Preoperative bowel preparation. A survey of colon and rectal surgeons

Assessment of mechanical bowel preparation prior to nephrectomy in the minimally invasive surgery era: insights from a national database analysis in the United States

Purpose

This study was performed to evaluate the association between mechanical bowel preparation (MBP) and perioperative outcomes following nephrectomy in the minimally invasive surgery (MIS) era.

Methods

All partial and radical nephrectomies between 2019 and 2021 from the National Surgical Quality Improvement Program database were evaluated. Thirty-day perioperative outcomes were compared between groups where MBP was performed vs. not, in both the MIS and open surgery (OS) cohorts. A propensity score matching technique was utilized within MIS cases to control for covariates. The chi-square and t tests were used to determine significance.

Results

A total of 11,869 cases met the inclusion criteria and were included in the analysis. Of these, 8,204 (69.1%; comprising 65.3% robotic and 34.7% laparoscopic) underwent MIS, while 3,655 (30.9%) underwent OS. The rate of MBP was higher in the MIS group (16.0% vs. 10.0%, p < 0.001). Within the MIS group, MBP was associated with reduced rates of postoperative ileus (0.9% vs. 1.9%, p = 0.02), while other complications were comparable. Propensity score matching showed no association between MBP and postoperative ileus. However, a lower rate of 30-day readmission in the MBP group became statistically significant (4.4% vs. 6.4%, p = 0.01). Conversely, patients in the MBP group also demonstrated higher rates of pneumonia (1.29% vs. 0.46%, p = 0.002) and pulmonary embolism (0.6% vs. 0%, p < 0.001) after matching.

Conclusion

MBP practice prior to nephrectomy is infrequent in both OS and MIS cases, with minor differences in perioperative outcomes for patients undergoing MIS. Routine MBP should continue to be excluded from the standard of care for nephrectomy in the MIS era.

Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery

BACKGROUND

The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include anastomotic leakages and surgical site infections (SSI)s, which can lead to prolonged recovery with impaired long-term health.  Compared with other abdominal procedures, colorectal resections have an increased risk of adverse events due to the physiological bacterial colonisation of the large bowel. Preoperative bowel preparation is used to remove faeces from the bowel lumen and reduce bacterial colonisation. This bowel preparation can be performed mechanically and/or with oral antibiotics. While mechanical bowel preparation alone is not beneficial, the benefits and harms of combined mechanical and oral antibiotic bowel preparation is still unclear.

OBJECTIVES

To assess the evidence for the use of combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL and trial registries on 15 December 2021. In addition, we searched reference lists and contacted colorectal surgery organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult participants undergoing elective colorectal surgery comparing combined mechanical and oral antibiotic bowel preparation (MBP+oAB) with either MBP alone, oAB alone, or no bowel preparation (nBP). We excluded studies in which no perioperative intravenous antibiotic prophylaxis was given.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. Pooled results were reported as mean difference (MD) or risk ratio (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel method. The certainty of the evidence was assessed with GRADE.

MAIN RESULTS

We included 21 RCTs analysing 5264 participants who underwent elective colorectal surgery. None of the included studies had a high risk of bias, but two-thirds of the included studies raised some concerns. This was mainly due to the lack of a predefined analysis plan or missing information about the randomisation process. Most included studies investigated both colon and rectal resections due to malignant and benign surgical indications. For MBP as well as oAB, the included studies used different regimens in terms of agent(s), dosage and timing.  Data for all predefined outcomes could be extracted from the included studies. However, only four studies reported on side effects of bowel preparation, and none recorded the occurrence of adverse effects such as dehydration, electrolyte imbalances or the need to discontinue the intervention due to side effects. Seventeen trials compared MBP+oAB with sole MBP. The incidence of SSI could be reduced through MBP+oAB by 44% (RR 0.56, 95% CI 0.42 to 0.74; 3917 participants from 16 studies; moderate-certainty evidence) and the risk of anastomotic leakage could be reduced by 40% (RR 0.60, 95% CI 0.36 to 0.99; 2356 participants from 10 studies; moderate-certainty evidence). No difference between the two comparison groups was found with regard to mortality (RR 0.87, 95% CI 0.27 to 2.82; 639 participants from 3 studies; moderate-certainty evidence), the incidence of postoperative ileus (RR 0.89, 95% CI 0.59 to 1.32; 2013 participants from 6 studies, low-certainty of evidence) and length of hospital stay (MD -0.19, 95% CI -1.81 to 1.44; 621 participants from 3 studies; moderate-certainty evidence). Three trials compared MBP+oAB with sole oAB. No difference was demonstrated between the two treatment alternatives in terms of SSI (RR 0.87, 95% CI 0.34 to 2.21; 960 participants from 3 studies; very low-certainty evidence), anastomotic leakage (RR 0.84, 95% CI 0.21 to 3.45; 960 participants from 3 studies; low-certainty evidence), mortality (RR 1.02, 95% CI 0.30 to 3.50; 709 participants from 2 studies; low-certainty evidence), incidence of postoperative ileus (RR 1.25, 95% CI 0.68 to 2.33; 709 participants from 2 studies; low-certainty evidence) or length of hospital stay (MD 0.1 respectively 0.2, 95% CI -0.68 to 1.08; data from 2 studies; moderate-certainty evidence). One trial (396 participants) compared MBP+oAB versus nBP. The evidence is uncertain about the effect of MBP+oAB on the incidence of SSI as well as mortality (RR 0.63, 95% CI 0.33 to 1.23 respectively RR 0.20, 95% CI 0.01 to 4.22; low-certainty evidence), while no effect on the risk of anastomotic leakages (RR 0.89, 95% CI 0.33 to 2.42; low-certainty evidence), the incidence of postoperative ileus (RR 1.18, 95% CI 0.77 to 1.81; low-certainty evidence) or the length of hospital stay (MD 0.1, 95% CI -0.8 to 1; low-certainty evidence) could be demonstrated.

