Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery

Safety and Efficacy of Polyethylene Glycol Versus Placebo in the Bowel Preparation for Elective Colorectal Surgeries: A Systemic Review and Meta-Analysis

The most suitable type of preoperative colonic preparation for colorectal surgery is controversial. Polyethylene glycol (PEG) has been widely used and some regard it as more suitable for bowel cleansing. However, it also has some limitations, such as nausea and vomiting. These problems have caused surgeons to question whether bowel cleansing offers any benefit at all. This study aims to assess the safety and efficacy of PEG, compare it with other available bowel preparations, conduct a detailed analysis of the available evidence, and inform clinical practice guidelines for bowel preparation before elective colorectal surgeries. MeSH terms and keywords, including "colorectal surgeries", "polyethylene glycol", and "placebo", were used to run a literature search on PubMed, Embase, Cochrane, and Clinicaltrials.gov from inception to January 2025. Randomized controlled trials (RCTs) comparing PEG with placebo for patients undergoing colorectal surgeries were included. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method in RevMan (Cochrane Collaboration, London, UK). Random effects meta-analysis was undertaken. Ten RCTs with a total of 2613 patients were included. Polyethylene showed no significant benefits over placebo regarding quality of bowel preparation (RR = 1.03, 95% CI: 0.91-1.17, p = 0.64) and incidence of surgical site infections (SSIs) (RR = 1.29, 95% CI: 0.95-1.75; p = 0.11). Both groups were comparable in terms of anastomotic leak (RR = 1.14, 95% CI: 0.70-1.85, p = 0.60), intra-abdominal abscess (RR = 0.77, 95% CI: 0.36-1.65, p = 0.50), ileus (RR = 1.16, 95% CI: 0.44-3.05, p = 0.76), anastomotic dehiscence (RR = 0.79, 95% CI: 0.39-1.59, p = 0.51), vomiting (RR = 0.54, 95% CI: 0.27-1.09, p = 0.09), and repeated operations (RR = 0.66, 95% CI: 0.20-2.24, p = 0.51). PEG has no significant benefits over placebo for bowel preparation before colorectal surgeries. Further research and RCTs are necessary to identify and explore other therapeutic options for patients undergoing colorectal surgeries.

Bacterial Decontamination: Bowel Preparation and Chlorhexidine Bathing

Infectious complications following bowel surgery continues to be a leading cause of postoperative morbidity. Both patient- and procedure-related factors contribute to risk. Compliance with evidence-based process measures is the best strategy for prevention of surgical site infections. Three process measures that aim to reduce the bacterial load present at the time of surgery are mechanical bowel preparation, oral antibiotics, and chlorhexidine bathing. There is heightened awareness of surgical site infections, in part due to improved access to reliable postoperative complication data for colon surgery as well as incorporation of surgical site infection into public reporting and pay-for-performance payment models. As a result, the literature has improved with regard to the effectiveness of these methods in reducing infectious complications. Herein, we provide the evidence to support adoption of these practices into colorectal surgery infection prevention programs.

The effectiveness of preoperative colon cleansing on post-operative surgical site infection after hip hemiarthroplasty

AIM

This study aimed to evaluate the effectiveness of prophylactic mechanical bowel preparation in elderly patients undergoing hip hemiarthroplasty in a single training institution over a period of 2 years.

PATIENTS AND METHODS

The study was conducted in a prospective-randomised manner. All patients, who underwent primary hip hemiarthroplasty for femoral neck fracture in our institution between 20 February 2015 and 29 December 2016, were included. B.T. Enema (sodium dihydrogen phosphate + disodium hydrogen phosphate) 135 ml (Yenisehir Laboratory, Ankara, Turkey) was used for colon cleansing.

