12 patients, the procedure was started laparoscopically but had to be converted due to adverse anatomical conditions. The conservative approaches mostly included Dixon resections (19 patients), sigmoid colon resections (5 patients), left-side hemicolectomies (6 patients), and Miles' tumor resections, with rectal amputation (4 patients). Our study highlighted the fact that MBP does not have an unequivocal benefit for patients with colorectal infection, which has an impact on the development of anastomotic dehiscence.

The Impact of Surgical Bowel Preparation on the Microbiome in Colon and Rectal Surgery

Preoperative bowel preparation, through iterations over time, has evolved with the goal of optimizing surgical outcomes after colon and rectal surgery. Although bowel preparation is commonplace in current practice, its precise mechanism of action, particularly its effect on the human gut microbiome, has yet to be fully elucidated. Absent intervention, the gut microbiota is largely stable, yet reacts to dietary influences, tissue injury, and microbiota-specific byproducts of metabolism. The routine use of oral antibiotics and mechanical bowel preparation prior to intestinal surgical procedures may have detrimental effects previously thought to be negligible. Recent evidence highlights the sensitivity of gut microbiota to antibiotics, bowel preparation, and surgery; however, there is a lack of knowledge regarding specific causal pathways that could lead to therapeutic interventions. As our understanding of the complex interactions between the human host and gut microbiota grows, we can explore the role of bowel preparation in specific microbiome alterations to refine perioperative care and improve outcomes. In this review, we outline the current fund of information regarding the impact of surgical bowel preparation and its components on the adult gut microbiome. We also emphasize key questions pertinent to future microbiome research and their implications for patients undergoing colorectal surgery.

Effect of preoperative oral antibiotics and mechanical bowel preparation on the prevention of surgical site infection in elective colorectal surgery, and does oral antibiotic regime matter? a bayesian network meta-analysis

PURPOSE

Surgical site infection (SSI) impacts 5-20% of patients after elective colorectal surgery. There are varying reports on the effectiveness of oral antibiotics (OAB) with preoperative mechanical bowel preparation (MBP) in preventing SSI. We aim to determine the role of OAB and MBP in preventing SSI after elective colorectal surgery. We also determine if a specific OAB regimen will be more effective than others.

METHODS

This study investigated the impact of OAB and MBP in patients undergoing elective colorectal surgery. PubMed, MEDLINE, Ovid, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Embase databases were searched for randomized clinical trials (RCTs) published by June 2022. All RCTs comparing various preoperative bowel preparation regimens, including pairwise or multi-intervention comparisons, were included. To establish the role of OAB and MBP in preventing SSI, we conducted a Bayesian network meta-analysis on all RCTs. We further performed subgroup analysis to determine the most effective OAB regimen.

RESULTS

Among included 46 studies with a total of 12690 patients, patients in the MBP + OAB group were less likely to have SSI than those having MBP-only (OR 0.55, 95% CrI 0.39-0.76), and without MBP and OAB (OR 0.52, 95% CrI 0.32-0.84). OAB regimen C (kanamycin + metronidazole) and A (neomycin + metronidazole) demonstrated a significantly reduced incidence of SSI, compared to regimen B (neomycin + erythromycin) with OR 0.24 (95% CrI 0.07-0.79) and 0.26 (95% CrI 0.07-0.99) respectively.

CONCLUSIONS

OAB with MBP reduces the risk of SSI after elective colorectal surgery. Providing adequate aerobic and anaerobic coverage with OAB may confer better protection against SSI.

Bowel Preparation Before Nonelective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused

BACKGROUND

Although strong evidence exists for combined mechanical and oral antibiotic bowel preparation before elective colorectal resection, the utility of preoperative bowel preparation for patients undergoing sigmoid resection after endoscopic decompression of sigmoid volvulus has not been previously examined. The goal of this study was to evaluate the association between bowel preparation and postoperative outcomes for patients undergoing semielective, same-admission sigmoid resection for acute volvulus.