AUTHORS' CONCLUSIONS

Based on moderate-certainty evidence, our results suggest that MBP+oAB is probably more effective than MBP alone in preventing postoperative complications. In particular, with respect to our primary outcomes, SSI and anastomotic leakage, a lower incidence was demonstrated using MBP+oAB. Whether oAB alone is actually equivalent to MBP+oAB, or leads to a reduction or increase in the risk of postoperative complications, cannot be clarified in light of the low- to very low-certainty evidence. Similarly, it remains unclear whether omitting preoperative bowel preparation leads to an increase in the risk of postoperative complications due to limited evidence. Additional RCTs, particularly on the comparisons of MBP+oAB versus oAB alone or nBP, are needed to assess the impact of oAB alone or nBP compared with MBP+oAB on postoperative complications and to improve confidence in the estimated effect. In addition, RCTs focusing on subgroups (e.g. in relation to type and location of colon resections) or reporting side effects of the intervention are needed to determine the most effective approach of preoperative bowel preparation.

Association of bowel preparation with surgical-site infection in gynecologic oncology surgery: Post-hoc analysis of a randomized controlled trial

OBJECTIVE

To determine the relationship between bowel preparation and surgical-site infection (SSI) incidence following colorectal resection during gynecologic oncology surgery.

METHODS

This post-hoc analysis used data from a randomized controlled trial of patients enrolled from 03/01/2016-08/20/2019 with presumed gynecologic malignancy investigating negative-pressure wound therapy among those requiring laparotomy. Patients were treated preoperatively without bowel preparation, oral antibiotic bowel preparation (OABP), or OABP plus mechanical bowel preparation (MBP) per surgeon preference. Univariate and multivariable analyses with stepwise model selection for SSI were performed for confirmed gynecologic malignancies requiring colorectal resection.

RESULTS

Of 161 cases, 15 (9%) had no preparation, 39 (24%) OABP only, and 107 (66%) OABP+MBP. The overall SSI rate was 19% (n = 31)-53% (n = 8/15) in the no preparation, 21% (n = 8/39) in the OABP alone, and 14% (n = 15/107) in the OABP+MBP groups (P = 0.003). The difference between OABP and OABP+MBP was non-significant (P = 0.44). The median length of stay was 9 (range, 6-12), 6 (range, 5-8), and 7 days (range, 6-10), respectively (P = 0.045). The overall complication rate (34%; n = 54) did not significantly vary by preparation type (P = 0.23). On univariate logistic regression analysis, OABP (OR, 0.23; 95% CI: 0.06-0.80) and OABP+MBP (OR, 0.14; 95% CI: 0.04-0.45) were associated with decreased SSI risk compared to no preparation (P = 0.004). On multivariate analysis, both methods of preparation retained a significant impact on SSI rates (P = 0.004).

CONCLUSION

Bowel preparation is associated with reduced SSI incidence and is beneficial for patients undergoing gynecologic oncology surgery with anticipated colorectal resection. Further investigation is needed to determine whether OABP alone is sufficient.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database

BACKGROUND

Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies.

