Surgical and Patient Outcomes Using Mechanical Bowel Preparation Before Laparoscopic Gynecologic Surgery: A Randomized Controlled Trial

Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis

OBJECTIVE

To assess the efficacy and safety of mechanical bowel preparation (MBP) before benign laparoscopic or vaginal gynecologic surgeries.

DATA SOURCES

Database searches of MEDLINE (PubMed), Embase (OVID), Cochrane Central Register of Controlled Trials, and Web of Sciences and citations and reference lists published up to December 2021.

METHODS OF STUDY SELECTION

Randomized clinical trials in any language comparing MBP with no preparation were included. Two reviewers independently screened 925 records and extracted data from 12 selected articles and assessed the risk of bias with the Cochrane risk-of-bias tool for randomized trials tool. A random-effects model was used for the analysis. Surgeon findings (surgical field view, quality of bowel handling and bowel preparation), operative outcomes (blood loss, operative time, length of stay, surgical site infection), and patient's preoperative symptoms and satisfaction were collected.

TABULATION, INTEGRATION, AND RESULTS

Thirteen studies (1715 patients) assessing oral and rectal preparations before laparoscopic and vaginal gynecologic surgeries were included. No significant differences were observed with or without MBP on surgical field view (primary outcome, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97-1.05, p = .66, I2 = 0%), bowel handling (RR 1.01, 95% CI 0.95-1.08, p = .78, I2 = 67%), or bowel preparation. In addition, there were no statistically significant differences in perioperative findings. MBP was associated with increased pain (mean difference [MD] 11.62[2.80-20.44], I2 = 76, p = .01), weakness (MD 10.73[0.60-20.87], I2 = 94, p = .04), hunger (MD 17.52 [8.04-27.00], I2 = 83, p = .0003), insomnia (MD 10.13[0.57-19.68], I2 = 82, p = .04), and lower satisfaction (RR 0.68, 95% CI 0.53-0.87, I2 = 76%, p = .002) compared with controls.

CONCLUSIONS

MBP has not been associated with improved surgical field view, bowel handling, or operative outcome. However, in view of the adverse effects induced, its routine use before benign gynecologic surgeries should be abandoned.

The Effect of Mechanical Bowel Preparation on the Surgical Field in Laparoscopic Gynecologic Surgeries: A Prospective Randomized Controlled Trial

PURPOSE

To evaluate the effects of mechanical bowel preparation (MBP) on the intraoperative visualization of the surgical field, bowel handling, intestinal load, and overall ease of surgery in patients undergoing elective laparoscopic gynecological surgeries.

METHODS

The patients randomized to a MBP group and a no preparation (NMBP) group. The senior surgeon remained blinded to the bowel regimen used by the patient. Intraoperative visualization of the surgical field, bowel handling, intestinal load, and overall ease of surgery were evaluated using a numeric rating scale (NRS).

RESULTS

We enrolled 120 patients, of whom 109 completed the study, with 51 and 58 patients in the MBP and NMBP groups, respectively. The intraoperative visualization of the surgical field, intestinal load, and NRS scores for overall ease of surgery were better in the NMBP group (p = .03, p = .048, and p = .022, respectively). The results of the assessments also revealed no significant differences in surgical field visualization, ease of bowel handling, overall ease of surgery, or the time that patients experienced passage of flatus between obese (BMI > 30 kg/m²) and non-obese (BMI ≤ 30 kg/m²) patients in the two groups.

CONCLUSIONS

The current study revealed that MBP did not improve the intraoperative visualization of the surgical field or the overall ease of surgery. Moreover, MBP had no benefit when operating on patients who had a high BMI. Therefore, we do not recommend routine MBP before laparoscopic gynecological surgeries.

Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?

AIM

To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures.

METHODS

A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function.

RESULTS

One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group.

CONCLUSION

Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned.

CLINICAL TRIAL REGISTRATION

ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).

Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery

Bowel preparation traditionally refers to the removal of bowel contents via mechanical cleansing measures. Although it has been a common practice for more than 70 years, its use is based mostly on expert opinion rather than solid evidence. Mechanical bowel preparation in minimally invasive and vaginal gynecologic surgery is strongly debated, since many studies have not confirmed its effectiveness, neither in reducing postoperative infectious morbidity nor in improving surgeons' performance. A comprehensive search of Medline/PubMed and the Cochrane Library Database was conducted, for related articles up to June 2019, including terms such as "mechanical bowel preparation," "vaginal surgery," "minimally invasive," and "gynecology." We aimed to determine the best practice regarding bowel preparation before these surgical approaches. In previous studies, bowel preparation was evaluated only via mechanical measures. The identified randomized trials in laparoscopic approach and in vaginal surgery were 8 and 4, respectively. Most of them compare different types of preparation, with patients being separated into groups of oral laxatives, rectal measures (enema), low residue diet, and fasting. The outcomes of interest are the quality of the surgical field, postoperative infectious complications, length of hospital stay, and patients' comfort during the whole procedure. The results are almost identical regardless of the procedure's type. Routine administration of bowel preparation seems to offer no advantage to any of the objectives mentioned above. Taking into consideration the fact that in most gynecologic cases there is minimal probability of bowel intraluminal entry and, thus, low surgical site infection rates, most scientific societies have issued guidelines against the use of any bowel preparation regimen before laparoscopic or vaginal surgery. Nonetheless, surgeons still do not use a specific pattern and continue ordering them. However, according to recent evidence, preoperative bowel preparation of any type should be omitted prior to minimally invasive and vaginal gynecologic surgeries.

Does Mechanical Bowel Preparation Ameliorate Surgical Performance in Anterior Lumbar Interbody Fusion?

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

To investigate whether mechanical bowel preparation (MBP) improve surgical performance and decrease operative complications in anterior lumbar interbody fusion (ALIF).

METHODS

This study involved a retrospective analysis of 48 consecutive patients who underwent ALIF with MBP and a control cohort of 50 consecutive patients who underwent the same surgeries without MBP. The quality of each surgical procedure, operative time, estimated blood loss (EBL), intraoperative complications, changes in vital signs and patient symptoms on the day of surgery, and bowel function postoperatively were also compared between the procedures.

RESULTS

Baseline demographic characteristics were similar between the 2 groups (all Ps > .05). The quality of each procedure, operative time, EBL, intraoperative complications, and changes in body temperature and heart rate were not different between the groups (all Ps > .05). The MBP group showed more headache, tiredness, thirst, and abdominal discomfort (all Ps < .001) and decrease of the systolic blood pressure (P = .041) on the day of surgery. The return of bowel movement was not different between the groups (P = .278).

CONCLUSIONS

Given the similar surgical result with the substantial patient discomfort, MBP can be omitted in ALIF.

Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery

INTRODUCTION

In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice.

METHODS

We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review.

RESULTS

The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery.

CONCLUSION

Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

IMPORTANCE

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology.

OBJECTIVE

The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology.

EVIDENCE ACQUISITION

Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed.

RESULTS

Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life.

CONCLUSIONS AND RELEVANCE

High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.

Laparoscopic colorectal resections with and without routine mechanical bowel preparation: A comparative study

BACKGROUND

The benefit of mechanical bowel preparation (MBP) in patients undergoing laparoscopic colorectal resections remains a question. This study aimed to evaluate the effect of omitting MBP on patients undergoing laparoscopic bowel resections.

METHODS

The outcomes of patients who underwent elective colorectal resections for cancer of colon and upper rectum without MBP were compared to a retrospective cohort who had MBP.

RESULTS

There were 97 patients in the No-MBP group and 159 patients in the MBP group. Their mean age, operative risk, tumor size and stage of disease were similar. There were no significant differences in operative time and estimated blood loss. The anastomotic leakage rate was 1.0% in the No-MBP group and 0.6% in the MBP group, (p = 1.00). Wound infection rate were 4.1% and 3.8% in the No-MBP group and the MBP group respectively (p = 1.00). Overall surgical morbidity rate was 11.3% in the No-MBP group and 8.2% in the MBP group (p = 0.40). Conversion rates were 5.2% in the No-MBP group and 6.9% in the MBP group, (p = 0.57).

CONCLUSION

The omission of mechanical bowel preparation does not increase surgical morbidities in patients undergoing laparoscopic bowel resections. It also has no effect on operating time and conversion rate.

Evaluating Mechanical Bowel Preparation Prior to Total Laparoscopic Hysterectomy

Background and Objectives:

Mechanical bowel preparation (MBP) has been used prior to total laparoscopic hysterectomy (TLH), but evidence for its use is lacking. Our study seeks to assess whether or not completion of preoperative MBP prior to TLH improves visualization of the surgical field, bowel handling, or overall ease of the operation.

Methods:

Women aged 18–65 years undergoing TLH for benign indications at a level 1 trauma center were randomized to a bowel preparation (BP; n = 39) or non–bowel preparation (NP; n = 39) regimen. After each operation, the surgeon completed a survey about intraoperative visualization of the surgical field, bowel handling, and the overall ease of the operation. The surgeon was also asked whether or not he thought the patient had completed MBP. The patient completed a survey about pre- and postoperative gastrointestinal discomfort. The surgeon was blinded to whether MBP was completed before the operation.