STUDY DESIGN

Patients from the 2012 to 2019 Colectomy-Targeted American College of Surgeons NSQIP dataset who underwent sigmoid resection with primary anastomosis after admission for sigmoid volvulus were included. Multivariable logistic regression was used to compare the risk-adjusted 30-day postoperative outcomes of patients who received combined preoperative bowel preparation with those of patients who received either partial (mechanical or oral antibiotic alone) or incomplete bowel preparation. Effort was made to exclude patients whose urgency of clinical condition at hospital admission precluded an attempt at preoperative decompression and subsequent bowel preparation.

RESULTS

Included were 2,429 patients, 322 (13.3%) of whom underwent complete bowel preparation and 2,107 (86.7%) of whom underwent partial or incomplete bowel preparation. Complete bowel preparation was protective against several postoperative complications (including anastomotic leak), mortality, and prolonged postoperative hospitalization.

CONCLUSIONS

This study demonstrates a significant benefit for complete bowel preparation before semielective, same-admission sigmoid resection in patients with acute sigmoid volvulus. However, only a small percentage of patients in this national sample underwent complete preoperative bowel preparation. Broader adoption of bowel preparation may reduce overall rates of complication in patients who require sigmoid colectomy due to volvulus.

Effect of bowel preparation on intestinal permeability and inflammatory response during postoperative ileus in mice

BACKGROUND

Postoperative ileus entails pathophysiological changes in mucosal permeability and an intestinal inflammatory immune response. We hypothesized that preoperative selective decontamination of the digestive tract combined with preoperative mechanical bowel preparation might be advantageous to prevent or reduce permeability changes and immune response in postoperative ileus.

METHODS

Postoperative ileus was induced in mice by standardized small bowel manipulation. Intervention groups received selective decontamination and/or intestinal lavage with normal saline simulating mechanical bowel preparation before postoperative ileus induction. At 1, 3, and 9 hours after surgery, ileum samples were harvested for measurements of fluorescein (332 Da) permeability, quantification of tumor necrosis factor α-mRNA level, and leukocyte infiltration of the intestinal wall.

RESULTS

Mucosal fluorescein permeability increased at 1 hour (8.6 ± 1.1 vs 5.9 ± 0.9 10^-6 cm/s; P < .01) and 3 hours (8.5 ± 0.6 vs 6.5 ± 0.2 10^-6 cm/s; P < .05) after induction of postoperative ileus. This increase was prevented by mechanical bowel preparation and selective decontamination+mechanical bowel preparation interventions at both points in time. Expression of tumor necrosis factor α was more than 2-fold increased (P < .05) in the very early phase after induction of postoperative ileus but did not occur in mechanical bowel preparation-pretreated animals. Myeloperoxidase staining revealed that mechanical bowel preparation inhibited postoperative ileus-associated leukocyte infiltration of the intestinal muscularis at 3 and 9 hours after surgery, but not selective decontamination + mechanical bowel preparation treatment. The number of leukocytes after mechanical bowel preparation-only treatment remained at the level of sham-controls.

CONCLUSION

Mechanical bowel preparation prevents permeability and leukocyte infiltration of the intestinal wall in the early phase of postoperative ileus in mice.

A Review of Bowel Preparation Before Colorectal Surgery

Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.

A comparison between limited bowel preparation and comprehensive bowel preparation in radical cystectomy with ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Our aim is to evaluate the value of limited bowel preparation (LBP) in radical cystectomy (RC) with ileal urinary diversion (IUD).

METHODS

A systematic literature search was conducted on electronic database up to February 2020. All data were analyzed using RevMan5 (version 5.3). A subgroup analysis comparing the efficacy of CBP and no bowel preparation (NBP) was also performed.

