Preparación mecánica intestinal, ¿se justifica en la actualidad? Artículo de revisión / Mechanical bowel preparation, is it currently justified? Review article

La preparación intestinal se ha utilizado en cirugía de colon y recto por una variedad de razones, se cree que un colon limpio facilita la manipulación del intestino, permite el paso y disparo de engrapadoras quirúrgicas y permite la colonoscopia intraoperatoria, si es necesario. Sin embargo, el aspecto más estudiado y debatido de la preparación intestinal es su papel en la reducción de la morbilidad quirúrgica, es decir, las infecciones del sitio quirúrgico (ISQ). La cirugía de colon y recto tiene una de las tasas más altas de ISQ reportadas para todos los tipos de cirugía electiva, con revisiones recientes que muestran tasas que varían del 5,4% al 23,2%, con una media ponderada del 11,4%. (1). La preparación mecánica del intestino (PMI) se usó como un medio para disminuir la concentración bacteriana intraluminal con la esperanza de reducir las tasas de infección. Eventualmente, se agregaron antibióticos no absorbibles a las preparaciones intestinales para reducir aún más el contenido bacteriano intestinal(AU)

Bowel preparation has been used in colon and rectal surgery for a variety of reasons. A clean colon is thought to facilitate bowel manipulation, enable passage and firing of surgical staplers, and allow for intraoperative colonoscopy, if needed. The most studied and debated aspect of bowel preparation, however, is its role in reducing surgical morbidity, namely surgical site infections(SSIs). Colon and rectal surgery has among the highest rates of SSIs reported for all types of elective surgery, with recent reviews demonstrating rates varying from 5.4% to 23.2%, with a weighted mean of 11.4%(AU)

Role of Mechanical Bowel Preparation for Elective Colorectal Surgery / 대한소화기학회지

The presence of bowel contents during colorectal surgery has been related to surgical site infections (SSI), anastomotic leakage (AL) and postoperative complications theologically. Mechanical bowel preparation (MBP) for elective colorectal surgery aims to reduce fecal materials and bacterial count with the objective to decrease SSI rate, including AL. Based on many observational data, meta-analysis and multicenter randomized control trials (RTC), non-MBP did not increase AL rates or SSI and other complications in colon and even rectal surgery. In 2011 Cochrane review, there is no significant benefit MBP compared with non-MBP in colon surgery and also no better benefit MBP compared with rectal enemas in rectal surgery. However, in surgeon's perspectives, MBP is still in widespread surgical practice, despite the discomfort caused in patients, and general targeting of the colon microflora with antibiotics continues to gain popularity despite the lack of understanding of the role of the microbiome in anastomotic healing. Recently, there are many evidence suggesting that MBP+oral antibiotics (OA) should be the growing gold standard for colorectal surgery. However, there are rare RCT studies and still no solid evidences in OA preparation, so further studies need results in both MBP and OA and only OA for colorectal surgery. Also, MBP studies in patients with having minimally invasive surgery (MIS; laparoscopic or robotics) colorectal surgery are still warranted. Further RCT on patients having elective left side colon and rectal surgery with primary anastomosis in whom sphincter saving surgery without MBP in these MIS and microbiome era.

The Impact of Mechanical Bowel Preparation in Elective Colorectal Surgery: A Propensity Score Matching Analysis

PURPOSE: To evaluate the influence of preoperative mechanical bowel preparation (MBP) based on the occurrence of anastomosis leakage, surgical site infection (SSI), and severity of surgical complication when performing elective colorectal surgery. MATERIALS AND METHODS: MBP and non-MBP patients were matched using propensity score. The outcomes were evaluated according to tumor location such as right- (n=84) and left-sided colon (n=50) and rectum (n=100). In the non-MBP group, patients with right-sided colon cancer did not receive any preparation, and patients with both left-sided colon and rectal cancers were given one rectal enema before surgery. RESULTS: In the right-sided colon surgery, there was no anastomosis leakage. SSI occurred in 2 (4.8%) and 4 patients (9.5%) in the non-MBP and MBP groups, respectively. In the left-sided colon cancer surgery, there was one anastomosis leakage (4.0%) in each group. SSI occurred in none in the rectal enema group and in 2 patients (8.0%) in the MBP group. In the rectal cancer surgery, there were 5 anastomosis leakages (10.0%) in the rectal enema group and 2 (4.0%) in the MBP group. SSI occurred in 3 patients (6.0%) in each groups. Severe surgical complications (Grade III, IV, or V) based on Dindo-Clavien classification, occurred in 7 patients (14.0%) in the rectal enema group and 1 patient (2.0%) in the MBP group (p=0.03). CONCLUSION: Right- and left-sided colon cancer surgery can be performed safely without MBP. In rectal cancer surgery, rectal enema only before surgery seems to be dangerous because of the higher rate of severe postoperative complications.

