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Bowel Preparation or Not?

Bowel Preparation or Not?. Kamal Itani, MD Professor of Surgery Boston University Chief of Surgery VA Boston Health Care System Boston, MA. Disclosure.

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Bowel Preparation or Not?

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  1. Bowel Preparation or Not? Kamal Itani, MD Professor of Surgery Boston University Chief of Surgery VA Boston Health Care System Boston, MA

  2. Disclosure Dr Itani reports receiving grants/research support from Mediflex, Pfizer Inc, and Wyeth Pharmaceuticals; receiving honoraria from Merck and Company and Pfizer Inc; serving as a consultant for Merck and Company; and serving on the speakers’ bureau for Pfizer Inc.

  3. Mechanical Bowel Preparation Definition • The administration of substances to induce voiding of the intestinal and colonic contents Rationale • Necessary to decrease the amount of stool within the colon and thereby reduce the volume of bacteria Assumptions • Improves healing of a colonic anastomosis; decreases the risk of leak and infection; improves the handling of bowel intraoperatively

  4. Mechanical Bowel Preparation in Elective Colorectal Surgery • Advantages: Clean bowel, decreased bacterial load, prevents anastomotic disruption(?) • Disadvantages: Patient discomfort, compliance, electrolyte abnormalities, dehydration

  5. Mechanical Bowel Preparation • “Mechanical preparation by means of purgation and enemas is utilized in nearly all patients undergoing elective operations of the colon. Clinical experience long ago demonstrated that mechanical removal of gross feces from the colon was associated with decreased morbidity and mortality rates in patients undergoing operations of the colon. Controversy today concerns only the addition of antibiotics to preoperative mechanical preparation.” Nichols RL et al. Surg Gynecol Obstet. 1971;132:323-337.

  6. Mechanical Bowel Preparation • Mineral oil and enemas: 40s–70s • Whole-gut irrigation: 70s • Oral preparation (laxatives, magnesium sulfate, polyethylene glycol (PEG), sodium picosulfate, mannitol, sodium phosphate (SP), etc)

  7. Bowel Preparation in Elective Colorectal Surgery • 2 days before surgery (at home) • Low-residue or liquid diet • Magnesium sulfate 30 mL of 50% solution orally at 10 AM, 2 PM, and 6 PM • Fleet enemas until diarrhea effluent clear in the evening • The day before surgery (at home or in hospital if necessary) • Admit in morning (if necessary) • Clear liquid diet, intravenous (IV) fluids as needed • Magnesium sulfate, as above at 10 AM and 2 PM OR whole-gut lavage with PEG-3350 oral solution (1L/h for 2–3 hours until diarrhea effluent clear) • Neomycin and erythromycin base, 1 g each orally at 1 PM, 2 PM, and 11 PM • Day of surgery • Operation at 8 AM • A single dose of IV antibiotic just before incision; repeat dosage if operation lasts more than 2 hours

  8. Mechanical Bowel Preparation in Elective Colorectal Surgery • Type of mechanical bowel preparation (MBP) remains controversial • PEG and SP are safe and effective in colorectal cleansing • Effect of PEG and SP on SSI was assessed by post hoc analysis of data from a controlled trial of IV antibiotic prophylaxis (ertapenem vs cefotetan)

  9. Methods • Study design • Secondary analysis of a multicenter (51 US sites), double-blind, randomized, prospective study • Men and women >18 years of age • Scheduled elective colon or rectum surgery with sufficient time for MBP (SP or PEG) • Randomized (1:1) to ertapenem (1 g) or cefotetan (2 g) • Analysis at 4 weeks posttreatment • Proportion of evaluable patients with SSIs by MBP Itani KM et al. Am J Surg. 2007;193:190-194.

  10. Effect of Mechanical Bowel Preparation on Postoperative SSI Itani KM et al. Am J Surg. 2007;193:190-194.

  11. Effect of Mechanical Bowel Preparation and Type of Antibiotic Prophylaxis on Postoperative SSI Rates Itani KM et al. Am J Surg. 2007;193:190-194.

  12. Mechanical Bowel Preparation in Elective Colorectal Surgery • 7 prospective clinical trials in the 90s and 00s comparing MBP with no MBP • Bucher P et al. Arch Surg. 2004;139:1359-1364 (meta-analysis) • 5.6% vs 2.8% anastomotic leak (P = .03) • 3.7% vs 2.0% intra-abdominal infection (P = .18) • 7.5% vs 5.5% wound infection (P = .15)

  13. Mechanical Bowel Preparation in Elective Colorectal Surgery • Prospective randomized trial started in 2003 (950 patients); preliminary report on 93 patients at SSAT 2005 (MBP does not reduce postoperative infectious complications) • Progress report: Bucher P et al. Br J Surg. 2005;92:409-414 • 22% vs 8% intra-abdominal infection (P = .028) • 6% vs 1.0% anastomotic leak (P = .21) • 24% vs 11% extra-abdominal morbidity (P = .034) • 14.9 days vs 9.9 days length of stay (P = .024) SSAT = Society for Surgery of the Alimentary Tract.

  14. Morphologic Alterations With Mechanical Bowel Preparation • Moderate to severe loss of superficial mucus (96% vs 52%, P < .001) • Moderate to severe loss of epithelial cells (88% vs 40%, P < .01) • Severe lymphocyte infiltration (48% vs 12%, P < .02) • Severe polymorphonuclear cell infiltration (52% vs 8%, P < .02) Bucher P et al. Dis Colon Rectum. 2006;49:109-112.

  15. Conclusions • SP is a superior MBP for prophylaxis of SSI compared with PEG in elective colorectal surgery • Enhanced by type of IV prophylactic antibiotic • Combination of SP and ertapenem was most effective • Future studies comparing preoperative MBP (with/without) should consider: • Type of prophylactic IV antibiotic • SP as standard MBP • Oral antibiotics might further lower SSI rates

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