RESULTS

Six randomized controlled trials (RCTs) including 743 patients were finally enrolled for statistical analysis. According to the meta-analysis, there was no significant difference between LBP group and comprehensive bowel preparation (CBP) group, concerning operative time (p = 0.79), length of stay (p = 0.46), the time to first toleration of clear liquids (p = 0.95), and overall complications (p = 0.29). However, the time to first bowel activity (SMD: - 0.77, 95% CI - 1.47 to - 0.07, p = 0.03), risk of fever (RR: 0.53, 95% CI 0.33-0.85, p = 0.008), time to first flatus (SMD: - 1.06, 95% CI - 2.02 to - 0.10, p = 0.03), and risk of wound healing disorders (RR: 0.65, 95% CI 0.44-0.95, p = 0.03) were significantly lower in LBP group compared with CBP group. Subgroup analysis showed a significant lower risk of wound healing disorders in favor of NBP (RR: 0.50, 95% CI 0.29-0.87, p = 0.01).

CONCLUSIONS

Current evidence indicated that LBP protocols might accelerate recovery of gastrointestinal function, promote wound healing, and reduce the risk of fever without increasing complications in patients undergoing RC with IUD. Besides, bowel preparation also did not hinder wound healing. Further, well-designed RCTs conducted by experienced surgeons are warranted before making the final clinical guidelines.

Prospective randomised controlled trial using the REthinking Clinical Trials (REaCT) platform and National Surgical Quality Improvement Program (NSQIP) to compare no preparation versus preoperative oral antibiotics alone for surgical site infection rates in elective colon surgery: a protocol

INTRODUCTION

Despite 40 randomised controlled trials (RCTs) investigating preoperative oral antibiotics (OA) and mechanical bowel preparation (MBP) to reduce surgical site infection (SSI) rate following colon surgery, there has never been an RCT published comparing OA alone versus no preparation. Of the four possible regimens (OA alone, MBP alone, OA plus MBP and no preparation), randomised evidence is conflicting for studied groups. Furthermore, guidelines vary, with recommendations for OA alone, OA plus MBP or no preparation. The National Surgical Quality Improvement Program (NSQIP) has automated data collection for surgical patients. Similarly, the 'REthinking Clinical Trials' (REaCT) platform increases RCT enrolment by simplifying pragmatic trial design. In this novel RCT protocol, we combine REaCT and NSQIP to compare OA alone versus no preparation for SSI rate reduction in elective colon surgery. To our knowledge, this is the first published RCT protocol that leverages NSQIP for data collection. In our feasibility study, 67 of 74 eligible patients (90%) were enrolled and 63 of 67 (94%) were adherent to protocol. The 'REaCT-NSQIP' trial design has great potential to efficiently generate level I evidence for other perioperative interventions.

METHODS AND ANALYSIS

SSI rates following elective colorectal surgery after preoperative OA or no preparation will be compared. We predict 45% relative rate reduction of SSI, improvement in length of stay, reduced costs and increased quality of life, with similar antibiotic-related complications. Consent, using the 'integrated consent model', and randomisation on a mobile device are completed by the surgeon in a single clinical encounter. Data collection for the primary end point is automatic through NSQIP. Analysis of cost per weighted case, cost utility and quality-adjusted life years will be done.

ETHICS AND DISSEMINATION

This study is approved by The Ontario Cancer Research Ethics Board. Results will be disseminated in surgical conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03663504; Pre-results, recruitment phase.

Influence of preoperative enema application on the return of gastrointestinal function in elective Cesarean sections: a randomized controlled trial

AIM

There is an extensive literature on the mechanical bowel preparation by an enema in colorectal, abdominal, and gynecologic surgeries that provide evidence against the use of enema. There are, however, few studies investigating the effect of enema prior to elective Cesarean sections. The aim of this study is to investigate whether preoperative enema facilitates the return of gastrointestinal activity in pregnant women undergoing elective Cesarean section.

MATERIALS AND METHODS

The surgeon-blinded prospective randomized controlled study included 225 elective Cesarean patients between the ages of 18 and 44. The patients were randomized into two groups: those who had enema preoperatively (n = 114) and those who did not (n = 111). The outcome measures were first bowel sound time and first flatus time, the length of hospital stay, the rate of mid ileus symptoms, and additional analgesic and antiemetic need.