RESULTS

Ninety-five patients were followed up for at least 1 year after surgery (16.3 ± 4.2 months). Of these, 46 were in the enema group and 49 were in the control group. Demographic and clinical characteristics of patients were similar in both groups (p > 0.05). Infection rates between the two groups were not significantly different (p > 0.05). In addition, ASA, age, sex, presence of diabetes mellitus, duration of surgery, time to surgery, ambulation status and blood count did not have a significant effect on surgical site infections (p > 0.05). However, all infections in the enema group were monobacterial and were successfully treated, whereas two of the four infections in the control group were polymicrobial and could not be successfully treated.

CONCLUSION

Although preoperative colon cleansing did not reduce the overall incidence of post-operative infections, our study suggested that it may reduce polymicrobial infections after hip hemiarthroplasty. Polymicrobial infections after hip hemiarthroplasty seem to have worse prognosis. Therefore, the effectiveness of preoperative colon cleansing in remediating such infections must be investigated in a larger number of patients.

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 < 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.

Antimicrobial Bowel Preparation for Elective Colon Surgery

BACKGROUND

Mechanical bowel preparation continues to be a controversial subject for the pre-operative management of patients undergoing elective colon resection.

METHODS

The English literature on bowel preparation was searched to identify pertinent publications.

RESULTS

The published literature over the past 80 y confirms that mechanical bowel preparation alone does not reduce surgical site infections. However, the use of appropriate oral antibiotics following mechanical bowel preparation with pre-operative systemic antibiotics reduces rates of surgical site infections and anastomotic leaks when compared with systemic antibiotics alone.

CONCLUSIONS

Mechanical bowel preparation with pre-operative oral antibiotics and pre-operative systemic antibiotics are the standard of care for elective colon surgery. Refinement in methods of bowel preparation needs additional clinical investigations to further enhance outcomes.

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.

The comparison of saline enema and bisacodyl in rectal preparation before anorectal surgery

BACKGROUND

Given the limited data on the need of mechanical bowel preparation application before anorectal surgeries and the preferred method for bowel preparation, we aimed to compare saline enema and bisacodyl in rectal preparation before anorectal surgery.

MATERIALS AND METHODS

This is a randomized clinical trial study. Seventy-nine hospitalized patients for anorectal surgery (hemorrhoid, fissure, and fistula) were recruited by convenient sampling and then randomly allocated to receive 500 cc Saline by rectal enema or six bisacodyl tablets (Sobhan company) beginning from a day before the operation in order to prepare the bowel. After surgery, surgeons' satisfaction of the surgery and patients' satisfaction of the preparation process were evaluated in the ward using Likert score by a nurse blind to the study. Also, the patients were interviewed for pain after the first defecation, using numeric rating scale based on a 0-10 scores. All patients were actively followed-up after discharge for 1 mo concerning postoperative complications. The obtained data were analyzed by SPSS software (version 16), Mann-Whitney, chi-squared, and Fisher exact tests at the significant level of P < 0/0.5.

RESULTS

A total of 79 patients participated in the study, 38 received 500-cc saline by rectal enema and 41 bisacodyl tablets. No significant differences were observed between the two groups in most variables except for pain after the first defecation (P = 0.032).

CONCLUSIONS

According to the results, the bisacodyl approach results in less pain in the first postoperative defecation and fewer complications than the rectal enema. Thus, bisacodyl can be suggested as a superior counterpart for enema.

Dysmotility by mechanical bowel preparation using polyethylene glycol

BACKGROUND

The effects of mechanical bowel preparation (MBP) on morbidity (e.g., anastomotic leakage and surgical site infection) have been evaluated. Its effect on early recovery after surgery has drawn renewed attention, and its use is discouraged in the postsurgical management of enhanced recovery. However, most surgeons in Japan prefer polyethylene glycol (PEG) for MBP. We investigated the effect of MBP with PEG on postoperative intestinal motility.