STUDY DESIGN

We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012-2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL.

RESULTS

In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70-0.96], ABP [0.69, 95%CI: 0.52-0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51-0.86], ABP [0.56, 95%CI: 0.34-0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50-0.67; AL:OR = 0.46, 95%CI:0.36-0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13-0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37-0.69], AL [OR = 0.47, 95%CI: 0.25-0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47-0.72, AL [OR = 0.49, 95%CI: 0.35-0.68]).

CONCLUSIONS

MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

Oral Antibiotic Prophylaxis Lowers Surgical Site Infection in Elective Colorectal Surgery: Results of a Pragmatic Cohort Study in Catalonia

BACKGROUND

The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia.

METHODS

Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established.

RESULTS

Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses.

CONCLUSIONS

oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.

Preoperative mechanical bowel preparation with oral antibiotics reduces surgical site infection after elective colorectal surgery for malignancies: results of a propensity matching analysis

BACKGROUND

Surgical site infections (SSIs) are a major postoperative complication after colorectal surgery. Current study aims to evaluate prophylactic function of oral antibiotic (OA) intake in combination with mechanical bowel preparation (MBP) relative to MBP alone with respect to postoperative SSI incidence.

METHODS

A retrospective analysis of eligible patients was conducted using the databases of the Gastrointestinal Surgery Centre, Third Affiliated Hospital of Sun Yat-sen University from 2011 to 2017. Data pertaining to postoperative hospital stay length, expenses, SSI incidence, anastomotic fistula incidence, and rates of other complications were extracted and compared. A propensity analysis was conducted to minimize bias associated with demographic characteristics. Subgroup analyses were performed to further explore protective effects of OA in different surgical sites.

RESULTS

The combination of OAs and MBP was related to a significant decrease in the incidence of overall SSIs, superficial SSI, and hospitalization expenses. The MBP + OA modality was particularly beneficial for patients undergoing left-side colon or rectum resections, with clear prophylactic efficacy. The combination of MPB + OA did not exhibit significant prophylactic efficacy in patients undergoing right hemi-colon resection. Age, surgical duration, and application of OA were all independent factors associated with the occurrence of SSIs.

CONCLUSION

These results suggest that the combination of OA + MBP should be recommended for patients undergoing elective colorectal surgery, particularly for operations on the left side of the colon or rectum.

TRIAL REGISTRATION

NCT04258098. Retrospectively registered.

[Oral antibiotic prophylaxis for bowel decontamination before elective colorectal surgery : Current body of evidence and recommendations]

Despite a growing body of evidence from randomized controlled studies, register data and meta-analyses, there is an ongoing controversy about decontamination of the digestive tract before elective colorectal surgery. Currently, mechanical bowel preparation alone can no longer be recommended as there is a lack of evidence for an advantage in terms of risk reduction for infectious complications, anastomotic leakage, morbidity and mortality. In contrast, the administration of oral antibiotics in addition to the obligatory intravenous single shot antibiotic prophylaxis has shown an additive reduction of the risk of up to 50% for the occurrence of postoperative infectious complications; however, due to a lack of data it is unclear if mechanical bowel preparation could even improve the positive effects of combined intravenous and oral antibiotics. Therefore, further studies are necessary. At the current time the occurrence of anastomotic leakage cannot be prevented, independent of whether preoperative bowel decontamination is performed.

Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members

Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.

The Role of Bowel Preparation in Open, Minimally Invasive, and Converted-to-Open Colectomy

BACKGROUND

Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies.

METHODS

We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157).

RESULTS

Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period.

CONCLUSIONS

MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.

Comparative Effectiveness and Risks of Bowel Preparation Before Elective Colorectal Surgery

OBJECTIVE

The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery.

BACKGROUND

SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial.

METHODS

We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation.

RESULTS

26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation.

CONCLUSIONS

The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.

Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review

The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.

Current practice patterns of preoperative bowel preparation in colorectal surgery: a nation-wide survey by the Chinese Society of Colorectal Cancer

Background

The optimal preoperative bowel preparation for colorectal surgery remains controversial. However, recent studies have established that bowel preparation varies significantly among countries and even surgeons at the same institution. This survey aimed to obtain information on the current practice patterns of bowel preparation for colorectal surgery in China.

Methods

A paper-based survey was circulated to the members of the Chinese Society of Colorectal Cancer (CSCC). The survey responses were collected and analyzed. Statistical analysis was performed for all the categorical variables according to the responses to individual questions.