Preparación Mecánica del Colon para la Cirugía. ¿Es Necesaria? / Mechanical bowel preparation for surgery. Is it necessary?

Antecedentes: la preparación mecánica del colon (PMC) para la cirugía ha sido de práctica habitual durante décadas. Recientemente han sido publicados muchos trabajos con resultados adversos de la PMC y se ha puesto en duda la necesidad de la misma. Objetivo: evaluar la PMC en una serie consecutiva de enfermos operados en tiempo electivos por patología colónica benigna y maligna. Lugar de aplicación: Sanatorio Dupuytren y Clínica Colegiales. Diseño: estudio prospectivo. Serie consecutiva randomizada y comparativa. Población: n= 251 pacientes randomizados en dos grupos, A=132 pacientes con PMC y B=119 paciente sin PMC. Método: ambos grupos fueron similares en cuanto a sexo, edad y patología (benigna y maligna). Todos fueron operados por el mismo equipo quirúrgico y se excluyeron patologías rectales o cuando hubo anastomosis colo-rectales. Se evaluaron complicaciones inmediatas como infección del sitio quirúrgico, de la pared y dehiscencia anastomótica y la mortalidad. Resultados: no hubo diferencias significativas con respecto a la morbilidad entre el colon derecho y el colon izquierdo: con PMC colon derecho 9.83% y colon izquierdo 7.75%, y sin PMC colon derecho 5.73% vs. colon izquierdo 4.65%. La mortalidad fue de 2 pacientes (1.5%), reoperados con dehiscencia anastomótica, 1 con PMC y 1 sin PMC. Conclusiones: en esta serie no hubo ventajas significativas en los resultados postoperatorios cuando se realizó PMC.

Background: mechanical bowel preparation (MBP) has been the standard practice during decades. Recently, numerous papers with some adverse events related to MBP, have been published raising doubts about the need for its application. Objective: to assess a consecutive series of patients operated on for elective malignant and benign pathology. Setting: Sanatoriums Dupuytren and Colegiales. Design: Prospective, randomized study. Population: two-hundred fifty-one patients of both genders, randomized in 2 groups. A) With MBP: 132 and B) Without MBP: 119. Methods: both groups were similar with regard to age, gender, and pathology. All patients were operated on by the same surgical team. Rectal disease and rectal anastomoses were excluded. Early complications such as anastomotic leakage, abdominal abscesses, and wound infection, and mortality were analyzed. Results: there were not significant differences in morbidity between the right colon (RC), and the left colon (LC) in both groups. Group A) CD: 9,83% vs. CI: 7,75%. Group B) CD: 5.73 % vs. CI: 4,65%. Mortality was 1.5% (2 patients), one with and the other without MBP, both reoperated on for LC anastomotic leakage. Conclusions: in the present series there were not any significant advantages in postoperative outcome when MBP was performed.

Mechanical Bowel Preparation and Prophylactic Antibiotic Administration in Colorectal Surgery: A Survey of the Current Status in Korea

PURPOSE: The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery. METHODS: A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics. RESULTS: A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation. CONCLUSION: The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.

Cirugía colónica laparoscópica sin preparación mecánica: resultados preliminares y análisis de factibilidad / Laparoscopic colectomy, without mechanical bowel cleansing: preliminary results and feasibility

Introducción: La preparación mecánica del colón (PMC) es una práctica común, utilizada por la mayoría de los cirujanos. A pesar de no existir evidencia científica significativa que la avale, se ha convertido en un dogma en la última mitad de siglo XX. La factibilidad del abordaje laparoscópico sin PMC no está aún completamente aclarada. Objetivo: el objetivo del presente estudio es evaluar la factibilidad técnica, y la seguridad del abordaje laparoscópico en cirugía colorrectal sin preparación mecánica. Diseño: análisis retrospectivo y descriptivo, de una base de datos prospectiva. Población: 108 pacientes sometidos a colectomía laparoscópica, sin PMC. Métodos: Periodo analizado: Marzo de 2007 a Marzo de 2010, Forma de registro de datos: consecutiva, sucesiva y no selectiva en una base de datos prospectiva Excel 2011 para Mac. Se tatuaron en forma sistemática todas las lesiones que el cirujano consideró de difícil localización intraoperatoria. Se analizaron variables como edad, sexo, grado de ASA, índice de masa corporal (IMC), cirugías previas, patología, tipo y duración de cirugía, tasa de conversión y su causa. Se utilizó la escala de Dindo y Clavien para categorizar la morbilidad. Para simplificar el análisis se dividieron las colectomías en dos grupos. Los resultados se compararon con los hallados en la bibliografía. Resultados: La media de edad fue 60 años (24-84), el 60% de la serie eran hombres. El 6,5% (7) de los pacientes eran obesos. 37 pacientes (45%) tuvieron una categorización de la clasificación de ASA III o mayor. El 40 % tenían antecedentes de cirugías abdominales previas. El 68% de la patología fue oncológica. Se operaron de forma programada 104 pacientes. Se realizaron 70 anastomosis en 71 colectomías izquierdas y 33 derechas. La tasa de conversión global fue del 11% (12/108). En ningún caso el motivo fue por dificultad en la manipulación del colon...

