Post on 21-Apr-2018
Bowel Prep Prior to Colon/Rectal Surgery: Valuable vs. Overrated
Alian Garay-ValuableAnnie Kulungowski-OverratedDepartment of Surgery Grand
RoundsSeptember 24, 2007
Bowel Preps are Overrated
History of bowel preparationWhat are bowel preps? How to perform?What do colorectal surgeons in the US do?/What do surgeons at UCH/DHMC do?Bowel preparation for colorectal surgery is overrated-The data do not lie.Closing Remarks
Colonic Flora
Enormous reservoirColonic microflora-anaerobic
Bacteroides fragilis 1011 CFU/g stoolAerobic coliforms 107 CFU/g stool
Prior to 1975 postoperative infection-10-40%
History Lesson1898-Halsted-aseptic anastomosis-suture over inflatable cylinder
Early methods included:Charcoal, chlorine, salicylatesNo influence on post-op infectionToxic complications
1953 E.J. Poth proposes neomycin/sulfathalidine for intestinal antisepsis
History Lesson
Nichols, Condon, Gorbach, et al. Veterans Administration Cooperative study on bowel preparation for elective colorectoal operations. Ann Surg. 1978; 188(2): 249–254.
Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:320-324.
Bowel Preparation
Old methods-castor oil, senna, dulcolaxSide effects-cleaning insufficient
Required addition of enemas
MannitolSide effects-dehydration, electrolyte disturbances and colonic explosion
Current Agents
Polyethylene glycol(PEG-ELS)-1980, osmotically balanced
Benefit-less electrolyte/water changesDown side-4 liters salty fluid
Nausea, vomiting, fullnessAt least 5-15% are unable to complete the prep
Grundel et al. Improvements in mechanical bowel preparation for elective colorectal surgery. Dis Colon Rectum 1997; 40:585-91Zmora et al. Bowel Preparation for Colorectal Surgery. Dis Colon Rectum 2000; 44:1537-1549.
Current Agents
Sulfate-free electrolyte lavage solution-(NuLytely, SF-ELS)
Benefit-No rotten egg smellSlightly better compliance
Reduced Volume Lavage-Bisacodyl 20 mg at 12 p.m. and 6 p.m. 2L SF-ELS
Benefit-less fullness, N/V
Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:320-324.
Current Agents
Phosphates
Oral sodium phosphate(Phosphosoda)-45 ml solution with water given evening before surgery and repeated 12 hours later
Phosphate tabs-(Visicol)-40 tablets with 10 glasses of water
Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:320-324.
Trends in Preparation for Colorectal Surgery: Survey of the Members of the American Society of Colon and Rectal Surgeons
In 2003, 1295 questionnaires were sent out to American colon and rectal surgeons515 returned questionnaires for a 40% response rate
Zmora et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. The American Surgeon 2003; 69:150-155.
UCHSC/DHMC Bowel Prep
On line survey of attendings at UCHSC/DHMCUCHSC-Response rate of 70%DHMC-Response rate of 30%, one physician refused
weakest type of evidence, “expert opinion”and stated he was not in favor that
Overall response rate of 56%
Usefulness of Bowel Preparation in Infection Prevention at UCHSC/DHMC
0
67
33
100
0 011
78
110
102030405060708090
100
OralAbx
IV Abx BowelPrep
YesDoubtfulNo
Preparation Methods at UCHSC/DHMC
2211
67
100
0 0
78
22
00102030405060708090
100
Oral Abx IV abx Bowel Prep
YesSelectiveNever
Mechanical bowel preparation for colonic resection and anastomosis
Ivring and Scrimgeour. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surgery 1987; 74:580-581.
Type of resection n Elective Emergency Wound Infection
Sigmoid/Descending Colon
24 18 6 4 (2 emer, 2 elective)
Anterior resection
High 12 9 3 1 (elective)
Low 10 7 3 __
Right Hemicolectomy 26 19 7 1 (emergent)
Totals 72 53 19 6 (8%)
Requirement for Bowel Preparation in Colorectal Surgery
Burke, P. Mealy, K. Requirement for bowel preparation in colorectal surgery. Br J Surgery 1994; 81:907-10
Bowel Prep n=82
No Prep n=87
No. of deaths 2 (2%) 0Complications 15 (17%) 16 (18%)
Cardi/Pulm 8 (10%) 9 (10%)
Wound infection 4 (4%) 3 (3%)
Anast. leakage 3 (3%) 4 (4%)
Bowel Preparation with Oral Polyethylene Glycol Electrolyte Solution vs. No Preparation in Elective Open Colorectal Surgery
Pekka, R, Miettinen, J. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery. Dis Colon and Rectum 2000;43:669-75.
Colon and Rectal Surgery Without Mechanical Bowel Preparation: A Randomized Prospective Trial
Zmora, O. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg. 2003; 237:363-367.