Results

Three hundred forty-one members completed the questionnaire. Regarding surgical practice, 203 (59.5%) performed > 50% of the colorectal operations laparoscopically or robotically; the use of mechanical bowel preparation (MBP) alone was significantly higher (63.5 vs 31.9%; P < 0.001). The respondents who performed > 200 colonic or rectal resections provided significantly more MBP alone (79.6 vs 39.1%, P < 0.001; 76.6 vs 43.2%, P < 0.001; respectively). Among hospitals with fewer than 500 beds, 52.4% of the respondents used MBP + oral antibiotics preparation (OAP) + enema, a significantly higher percentage than the respondents of hospitals with more than 500 beds (P < 0.001). Nearly 40% of the respondents prescribed OAP in regimens; meanwhile, 74.8% prescribed preoperative intravenous antibiotics.

Conclusions

The study demonstrates considerable variation among members from the CSCC. These findings should be considered when developing multicenter trials and to provide more definitive answers.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1440-4) contains supplementary material, which is available to authorized users.

Effectiveness of mechanical bowel preparation versus no preparation on anastomotic leakage in colorectal surgery: a systematic review and meta-analysis

It has been a standard practice to perform mechanical bowel preparation (MBP) prior to colorectal surgery to reduce the risk of colorectal anastomotic leakages (CAL). The latest Cochrane systematic review suggests there is no benefit for MBP in terms of decreasing CAL, but new studies have been published. The aim of this systematic review and meta-analysis is to update current evidence for the effectiveness of preoperative MBP on CAL in patients undergoing colorectal surgery. Consequently, PubMed, MEDLINE, Embase, CENTRAL and CINAHL were searched from 2010 to March 2017 for randomised controlled trials (RCT) that compared the effects of MBP in colorectal surgery on anastomotic leakages. The outcome CAL was expressed in odds ratios and analysed with a fixed-effects analysis in a meta-analysis. Quality assessment was performed by the cochrane risk of bias tool and grades of recommendation, assessment, development and evaluation (GRADE) methodology. Eight studies (1065 patients) were included. The pooled odds ratio showed no significant difference of MBP in colorectal surgery on CAL (odds ratio (OR) = 1.15, 95% CI = 0.68-1.94). According to GRADE methodology, the quality of the evidence was low. To conclude, MBP for colorectal surgery does not lower the risk of CAL. These results should, however, be interpreted with caution due to the small sample sizes and poor quality. Moreover, the usefulness of MBP in rectal surgery is not clear due to the lack of stratification in many studies. Future research should focus on high-quality, adequately powered RCTs in elective rectal surgery to determine the possible effects of MBP.

Prognostic impact of anastomotic leakage after elective colon resection for cancer - A propensity score matched analysis of 628 patients

BACKGROUND

There is limited information regarding the impact of anastomotic leakage on oncologic outcome in exclusively colon cancer patients.

METHODS

The colorectal database of the Department of Surgery of the University of Heidelberg was used to assess the impact of anastomotic leakage on oncologic outcome in patients undergoing curative resection for Stage I-III colon cancer. Risk-adjusted Cox regression analysis and propensity score methods were used to assess overall, disease-free, and relative survival.

RESULTS

628 patients of which 26 (4.1%) experienced anastomotic leakage were analysed. Anastomotic leakage was associated with significantly worse overall, disease-free and relative survival in univariate and multivariate analysis. The analysis after exact propensity score matching confirmed the negative impact of anastomotic leakage on overall (HR 2.62, 95% CI 1.33-5.18, p = .011), disease-free (HR 2.28, 95% CI 1.16-4.47, p = .027) and relative survival (HR 3.70, 95% CI 1.82-7.52, p < .001). 5-year overall survival was 51.6% (95% CI 34.5-77.2%) for patients with anastomotic leakage compared to 77.7% (95% CI 73.0-82.8%) for patients without anastomotic leakage.

CONCLUSIONS

All conceivable efforts should be made to avoid anastomotic leakage after colon resection for cancer not only to evade short-term consequences but also to allow for adequate long-term outcome.

A European survey of bowel preparation in colorectal surgery

AIM

Meta-analysis has shown that mechanical bowel preparation (MBP) does not improve outcomes in colonic surgery; however, there is uncertainty regarding MBP use in laparoscopic and rectal surgery and the addition of oral antibiotic regimens. The aim of this study was to assess current use of bowel preparation among European surgeons.

METHOD

An online survey was circulated to members of the European Society of Coloproctology. Chi-squared analysis was used to compare subgroups.

