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

Bowel preparation for elective colectomy in Crohn's disease: results from a global cohort study using the NSQIP database

AIM

The role of bowel preparation before colectomy in Crohn's disease patients remains controversial. This retrospective analysis of a prospective cohort study aimed to investigate the clinical outcomes associated with mechanical and antibiotic colon preparation in patients diagnosed with Crohn's disease undergoing elective colectomy.

METHOD

Data were collected from the American College of Surgeons National Surgical Quality Improvement Program participant user files from 2016 to 2021. A total of 6244 patients with Crohn's disease who underwent elective colectomy were included. The patients were categorized into two groups: those who received combined colon preparation (mechanical and antibiotic) and those who did not receive any form of bowel preparation. The primary outcomes assessed were the rate of anastomotic leak and the occurrence of deep organ infection. Secondary outcomes included all-cause short-term mortality, clinical-related morbidity, ostomy creation, unplanned reoperation, operative time, hospital length of stay and ileus.

RESULTS

Combined colon preparation was associated with significantly reduced risks of anastomotic leak (relative risk 0.73, 95% CI 0.56-0.95, P = 0.021) and deep organ infection (relative risk 0.68, 95% CI 0.56-0.83, P < 0.001). Additionally, patients who underwent colon preparation had lower rates of ostomy creation, shorter hospital stays and a decreased incidence of ileus. However, there was no significant difference in all-cause short-term mortality or the need for unplanned reoperation between the two groups.

CONCLUSION

This study shows that mechanical and antibiotic colon preparation may have clinical benefits for patients with Crohn's disease undergoing elective colectomy.

Is There a Role for Mechanical and Oral Antibiotic Bowel Preparation for Patients Undergoing Minimally Invasive Colorectal Surgery? A Systematic Review and Meta-analysis

INTRODUCTION

To date, all meta-analyses on oral antibiotic prophylaxis (OA) and mechanical bowel preparation (MBP) in colorectal surgery have included results of both open and minimally invasive approaches. Mixing both procedures may lead to false conclusions. The aim of the study was to assess the available evidence of mechanical and oral antibiotic bowel preparation in reducing the incidence of surgical site infection (SSI) and other complications following minimally invasive elective colorectal surgery.

METHODS

We searched PubMed, Science Direct, Google Scholar and Cochrane Library from 2000 to May 1, 2022. Comparative randomized and non-randomized studies were included. We reviewed the use of oral OA, MBP and combinations of these treatments. The methodological quality of the included studies was assessed using the Rob v2 and Robins-I tools.

RESULTS

We included 18 studies (7 randomized controlled trials and 11 cohort studies). Meta-analysis of the included studies showed that the combination of MBP + OA was associated with a significant reduction in SSI, AL and overall morbidity compared with the other options no preparation, MBP only and OA only.  CONCLUSION: Adding OA with MBP has a positive impact in reducing the incidence of SSI, AL and overall morbidity after minimally invasive colorectal surgery. Therefore, the combination of OA and MBP should be encouraged in this selected group of patients undergoing minimally invasive surgery.

Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis

OBJECTIVE

A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection.

METHODS

Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation.

RESULTS

The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI.

CONCLUSION

MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.

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.

Racial Disparities and Upward Trend in Bowel Preparation for Elective Colectomy in the National Surgical Quality Improvement Program Procedure Targeted Dataset: 2012 to 2018

Objective

The primary objective of this study was to assess trends in bowel preparation among patients who had elective colectomy between 2012 and 2018. The secondary objective was to assess patient and procedure-related factors predictive of bowel preparation use or lack thereof.

Background

Numerous studies have demonstrated that bowel preparation before elective colorectal surgery can reduce the risk of postoperative complications. Studies of surgeon practices found 75% to 98% prescribe bowel preparation to their patients, although biases in the study design may lead to overestimation of bowel preparation practice.

Methods

Cross-sectional study of the National Surgical Quality Improvement Program colectomy procedure targeted dataset. We included patients from 18 to 90 years old who underwent elective colectomy (n = 101,096). The primary outcomes were bowel preparation before elective colectomy, including oral antibiotic only, mechanical only, both oral and mechanical, or none.

Results

Twenty percent of patients did not do any bowel preparation before elective colectomy. Almost all covariates were independently associated with any bowel preparation, although some were not clinically relevant. The odds that Black/African American or Hispanic patients had any bowel preparation were lower than that of White patients. Additionally, the odds minimally invasive colectomy patients completed any bowel preparation was 1.46 times that of open surgery patients.

Conclusions

This study is the first of its kind to assess trends in bowel preparation using an objective dataset. Our study highlights disparities in bowel preparation. Further studies should focus on delineating the root cause of this disparity, identifying the barriers, and finding solutions.

Mechanical plus oral bowel preparation with paromomycin and metronidazole reduces infectious complications in elective colorectal surgery: a matched case-control study

PURPOSE

Infectious complications are as high as 30% in elective colorectal surgery. In recent years, several studies have discussed the topic of preoperative bowel decontamination prior to colorectal surgery in order to reduce postoperative infectious complications and have found significant effects of oral antibiotic administration with a large variety of drugs used. No study has evaluated the combination of oral paromomycin and metronidazole in this context.

METHODS

We performed a prospective single-center study with a matched-pair retrospective cohort to evaluate postoperative infectious complications (superficial site infections, organ space abscess, anastomotic leakage) in elective colorectal surgery.

PATIENTS

A total of 120 patients were available for study inclusion; 101 gave informed consent and were included. A total of 92 patients were matched and subsequently analyzed. We could show a reduction in overall infectious complications in the intervention group (15.2% vs 30.8%, p = 0.018; odds ratio 0.333, 95% CI 0.142-0.784) as well as a reduction in superficial surgical site infections (8.7 vs 19.6%, p = 0.041, OR 0.333, 95% CI 0.121-0.917). The frequency of the other infectious complications such as intraabdominal abscesses and anastomotic leakage showed a tendency towards decreased frequencies in the intervention group (OR 0.714, 95% CI 0.235-2.169 and OR 0.571; 95% CI 0.167-1.952, respectively). Finally, the oral antibiotic administration led to an almost significantly reduced length of stay (12.24 days vs 15.25 days; p = 0.057).

CONCLUSIONS

Oral paromomycin and metronidazole with intravenous ertapenem effectively reduce infectious complications in elective colorectal surgery.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov (NCT03759886) December 17, 2018.