Results:

There was no difference in intraoperative visualization, bowel handling, or overall ease of the operation between the BP and NP groups. Comfort levels before and after surgery were not significantly different between the two groups. The surgeon was able to correctly predict whether the patient performed MBP in 59% of cases.

Conclusion:

The routine use of MBP before TLH does not improve intraoperative visualization, bowel handling, or overall ease of performing the procedure. It also has no significant effect on patient comfort levels. MBP is not indicated before TLH for benign indications.

The use of mechanical bowel preparation in laparoscopic gynecologic surgery: a decision analysis

OBJECTIVE

The use of mechanical bowel preparation prior to laparoscopy is common in gynecology, but its use may affect the rates of perioperative events and complications. Our objective was to compare different mechanical bowel preparations using decision analysis techniques to determine the optimal preparation prior to laparoscopic gynecological surgery.

STUDY DESIGN

A decision analysis was constructed modeling perioperative outcomes with the following mechanical bowel preparations: magnesium citrate, sodium phosphate, polyethylene glycol, enema, and no bowel preparation. Comparisons were made using published utility values. Secondary analyses included the percentages that had 1 or more preoperative events and 1 or more intra- or postoperative complications.

RESULTS

Overall, the highest utility values were for no bowel preparation (0.98) and magnesium citrate (0.97), whereas the other values were as follows: enema (0.95), sodium phosphate (0.94), and polyethylene glycol (0.91). The difference between no bowel preparation and magnesium citrate was less than the published minimally important differences for utilities, so there is likely no real difference between these strategies. The probability of having at least 1 preoperative event was lowest for no bowel preparation (1%), whereas the probability of having at least 1 intra- or postoperative complication was lowest with magnesium citrate (8%).

CONCLUSION

The highest utilities were seen with no bowel preparation, but the absolute difference between no bowel preparation and magnesium citrate was less than the minimally important difference. With similar overall utilities, our model raises questions as to whether mechanical bowel preparation is a necessary step prior to laparoscopic gynecological surgery. However, if a surgeon prefers a bowel preparation, magnesium citrate is the preferred option.

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.

Is Mechanical Bowel Preparation Necessary for Gynecologic Surgery? A Systematic Review and Meta-Analysis

OBJECTIVE

To clarify the efficacy and side effects of mechanical bowel preparation (MBP) before gynecologic surgery.

METHODS

A systematic review was conducted. Embase, PubMed, the Cochrane Central Register of Controlled Trials in the Cochrane Library and China National Knowledge Infrastructure were searched. Randomized controlled trials on MBP prior to gynecologic surgery were included. The software package Revman 5.3 was used for statistical analysis. Odds ratio (OR) and standard mean deviation were calculated for dichotomous and continuous variable, respectively.

RESULTS

The quality of the included studies was moderate to good. MBP prior to laparoscopic gynecologic benign surgery or vaginal prolapse surgery has not been proven to be valuable for surgical performance, mainly involving visualization of the surgical field (OR 1.52, 95% confidence interval [CI] 1 to 2.32; Z = 1.95, p = 0.05), bowel handling (OR 2.21, 95% CI 0.83 to 5.84; Z = 1.59, p = 0.11), surgical complications (OR 1.3, 95% CI 0.46 to 3.67; Z = 0.5, p = 0.62) and bowel preparation. The discomfort due to oral catharsis is severer than no bowel preparation and enema, however without any difference between enema and no bowel preparation.

CONCLUSION

The routine practice of MBP before gynecologic surgery needs to be reconsidered. This traditional clinical behavior has to be abandoned before benign laparoscopic surgery. Studies on the role of MBP for gynecologic laparotomy and gynecologic cancer are urgent. © 2015 S. Karger AG, Basel.

Is mechanical bowel preparation still necessary for gynecologic laparoscopic surgery? A meta-analysis

INTRODUCTION

A number of studies have proven that mechanical bowel preparation (MBP) has no benefits in elective colorectal surgery. However, studies specifically related to gynecologic laparoscopic surgery are scant. We undertook a meta-analysis to assess the necessity of MBP before gynecologic laparoscopic surgery.

METHODS

The electronic databases MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched to identify relevant randomized controlled trials. Two authors independently extracted data from each study. The primary outcome of interest was the quality of surgical field. Secondary outcomes of interest included postoperative pain, abdominal swelling, nausea/vomiting, and length of hospital stay.