RESULTS

In the non-enema group, the time of the first bowel sound, flatus time, length of hospital stay, the rates of additional analgesic need, additional antiemetic need, and mild ileus symptoms were respectively 10.5 ± 5.8 hours, 16.0 ± 7.6 hours, 1.9 ± 0.3 days, 8.1%, 7.2%, and 2.7%. For the enema group, the same parameters were respectively 11.6 ± 4.7 hours, 17.5 ± 6.5 hours, 1.8 ± 0.3 days, 7%, 6.1% ,and 1.8%. For all parameters, the difference between the groups was not statistically significant (p values were respectively .09, .12, .8, .79, .68, and .26).

CONCLUSIONS

The study suggests that preoperative enema in elective cesarean sections does not prevent postoperative gastrointestinal complications and does not shorten the recovery of bowel movements or length of hospital stay.

Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway

Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.

Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection: A Network Meta-analysis

IMPORTANCE

There has been a resurgence of interest in the use of mechanical bowel preparation (MBP) and oral antibiotics (OAB) before elective colorectal surgery. Until now, clinical trials and meta-analyses have not compared all 4 approaches (MBP with OAB, OAB only, MBP only, or no preparation) simultaneously.

OBJECTIVE

To perform a network meta-analysis to clarify which approach in colorectal surgery is associated with the lowest rate of surgical site infection (SSI).

DATA SOURCES

Five electronic databases were searched, including PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club. and Database of Abstracts of Review of Effectiveness from database inception to November 27, 2017.

STUDY SELECTION

Only data from randomized clinical trials were included. Inclusion criteria were RCTs that reported on SSI rates or other complications based on MBP or OAB status. Quality of studies was appraised by the Cochrane Collaboration risk of bias tool.

DATA EXTRACTION AND SYNTHESIS

The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

MAIN OUTCOMES AND MEASURES

Total, incisional, and organ/space SSI rates. Secondary outcomes included rates of anastomotic leak, mortality, readmissions/reoperations, urinary tract infection, and pulmonary complications.

RESULTS

Thirty-eight randomized clinical trials among 8458 patients (52.1% male) were included, providing 4 direct comparisons and 2 indirect comparisons for 8 outcome measures. On Bayesian analysis, MBP with OAB vs MBP only was associated with reduced SSI (odds ratio [OR], 0.71; 95% equal-tail credible interval [CrI], 0.57-0.88). There was no significant difference between MBP with OAB vs OAB only (OR, 0.95; 95% CrI, 0.56-1.62). Oral antibiotics without MBP was not associated with a statistically significant reduction in SSI compared with any other group (except for a risk reduction in organ/space SSI when indirectly compared with no preparation) (OR, 0.13; 95% CrI, 0.02-0.55). There was no difference in SSI between MBP only vs no preparation (OR, 0.84; 95% CrI, 0.69-1.02).

CONCLUSIONS AND RELEVANCE

In this network meta-analysis of randomized clinical trials, MBP with OAB was associated with the lowest risk of SSI. Oral antibiotics only was ranked as second best, but the data available on this approach were limited. There was no difference between MBP only vs no preparation. In addition, there was no difference in rates of anastomotic leak, readmissions, or reoperations between any groups.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Does bowel preparation for inflammatory bowel disease surgery matter?

AIM

The purpose of this study was to determine if bowel preparation influences outcomes in patients with inflammatory bowel disease undergoing surgery.

METHODS

The database of the American College of Surgeons National Surgical Quality Improvement Program, Procedure Targeted Colectomy, from 2012 to 2014 was analyzed. Inflammatory bowel disease patients undergoing colorectal resection with or without bowel preparation were included in the study.

RESULTS

In all, 3679 patients with inflammatory bowel disease were identified. 42.5% had no bowel preparation, 21.5% had mechanical bowel preparation only, 8.8% had oral antibiotic bowel preparation only and 27.2% had combined mechanical and oral antibiotic preparation. Combined mechanical and oral antibiotic preparation is associated with lower rates of anastomotic leak, ileus, surgical site infection, organ space infection, wound dehiscence and sepsis/septic shock.