MATERIALS AND METHODS

We prospectively evaluated a consecutive series of 258 colon cancer patients who underwent colonic resection and primary anastomosis. We orally administered 2000 mL of PEG in the PEG group and did not administer PEG to patients in the no-PEG group. Postoperative gastrointestinal motility was assessed with radiopaque markers. All patients ingested radiopaque markers 2 h before surgery. Postoperative intestinal motility was radiologically assessed by counting the number of residual markers. Abdominal radiography was conducted on postoperative days 1, 3, and 5 to count residual markers in the large and small intestines.

RESULTS

The total number of residual markers in the no-PEG group was less than that in the PEG group on day 5 (P < 0.01) but not on days 1 and 3. On all 3 d, the numbers of residual markers in the small intestine were significantly less in the no-PEG group than in the PEG group (P < 0.001). There were no differences in postoperative complications between the no-PEG and PEG groups.

CONCLUSIONS

PEG can negatively affect postoperative intestinal motility, and MBP using PEG is unnecessary in elective colon cancer surgery.

Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial

BACKGROUND

We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial.

METHODS

Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined.

RESULTS

The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups.

CONCLUSION

We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections.

The prevention of surgical site infection in elective colon surgery

Infections at the surgical site continue to occur in as many as 20% of elective colon resection cases. Methods to reduce these infections are inconsistently applied. Surgical site infection (SSI) is the result of multiple interactive variables including the inoculum of bacteria that contaminate the site, the virulence of the contaminating microbes, and the local environment at the surgical site. These variables that promote infection are potentially offset by the effectiveness of the host defense. Reduction in the inoculum of bacteria is achieved by appropriate surgical site preparation, systemic preventive antibiotics, and use of mechanical bowel preparation in conjunction with the oral antibiotic bowel preparation. Intraoperative reduction of hematoma, necrotic tissue, foreign bodies, and tissue dead space will reduce infections. Enhancement of the host may be achieved by perioperative supplemental oxygenation, maintenance of normothermia, and glycemic control. These methods require additional research to identify optimum application. Uniform application of currently understood methods and continued research into new methods to reduce microbial contamination and enhancement of host responsiveness can lead to better outcomes.

Prevention of surgical site infection in colorectal surgery

SUMMARY The rate of surgical site infection (SSI) for colorectal surgery is among the highest of all operations performed, ranging between 12 and 26% depending on definition applied, surveillance, the prevalence of emergency surgery and the penetration of laparoscopic surgery. With over 135,000 colorectal cancer operations per year, the cost of SSI to the healthcare system are in excess of US$1 billion a year. The Surgical Care Improvement Project (SCIP) has linked hospital reimbursement to compliance with five preventative process measures in colorectal surgery. The success of SCIP in reducing SSI is in doubt, but the addition of other evidence-based measures to SCIP might improve SSI rates. These measures, as well as the contributions of SCIP, are discussed in detail in this review. Implementation of some or all these measures, in addition to SCIP, should be considered by key stakeholders for baseline data collection, monitored for effectiveness and modified as necessary to improve outcomes.

Bowel Preparation before Elective Surgery

Mechanical bowel preps were initially thought to decrease the bacterial load of the colon and therefore decrease infection. Traditional bowel preps include osmotic, laxative, and combination regimen. Data demonstrate that mechanical bowel preps are generally equivalent; however, the addition of oral antibiotics may further reduce the risk of infection. Recent data suggest that mechanical bowel preparations may not be necessary, and that dietary restrictions before surgery may also be obsolete. In this review, the authors address the types of mechanical bowel preparations (MBPs), differences in outcomes between MBPs, the role of oral antibiosis and enemas, the benefits of no MBP, and dietary preparations for elective colon and rectal surgery.

Ring drape do not protect against surgical site infections in colorectal surgery: a randomised controlled study

INTRODUCTION

Surgical site infections (SSIs) remain a major problem in colorectal surgery.

METHOD

In this prospective, randomised study, we compared two kinds of wound protection, namely, "plastic ring drape" versus "standard cloth towels". One hundred one patients were randomised to the control group (wet cloth towels) and 98 to the study cohort (ring drape). SSIs were classified according to Centers for Disease Control and Prevention recommendations.