RESULTS

A total of 426 surgeons responded to the survey. MBP is routinely prescribed by 29.6% of respondents prior to colonic surgery and in 77.0% prior to rectal surgery. In the cohort performing > 30% of colorectal operations laparoscopically (n = 294), routine use of MBP in colonic surgery was significantly lower (19.7% vs 51.5%, P < 0.01). Less than 10% prescribe oral antibiotic bowel preparation whereas 96% prescribe perioperative intravenous antibiotics.

CONCLUSION

Among the majority of respondents to this survey, MBP is used routinely for rectal operations. For colonic surgery, laparoscopic surgeons have a significantly lower use of MBP. Use of oral antibiotic bowel preparation remains uncommon.

Oral and Parenteral Versus Parenteral Antibiotic Prophylaxis in Elective Laparoscopic Colorectal Surgery (JMTO PREV 07-01): A Phase 3, Multicenter, Open-label, Randomized Trial

OBJECTIVE

To confirm the efficacy of oral and parenteral antibiotic prophylaxis (ABX) in the elective laparoscopic colorectal surgery.

BACKGROUND

There is no evidence for the establishment of an optimal ABX regimen for laparoscopic colorectal surgery, which has become an important choice for the colorectal cancer patients.

METHODS

The colorectal cancer patients scheduled to undergo laparoscopic surgery were eligible for this multicenter, open-label, randomized trial. They were randomized to receive either oral and parenteral prophylaxis (1 g cefmetazole before and every 3 h during the surgery plus 1 g oral kanamycin and 750 mg metronidazole twice on the day before the surgery; Oral-IV group) or parenteral prophylaxis alone (the same IV regimen; IV group). The primary endpoint was the incidence of surgical site infections (SSIs). Secondary endpoints were the incidence rates of Clostridium difficile colitis, other infections, and postoperative noninfectious complications, as well as the frequency of isolating specific organisms.

RESULTS

Between November 2007 and December 2012, 579 patients (289 in the Oral-IV group and 290 in IV group) were evaluated for this study. The incidence of SSIs was 7.26% (21/289) in the Oral-IV group and 12.8% (37/290) in the IV group with an odds ratio of 0.536 (95% CI, 0.305-0.940; P = 0.028). The 2 groups had similar incidence rates of C difficile colitis (1/289 vs 3/290), other infections (6/289 vs 5/290), and postoperative noninfectious complications (11/289 vs 12/290).

CONCLUSIONS

Our oral-parenteral ABX regimen significantly reduced the risk of SSIs following elective laparoscopic colorectal surgery.

The role of oral antibiotics prophylaxis in prevention of surgical site infection in colorectal surgery

BACKGROUND

Surgical site infection (SSI) continues to be a challenge in colorectal surgery. Over the years, various modalities have been used in an attempt to reduce SSI risk in elective colorectal surgery, which include mechanical bowel preparation before surgery, oral antibiotics and intravenous antibiotic prophylaxis at induction of surgery. Even though IV antibiotics have become standard practice, there has been a debate on the exact role of oral antibiotics.

AIM

The primary aim was to identify the role of oral antibiotics in reduction of SSI in elective colorectal surgery. The secondary aim was to explore any potential benefit in the use of mechanical bowel preparation (MBP) in relation to SSI in elective colorectal surgery.

METHODS

Medline, Embase and the Cochrane Library were searched. Any randomised controlled trials (RCTs) or cohort studies after 1980, which investigated the effectiveness of oral antibiotic prophylaxis and/or MBP in preventing SSIs in elective colorectal surgery were included.

RESULTS

Twenty-three RCTs and eight cohorts were included. The results indicate a statistically significant advantage in preventing SSIs with the combined usage of oral and systemic antibiotic prophylaxis. Furthermore, our analysis of the cohort studies shows no benefits in the use of MBP in prevention of SSIs.

CONCLUSIONS

The addition of oral antibiotics to systemic antibiotics could potentially reduce the risk of SSIs in elective colorectal surgery. Additionally, MBP does not seem to provide a clear benefit with regard to SSI prevention.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial

OBJECTIVE

To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery.

METHODS

We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms.

RESULTS

One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0-4.0) days.

CONCLUSIONS

Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function.

LEVEL OF EVIDENCE

I.

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Open Colectomies

BACKGROUND

Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections.

OBJECTIVE

Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies.

DESIGN

This was a retrospective study using the Premier Perspective database.

SETTINGS

Included were patient hospitalizations nationwide from January 2006 to December 2013.

