Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial

Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study

BACKGROUND/PURPOSE

Preoperative mechanical bowel preparation (MBP) for elective intestinal operations has been a long accepted practice. However, MBP is often unpleasant and time-consuming for patients, and clinical trials in adults have not shown improved outcomes. We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications.

METHODS

Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children's hospital between 1990 and 2003.

RESULTS

Thirty-three patients (No PREP) were managed by a single surgeon who routinely omitted MBP, whereas another 110 patients (PREP) were prepared with enemas, laxatives, or both. Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics. The No PREP group had one anastomotic leak and no wound infections, whereas the PREP group had 2 anastomotic leaks and 1 wound infection (P = .58). These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group.

CONCLUSION

The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications. Eliminating MBP may reduce health care costs and inconvenience to patients. These findings warrant a large, prospective, randomized clinical trial to validate our findings and to investigate further the necessity of MBP in the pediatric population.

Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery

BACKGROUND

Mechanical bowel preparation (MBP) is performed routinely before colorectal surgery to reduce the risk of postoperative infectious complications. The aim of this randomized clinical trial was to compare the outcome of patients who underwent elective left-sided colorectal surgery with or without MBP.

METHODS

Patients scheduled for elective left-sided colorectal resection with primary anastomosis were randomized to preoperative MBP (3 litres of polyethylene glycol) (group 1) or surgery without MBP (group 2). Postoperative abdominal infectious complications and extra-abdominal morbidity were recorded prospectively.

RESULTS

One hundred and fifty-three patients were included in the study, 78 in group 1 and 75 in group 2. Demographic, clinical and treatment characteristics did not differ significantly between the two groups. The overall rate of abdominal infectious complications (anastomotic leak, intra-abdominal abscess, peritonitis and wound infection) was 22 per cent in group 1 and 8 per cent in group 2 (P = 0.028). Anastomotic leak occurred in five patients (6 per cent) in group 1 and one (1 per cent) in group 2 (P = 0.210) [corrected] Extra-abdominal morbidity rates were 24 and 11 per cent respectively (P = 0.034). Hospital stay was longer for patients who had MBP (mean(s.d.) 14.9(13.1) versus 9.9(3.8) days; P = 0.024).

CONCLUSION

Elective left-sided colorectal surgery without MBP is safe and is associated with reduced postoperative morbidity.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

For over a century the presence of bowel content during surgery has been linked to anastomotic leakage. Mechanical bowel preparation has been considered an efficient agent against leakage and infectious complications. This dogma is not based on solid evidence, but on observational data and expert's opinions.

OBJECTIVES

To determine the effectiveness and safety of prophylactic mechanical bowel preparation for morbidity and mortality rates in elective colorectal surgery.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials. We also searched relevant medical journals, and conference proceedings from major gastroenterological congresses and contacted experts in the field. We used the search strategy described by the Colorectal Cancer Review Group, without limitations for date of publication and language. I SELECTION CRITERIA: Randomised, clinical trials that compared any strategy in mechanical bowel preparation with no mechanical bowel preparation.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by the reviewers and cross-checked. The same reviewers assessed the methodological quality of each trial. Details of the randomisation (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up was recorded. For analysis the Peto odds ratio (OR) was used as defaults.

MAIN RESULTS

Of the 1592 patients (9 trials), 789 were allocated to mechanical bowel preparation (Group A) and 803 to no preparation (Group B) before elective colorectal surgery. For anastomotic leakage (main outcome) the results were: - Low anterior resection: 9.8% (11 of 112 patients in Group A) compared with 7.5% (9 of 119 patients in Group B); Peto OR 1.45, 95% confidence interval (CI): 0.57 to 3.67 (non-significant); - Colonic surgery: 2.9% (Group A) compared with 1.6% (Group B) ; Peto OR 1.80, 95% CI: 0.68 to 4.75 (non-significant); Overall anastomotic leakage: 6.2% (Group A) compared with 3.2% (Group B); Peto OR 2.03, 95% CI: 1.276 to 3.26 (p=0.003). For the secondary outcome of wound infection the result was: 7.4% (Group A) compared with 5.4% (Group B); Peto OR 1.46, 95% CI: 0.97 - to 2.18 (p=0.07); Sensitivity analyses excluding studies with dubious randomisation, studies published as abstracts only, and studies involving children did not change the overall conclusions

AUTHORS' CONCLUSIONS

There is no convincing evidence that mechanical bowel preparation is associated with reduced rates of anastomotic leakage after elective colorectal surgery. On the contrary, there is evidence that this intervention may be associated with an increased rate of anastomotic leakage and wound complications. It is not possible to be conclusion on the latter issue because of the clinical heterogeneity of trial inclusion criteria, methodological inadequacies in trial (in particular, poor reporting of concealment and allocation), potential performance biases, and failure of intention-to-treat analyses. Nevertheless, the dogma that mechanical bowel preparation is necessary before elective colorectal surgery should be reconsidered.

