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Mechanical Bowel Preparation

Mechanical Bowel Preparation. Changes in Our Surgical Practice. UK Department of Surgery Grand Rounds J. S. Hourigan, MD April 2010. (2010). 449 Patients Undergoing Low Anterior Resection….

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Mechanical Bowel Preparation

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  1. Mechanical Bowel Preparation Changes in Our Surgical Practice UK Department of Surgery Grand Rounds J. S. Hourigan, MD April 2010

  2. (2010) 449 Patients Undergoing Low Anterior Resection…. Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg. 2010 Jan;251(1):59-63.

  3. (2010) …..MBP Has No Influence on Anastomotic Failure Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg. 2010 Jan;251(1):59-63.

  4. Objectives…. Briefly Review the Recent History of Mechanical Bowel Preparation Review the Literature Regarding Mechanical Bowel Preparation Discuss MBP’s Influence on Anastomotic Leak and Septic Complications Propose an Evidence-Based Change in Our Surgical Practice

  5. dogma: a point of view or tenet put forth as authoritative without adequate grounds Which Way To Go?

  6. Doesn’t It Make “Sense” To Us?...... Decrease Volume of Intraluminal Content and Fecal Load Decrease the Bacterial Counts Avoid Major Spillage Improve Healing of Anastomosis Decrease Infectious Complications Improve Patient Outcomes

  7. Mechanical Bowel Prep 2009: Cochrane Review Shows No Benefit of MBP 1994-2000s: Several Other Trials Follow 1994: One of First RCT Showing No Benefit with MBP 1990s: Trauma Literature Accumulates Regarding No MBP 1980: Development of PEG-based Solutions Tolerated Better 1972: Hughes Presents Early Challenge to Dogma of MBP 1971: Nichols and Condon Describe Favorable Clinical Experience with Bowl Prep 1970s: Practice of Routine MBP Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT

  8. “Preoperative Preparation of the Colon” (1971) …Clinical Experience “Demonstrated Decreased M&M with Mechanical Removal of Gross Feces” Assumption Was Made That The Benefit Would Come From Significantly Lowering Nonselective Bacterial Counts “Controversy Today Concerns Only the Addition of Antibiotics To Preoperative Mechanical Preparation”… Nichols R, Condon R. Preoperative preparation of the colon. Sur Gynecol Obstet 1971;132: 323-327.

  9. Mechanical Bowel Prep 2009: Cochrane Review Shows No Benefit of MBP 1994-2000s: Several Other Trials Follow 1994: One of First RCT Showing No Benefit with MBP 1990s: Trauma Literature Accumulates Regarding No MBP 1980: Development of PEG-based Solutions Tolerated Better 1972: Hughes Presents Early Challenge to Dogma of MBP 1971: Nichols and Condon Described Favorable Clinical Experience with Bowel Prep 1970s: Practice of Routine MBP Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT

  10. (1972) “Asepsis in Large Bowel Surgery” • Mechanical Cleaning “Loads” the Bowel and Is Unnecessary • Antibiotics Have Restricted Part in Large-Bowel Surgery …This Has Been Considered the “Challenge” to Nichols’ Views Hughes ESR. Asepsis in large-bowel surgery; Hunterian Lecture. Ann Roy Coll Surg Eng 1972, v.51; 347-356.

  11. Mechanical Bowel Prep 2009: Cochrane Review Shows No Benefit of MBP 1994-2000s: Several Other Trials Follow 1994: One of First RCT Showing No Benefit with MBP 1990s: Trauma Literature Accumulates Regarding No MBP 1980: Development of PEG-based Solutions Tolerated Better 1972: Hughes Presents Early Challenge to Dogma of MBP 1971: Nichols and Condon Described Favorable Clinical Experience with Bowel Prep 1970s: Practice of Routine MBP Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT

  12. 2003 1973 1978 1992 1994 1990 2009 1977 1994 1991 2005 2002 1981 2005 1986 1989 1973 1991 1971 1985 1973 Nichols v. Hughes 1971 1978 1985 1995 1989 2006 1973 1981 1986 1977 1987 2003 1984 2006 1987 1985 1992 1995 2001 2009 1998 1985 1987 2002

  13. There is Considerable Discordance Between What We Do and What We Know…. Is It Possible That We Know Something More Than What the “Literature” Can Tell Us?

