bowel preparation for colon · pdf filebowel preparation for colon resection eric klein, m.d....

Bowel Preparation forColon Resection

Eric Klein, M.D.SUNY Downstate

Department of Surgery

www.downstatesurgery.org


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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)

No preparation(n = 165)

Mortality 1.2% 1.2%

Wound Infection

9.8% 6.1%

Anastomotic breakdown

0.6% 1.2%

Abdominal / pelvic collection

0.6% 0.6%


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)

No preparation (n = 75)

Anast. leakage(p = 0.21)

6% 1%

Intra-abdominal abscess(p = 0.62)

1% 3%

Wound abscess (p = 0.07)

13% 4%


Postoperative data

Mechanical bowel prep

(n = 78)


NGT removal(p = 0.007)

2.8 days 1.9 days

Hospital stay(p = 0.024)

14.9 days 9.9 days

Hospital stay* (p = 0.001)

11.7 days 9.1 days

* Patients without abdominal complication


Pre-operative mechanical bowel cleansing or not? An updated

meta-analysisWille-Jørgensen P, Guenaga KF,

Matos D, Castro AA.Colorectal Dis. 2005 Jul;7(4):304-10.


1592 patients from 9 RCTs



Anast. leakage(p = 0.003)

6% 3.2%

Wound infection (p = 0.07)

7.4% 5.4%

Mortality(NS)

1% 0.6%


Multicentre randomized clinical trial of mechanical bowel

preparation in elective colonic resection

Jung B, Påhlman L, Nyström 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



Wound infection 7.9% 6.4%

Deep abscess 0.7% 1.7%

Anastomotic dehiscence

1.9% 2.6%

Postoperative stay

8.6 days 8.8 days


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)

No oral antibiotics(n = 197)

C. difficile colitis(p = 0.03)

7.4% 2.6%

Wound infection(p = 0.20)

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 GuidelinesRevision 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 Forßmannwww.downstatesurgery.org

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Ignaz Semmelweiswww.downstatesurgery.org

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bowel preparation for colon · pdf filebowel preparation for colon resection eric klein, m.d....

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