PATIENTS

A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study.

MAIN OUTCOME MEASURES

Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery).

RESULTS

Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63-0.82)), ertapenem (OR = 0.65 (95% CI, 0.58-0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49-0.64)), and "other" (OR = 0.81 (95% CI, 0.73-0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings.

LIMITATIONS

The study was limited by its lack of detailed clinical information in the billing data set used.

CONCLUSIONS

In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.

Antimicrobial Bowel Preparation for Elective Colon Surgery

BACKGROUND

Mechanical bowel preparation continues to be a controversial subject for the pre-operative management of patients undergoing elective colon resection.

METHODS

The English literature on bowel preparation was searched to identify pertinent publications.

RESULTS

The published literature over the past 80 y confirms that mechanical bowel preparation alone does not reduce surgical site infections. However, the use of appropriate oral antibiotics following mechanical bowel preparation with pre-operative systemic antibiotics reduces rates of surgical site infections and anastomotic leaks when compared with systemic antibiotics alone.

CONCLUSIONS

Mechanical bowel preparation with pre-operative oral antibiotics and pre-operative systemic antibiotics are the standard of care for elective colon surgery. Refinement in methods of bowel preparation needs additional clinical investigations to further enhance outcomes.

Comparing Mechanical Bowel Preparation With Both Oral and Systemic Antibiotics Versus Mechanical Bowel Preparation and Systemic Antibiotics Alone for the Prevention of Surgical Site Infection After Elective Colorectal Surgery: A Meta-Analysis of Randomized Controlled Clinical Trials

BACKGROUND

The discussion on the role of mechanical bowel preparation and oral antibiotics in elective colorectal surgery is still ongoing.

OBJECTIVE

This meta-analysis aimed to determine whether oral systemic antibiotics with mechanical bowel preparation are superior to systemic antibiotics and mechanical bowel preparation for prophylaxis of bacterial infection during elective colorectal operation.

DATA SOURCES

Embase, PubMed, and the Cochrane Library were searched using the terms oral, antibiotics/antimicrobial, colorectal/rectal/colon/rectum, and surgery/operation.

STUDY SELECTION

All of the available randomized controlled trials that compared the efficacy of combined oral and systemic antibiotics and mechanical bowel preparation with systemic antibiotics alone and mechanical bowel preparation in colorectal surgery and defined surgical site infection based on Centers for Disease Control and Prevention criteria were included.

INTERVENTION

All of the statistical analyses were performed using Review Manager 5.2 software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random-effects model was used.

MAIN OUTCOME MEASURES

We focused on incidence of surgical site infection among the groups.

RESULTS

Seven randomized controlled trials that consisted of 1769 cases were eligible for analysis. We found that both total surgical site infection and incisional surgical site infection were significantly reduced in patients who received oral systemic antibiotics and mechanical bowel preparation compared with patients who received systemic antibiotics alone and mechanical bowel preparation (total: 7.2% vs 16.0%, p < 0.00001; incisional: 4.6% vs 12.1%, p < 0.00001). However, no significant difference was detected in the rate of organ/space surgical site infection (4.0% vs 4.8%; p = 0.56) after elective colorectal surgery.

LIMITATIONS

The meta-analysis was limited by the risk of bias because a majority of the studies did not use the blinding method.

CONCLUSIONS

Oral systemic antibiotics and mechanical bowel preparation significantly lowered the incidence of surgical site infection after elective colorectal surgery compared with systemic antibiotics alone and mechanical bowel preparation.

Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery

Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.

Mechanical bowel preparation versus no preparation before colorectal surgery: A randomized prospective trial in a tertiary care institute

Background:

In the first half of 20^th century; mortality from colorectal surgery often exceeded 20%, mainly due to sepsis. Modern surgical techniques and improved perioperative care have significantly lowered the mortality rate. Mechanical bowel preparation (MBP) is aimed at cleansing the large bowel of fecal content thus reducing morbidity and mortality related to colorectal surgery. We carried out a study aimed to investigate the outcomes of colorectal surgery with and without MBPs, to avoid unpleasant side-effects of MBP and also to design a protocol for preparation of a patient for colorectal surgery.

Materials and Methods:

This was a prospective study over a period of March 2008-May 2010 carried out at Department of General Surgery of our institution. A total of 63 patients were included in this study; among those 32 patients were operated with MBPs and 31 without it; admitted in in-patient department undergoing resection of left colon and rectum for benign and malignant conditions in both emergency and elective conditions.

