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
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
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