CONCLUSION

Combined mechanical and oral antibiotic preparation for inflammatory bowel disease patients undergoing colectomy is associated with decreased rates of surgical site infection, anastomotic leak, ileus. Combined bowel preparation should be the standard of care for inflammatory bowel disease patients undergoing colorectal resection.

Bowel Preparation Is Associated with Reduced Morbidity in Elderly Patients Undergoing Elective Colectomy

BACKGROUND

Bowel preparation in elderly patients is associated with physiologic derangements that may result in postoperative complications. The aim of this study is to determine the impact of bowel preparation on postoperative outcomes in elderly patients.

METHODS

Patients age 75 years and older who underwent elective colectomy were identified from the 2012-2014 American College of National Surgical Quality Improvement Program (ACS-NSQIP database). Patients were grouped into no bowel preparation, mechanical bowel preparation (MBP), oral antibiotic preparation (OABP), or combined MBP + OABP. Logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes.

RESULTS

There were 4829 patients included in the analysis. Morbidity was 34.3% in no bowel prep, 32.4% in MBP, 24.8% in OABP, and 24.6% in MBP + OABP groups (p < 0.001). The MBP + OABP group compared with no bowel prep was associated with reduced rates of anastomotic leak, ileus, superficial surgical site infection (SSI), organ space SSI, respiratory compromise, and reduced length of stay. There was no difference in the rate of acute kidney injury between the groups.

CONCLUSION

MBP + OABP was associated with reduced morbidity compared with no bowel preparation in elderly patients undergoing elective colorectal resection. MBP alone was not associated with differences in outcomes compared with no bowel preparation. The use of MBP + OABP is safe and effective in elderly patients undergoing elective colectomy.

New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients

PURPOSE

The influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study.

METHODS

Data from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated.

RESULTS

Patients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029).

CONCLUSION

Preoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.

Colonic transit: what is the impact of a diverting loop ileostomy?

BACKGROUND

Diverting loop ileostomy (DLI) is used following low anterior resections (LAR) or ultra-low anterior resections (ULAR) to reduce anastomotic leak (AL). Preoperative mechanical bowel preparation (MBP) is traditionally used with DLI. However, clearance of the left colon can be achieved with a fleet enema without the physiological compromise of MBP. We aimed to assess colonic transit following DLI in this context.

METHODS

A prospective, observational study was performed with patients with rectal cancer undergoing LAR or ULAR in a tertiary colorectal unit with preoperative fleet enema. Radiopaque markers were inserted into the caecum following rectal resection and formation of a DLI with placement confirmed by image intensifier and endoscopy. X-rays were performed at days 1, 3, 5 and 14 post-operation with data collected prospectively.

RESULTS

Ten patients (mean age 57, nine males) were enrolled. Mean time to functioning stoma was 1.9 days (range 1-3). There was no movement in the majority of markers in all patients at Day 5 post-operation. In all seven patients with Day 14 X-rays, the majority of markers remained in the right colon. Two patients had delayed AL, with markers found within the pelvis in both of these patients.

CONCLUSIONS

This is the first study to assess colonic transit following DLI using fleet enema only, with results suggesting colonic motility is abolished in this setting. The use of a fleet enema without MBP may be sufficient prior to rectal resection surgery when DLI is employed. AL may actually increase colonic transit. Further research is warranted.

Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery

OBJECTIVES

To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery.

METHODS

National Surgical Quality Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis.

RESULTS

Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32-0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90).

CONCLUSIONS

These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.

Postoperative outcomes following mechanical bowel preparation before proctectomy: a meta-analysis

AIM

Previous meta-analyses of mechanical bowel preparation (MBP) before colorectal surgery have grouped colon and rectal resection together. An increased postoperative morbidity has been suggested in the absence of MBP following proctectomy. The current study used meta-analytical techniques to evaluate the comparative outcome of patients who received MBP prior to proctectomy.

METHOD

A comprehensive search was performed for published studies examining the effect of MBP before proctectomy on patient outcome. Random effects methods were used to combine data.