Results:

Anastomotic leakage, intra-abdominal collections was detected clinically and radiologically in 2 and 4 patients in each group respectively. P > 0.5 in both situations, indicating statistically no difference between results of two groups. Wound infections were detected in 12 (37.5%) patients with MBP group and 11 (35.48%) patients without MBP.

Conclusion:

The present results suggest that the omission of MBP does not impair healing of colonic anastomosis; neither increases the risk of leakage.

Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial

BACKGROUND

We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial.

METHODS

Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined.

RESULTS

The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups.

CONCLUSION

We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections.

The prevention of surgical site infection in elective colon surgery

Infections at the surgical site continue to occur in as many as 20% of elective colon resection cases. Methods to reduce these infections are inconsistently applied. Surgical site infection (SSI) is the result of multiple interactive variables including the inoculum of bacteria that contaminate the site, the virulence of the contaminating microbes, and the local environment at the surgical site. These variables that promote infection are potentially offset by the effectiveness of the host defense. Reduction in the inoculum of bacteria is achieved by appropriate surgical site preparation, systemic preventive antibiotics, and use of mechanical bowel preparation in conjunction with the oral antibiotic bowel preparation. Intraoperative reduction of hematoma, necrotic tissue, foreign bodies, and tissue dead space will reduce infections. Enhancement of the host may be achieved by perioperative supplemental oxygenation, maintenance of normothermia, and glycemic control. These methods require additional research to identify optimum application. Uniform application of currently understood methods and continued research into new methods to reduce microbial contamination and enhancement of host responsiveness can lead to better outcomes.

Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery

BACKGROUND

Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery.

STUDY DESIGN

This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission.

RESULTS

Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38).

CONCLUSIONS

Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.

Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections

BACKGROUND

Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation.

OBJECTIVE

The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort.

DESIGN

This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery.

SETTINGS

This study was conducted in 112 Veterans Affairs hospitals.

PATIENTS

Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009.

MAIN OUTCOME MEASURE

The primary outcome measured was the incidence of surgical site infection.

RESULTS

Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21-0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34-0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement Project-1) had a modest protective effect, with no effect observed for other Surgical Care Improvement Project measures. Hospitals with higher rates of oral antibiotics use had lower surgical site infection rates (R = 0.274, p < 0.0001).

LIMITATIONS

Determination of the use of oral antibiotics and mechanical bowel preparation is based on retrospective prescription data, and timing of actual administration cannot be determined.

CONCLUSIONS

Use and type of preoperative bowel preparation varied widely. These results strongly suggest that preoperative oral antibiotics should be administered for elective colorectal resections. The role of oral antibiotics independent of mechanical bowel preparation should be examined in a prospective randomized trial.

Usefulness of sennoside as an agent for mechanical bowel preparation prior to elective colon cancer surgery

OBJECTIVE

We retrospectively evaluated the usefulness of sennoside as an agent for mechanical bowel preparation prior to elective colon cancer surgery.

METHODS

A total of 86 patients were given 12 mg of sennoside on the evening prior to resective surgery for colon cancer, followed by intravenous antimicrobial prophylaxis used on the day of surgery or until postoperative day 2.

RESULTS

The incidence of surgical site infection in the study group was 4.7%, which was comparable to that in the historical control patients (3.5%, p>0.99), who had received polyethylene glycol for mechanical bowel preparation prior to colon surgery. On multivariate logistic regression analysis, only body mass index (p=0.04) was an independent significant factor affecting the surgical site infection. The intraoperative spillage was not influenced by the presence of stenosis, although the amount of fecal matter was higher in the upstream colon segment (p<0.01) and downstream segment (p=0.07) in patients with a stenotic lesion occupying more than two-thirds of the lumen (n=29) than in those without such severe stenosis (n=57).

CONCLUSION

Sennoside seems to be an acceptable agent for mechanical bowel preparation even in patients with stenosis.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Antimicrobial prophylaxis in surgery: an international survey

BACKGROUND

We investigated current clinical practice of antimicrobial prophylaxis (AMP) in surgery.

METHODS

Survey administration of AMP to patients without co-morbidity or allergy undergoing surgery, among surgeons indexed as corresponding authors for articles published in general surgery, orthopedics, gynecology, and cardiac surgery journals.

