Bowel Preparation in Elective Bowel Preparation in Elective Colorectal Surgery: ValuableColorectal Surgery: Valuable

John C JamesJohn C James8/3/20098/3/2009

Definition Definition –– Bowel PrepBowel Prep

Low residue or clear liquid diet 3 days Low residue or clear liquid diet 3 days prior to surgery and NPO at midnight prior to surgery and NPO at midnight preoppreop

Preoperative antibioticsPreoperative antibiotics

Mechanical Bowel Prep (MBP)Mechanical Bowel Prep (MBP)

HistoryHistory

Mechanical Bowel Prep (MBP) since late Mechanical Bowel Prep (MBP) since late 1900s1900s

MBP before colorectal surgery generally MBP before colorectal surgery generally accepted in late 1960s accepted in late 1960s –– Reduce bulk of stool preventing disruption of Reduce bulk of stool preventing disruption of

the the anastamosisanastamosis

Historical Variations and Historical Variations and CombinationsCombinations

Castor oil / Castor oil / sennasenna/ / bisacodylbisacodyl/ phenolphthalein / / phenolphthalein / Na Na picosulfatepicosulfate/ Mg citrate/ Mg citrateEnemas: tap water / soap suds / tannic acidEnemas: tap water / soap suds / tannic acidIsotonic SolutionIsotonic Solution–– Caused electrolyte imbalances and fluid shiftsCaused electrolyte imbalances and fluid shifts

MannitolMannitol–– Osmotic diarrhea, electrolyte imbalances and fluid Osmotic diarrhea, electrolyte imbalances and fluid

shiftsshifts

PEGPEG

19801980OsmoticallyOsmotically balancedbalancedFewer electrolyte imbalancesFewer electrolyte imbalancesBut 4L salty intake in short timeBut 4L salty intake in short time–– not tolerated as wellnot tolerated as well

NaPhosNaPhos

Smaller dosesSmaller dosesSignificantly higher tolerability and patient Significantly higher tolerability and patient acceptance*acceptance*Not recommended in renal Not recommended in renal failure/CHF/cirrhosisfailure/CHF/cirrhosis

**KastenbergKastenberg, Clinical Gastroenterology, 2007, Clinical Gastroenterology, 2007

DogmaDogma

For decades surgeons have been utilizing For decades surgeons have been utilizing mechanical bowel preparations prior to mechanical bowel preparations prior to elective colon surgeryelective colon surgeryMany recent articles suggest it could be Many recent articles suggest it could be associated with associated with anastamoticanastamotic leakageleakageBut small randomized clinical trialsBut small randomized clinical trials

2009 Meta2009 Meta--AnalysisAnalysis

Larger Larger –– 4859 pts. Including two recent 4859 pts. Including two recent larger studies.larger studies.

No statistical differences for all outcomes No statistical differences for all outcomes consideredconsidered

Karem. Annals of Surgery, 2009

Karem. Annals of Surgery, 2009

Contant. Lancet. 2007

MetaMeta--AnalysisAnalysis

This metaThis meta--analysis plays down the analysis plays down the significancesignificance……

It would take 333 patients before a It would take 333 patients before a difference were seendifference were seen

Admits no higher risk of Admits no higher risk of anastamoticanastamotic leak leak as some smaller studies suggestas some smaller studies suggest

ProsPros

No higher risk of leakNo higher risk of leak

Possible lower risk of abscessPossible lower risk of abscess

Others?...Others?...

Survey 2003Survey 2003

American Society of Colon and Rectal American Society of Colon and Rectal SurgerySurgery10 per cent questioned the importance of 10 per cent questioned the importance of mechanical prep, butmechanical prep, but……More than 99 per cent routinely used it.More than 99 per cent routinely used it.–– 47 per cent used sodium phosphate, 32 per 47 per cent used sodium phosphate, 32 per

cent used polyethylene glycol, and 14 per cent used polyethylene glycol, and 14 per cent alternated between these two options cent alternated between these two options

20062006

Kehlet. JACS. 2006

More Reasons for MBPMore Reasons for MBP

Facilitates palpation of bowel and helps locate occult tumors

Allows for intra-operative colonoscopy& Bxif necessary

In laparoscopic surgery, it decreases bowel weight and eases manipulation

ConclusionsConclusions

No significant infectious risks to MBPNo significant infectious risks to MBPPossible lower infection riskPossible lower infection riskOther more qualitative benefits Other more qualitative benefits intraoperativelyintraoperativelyVALUABLE!VALUABLE!

ReferencesReferencesKastenbergKastenberg D, D, Tolerability and Patient Acceptance of Sodium Phosphate Tablets Tolerability and Patient Acceptance of Sodium Phosphate Tablets Compared With 4Compared With 4--L PEG Solution in Colon Cleansing: Combined Results of 2 L PEG Solution in Colon Cleansing: Combined Results of 2 Identically Designed, Randomized, Controlled, Parallel Group, Identically Designed, Randomized, Controlled, Parallel Group, MulticenterMulticenter Phase 3 Phase 3 TrialsTrials. Journal of Clinical Gastroenterology. Volume 41(1),. Journal of Clinical Gastroenterology. Volume 41(1), January 2007,January 2007, pp 54pp 54--6161ZmoraZmora O. O. Trends in preparation for colorectal surgery: survey of the membTrends in preparation for colorectal surgery: survey of the members of the ers of the American Society of Colon and Rectal SurgeonsAmerican Society of Colon and Rectal Surgeons. . Am Am SurgSurg.. 2003 Feb;69(2):1502003 Feb;69(2):150--4 4 Slim K. Slim K. Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials on the Role of Mechanical Bowel Preparation Before Colorectal Surgery. Annals of Surgery, 249(2)Feb 2009RoigRoig JV. JV. Mechanical bowel preparation and antibiotic prophylaxis in colorMechanical bowel preparation and antibiotic prophylaxis in colorectal ectal surgery: use by and opinions of Spanish surgeons. Colorectal Dissurgery: use by and opinions of Spanish surgeons. Colorectal Diseaseease. 2008, 11,44. 2008, 11,44--4848ZmoraZmora O. O. Laparoscopic Laparoscopic colectomycolectomy without mechanical bowel preparationwithout mechanical bowel preparation. . IntInt J J Colorectal Dis. 2006, 21:683Colorectal Dis. 2006, 21:683--687687ContantContant C. C. Mechanical bowel preparation for elective colorectal surgery: a Mechanical bowel preparation for elective colorectal surgery: a multicentermulticentertrial. Lancettrial. Lancet. 2007, 370. 2007, 370Jung B. Jung B. MulticentreMulticentre randomized clinical trial of mechanical bowel preparation in randomized clinical trial of mechanical bowel preparation in elective colon resectionelective colon resection. Brit J . Brit J SurgSurg. 2007; 94: 689. 2007; 94: 689--695695