  14. First……What Are We Doing? A Collection of Surveys….

  15. (1990) • 352 Board-Certified Colon and Rectal Surgeons Surveyed … 100% Routinely Used Mechanical Bowel Preparation PEG Solution Used Most Commonly (58%) Solla JA, Rothenberger DA. Preoperative bowel preparation. A survey of colon and rectal surgeons. Dis Colon Rectum. 1990 Feb;33(2):154-9.

  16. “Current Practices….Among North American Colorectal Surgeons” (1997) … 100% Routinely Used Mechanical Bowel Preparation PEG Solution Used Most Commonly (70%) Nichols RL, Smith JW, et al. Current practices of preoperative bowel preparation among North American colorectal surgeons. Clin Infect Dis. 1997 Apr;24(4):609-19.

  17. “Trends in Preparation for Colorectal Surgery” (2003) • 515 ASCRS Members With on Average 14 Years Experience Each ….Survey Results Indicated 99% Routinely Used Mechanical Bowel Preparation 98% Routinely Used Intravenous Antibiotics 75% Routinely Used Oral Antibiotics Zmora O, Wexner SD, et al. “Trends in preparation for colorectal surgery: survey of the members of the ASCRS. Am Surg. 2003 Feb;69(2):150-4.

  18. (2007) “Cathartic Bowel Preparation: A Thing of the Past?” James McCormick, DO ….Most ASCRS Attendees Polled Admitted to Using MBP McCormick J. “Cathartic bowel preparation: a thing of the past?” ASCRS 2007 Meeting. Technologic and Pharmacologic Advances for Enhanced Recovery after Colectomy Symposium.

  19. (2007) And...ACPGBI Guidelines for Management of Colorectal Cancer Bowel Preparation Should Not Be Used Routinely Before Colorectal Cancer Resection Guidelines for the Management of Colorectal Cancer 3rd edition (2007). Issued by The Association of Coloproctology of Great Britain and Ireland; 30-31.

  20. (2010) In Follow-Up…..A Survey of Its Members Indicated the Following: Drummond R, McKenna R, Wright D. Current Practice in Bowel Preparation for Colorectal Surgery: A Survey of the Members of The Association of Coloproctology of GB & Ireland. Colorectal Dis. 2010 Feb 20.

  21. “Mechanical Bowel Preparation and Antibiotic Prophylaxis in Colorectal Surgery: Use By and Opinions of Spanish Surgeons” (2009) • 131 Spanish Colon and Rectal Surgeons Surveyed ….Survey Results Indicated 87% Routinely Use Mechanical Bowel Preparation (60% for Right Colon…90% for Left Colon…99% for Rectum) Roig JV, García-Fadrique A, et al. Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons. Colorectal Dis. 2009 Jan;11(1):44-8.

  22. (2004) Recognizes That No Clear Evidence Exists That MBP Reduces Infectious Complications, Anastomotic Leak, or Mortality Data Lacks Statistical Power to Exclude Type II Error Otchy D, Hyman N, et al. The Standards Practice Task Force. Practice Parameters for Colon Cancer. Dis Colon Rec August 2004; 1269-1284

  23. (2004) However, Bowel Preparation Is Justified Based On….. • Ease of Handling Bowel • Safety of Bowel Preparation • Low Cost Otchy D, Hyman N, et al. The Standards Practice Task Force. Practice Parameters for Colon Cancer. Dis Colon Rec August 2004; 1269-1284

  24. Second……What Do We Know? The Literature….

  25. Let’s First Assume MBP Is Actually a “Good Thing”…. If MBP Is So Critical to Operative “Success”, Why Do We Rarely Talk About the Adequacy of Bowel Preparation? Do We Routinely Cancel or Postpone Elective Cases if A Patient Does Not Finish MBP?

  26. “Inadequate Bowel Preparation and Spillage” (2005) • MBP Causes Significantly Higher Incidence of Liquid Contents • Spillage with Bowel Prep (17%) v. NO Bowel Prep (12%) Liquid (31%) SemiSolid (10%) Solid (3%) MBP “Loads” the Bowel (Hughes) Mahajna A, Krausz M, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005; 48:1626-31.

  27. Tendency Toward More Infectious Complications Anastomotic Leak (6.2% v. 3.8%) Wound Infection (12.5% v. 6.7%) Mahajna A, Krausz M, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005; 48:1626-31.

  28. Let’s Then Assume MBP is Not Such A “Good Thing” Does the Literature Support Not Using MBP Routinely in Elective Colorectal Surgery? Two Large Meta-Analyses….

