Rectal enema is an alternative to full mechanical bowel preparation for primary rectal cancer surgery

Mechanical bowel preparations not supported in elective colo-rectal surgeries with anastomosis: A retrospective study

OBJECTIVE

To analyze the risk and benefit of bowel preparations in elective colo-rectal surgery.

BACKGROUND

Mechanical bowel preparations (MBPs) have been popularized in colo-rectal surgery since studies in the 1970s, but recent data has called their use into question and examined complication rates between patients with and without bowel preparations.

METHODS

A retrospective case-review was performed consisting of 1237 elective colo-rectal surgeries performed by two surgeons between 2008 and 2021. Patients received either a MBP, a mechanical bowel preparation with oral antibiotics (OAMBP), oral antibiotics alone (OA), or no bowel preparation; some patients across all categories received an enema.

RESULTS

Bowel preparations combined (MBP and OAMBP) totaled 436 patients and showed no statistically significant difference (P > .05) in primary outcomes of wound infection and anastomotic leak when compared to the 636 patients without a bowel preparation and 165 patients with OA. The analysis controlled for comorbidities and presence of enema. Of secondary outcomes, urinary tract infections (UTIs) were significantly more common in patients who received a bowel preparation (P = .047). All other outcomes showed no significant difference between groups, including complications on day of surgery; complications, readmission with and without surgery, and ileus formation within 30 days of surgery; sepsis; pneumonia; and length of stay (LOS). The presence of enemas did not have a statistically significant effect on outcomes.

CONCLUSIONS

This study's data does not support the routine use of MBPs in elective colo-rectal surgery and draws into further question whether MBPs should remain standard of care.

Strategies for Antibiotic Administration for Bowel Preparation Among Patients Undergoing Elective Colorectal Surgery: A Network Meta-analysis

Importance

There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial.

Objective

To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes.

Data Sources

Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021.

Study Selection

Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria.

Data Extraction and Synthesis

NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model.

Main Outcomes and Measures

Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation.

Results

A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes.

Conclusions and Relevance

This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Intestinal motility distal of a deviating ileostomy after rectal resection with the construction of a primary anastomosis: results of the prospective COLO-MOVE study

PURPOSE

No consensus exists regarding the use of preoperative bowel preparation for patients undergoing a low anterior resection (LAR). Several comparative studies show similar outcomes when a single time enema (STE) is compared with mechanical bowel preparation (MBP). It is hypothesized that STE is comparable with MBP due to a decrease in intestinal motility distal of a newly constructed diverting ileostomy (DI).

METHODS

In this prospective single-centre cohort study, patients undergoing a LAR with primary anastomosis and DI construction were given a STE 2 h pre-operatively. Radio-opaque markers were inserted in the efferent loop of the DI during surgery, and plain abdominal X-rays were made during the first, third, fifth and seventh postoperative day to visualize intestinal motility.

RESULTS

Thirty-nine patients were included. Radio-opaque markers were situated in the ileum or right colon in 100%, 100% and 97.1% of the patients during respectively the first, third and fifth postoperative day. One patient had its most distal marker situated in the left colon during day five. In none of the patients, the markers were seen distal of the anastomosis.

CONCLUSION

Intestinal motility distally of the DI is decreased in patients who undergo a LAR resection with the construction of an anastomosis and DI, while preoperatively receiving a STE.

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.

Advances in rectal drug delivery systems

Drug delivery via the rectum is a useful alternative route of administration to the oral route for patients who cannot swallow. Traditional rectal dosage forms have been historically used for localized treatments including delivery of laxatives, treatment of hemorrhoids and for delivery of antipyretics. However, the recent trend is showing an increase in the development of novel rectal delivery systems to deliver drug directly into the systemic circulation by taking advantage of porto-systemic shunting. The present review is based on research studies carried out between years 1969-2017. Data for this review have been derived from keyword searches using Scopus and Medline databases. Novel rectal drug delivery systems including hollow-type suppositories, thermo-responsive and muco-adhesive liquid suppositories, and nanoparticulate systems incorporated into an appropriate vehicle have offered more control over delivery of drug molecules for local or systemic actions. In addition, various methods for in vitro-in vivo evaluation of rectal drug delivery systems are covered which is as important as the formulation, and must be carried out using appropriate methodology. Continuous research and development in this field of drug delivery may unleash the hidden potential of the rectal drug delivery systems.

Mechanical Bowel Preparation Does Not Affect Clinical Severity of Anastomotic Leakage in Rectal Cancer Surgery

BACKGROUND

Previous multicenter randomized trials demonstrated that omitting mechanical bowel preparation (MBP) did not increase anastomotic leakage rates or other infectious complications. However, the most serious concern regarding the omission of MBP is ongoing fecal peritonitis after anastomotic leakage occurs. The aim of this study was to compare the clinical manifestations and severity of anastomotic leakage between patients who underwent MBP and those who did not.

METHODS

This study was a single-center retrospective review of a prospectively maintained database. From January 2006 to September 2013, 1369 patients who underwent elective rectal cancer resection with primary anastomosis were identified and analyzed.

