The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis

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.

Best practices in bowel preparation for colorectal surgery: a 2020 overview

INTRODUCTION

Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted.

AREAS COVERED

This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed.

EXPERT OPINION

The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.

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.

Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy

This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.

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.

Does Preoperative Bowel Preparation Reduce Surgical Site Infections During Elective Ventral Hernia Repair?

BACKGROUND

To date, little is known about the benefits of preoperative bowel preparation in patients undergoing elective ventral hernia repair (VHR). The purpose of this study was to determine the effect of preoperative bowel preparation on 30-day wound events in patients undergoing elective VHR using the Americas Hernia Society Quality Collaborative (AHSQC).

STUDY DESIGN

All patients undergoing elective VHR from January 2013 through January 2016 were identified within the AHSQC. Patients undergoing emergency VHR and those with a CDC wound class IV were excluded from our analysis. Patients were divided into 2 groups: Clean (CDC wound class I) and Contaminated (CDC wound classes II and III). The association of preoperative bowel preparation with 30-day wound events was investigated using logistic regression modeling.

RESULTS

A total of 3,709 patients met inclusion criteria; 3,101 (83.6%) had CDC wound class I, and 608 (16.4%) had CDC wound classes II or III. Within the Clean group, patients who underwent preoperative bowel preparation were significantly more likely to experience a surgical site infection (SSI), surgical site occurrence (SSO), and surgical site occurrence requiring procedural intervention (SSOPI). Within the Contaminated group, patients who underwent preoperative bowel preparation were significantly more likely to experience an SSOPI.

CONCLUSIONS

The use of preoperative bowel preparation in patients undergoing elective VHR does not reduce the risk of 30-day wound events.

The impact of bowel preparation on the severity of anastomotic leak in colon cancer patients

BACKGROUND AND OBJECTIVES

The routine use of preoperative bowel preparation (BP) is heavily debated in the colorectal surgery literature. To date, no study has investigated the effect preoperative BP has on patients with an established anastomotic leak. We therefore seek to compare the severity of patient morbidity and mortality in patients with a known anastomotic leak based on type of preoperative BP using the Targeted Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP).

METHODS

All elective colon cancer operations performed with primary anastomosis were identified within the targeted colectomy database from 2012 to 2013. Patients who experienced a postoperative anastomotic leak were identified and stratified based on preoperative BP. Variables that had an association with mechanical BP at P < 0.10 were included in a multivariate logistic regression model to determine if BP was independently associated with postoperative morbidity and mortality.

RESULTS

A total of 6,297 patients underwent elective colon resection with primary anastomosis for colon cancer. Two hundred and nineteen (3.5%) patients experienced an anastomotic leak. Thirty-day wound morbidity and mortality was not worse in patients who underwent preoperative BP.

CONCLUSIONS

BP is not associated with worse patients outcomes in those patients with an established anastomotic leak following elective colon research with primary anastomosis. J. Surg. Oncol. 2016;114:810-813. © 2016 2016 Wiley Periodicals, Inc.

Operator-related risk factors of anastomotic leaks after colorectal surgery: an up-to-date

Digestive fistulas are a major complication after digestive surgery. Anastomotic leakage increases the hospitalization time, the prognosis and survival rate after colorectal surgical interventions.

The factors involved are either systemic (determined by the patients’ co-morbidities), or local (vicious surgical technique or the injuries produced by the disease that requires the anastomosis). Although there are many studies regarding the risk factors of anastomotic leaks, there is no consensus for the role played by each one of them in the healing process of digestive sutures. Most authors sustain that the importance of systemic factors is secondary, the main role being played by the surgeon and the local conditions of the anastomosis.

Knowledge of the risk factors can lead to new methods of reducing the incidence of anastomotic leaks by improving vascularization, limiting the tension and the duration of surgery, and by new surgical techniques used for digestive sutures.

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.

Oral Mechanical Bowel Preparation for Colorectal Surgery: Systematic Review and Meta-Analysis

BACKGROUND

Oral mechanical bowel preparation is often used before elective colorectal surgery to reduce postoperative complications.

OBJECTIVE

The purpose of this study was to synthesize the evidence on the comparative effectiveness and safety of oral mechanical bowel preparation versus no preparation or enema.

DATA SOURCES

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL without any language restrictions (last search on September 6, 2013). We also searched the US Food and Drug Administration Web site and ClinicalTrials.gov and supplemented our searches by asking technical experts and perusing reference lists.

STUDY SELECTION

We included English-language, full-text reports of randomized clinical trials and nonrandomized comparative studies of patients undergoing elective colon or rectal surgery. For adverse events we also included single-group cohort studies of at least 200 participants.

INTERVENTIONS

Interventions included oral mechanical bowel preparation, oral mechanical bowel preparation plus enema, enema only, and no oral mechanical bowel preparation or enema.

MAIN OUTCOME MEASURES

Anastomotic leakage, all-cause mortality, wound infection, peritonitis/intra-abdominal abscess, reoperation, surgical site infection, quality of life, length of stay, and adverse events were measured. We synthesized results across studies qualitatively and with Bayesian random-effects meta-analyses.