RESULTS

Three studies involving 372 participants were included in the meta-analysis. The results showed that MBP did not significantly increase the overall quality of surgical field exposure (odds ratio, 0.82; 95% confidence interval [CI], 0.46-1.49; P = 0.52). MBP also did not appear to significantly change the mean scores of postoperative pain (weighted mean difference, 0.09; 95%CI, -0.54-0.71; P = 0.79), the incidence of nausea/vomiting (odds ratio, 1.56; 95%CI, 0.80 to 3.03; P = 0.19), the mean scores of abdominal swelling (weighted mean difference, -0.26; 95%CI, -0.83-0.30; P = 0.36), and length of hospital stay (weighted mean difference, 0.05; 95%CI, -0.13-0.22; P = 0.62).

CONCLUSIONS

Our results suggest that routine use of MBP for gynecologic laparoscopic surgery should not be recommended. However, additional randomized controlled trials using large samples are needed to confirm these findings.

Postoperative bowel function, symptoms, and habits in women after vaginal reconstructive surgery

INTRODUCTION AND HYPOTHESIS

The objective was to characterize postoperative bowel symptoms in women undergoing vaginal prolapse reconstructive surgery randomized to preoperative bowel preparation vs a regular diet.

METHODS

Subjects (N = 121) completed two bowel diaries: a 7-day bowel diary immediately before surgery and a 14-day diary postoperatively. Self-reported bowel diary data and symptoms included the time to first bowel movement (BM), daily number of BMs, Bristol Stool Form Scale score, pain, and urgency associated with BM, episodes of fecal incontinence, and use of laxatives. Antiemetic use was abstracted from medical records. Outcomes of groups were compared using Chi-squared/Fisher's exact test or Student's t test as appropriate.

RESULTS

Mean time to first postoperative BM was similar in the bowel preparation (n = 60) and control groups (n = 61), 81.2 ± 28.9 vs 78.6 ± 28.2 h, p = 0.85. With the first BM, there were no significant differences between bowel preparation and control groups regarding pain (17.2 vs 27.9 %, p = 0.17), fecal urgency with defecation (56.9 vs 52.5 %, p = 0.63), fecal incontinence (14.0 vs 15.0 %, p = 0.88) and >1 use of laxatives (93.3 vs 96.7 % p = 0.44) respectively. Antiemetic use was similar in both groups (48.3 vs 55.7 % respectively, p = 0.42).

CONCLUSIONS

There were no differences in the return of bowel function and other bowel symptoms postoperatively between the randomized groups. Lack of bowel preparation does not have an impact on the risk of painful defecation postoperatively. This information may be used to inform patients regarding expectations for bowel function after vaginal reconstructive surgery.

Bowel preparation before vaginal prolapse surgery: a randomized controlled trial

OBJECTIVE

To compare surgeons' intraoperative surgeon acceptability or assessment of the operative field regarding bowel contents and patients' satisfaction with or without a mechanical bowel preparation before reconstructive vaginal prolapse surgery.

METHODS

In this single-blind, randomized trial, women scheduled to undergo vaginal prolapse surgery with a planned apical suspension and posterior colporrhaphy were allocated using block randomization to an intervention or control group. Surgeons were blinded to patient allocation. One day before surgery, mechanical bowel preparation instructions consisted of a clear liquid diet and two self-administered saline enemas; the participants in the control group sustained a regular diet and nothing by mouth after midnight. The primary outcome was surgeons' intraoperative assessment of the surgical field regarding bowel content as measured on a 4-point Likert scale (1, excellent; 4, poor). Secondary outcomes included participant satisfaction and bowel symptoms. The primary outcome was determined by intention-to-treat analysis and other analyses were per protocol.

RESULTS

Of the 150 women randomized (75 women to intervention and control group), 145 completed the study. No differences existed in the demographic, clinical, and intraoperative characteristics between groups (P>.05). Surgeons' intraoperative assessment rating was 85% "excellent or good" with bowel preparation compared with 90% for participants in the control group (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.21-1.61; P=.30). The bowel preparation group was less likely to report "complete" satisfaction compared with the participants in the control group (OR 0.11, 95% CI 0.04-0.35; P<.001). Abdominal fullness and cramping, fatigue, anal irritation, and hunger pains were greater in the bowel preparation group (all P<.01).

CONCLUSION

Before reconstructive vaginal surgery, mechanical bowel preparation conferred no benefit regarding surgeons' intraoperative assessment of the operative field, reflected decreased patient satisfaction, and had increased abdominal symptoms.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01431040.

LEVEL OF EVIDENCE

I.