The mechanical bowel preparation (MBP) is a common practice, used by most surgeons. Despite the absence, of significant scientific evidence, has become a dogma in the latter half of the twentieth century. The feasibility of the laparoscopic approach without MBP is not yet completely clarified. Aim: the objective of this study is to evaluate the technical feasibility, and the security of laparoscopy in colorectal surgery without mechanical preparation. Design: a Descriptive and retrospective analysis has been conducted from a prospective database. Population: 108 patients who underwent a laparoscopic colonic resection without MBP were analyzed. Methods: Period: March 2007 to March 2010. A consecutive, and unselective data was registered in a prospective Excel database. All lesions were tattooed when considered difficult to locate during surgery. Variables such a as age, gender, ASA, BMI, history of surgical treatment, histopathological results, type and length of surgery, convertion rate and its causes were analyzed. Dindo and Clavien’s classification was used to categorized morbidity and mortality. In order to simplify the analysis, colectomies where dived into 2 groups: right and left procedures. Results were compared with the literature. Results: The average age found was 60 years (24-84), 60% of the patients were males. 6.5% were obese. According to the ASA classification, 37 patients (45%) were categorized as ASA III-IV. Forty percent had a history of abdominal surgeries. 68% of the surgical procedures were done for cancer. There were 104 programmed surgeries, 70 anastomosis were performed in 71 left colectomies and in 33 right colectomies. The global conversion rate was of 11% (12/108). None of this conversion was due to lack of small lesion identification. The surgical time was of 180’ (85’-360’). Morbidity rate was 21% (23/108) and the mortality rate found was 0.9% (1/108)...

The Safety of Elective Colorectal Surgery without Mechanical Bower Preparation / 고신대학교의과대학학술지

OBJECTIVES: To reduce the risk of postoperative infectious complications and anastomotic leakage in colorectal surgery, preoperative mechanical bowel preparation (MBP) is performed routinely. The aim of this study was to evaluate the safety of primary anastomosis in elective colorectal surgery without MBP. METHODS: From Jan. 2005 to Dec. 2006, three hundred and seventy-nine patients of elective colorectal surgery with primary anastomosis were performed with MBP in 352 cases (Prep group) and without MBP in 24 cases (Non-prep group). For preoperative MBP, 4 liters of polyethylene glycol solution was administered. Postoperative infectious complications and other morbidity were reviewed with medical records and prospectively collected data. RESULTS: Demographic, clinical and treatment characteristics did not differ significantly between the two groups. The overall rate of abdominal infectious complications (wound infection, anastomotic leak) was 2.9 % in the Prep group and 9 % in the Non-prep group (P > 0.05). Anastomotic leak occurred in nine patients (2.6%) in the Prep group and one (4.5%) in the Non-prep group. CONCLUSIONS: The incidence of infectious complications after elective colorectal surgery without MBP did not differ significantly compare to that with MBP. However, prospective, randomized clinical trial is needed to assess the safety of primary anastomosis in elective colorectal surgery without MBP.

The Impact of Bowel Preparation on Anastomotic Complications after Laparoscopic Colorectal Resection: A Prospective Comparative Study between Oral Polyethylene Glycol and Phosphate Enema

