Bowel Preparation Colon Resection

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org
Bowel Preparation for Colon Resection

Eric Klein, M.D. SUNY Downstate Department of Surgery
www.downstatesurgery.org
Historical Perspective
During World War II, failure to treat penetrating colon injuries with diversion could result in court martial.
Miller PR, Fabian TC, et al. Improving outcomes following penetrating colon wounds: application of a clinical pathway. Ann Surg. 2002 Jun;235(6):775-81.
Madden (1965)
Primary resection and immediate anastomosis of perforated lesions of the colon
85 cases from literature 25 additional cases 9.1% mortality
Madden JL. Primary resection and anastomosis in the treatment of perforated lesions of the colon. Amer Surg 31: 781, 1965.
Case Series (1987)

In a series of 72 consecutive elective and emergency colectomies with primary anastomosis, all pre- and perioperative mechanical preparation of the bowel was omitted and the patient covered only by a single peroperative intravenous dose of cefuroxime and metronidazole. No anastomotic dehiscence was clinically apparent and wound infection was noted in only 8.3 per cent of patients.
Irving AD, Scrimgeour D. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surg 1987; 74: 580-1.
Editorial
The paper which challenges accepted surgical practice, is a veritable little bomb of a paper, brief, iconoclastic, and disrespectful of hallowed tradition in colorectal surgery.
Is Mechanical Bowel Preparation Mandatory for Elective Colon Surgery?

Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Arch Surg. 2005 Mar;140(3):285-8.
Israel
Colon Resections
Excluded low LAR and surgery for polypoid lesions Prophylactic antibiotics (1 hour preop, 48 hours post-op)
Ceftriaxone 1g Metronidazole 500mg
Group 1 Soffodex Group 2 No bowel prep
No statistically significant results

Mechanical bowel prep (n = 164) 1.2% 9.8% 0.6% 0.6% No preparation (n = 165) 1.2% 6.1% 1.2% 0.6%
Mortality Wound Infection Anastomotic breakdown Abdominal / pelvic collection
Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery.
Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Br J Surg. 2005 Apr;92(4):409-14.
Switzerland
Infectious abdominal complications

Mechanical bowel prep (n = 78) 6% 1% No preparation (n = 75) 1% 3%
Anast. leakage (p = 0.21) Intra-abdominal abscess (p = 0.62) Wound abscess (p = 0.07)
13%
4%
Postoperative data
Mechanical bowel prep (n = 78) 2.8 days 14.9 days 11.7 days No preparation (n = 75) 1.9 days 9.9 days 9.1 days
NGT removal (p = 0.007) Hospital stay (p = 0.024) Hospital stay* (p = 0.001)
* Patients without abdominal complication
Pre-operative mechanical bowel cleansing or not? An updated meta-analysis

Wille-Jrgensen P, Guenaga KF, Matos D, Castro AA. Colorectal Dis. 2005 Jul;7(4):304-10.
1592 patients from 9 RCTs

Mechanical bowel prep (n = 789) 6% 7.4% 1% No preparation (n = 803) 3.2% 5.4% 0.6%
Anast. leakage (p = 0.003) Wound infection (p = 0.07) Mortality (NS)
Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection
Jung B, Phlman L, Nystrm PO, Nilsson E. Br J Surg. 2007 Jun;94(6):689-95.
1505 patients randomized

1 German and 20 Swedish hospitals Cancer, adenoma, diverticular disease All patients had an anastomosis All patients receieved oral or IV prophylactic antibiotics Bowel preparations
Oral (polyethylene glycol or sodium phosphate) Some patients had a rectal enema
Not statistically significant overall

Mechanical bowel prep (n = 686) 7.9% 0.7% 1.9% 8.6 days No preparation (n = 657) 6.4% 1.7% 2.6% 8.8 days
Wound infection Deep abscess Anastomotic dehiscence Postoperative stay
Preoperative Oral Antibiotics in Colorectal Surgery Increases the Rate of Clostridium difficile Colitis
Wren SM, Ahmed N, Jamal A, Safadi BY. Arch Surg. 2005 Aug;140(8):752-6.
Retrospective case-controlled
Elective operations
Resections with or without anastomosis Colostomy formation Colostomy takedown
Exclusions
C. diff within 30 days prior to surgery bowel obstruction < 30 day follow-up (or survival)
Bowel Preparation
All patients received mechanical bowel preparation All patients received prophylactic IV antibiotics
Results
Oral antibiotics (n = 107) C. difficile colitis (p = 0.03) Wound infection (p = 0.20) 7.4% No oral antibiotics (n = 197) 2.6%
14.9%
13.2%
Reasons to continue mechanical bowel preparation

Need to palpate small tumors Need for intraoperative colonoscopy Easier to handle lightweight bowel laparoscopically Low pelvic anastomosis
Reasons NOT to continue mechanical bowel preparation

Significant patient discomfort Causes electrolyte abnormalities Causes hypovolemia Associated with bacterial translocation through the bowel wall A poorly prepped bowel will allow easier spillage of stool than an unprepped bowel
The Association of Coloproctology of Great Britain and Ireland

Guidelines for the Management of Colorectal Cancer (2007) Bowel preparation should not be used routinely before colorectal cancer resection. (Recommendation grade B)
http://www.acpgbi.org.uk/assets/documents/COLO_guides.pdf
Australian Cancer Network

Colorectal Cancer Guidelines Revision Committee (2005) Mechanical bowel preparation is not indicated in elective colorectal operations unless there are anticipated problems with faecal loading that might create technical difficulties with the procedure, e.g. laparoscopic surgery, low rectal cancers.
http://www.nhmrc.gov.au/_files_nhmrc/file/nics/material_resources/epgr_review_chapter_9.pdf
American Society of Colon and Rectal Surgeons
Werner Formann
Ignaz Semmelweis

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www.downstatesurgery.

Bowel Preparation for Colon Resection

Case Series (1987)

Is Mechanical Bowel Preparation Mandatory for Elective Colon Surgery?

Group 1 Soffodex Group 2 No bowel prep

No statistically significant results

Mortality Wound Infection Anastomotic breakdown Abdominal / pelvic collection

Infectious abdominal complications

Anast. leakage (p = 0.21) Intra-abdominal abscess (p = 0.62) Wound abscess (p = 0.07)

NGT removal (p = 0.007) Hospital stay (p = 0.024) Hospital stay* (p = 0.001)

* Patients without abdominal complication

Pre-operative mechanical bowel cleansing or not? An updated meta-analysis

1592 patients from 9 RCTs

Anast. leakage (p = 0.003) Wound infection (p = 0.07) Mortality (NS)

1505 patients randomized

Not statistically significant overall

Wound infection Deep abscess Anastomotic dehiscence Postoperative stay

Reasons to continue mechanical bowel preparation

Reasons NOT to continue mechanical bowel preparation

The Association of Coloproctology of Great Britain and Ireland

Australian Cancer Network

American Society of Colon and Rectal Surgeons

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