RESULTS

Eleven studies including 1258 patients were identified. There was no significant difference in overall morbidity (OR 1.062, 95% CI 0.584-1.933, P = 0.844), anastomotic leakage (OR 1.144, 95% CI 0.767-1.708, P = 0.509), surgical site infection (OR 0.946, 95% CI 0.549-1.498, P = 0.812) or mortality (OR 1.377, 95% CI 0.549-3.455, P = 0.495) between those who did not and those who did receive MBP prior to proctectomy.

CONCLUSION

The current study did not demonstrate a beneficial effect of MBP prior to proctectomy, but the data were limited. Decision-making as to its use should be made on a case-by-case basis.

Laparoscopic colon resection: To prep or not to prep? Analysis of 1535 patients

BACKGROUND

Mechanical bowel preparation (MBP) before elective open colon resection does not reduce the rate of postoperative anastomotic leakage. However, MBP is still routinely used in many countries, and there are very limited data regarding the utility of preoperative MBP in patients undergoing laparoscopic colon resection (LCR). The aim of this study was to challenge the use of MBP before elective LCR.

METHODS

It is a retrospective analysis of a prospectively collected database. All patients undergoing elective LCR with primary anastomosis and no stoma were included. Preoperative MBP with polyethylene glycol solution was used routinely between April 1992 and December 2004, and then it was abandoned. The early postoperative outcomes in patients who had preoperative MBP (MBP group) and in patients who underwent LCR without preoperative MBP (No-MBP group) were compared.

RESULTS

From April 1992 to December 2014, 1535 patients underwent LCR: 706 MBP patients and 829 No-MBP patients. There were no differences in demographic data, indication for surgery and type of procedure performed between MBP and No-MBP group patients. The incidence of anastomotic leakage was similar between the two groups (3.4 vs. 3.6 %, p = 0.925). No differences were observed in intra-abdominal abscesses (0.6 vs. 0.8 %, p = 0.734), wound infections (0.6 vs. 1.4 %, p = 0.149), infectious extra-abdominal complications (1.8 vs. 3 %, p = 0.190), and non-infectious complications (6.1 vs. 6.8 %, p = 0.672). The overall reoperation rate was 4.6 % for MBP patients and 5 % for No-MBP patients (p = 0.813).

CONCLUSION

The use of preoperative MBP does not seem to be associated with lower incidence of intra-abdominal septic complications after LCR.

In the Absence of a Mechanical Bowel Prep, Does the Addition of Pre-Operative Oral Antibiotics to Parental Antibiotics Decrease the Incidence of Surgical Site Infection after Elective Segmental Colectomy?

BACKGROUND

Pre-operative oral antibiotics administered the day prior to elective colectomy have been shown to decrease the incidence of surgical site infections (SSI) if a mechanical bowel prep (MBP) is used. Recently, the role for mechanical bowel prep has been challenged as being unnecessary and potentially harmful. We hypothesize that if MBP is omitted, oral antibiotics do not alter the incidence of SSI following colectomy.

METHODS

We selected patients who underwent an elective segmental colectomy from the 2012 and 2013 National Surgical Quality Improvement Program colectomy procedure targeted database. Indications for surgery included colon cancer, diverticulitis, inflammatory bowel disease, or benign polyp. Patients who received mechanical bowel prep were excluded. The primary outcome measured was surgical site infection, defined as the presence of superficial, deep or, organ space infection within 30 d from surgery.

RESULTS

A total of 6,399 patients underwent elective segmental colectomy without MBP. The incidence of SSI differed substantially between patients who received oral antibiotics, versus those who did not (9.7% vs. 13.7%, p=0.01). Multivariate analysis indicated that age, smoking status, operative time, perioperative transfusions, oral antibiotics, and surgical approach were associated with post-operative SSI. When controlling for confounding factors, the use of pre-operative oral antibiotics decreased the incidence of surgical site infection (odds ratio=0.66, 95% confidence interval=0.48-0.90, p=0.01).

CONCLUSION

Even in the absence of mechanical bowel prep, pre-operative oral antibiotics appear to reduce the incidence of surgical site infection following elective colectomy.