RESULTS

Anastomotic leakage rates were not significantly different between patients who did not undergo MBP (77/831, 9.27%) and those who did (42/538, 7.81%). However, a significantly lower rate of clinical leakage requiring surgical exploration was observed in the leakage without MBP group (30/77, 39.0%) compared with the leakage with MBP group (30/42, 71.4%) (P = 0.001). There were no significant differences in the clinical severity of anastomotic leakage as assessed by the length of hospital stay, time to resuming a normal diet, length of antibiotic use, ileus rate, transfusion rate, ICU admission rate, and mortality rate between the leakage without MBP and leakage with MBP groups.

CONCLUSION

MBP was not found to affect the clinical severity of anastomotic leakage in elective rectal cancer surgery.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Effectiveness of Minimal Bowel Preparation With Oral Bisacodyl Before Laparoscopic Radical Proctectomy: Case-Control Comparison of Bisacodyl and Polyethylene Glycol as Oral Laxative Agents

The aim of this study was to evaluate the usefulness of minimal mechanical bowel preparation (MBP) using oral bisacodyl before laparoscopic rectal cancer surgery. Preoperative MBP using conventional oral laxatives in laparoscopic proctectomy may detrimentally affect morbidity and surgical outcomes. Between March 2010 and December 2014, 272 rectal cancer patients who underwent laparoscopic proctectomy were included in the current study. A total of 85 patients undergoing bowel preparation with oral bisacodyl (bisacodyl group) were individually matched to patients receiving polyethylene glycol (PEG group) using propensity score matching. Operative outcomes, morbidity, and mortality were compared between the matched groups. The quality of bowel cleansing was much poorer in the bisacodyl group than in the PEG group (excellent, 43.5% versus 68.2%; fair, 41.2% versus 16.5%; and poor, 15.3% versus 15.3%; P &lt; 0.001). The degree of small bowel distension (collapsed, 56.4% versus 52.9%; mildly distended, 41.2% versus 40.0%; and severely distended, 2.4% versus 7.1%; P = 0.452) and postoperative outcomes, including time to first flatus (3.0 versus 3.0 days, P = 0.426); hospital stay (16.0 versus 15.0 days, P = 0.215); anastomotic leakage rate (8.2% versus 5.9%, P = 0.549); and mortality (0 versus 1.2%, P = 1.000), were similar between the bisacodyl group and the PEG group, respectively. MBP using oral bisacodyl before laparoscopic proctectomy was feasible and safe with respect to morbidity and surgical outcomes. Minimal bowel preparation with bisacodyl seems to be a useful preparation method for laparoscopic proctectomy.

Enhanced recovery after gastro-intestinal surgery: The scientific background

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes?

Most of the studies concerning enhanced recovery after surgery (ERAS) protocols in colorectal surgery include heterogeneous groups of patients undergoing open or laparoscopic surgery, both due to colonic and rectal cancer, thus creating a potential bias. The data investigating the differences between patients operated for either colonic or rectal cancer are sparse. The aim of the study was to compare short-term outcomes of laparoscopic surgery for colonic and rectal cancer with ERAS protocol. The analysis included consecutive prospectively registered patients operated for a colorectal cancer between January 2012 and September 2015. Patients were divided into two groups (colon vs. rectum). The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilization and time to first flatus). Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. Patients in Group 1 (150 patients) were discharged home earlier than in Group 2 (82 patients)—median LOS 4 versus 5 days, respectively. There was no statistical difference in complication rate (27.3 vs. 36.6 %) and readmissions (7.3 vs. 6.1 %). Compliance with the protocol was 86.9 and 82.6 %, respectively. However, in Group 1, the following procedures were used less frequently: bowel preparation (24 vs. 78.3 %) and postoperative drainage (23.3 vs. 71.0 %). There were no differences in recovery parameters between the groups. Univariate logistic regression showed that the type of surgery, drainage and stoma creation significantly prolonged LOS. In a multivariate logistic regression model, only a bowel preparation and drainage were shown to be significant. Although functional recovery and high compliance with ERAS protocol are possible irrespective of the type of surgery, laparoscopic rectal resections are associated with a longer LOS.

ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes?

Most of the studies concerning enhanced recovery after surgery (ERAS) protocols in colorectal surgery include heterogeneous groups of patients undergoing open or laparoscopic surgery, both due to colonic and rectal cancer, thus creating a potential bias. The data investigating the differences between patients operated for either colonic or rectal cancer are sparse. The aim of the study was to compare short-term outcomes of laparoscopic surgery for colonic and rectal cancer with ERAS protocol. The analysis included consecutive prospectively registered patients operated for a colorectal cancer between January 2012 and September 2015. Patients were divided into two groups (colon vs. rectum). The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilization and time to first flatus). Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. Patients in Group 1 (150 patients) were discharged home earlier than in Group 2 (82 patients)-median LOS 4 versus 5 days, respectively. There was no statistical difference in complication rate (27.3 vs. 36.6 %) and readmissions (7.3 vs. 6.1 %). Compliance with the protocol was 86.9 and 82.6 %, respectively. However, in Group 1, the following procedures were used less frequently: bowel preparation (24 vs. 78.3 %) and postoperative drainage (23.3 vs. 71.0 %). There were no differences in recovery parameters between the groups. Univariate logistic regression showed that the type of surgery, drainage and stoma creation significantly prolonged LOS. In a multivariate logistic regression model, only a bowel preparation and drainage were shown to be significant. Although functional recovery and high compliance with ERAS protocol are possible irrespective of the type of surgery, laparoscopic rectal resections are associated with a longer LOS.