Mechanical Bowel Preparation for Elective Colorectal Surgery: A Meta-analysis
Seven RCT includedTotal patients 1297Mechanical bowel prep-642No bowel prep-655
Bucher, P, Mermillod, B. Mechanical bowel preparation for electivecolorectal surgery: a meta-analysis. Arch Surgery. 2004; 139:1359-1364
Received MBP
No MBP
AnastomoticDehiscence
36/642 (5.6%)
18/655(2.8%)
P=.03OR 1.85
P=.18OR 1.69
P=.15OR=1.38
P=.16OR=1.72
Mortality(1 excluded)
5/526(1%)
3/532(.5%)
P=.6OR=1.42
Intra-abdominalInfection(3 excluded)
17/458(4.7%)
9/461(2%)
Wound infection
48/642(7.5%)
36/665(5.5%)
Reoperation(1 excluded)
19/369(5.2%)
10/369(2.2%)
Mechanical Bowel Preparation for Elective Colorectal Surgery
Retrospective review of 9 prospective RCT1592 patients
MBP 789No MBP 803
Main outcome Anastomotic LeakageSecondary outcome Mortality, Peritonitis
Reoperation, Wound infection, Infectious extra-abdominal and non-infectious extra-abdominal , SSI
Guenaga, K. Mechanical bowel preparation for elective colorectal surgery. The Cochrane Collaboration 2007;1-27.
The Cochrane Review 2007Mechanical Bowel Prep
No Mechanical Bowel Prep
AnastomoticLeak
48/722 (6.2%) 25/777(3.2%) OR=2.03p=.003OR=1.72
OR=2.28p=.05OR=1.8
OR=1.46p=.07
Mortality 5/509 (1%) 3/516 (.6%)
Peritonitis 16/278 (5.7%) 7/275 (2.5%)
Reoperation 16/339 (4%) 9/392 (2.2%)
Wound Infection
59/789 (7.4%) 43/803 (5.4%)
Theories
Bowel wall edemaCompromises microcirculation ischemia
Liquid feces spillage into peritoneumUnprepared bulky stoolBowel handlingBacterial translocation SBP with PEG
Preoperative Oral Antibiotics in Colorectal Surgery Increases the Rate of Clostridium difficile Colitis
304 patients given cathartics and IV abx107 also had po abxC. diff colitis 4.2%
Wren, S. et al. Preoperative oral antibiotics in colorectal surgeryincrease the rate of Clostridium difficile colitis. Arch Surgery 2005;140:752-756.
Colonic Ischemia with Laxative Use in Young Adults
Two healthy young adults, 33 and 19Occurred after using Dulcolax for constipation33 yo took 20 mg19 yo took 10 mgIncreased intraluminal pressure >30 mmHgBlood flow shunts from mucosa to serosa
Morra, H. et al. Colonic ischemia with laxativeUse in young adults. Am J of Gastro 2005;100:2134-36
Renal Failure
Diabetics receiving oral sodium phosphate risk of renal failureBeware of phosphate preps
Using diureticsNSAIDSARBs/ACEI
Ma, Chow, et al. Acute renal failure following oral sodium phosphate bowel preparation in diabetes. Diabetes Care 2007;30:182=83.
What can be done to prevent complications during colorectal surgery?
Timely administration of PAWithin 1 hour of incision
Correct antibiotic choiceOral-neo+erythro or neo+metroParenteral-Cefotetan, Cefoxitin, Cefazolin+ metro or amp-sulbactam
.
Bratzler, D. and Hunt, D. The Surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.Clinical Infectious Diseases2006; 43(3):322-30
Closing Remarks
CostlyIncreased complications
Anastomotic dehiscenceWound infectionIntraabdominal abscessRenal failure/electrolyte imbalanceC. diffDiarrhea
UncomfortableSurgical dogma scientific evidence
ReferencesBratzler, D. and Hunt, D. The Surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.Clinical Infectious Diseases 2006; 43(3):322-30Bucher, P, Mermillod, B. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surgery. 2004; 139:1359-1364Burke, P. Mealy, K. Requirement for bowel preparation in colorectal surgery. Br J Surgery 1994; 81:907-10Grundel et al. Improvements in mechanical bowel preparation for elective colorectal surgery. Dis Colon Rectum 1997; 40:585-91Guenaga, K. Mechanical bowel preparation for elective colorectal surgery. The Cochrane Collaboration 2007;1-27.Ivring and Scrimgeour. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surgery 1987; 74:580-581.Ma, Chow, et al. Acute renal failure following oral sodium phosphate bowel preparation in diabetes. Diabetes Care 2007;30:182=83.Morra, H. et al. Colonic ischemia with laxative use in young adults. Am J of Gastro 2005;100:2134-36Nichols, Condon, Gorbach, et al. Veterans Administration Cooperative study on bowel preparation for elective colorectoal operations. Ann Surg. 1978; 188(2): 249–254. Pekka, R, Miettinen, J. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery. Dis Colon and Rectum 2000;43:669-75.Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:320-324.Wren, S. et al. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surgery 2005;140:752-756. Zmora, O. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg. 2003; 237:363-367.Zmora et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. The American Surgeon 2003; 69:150-155.Zmora et al. Bowel Preparation for Colorectal Surgery. Dis Colon Rectum 2000; 44:1537-1549.