RESULTS

A total of 18 randomized clinical trials, 7 nonrandomized comparative studies, and 6 single-group cohorts were included. In meta-analyses of randomized clinical trials, the credibility intervals of the summary OR included the null value of 1.0 for comparisons of oral mechanical bowel preparation and either no oral preparation or enema for overall mortality, anastomotic leakage, wound infection, peritonitis, surgical site infection, and reoperation. These results were robust to extensive sensitivity analyses. Evidence on adverse events was sparse.

LIMITATIONS

The study was limited by weaknesses in the underlying evidence, such as incomplete reporting of relevant information, exclusion of non-English and relevant unpublished studies, and possible missed indexing of nonrandomized studies.

CONCLUSIONS

Our results could not exclude modest beneficial or harmful effects of oral mechanical bowel preparation compared with no preparation or enema.

Accuracy of national surgery quality improvement program models in predicting postoperative morbidity in patients undergoing colectomy

BACKGROUND

The National Surgery Quality Improvement Program (NSQIP) is the standard for assessment of acuity-adjusted outcomes in surgery. The validity of NSQIP has not been well established in colorectal surgery. Technical and process variables, which NSQIP may not consider, affect morbidity rate.

OBJECTIVE

A retrospective observational study was undertaken to determine the accuracy of NSQIP models in predicting morbidity for patients undergoing laparoscopic or open colectomy.

METHODS

NSQIP participant use files for 2005 to 2008 were obtained. Data were selected using Current Procedural Terminology coding for open or laparoscopic colectomy. NSQIP-generated predicted morbidities were used to create area under the receiver operator curves (AUROCs).

RESULTS

AUROCs demonstrated an accurate predictive model if the value was above 0.8 and indicated a marginal predictor mode if below 0.7. The AUROC for the general NSQIP model was 0.817 (confidence interval [CI] = 0.815-0.819, p < 0.001). AUROC for the combined laparoscopic and open colectomy group was 0.703 (CI = 0.698-0.709, p value < 0.001). AUROCs for the individual laparoscopic and open colectomy groups were 0.627 (CI = 0.615-0.640, p < 0.001) and 0.701 (CI = 0.695-0.707, p < 0.001).

CONCLUSION

This study demonstrates that although NSQIP-generated morbidities used to create AUROCs are accurate for patients in an overall surgical model, predictive models for morbidity are marginal for laparoscopic and open abdominal colectomies. NSQIP risk models tend to emphasize comorbidities rather than intraoperative details or technical aspects of colonic resections.

A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection

OBJECTIVE

To assess the utility of full bowel preparation with oral nonabsorbable antibiotics in preventing infectious complications after elective colectomy.

BACKGROUND

Bowel preparation before elective colectomy remains controversial. We hypothesize that mechanical bowel preparation with nonabsorbable oral antibiotics is associated with a decreased rate of postoperative infectious complications when compared with no bowel preparation.

METHODS

Patient and clinical data were obtained from the Michigan Surgical Quality Collaborative-Colectomy Best Practices Project. Propensity score analysis was used to match elective colectomy cases based on primary exposure variable-full bowel preparation (mechanical bowel preparation with nonabsorbable oral antibiotics) or no bowel preparation (neither mechanical bowel preparation given nor nonabsorbable oral antibiotic given). The primary outcomes for this study were occurrence of surgical site infection and Clostridium difficile colitis.

RESULTS

In total, 2475 cases met the study criteria. Propensity analysis created 957 paired cases (n = 1914) differing only by the type of bowel preparation. Patients receiving full preparation were less likely to have any surgical site infection (5.0% vs 9.7%; P = 0.0001), organ space infection (1.6% vs 3.1%; P = 0.024), and superficial surgical site infection (3.0% vs 6.0%; P = 0.001). Patients receiving full preparation were also less likely to develop postoperative C difficile colitis (0.5% vs 1.8%, P = 0.01).

CONCLUSIONS

In the state of Michigan, full bowel preparation is associated with decreased infectious complications after elective colectomy. Within this context, the Michigan Surgical Quality Collaborative recommends full bowel preparation before elective colectomy.

Bowel preparation for colorectal surgery: with and without mannitol

Introduction

In our country due to some limitations, mannitol is widely used for bowel preparation. Bowel preparation with mannitol has several side effects.

Aim

To compare complication of mechanical bowel preparation with and without mannitol.

Material and methods

This case control study was carried out in Imam Khomeini and Abuzar children’s hospitals. Sixty cases of patients who underwent colorectal surgery were included in this study. Pull-through, colostomy closure, and anorectoplasty were the surgical procedures. Subjects were randomly placed in the case or control group. Infection, electrolyte disturbances, fever, and leukocytosis were recorded. Multivariate analysis was done using PRISM. Odds ratio was calculate with CI = 95%.

Results

Fourteen boys and 16 girls were included in group I. Ten boys and 20 girls were included in group II. Twenty colostomies, 6 pull-throughs, and 4 anorectoplasties were performed in group I. Twenty-one colostomies, 5 pull-throughs, and 4 anorectoplasties were done in group II. Mean age of the patients was 2.63 ±1.9 and 2.66 ±1.68 for group I and group II respectively (p = 0.262). Following bowel preparation with mannitol, 14 patients had mild fever with mean body temperature of 38.1°C. Three subjects had postsurgical fever within 48 h of surgery. In group II, postoperative fever was found in 2 subjects.

Conclusions

Hypernatremia, hypokalemia, and leukocytosis were more common in patients who underwent bowel preparation with mannitol.