Prevention of infectious complications after elective colorectal surgery in children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee comprehensive review

OBJECTIVE

This goal of this review was to examine the clinical evidence in support of commonly utilized measures intended to reduce complications following elective colorectal surgery.

DATA SOURCE

Literature searches were performed to identify relevant studies from Medline, PubMed, and Cochrane databases.

STUDY SELECTION

The American Pediatric Surgery Association Outcomes and Clinical Trials Committee selected eight questions to address this topic systematically in the context of three management areas: 1) appropriate utilization of systemic antibiotics for colorectal procedures, 2) reduction of stool burden through mechanical bowel preparation, and 3) intraluminal gut decontamination through use of enteral nonabsorbable antibiotics. Primary outcomes of interest included the occurrence of infectious and mechanical complications related to stool burden and intraluminal bacterial concentration (incisional surgical site infection, anastomotic leakage, and intraabdominal abscess).

RESULTS

The evidence in support of each management category was systematically reviewed, graded, and summarized in the context of the review's primary outcomes. Practice recommendations were made as deemed appropriate by the committee.

CONCLUSIONS

Clinical evidence in support of interventions to reduce infectious complications following colorectal surgery is derived almost exclusively from the adult literature. High-quality evidence to guide clinical practice in children is sorely needed, as the available data may have only limited relevance to pediatric colorectal diseases.

The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis

BACKGROUND

Although the use of mechanical bowel preparation (MBP) is still widely promoted as the dogma before patients undergo ileal urinary diversion, an increasing number of clinical trials have suggested that there is no benefit. Thus, we performed a meta-analysis to evaluate the efficacy of MBP in ileal urinary diversion surgery.

METHODS

A literature search was performed in electronic databases, including PubMed, Embase, Science Citation Index Expanded as well as the Cochrane Library and the Cochrane Clinical Trials Registry, from 1966 to January 1, 2013. Clinical trials comparing outcomes of MBP versus no MBP for ileal urinary diversion surgery were included in the meta-analysis. Pooled odds ratios with 95% confidence intervals were calculated using the fixed- or random-effects models.

RESULTS

In total, two randomized controlled trials and five cohort studies were included in this meta-analysis. The primary outcomes, such as bowel leak and bowel obstruction, showed no statistical difference between the two groups. Additionally, the overall mortality rate and death rate related to operation also manifested that MBP does not offer an advantage over the no MBP.

CONCLUSION

This meta-analysis suggests that MBP does not reduce the incidence of perioperative complications in urinary diversion compared with no MBP. However, large randomized controlled clinical trials are needed to confirm this finding.

Peri-operative management in urinary diversion surgery: A time for change?

INTRODUCTION

Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary.

METHODS

An online multiple-choice questionnaire (via Monkey Survey) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program.

RESULTS

Of the 41 consultant urologists surveyed, 80.4% (n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24-48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation.

CONCLUSION

The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.

Mechanical bowel preparation and prophylactic antibiotic administration in colorectal surgery: a survey of the current status in Korea

Purpose

The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery.

Methods

A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics.

Results

A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation.

Conclusion

The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.

Mechanical bowel preparation for esophagocoloplasty in children: is it really necessary?

Esophagocoloplasty is a commonly performed procedure for esophageal replacement in children. Traditionally, mechanical bowel preparation (MBP) is performed before this operation. However, this practice has been questioned, initially in adults and now in children. The aim of this study was to evaluate the influence of MBP on esophagocoloplasty in a series of children. Data collected from 164 patients who underwent esophagocoloplasty in the Pediatric Surgery Division, University of São Paulo Medical School, from February 1978 to July 2011 were reviewed for postoperative complications. In 134 patients, at least one kind of MBP was performed before the surgery (PREP group). MBP was omitted in 30 patients (NO-PREP group). There was no statistical difference between the groups in the rates of evisceration, colocolic, or cologastric anastomotic dehiscence and death. However, in the NO-PREP group, the incidence of cervical leakage (6.6%) was significantly decreased in comparison with the classical PREP group (25.3%) (P= 0.03). The results of this study suggest that the omission of MBP has a positive impact on the incidence of postoperative complications in esophagocoloplasty.