  29. #1 2009 “Mechanical Bowel Preparation for Elective Colorectal Surgery”

  30. “Mechanical Bowel Preparation for Elective Colorectal Surgery” (2009) • Second Update (v.3) with Five Additional New Trials Included • 14 RCTs with 4776 Participants • Anastomotic Leakage was Primary Outcome Measure • Secondary Outcome Measures Included Wound Infection • Prophylactic Antibiotics Used In Both Treatment Groups Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  31. Anastomotic Leak 4.2% v 3.4% Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  32. Wound Infection 9.6% v. 8.3% Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  33. No Statistically Significant Difference Between MBP and No-MBP (2009) ….This Represented a “Change” From 2005 2005 Statistically Significant Increase in Anastomotic Leak with MBP 2003 No Difference 2009 No Difference Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  34. The Lack of Proven Benefit for MBP Allowed Authors To Suggest the Abandonment of MBP…. ….Except When Needed To Identify Pathology or Perform Intra-Op Colonoscopy Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  35. UK (1) Sweden (1) Israel (2) Switzerland (1) Germany (1) Belgium (1) Spain (1) Ireland (1) Peru (1) Finland (1) Brazil (2) Nether (2) Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

  36. #2 2009 “Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials on the Role of Mechanical Bowel Preparation Before Colorectal Surgery”

  37. (2009) “Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials on the Role of Mechanical Bowel Preparation Before Colorectal Surgery” (2003: Significant Increase in Anastomotic Leak with PEG MBP; 5.3% v. 3.2%) 14 Randomized Clinical Trials with 4859 Participants Slim K, Vciaut E, et al. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg Feb 2004; 91:1125-30. Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  38. 15.7% v. 14.5% …No-MBP Was Favored for “All SSI” with Statistical Significance All SSI Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  39. Two Interesting Side Notes With Conflicting Preference for MBP Were Recognized in This MA…. Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  40. First,…. …Bucher et al Demonstrated the Negative Effects of MBP Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation v. no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92: 409-414. Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  41. MBP 22% No-MBP 8% MBP 6% No-MBP 1% MBP 24% No-MBP 11% MBP 15 No-MBP 10 • Overall Infectious Complications • Anastomotic Leak • Extra-Abdominal Complications • Hospital Stay (Days) Bucher et al (MBP n = 78/No-MBP n = 75) for Left Colon (2005) p=0.028 p=0.021 p=0.034 p=0.024 Therefore, Reduced Post-Operative Morbidity with No-MBP Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation v. no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92: 409-414.

  42. Second,…. ….A Statistically Significant Difference Was Demonstrated In Favor of Mechanical Bowel Preparation Therefore, Reduced Post-Operative Morbidity with MBP Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  43. (2009) Overall, The Authors Made the Following Conclusions…. • Higher Risk of Anastomotic Leakage is NOT Suggested • Harmful Effect of MBP Was Not Evident (As Suggested by Bucher) • MBP Does Not Reduce Infectious Morbidity of Colon Surgery… Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  44. (2009) ….And Suggested MBP Should Be Abandoned “At Least From the Patients’ Perspective” • Quality of Life and Patient Preference • Unwillingness To Have the Same Procedure Again? • Dehydration and Electrolyte Disturbance • Bacterial Translocation Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.

  45. Within Both Large Meta-Analyses… Two “Large Trials” are Important to Note…. Contant et al And Jung et al

  46. Anastomotic Leak MBP (4.8%) v. No-MBP (5.4%) • Abscess with LeakMBP (0.3%) v. No-MBP (2.5%) p = 0.001 (2007) ….Abscesses Not Considered to Be of Major Clinical Importance Contant ME, Hop W. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112-17.

  47. … MBP Before Elective Colorectal Surgery Should Be Abandoned The Authors Made the Following Conclusions…. • No Difference Exists Between MBP and No-MBP • MBP Does Not Decrease/Prevent Infectious Complications • Negative Side-Effects Without Evidence of Benefit Contant ME, Hop W. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112-17.

  48. (2007) • Randomized to MBP (n=686) and No-MBP (n=657) • 324 Patients (24%) Overall Had At Least One Complication • No Significant Difference Between Groups in Complication Rates • No Benefit in Anastomotic Healing or Infection Rates with MBP • No Improvement in Overall Post-Op Course or Patient Outcome Jung B, Pahlman L, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colon resection. Br J Surgery 2007; 94:689-95.

  49. Authors Concluded… Once Again, The Practice of MBP Should Be Abandoned Jung B, Pahlman L, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colon resection. Br J Surgery 2007; 94:689-95.

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