PURPOSE: Although most randomized trials demonstrated no advantage of mechanical bowel preparation for colorectal resection, an oral solution is still widely used. The aims of this study were to evaluate whether a single phosphate enema is as effective as oral polyethylene glycol (PEG) solution in preventing anastomotic complications after laparoscopic colorectal surgery and to examine the clinical courses of anastomotic complications. METHODS: Between September 2006 and December 2007, 309 patients underwent laparoscopic colorectal resection with primary anastomosis. The bowel preparation used was PEG solution during initial period (PEG group), but since February 2007, a single phosphate enema (enema group) was utilized. Postoperative data were prospectively recorded. In patients with anastomotic complications, the clinical course was compared between the two groups. RESULTS: There were 150 patients in the PEG group and 159 patients in the enema group. Demographics did not differ between the two groups. Anastomotic leakage occurred in 3.3 percent of the patients in the PEG group and 5.7 percent of the patients in the enema group (P=0.326). The rates of anastomotic bleeding were 2.0 and 2.5 percent, respectively (P=0.761). The hospital stays for patients with anastomotic complication were not different between the two groups (P=0.137), but patients in the PEG group (80%) needed reoperation more frequently than those in the enema group (11.1%) (P=0.023). CONCLUSION: These results suggest that laparoscopic colorectal surgery may be safely performed with a single phosphate enema instead of oral polyethylene glycol.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Polyethylene Glycol and Sodium Phosphate Oral Lavage Solutions

PURPOSE: This study was undertaken to determine whether a mechanical bowel preparation with 90 ml of sodium phosphate (NaP) solution (Group II) increased the acceptability of bowel preparation and reduced discomfort compared with 2 liters of polyethylene glycol (PEG) combined with a bisacodyl 20 mg (Group I). METHODS: We conducted a prospective, randomized, single-blinded study. Forty-four patients undergoing elective colorectal surgery in the National Health Insurance Corporation Ilsan Hospital from March 2002 to November 2002 were included in this study. We assessed the patients' tolerance and cleansing ability, as well as the surgeon's satisfaction, by using a structured questionnaire. Postoperative complications were also evaluated. RESULTS: Patient tolerance to NaP was higher than it was to PEG (P=0.034). The cleansing ability and the surgeon's satisfaction were not different between the two groups (P=0.217, P=0.349). There is no significant postoperative complication except for 1 case of wound infection in both group. CONCLUSIONS: Both oral solutions proved to be equally effective and safe. However, patient tolerance to the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Two Liters and Four Liters of Polyethylene Glycol-Based Oral Lavage Solutions

PURPOSE: This study was undertaken to determine whether a mechanical bowel preparation with 2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg (Group II) increases the acceptability of bowel preparation and reduces discomfort compared with 4 liters of polyethylene glycol solution (Group I). METHODS: We conducted a prospective randomized single-blinded study. Eighty patients undergoing an elective colorectal surgery in Severance hospital from April 1999 to September 1999 were included in this study. The patients' tolerance, cleansing ability and surgeon's satisfaction were assessed by a structured questionnaire. Postoperative complications were also evaluated. RESULTS: The patients' tolerance of the group II (2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg) was better than that of the groups I (4 liters of polyethylene glycol solution). The cleaning ability and surgeon's satisfaction were not different between two groups (p=0.225, p=0.322). The incidence of postoperative complications was 2.3 percent in Group I and 2.7 percent in Group II. CONCLUSIONS: The mechanical bowel preparation with two liters of polyethylene glycol solution with a Bisacodyl 20 mg was more comfortable to patients and equally efficient compared with the mechanical bowel preparation with the 4 liters of polyethylene glycol solution regimen before elective colorectal surgery.

The Necessity for Mechanical Bowel Preparation before Colonic Resection and Primary Anastomosis

BACKGROUND: The results of recent reports suggest that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary. To determine whether mechanical bowel preparation influences the incidence of postoperative complications following colorectal surgery, the records of patients who had undergone colonic or rectal resection were retrospectively reviewed. METHODS: Between March 1992 and October 1997, colonic resection and primary anastomosis without colostomy was performed on 56 patients. Among these, 27 patients had undergone mechanical bowel preparation (MBP) before surgery, and 29 patients had not. We compared the data from both groups with respect to wound infection, anastomotic leak, intra-abdominal sepsis and death. RESULTS: The postoperative complication and mortality rates were similar in the two groups. Wound infection occurred in seven patients (four with MBP, three without), and the incidence of wound infection was similar in the two groups (14.8% versus 10.3%, P=0.700). Wound disruption occurred in two patients (one with MBP, one without). Anastomotic leaks occurred in two patients who had undergone bowel preparation. The overall anastomotic leak rate was 3.6% (7.4% versus 0%), but the incidence of anastomotic leaks was not significantly different between the two groups (P=0.228). No intra-abdominal sepsis was clinically apparent in either group. There was one death, a patient who had undergone bowel preparation. The mortality rate was not significantly different between the two groups (P=0.482). CONCLUSIONS: We believe that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary, so routine MBP should be further scrutinized.