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.

The Safety of Elective Colorectal Surgery without Mechanical Bower Preparation

Objectives To reduce the risk of postoperative infectious complications and anastomotic leakage in colorectal surgery, preoperative mechanical bowel preparation (MBP) is performed routinely. The aim of this study was to evaluate the safety of primary anastomosis in elective colorectal surgery without MBP. Methods From Jan. 2005 to Dec. 2006, three hundred and seventy-nine patients of elective colorectal surgery with primary anastomosis were performed with MBP in 352 cases (Prep group) and without MBP in 24 cases (Non-prep group). For preoperative MBP, 4 liters of polyethylene glycol solution was administered. Postoperative infectious complications and other morbidity were reviewed with medical records and prospectively collected data. Results Demographic, clinical and treatment characteristics did not differ significantly between the two groups. The overall rate of abdominal infectious complications (wound infection, anastomotic leak) was 2.9 % in the Prep group and 9 % in the Non-prep group (P &gt; 0.05). Anastomotic leak occurred in nine patients (2.6%) in the Prep group and one (4.5%) in the Non-prep group. Conclusions The incidence of infectious complications after elective colorectal surgery without MBP did not differ significantly compare to that with MBP. However, prospective, randomized clinical trial is needed to assess the safety of primary anastomosis in elective colorectal surgery without MBP.

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.

Augmentation cystoplasty in children without preoperative mechanical bowel preparation

OBJECTIVE

To retrospectively assess early postoperative complications in augmentation cystoplasty without preoperative mechanical bowel preparation (MBP).

MATERIAL AND METHODS

Between May 1987 and May 2006, 162 cystoplasties were performed in 158 children. The segments used were: sigmoid colon (81.5%), ileum (13%), and ileocecum (5.5%). The mean age was 8.65 years (range 2.1-22.7 years). No preoperative MBP of any kind was used in any of the patients and all of them received antibiotics preoperatively and postoperatively.

RESULTS

No intraoperative complications related to the procedure were reported. The mean hospital stay was 9.48 days (range 4-30 days). The mean time to intake of oral fluids was 94.77 h (range 48-288 h). Postoperative complications occurred in 9.87%: urinary fistula was the most common (2.4%); only 3 patients presented wound infection (1.85%); 5 patients required reoperative surgery (hemoperitoneum, patch necrosis and 3 cases of urinary peritonitis); 1 patient presented an intra-abdominal abscess that resolved with antibiotic treatment.

CONCLUSIONS

Preoperative MBP can be omitted in children that require augmentation cystoplasty without an increased risk of infectious or anastomotic complications. Further prospective, randomized clinical trials should be carried out in order to validate our findings in the pediatric population.

A multicenter evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown

BACKGROUND

In response to studies in adults that have failed to demonstrate a benefit for mechanical bowel preparation in colonic surgery, we sought to evaluate the utility of mechanical bowel preparation in a multicenter, retrospective study of children who underwent colostomy takedown.

METHODS

The records of 272 children who underwent colostomy takedown at 3 large children's hospitals were reviewed, and the utilization of mechanical bowel preparation and perioperative antibiotics was noted. Length of stay and the incidences of wound, anastomotic, and other complications were compared.

RESULTS

A polyethylene glycol bowel prep was administered to 187 children. All subjects received perioperative, intravenous antibiotics, and 52% of those with bowel preps received preoperative oral antibiotics. Subjects in the bowel prep group had a significantly higher incidence of wound infection (P = .04) and longer length of stay (P = .05). Oral antibiotics did not affect outcome.

CONCLUSIONS

The use of a mechanical bowel preparation in children before colostomy takedown was associated with a greater risk for wound infection, no protection from other complications, and a longer length of stay. This suggests that bowel preparation may be safely omitted in many children who undergo colonic surgery, thereby reducing cost and discomfort.

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.

Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation

BACKGROUND

A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery.

METHODS

A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery.

RESULTS

Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively).

CONCLUSIONS

No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery.

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.