[Preoperative bowel preparation--is it useful?]

Mechanical cleansing of the colon prior to elective colorectal surgery is a dogmatically established belief in surgery. Polyethylene glycol was extensively used in the 1980's and 1990's but has been largely replaced by other laxative solutions such as sodium phosphate which are better tolerated by the patient. Evidence-based data in the surgical literature question the dogma of routine mechanical bowel cleansing (8 randomized controlled studies and 4 meta-analyses). These data show with a good level of evidence that mechanical bowel preparation is unnecessary and perhaps harmful.

Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation

BACKGROUND

Mechanical bowel preparation is used routinely before colorectal surgery, but some randomized clinical trials have suggested that it is of no benefit. This study assesses whether such bowel preparation may safely be omitted before elective colorectal surgery.

METHODS

A search of the literature was performed; the inclusion criteria were randomized clinical trials comparing bowel preparation with no preparation in colorectal surgery. The methodological quality of included trials was assessed. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications. The meta-analysis was conducted using the Peto one-step method.

RESULTS

Eleven trials were retrieved, of which seven, containing 1454 patients, were included in the meta-analysis. There was no heterogeneity between the trials. Significantly more anastomotic leakage was found after mechanical bowel preparation (5.6 versus 3.2 per cent; odds ratio 1.75 (95 per cent confidence interval 1.05 to 2.90); P = 0.032). All other endpoints (wound infection, other septic complications and non-septic complications) also favoured the no-preparation regimen, but the differences were not statistically significant. Sensitivity analysis showed that these results were similar when trials of poor quality were excluded. Subgroup analysis showed that anastomotic leakage was significantly greater after bowel preparation with polyethylene glycol (PEG) compared with no preparation, but not after other types of preparation.

CONCLUSION

There is good evidence to suggest that mechanical bowel preparation using PEG should be omitted before elective colorectal surgery. Other bowel preparations should be evaluated by further large randomized trials.

Left colon stenosis caused by tuberculosis

The authors present a case of intestinal tuberculosis affecting exclusively the left colon causing severe undernourishment, abdominal pain, and bowel obstruction with a sealed colonic fistula in a 10-year-old child. These clinical characteristics and difficulties led to a diagnosis of intestinal tuberculosis in childhood. Intestinal tuberculosis affecting exclusively the colon is very rare, and differential diagnosis with Crohn's disease is difficult. Surgical complications are frequent, especially intestinal obstruction, and can be treated in most cases by resection of the affected segment and primary anastomosis.

Mechanical bowel preparation in the older surgical patient

A major risk of colon resection is contamination from the bowel. Poor cleansing of the colon has been associated with an increased incidence of wound infections and intra-abdominal abscesses. Despite controversy on the usefulness of colon cleansing methods, mechanical bowel preparation along with oral and intravenous antibiotics have become common preoperative practice. The population is aging, and surgeons and endoscopists are going to be increasingly involved in the care of older patients. This review focuses on various colon cleansing methods and examines specific issues in older patients.

Bio-ecological control of perioperative and ITU morbidity

BACKGROUND

Perioperative and intensive therapy unit (ITU) morbidity and mortality has remained unchanged during the past several decades, and this at an unacceptably high level. It is most likely, in the EU countries annually, that more than 1 million people suffer severe sepsis and some 300,000 die. Pharmaceutical attempts at prevention and treatment have, despite extensive efforts, hitherto failed to improve outcome more significantly. Much supports the fact that sepsis and its severe consequences are results of a malfunctioning innate immune system, impaired by both lifestyle and disease. A series of mostly simple measures to prevent further deterioration of the immune system, and to boost it, is recommended. Among the measures recommended are some modifications of surgical and postoperative management: restricted use of antibiotics, attempts made to maintain salivation and GI secretions, omission of prophylactic gastric decompression, postoperative drainage and preoperative bowel preparation, restricted use of stored blood, avoidance of overload with nutrients, uninterrupted enteral nutrition but also tight blood glucose control, supply of antioxidants, administration of prebiotic fibre and probiotic lactic acid bacteria. Nutritional control of postoperative morbidity includes use of so-called synbiotics, e.g. a combination of bioactive lactic acid bacteria (LAB) and bioactive plant fibres.

RESULTS

Dramatic reduction in (in reality, almost abolishment of) septic morbidity is reported following supplementation of specific bioactive lactic bacteria in combination with prebiotic plant fibres, as tried in controlled studies in connection with extensive abdominal operations, liver transplantation and severe acute pancreatitis.