Mechanical Bowel Preparation - why bother?

1. Mechanical Bowel Preparation- why bother? An overview of current evidence and our experience from a 2 year case series T Thakar, A Akingboye, R Nadarajah, F Younis & SV Gurjar Luton & Dunstable University Hospital

2. What is Mechanical Bowel Preparation (MBP)? The use of methods to vigorously cleanse the bowel of faecal contents Aims to minimise risk of septic complications in colorectal surgery, particularly SYMPTOMATIC ANASTOMOTIC LEAK

3. Traditional Belief • REDUCED faecal mass LOWERS bacterial load • LESS risk of spillage & contamination • LESS risk of sepsis and anastomotic leak …….which makes sense, right? BUT THE EVIDENCE TO DATE INCREASINGLY CHALLENGES THIS “DOGMA”

4. The DOWNSIDE of MBP • Volume/electrolyte imbalance risk • Inadequate MBP results in liquid stools • May need hospital admission • Time consuming & inconvenient • Nausea, pain, bloating Mainly associated with polyethyl glycol or PEG lavage solutions

6. COCHRANE REVIEW 2011 on MBP in elective colorectal surgery • 18 randomised clinical trials (RCTs) with 5805 total participants • 2906 in Group A had pre-operative MBP • 2899 in Group B had none • Primary outcome: Anastomotic leak • Secondary outcome: mortality, peritonitis, re-operation, wound infection

7. MBP v no MBP No statistical significant evidence of benefit from MBP

8. MBP v Enema for Rectal Surgery No statistical significant evidence of benefit from MBP

9. Conclusions of Cochrane Review • MBP may be safely omitted in cases where lesion can be easily identified • Poor MBP is WORSE than NO MBP • Consider MBP for intra-op colonoscopy or inadequate localisation • Further RCTs needed for laparoscopic & rectal surgery

10. Enhanced Recovery After Surgery 2013 Guidelines based on best available evidence to provide optimal perioperative care protocol • MBP should NOT be in routine use for colonic surgery • Pre-operatively tattoo obviates need for MBP in laparoscopic resections • But authors question the wisdom of extrapolating evidence mainly based on open surgery and applying it to laparoscopy • Recommend further research

11. The Association of Coloproctology of Great Britain and Ireland, 2007 Guidelines on the Management of Colorectal Cancer Controversially it seems that bowel preparation might lead to more anastomotic leakage and thus the procedure should be omitted…. The rationale for avoiding bowel preparation prior to low anterior resection is less compelling than for colonic resection. “Bowel preparation should not be used routinely before colorectal cancer resection”

12. Retrospective analysis of case series from Colorectal Dept Aim: to examine our current pre-operative practice for patients undergoing elective left-sided colonic & rectal surgery

13. Method • Retrospective review of consecutive cases over 2 years reviewed from 2 Consultant Colorectal Surgeons • Low residue diet, senna and enema pre-op • Included • elective left-colonic and rectal surgery • benign and cancer • Excluded • emergencies, Hartmann’s procedures & formation of defunctioning stomas

14. Results

15. Summary From our experience, traditional Mechanical Bowel Preparation is not necessary for elective left-colonic and rectal resections. This practice is supported by best available clinical evidence.

16. References • Mechanical Bowel Preparation for elective colorectal surgery (Review) Guenaga KF, Matos D, Wille-Jorgensen PThe Cochrane Collaboration, The Cochrane Library 2011, Issue 9 • Guidelines for Perioperative Care in Elective Colonic Surgery: U. O. Gustafsson et al Enhanced Recovery After Surgery (ERAS) Society Recommendations World J Surg (2013) 37:259–284 • Guidelines for the Management of Colorectal Cancer, The Association of Coloproctology of Great Britain and Ireland (2007)

17. Thank you