DISCUSSION

In the control group, 30 patients had an SSI, whereas 20 did so in the study group. This difference was not significant (p = 0.131).

CONCLUSION

Plastic ring drape for wound protection does not guard against SSIs in colorectal surgery.

Is there a role for bowel preparation and oral or parenteral antibiotics in infection control in contemporary colon surgery?

The numbers of unanswered questions are many. Can intraoperative application, such as topical antimicrobial use in pulsed lavage, reduce the microbial burden on the wound interface before closure? Can closed suction drains within the closed surgical incision reduce infection rates, especially in patients with a large body mass index? What is the role of delayed primary closure or secondary closure in the wound where obvious contamination has occurred, or in the circumstance of emergent colonic resection where considerable contamination is encountered from preexistent perforation? Should immediate negative-pressure wound dressings be applied in the open contaminated wound? These and many other questions still confront the surgeon in the challenge of the surgical wound in major colorectal surgery.

Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta-analysis

PURPOSE

The aim of this study was to estimate efficacy of mechanical bowel preparation with polyethylene glycol (PEG) in prevention of postoperative complications in elective colorectal surgery.

METHOD

A literature search of MEDLINE (PubMed), EMBASE, and the Cochrane Library was done to identify randomized controlled trials involving comparison of postoperative complications after mechanical bowel preparation with PEG (PEG group) and no preparation (control group). A meta-analysis was set up to distinguish overall difference between the two groups.

RESULTS

A total of five randomized controlled trials was identified according to our inclusion criteria. The use of PEG for mechanical bowel preparation did not significantly reduce the rate of surgical site infection (SSI; odds ratio (OR) 95% confidence interval (CI), 1.39 (0.85-2.25); P = 0.19) including incisional SSI (OR 95% CI, 1.44 (0.88-2.33); P = 0.15), organ/space SSI (OR 95% CI, 1.10 (0.43-2.78); P = 0.49), anastomotic leak (OR 95% CI,1.78 (0.95-3.33; P = 0.07), mortality (OR 95% CI, 1.24 (0.37-4.14; P = 0.73), infectious complications (OR 95% CI, 1.14 (0.62-2.08); P = 0.67), and hospital stay (weighted mean difference 95% CI, 2.17 (-2.90-7.25); P = 0.40) except main complications (OR 95% CI, 1.76 (1.09-2.85); P = 0.02), of which the rate increased significantly in the PEG group.

CONCLUSION

The use of mechanical bowel preparation with PEG does not significantly lower postoperative complications in elective colorectal surgery.

Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery?

BACKGROUND

In numerous scientific studies, oral antibiotic bowel preparation has reduced surgical site infections in patients undergoing colorectal surgery. The historical evolution of antibiotic bowel preparation is presented with a review of the scientific basis of its effectiveness.

METHODS

Review of the pertinent English language literature.

RESULTS

Successful oral antibiotic bowel preparation requires effective mechanical preparation. The progressive shift of preoperative preparation to the outpatient setting has led to a reduction in the use of oral antibiotics. Such preparation, however, continues to be effective although in current surgical practice is often augmented with perioperative, parenteral antimicrobials.

CONCLUSION

Oral antibiotic bowel preparation has a role in the prevention of surgical site infection in the patient undergoing colorectal surgery.

Assessing the Quality of Surgical Care

Because of better educated patients, more demanding payers, and regulatory agencies, safety and quality have become prominent criteria for evaluating surgical care. Providers are increasingly asked to document these areas, and patients are using this documentation to select surgeons and hospitals. Payers are using the data to direct patients to providers, and potentially to adjust reimbursement rates. Therefore, health care policy makers, health service researchers, and others are aggressively developing and implementing quality indicators for surgical practice. Given the complex interplay of structure, process, and outcomes, assessment of surgical quality presents a daunting task. We must firmly establish the links between these elements to validate current and future metrics, while engendering "buy-in'' on the part of surgeons.