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.

Nichols-Condon Bowel Prep

What is a bowel preparation?

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.

What is the practice of bowel preparation at UCHSC and

DHMC?

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

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

National Preparation Methods

Preparation Methods at UCHSC/DHMC

2211

67

100

0 0

78

22

00102030405060708090

100

Oral Abx IV abx Bowel Prep

YesSelectiveNever

Mechanical Bowel Prep Agents

Bowel Prep Agents UCHSC/DHMC

33 33 33

05

101520253035404550

NaP PEG Diet/Cath

IV Antibiotics

IV Antibiotics at UCHSC/DHMC

11

33

11 11

22

11

0

5

10

15

20

25

30

35

1 Ceph 2 3 2/F PCN+clav Erta

Mechanical Bowel Preparation is Overrated

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.

Infectious Complications

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.