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Bowel Preparation for Colon Resection


Eric Klein, M.D. SUNY Downstate Department of Surgery

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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.

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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.

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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.

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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.

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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

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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

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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

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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

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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%

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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

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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.

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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)

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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.

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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

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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

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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.

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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)

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Bowel Preparation
All patients received mechanical bowel preparation All patients received prophylactic IV antibiotics

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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

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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

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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)

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http://www.acpgbi.org.uk/assets/documents/COLO_guides.pdf

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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

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Werner Formann

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Ignaz Semmelweis