RESULTS

A total of 1,068 surgeons answered (response rate 68%). Of these, 26.1% do not begin infusion of the first antimicrobial dose within 1 h of incision, as suggested by guidelines, and 27.2% continue administering AMP for two or more days after surgery, including 7.6% who continue for four to seven days, in contradiction to the guidelines. There were significant differences between Europe and North America in the selection of AMP regimens. Furthermore, 19% of Europeans order infusion of the first antimicrobial dose during the incision compared with 3.9% of North Americans; 74.2% of Europeans discontinue AMP within 24 h after surgery compared with 86% of North Americans. Finally, 31% of general surgeons in North America administer supplementary oral prophylaxis for colectomy compared with only 5% of European surgeons.

CONCLUSIONS

The AMP strategies in day-to-day self-reported practice differ significantly. Uniform, evidence-based practice is warranted, especially in this era of increasing antimicrobial resistance.

Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial

Background

Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. The aim of the study was to assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation.

Methods

Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications.

Results

Two hundred forty four patients were included in the study, 120 in group A and 124 in group B. Demographic characteristics, type of surgical procedure and type of anastomosis did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups but the overall infectious complications rate was 20.0% in group A and 11.3% in group B (p .05). Wound infection (p = 0.18), anastomotic leak (p = 0.52), and intra-abdominal abscess (p = 0.36) occurred in 9.2%, 5.8%, and 5.0% versus 4.8%, 4.0%, and 2.4%, respectively. No mechanical bowel preparation seems to be safe also in rectal surgery.

Conclusions

These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

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.

Antimicrobial prophylaxis in colorectal surgery: focus on ertapenem

Despite improvement in infection control measures and surgical practice, surgical site infections (SSIs) remain a major cause of morbidity and mortality. In colorectal surgery, perioperative administration of a suitable antimicrobial regimen that covers both anaerobic and aerobic bacteria is universally accepted. In a prospective, double-blind, randomized study ertapenem was recently found to be more effective than cefotetan, a parenteral cephalosporin so broadly used as to be considered as gold standard in the prevention of SSIs following colorectal surgery. In this adequate and well controlled study, the superiority of ertapenem over cefotetan was clearly demonstrated from the clinical and bacteriological points of view. However, data that directly compares ertapenem with other antimicrobial regimen effective in preventing SSIs following colorectal surgery are lacking; furthermore, the possible risk of promotion of carbapenem resistance associated with widespread use of ertapenem prophylaxis as well as the ertapenem effects on the intestinal gut flora are of concern. Further comparative studies of ertapenem versus other widely used prophylactic regimens for colorectal surgery in patients submitted to mechanical bowel preparation versus no preparation as well as further research on adverse events of antibiotic prophylaxis, including emergence of resistance and Clostridium difficile infection, seem warranted.

How to choose the best preparation for colonoscopy

The success and accuracy of colonoscopy is largely dependent on appropriate cleansing of the colon. The ideal bowel preparation should be safe, well-tolerated and effective. Although colonoscopy preparations are vastly better than the earliest barium enemas used in X-ray regimens, none of the currently available formulations sufficiently fulfills the above criteria. Currently used techniques of colon cleansing include dietary and cathartic methods, gut lavage and the administration of phosphates. All of these methods are efficacious, particularly when administered in a split dose (one the evening before and one just before the planned colonoscopy). Gut lavage methods are the safest method; however, dietary and cathartic methods are also reasonably safe. Low-dose phosphate preparations are well tolerated, but safety concerns have led to the withdrawal of some phosphate products from the US market. A new oral sulfate product that achieves a desirable balance of safety, tolerability in patients and efficacy will shortly be introduced. Physicians should be aware of the range of colonoscopy preparations available and their limitations, so that the best preparation can be chosen for an individual patient.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Comparison of three solutions for total gut irrigation in pediatric patients

Total gut irrigation (TGI) is a safe method of bowel preparation in children. Many solutions are used but none is ideal. This study has been done to compare household common salt solution prepared by dissolving 10 g of pure NaCl salt (Active Reagent Quality) in 1 l of tap water, polyethylene glycol with electrolytes (PEG) and ringers lactate for TGI in children. We prospectively evaluated the three solutions in terms of efficacy, safety, rapidity, tolerability and cost effectiveness in patients undergoing a variety of colorectal procedures. Patients (126) were randomly assigned into one of the three groups; Group I, household common salt solution, 40; Group II, Peglec, 55; Group III, Ringer lactate, 31. TGI with PEG is the most rapid method of bowel preparation but is least tolerable. Household common salt solution is inexpensive and most tolerable of the three preparations. All three are similar in safety and effectiveness in bowel preparation. Household common salt solution is effective, safe, cost effective and the most tolerable method of bowel preparation.

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.