bowel preparation colon resection

8/2/2019 Bowel Preparation Colon Resection

1/28

Bowel Preparation for

Colon Resection

Eric Klein, M.D.

SUNY DownstateDepartment of Surgery

www.downstatesurgery.org


2/28

http://upload.wikimedia.org/wikipedia/commons/f/f8/Ignaz_Semmelweis_1860.jpghttp://upload.wikimedia.org/wikipedia/commons/2/2e/Bundesarchiv_B_145_Bild-F006444-0033%2C_M%C3%BCttergenesungswerk_bei_Bundespr%C3%A4sident_Heuss.jpg


3/28

Historical Perspective

During World War II, failure to treatpenetrating colon injuries with diversioncould result in court martial.

Miller PR, Fabian TC, et al. Improving outcomes following penetrating colon wounds:application of a clinical pathway. Ann Surg. 2002 Jun;235(6):775-81.



4/28

Madden (1965)

Primary resection and immediateanastomosis of perforated lesions of thecolon

85 cases from literature

25 additional cases

9.1% mortality

Madden JL. Primary resection and anastomosis in the treatment of perforated lesions ofthe colon. Amer Surg 31: 781, 1965.



5/28

Case Series (1987)

In a series of 72 consecutive elective andemergency colectomies with primaryanastomosis, all pre- and perioperative

mechanical preparation of the bowel wasomitted and the patient covered only by asingle peroperative intravenous dose ofcefuroxime and metronidazole. No

anastomotic dehiscence was clinicallyapparent and wound infection was notedin only 8.3 per cent of patients.

Irving AD, Scrimgeour D. Mechanical bowel preparation for colonic resection andanastomosis. Br J Surg 1987; 74: 580-1.



6/28

Editorial

The paper which challenges acceptedsurgical practice, is a veritable little bombof a paper, brief, iconoclastic, and

disrespectful of hallowed tradition incolorectal surgery.



7/28


8/28

Colon Resections

Excluded low LAR and surgery forpolypoid lesions

Prophylactic antibiotics (1 hour preop, 48hours post-op)

Ceftriaxone 1g

Metronidazole 500mg

Group 1 Soffodex

Group 2 No bowel prep



9/28

No statistically significant results

Mechanicalbowel prep

(n = 164)

No preparation

(n = 165)

Mortality 1.2% 1.2%

Wound

Infection

9.8% 6.1%

Anastomoticbreakdown

0.6% 1.2%

Abdominal /

pelvic collection

0.6% 0.6%



10/28

Randomized clinical trial ofmechanical bowel preparationversus no preparation beforeelective left-sided colorectal

surgery.Bucher P, Gervaz P, Soravia C,

Mermillod B, Erne M, Morel P.Br J Surg. 2005 Apr;92(4):409-14.

Switzerland


d


11/28

Infectious abdominal complications


(n = 78)

No preparation(n = 75)

Anast. leakage

(p = 0.21)

6% 1%

Intra-abdominal

abscess(p = 0.62)

1% 3%

Wound abscess

(p = 0.07)

13% 4%


d t t


12/28

Postoperative data


(n = 78)


NGT removal

(p = 0.007)

2.8 days 1.9 days

Hospital stay

(p = 0.024)

14.9 days 9.9 days

Hospital stay*

(p = 0.001)

11.7 days 9.1 days

* Patients without abdominal complication


d t t


13/28

Pre-operative mechanical bowelcleansing or not? An updated

meta-analysisWille-Jrgensen P, Guenaga KF,

Matos D, Castro AA.

Colorectal Dis. 2005 Jul;7(4):304-10.


d t t


14/28

1592 patients from 9 RCTs


(n = 789)


Anast. leakage

(p = 0.003)

6% 3.2%

Wound infection

(p = 0.07)

7.4% 5.4%

Mortality

(NS)

1% 0.6%


d t t


15/28

Multicentre randomized clinicaltrial of mechanical bowel

preparation in elective colonicresection

Jung B, Phlman L, Nystrm PO,

Nilsson E.Br J Surg. 2007 Jun;94(6):689-95.


d t t


16/28

1505 patients randomized

1 German and 20 Swedish hospitals

Cancer, adenoma, diverticular disease

All patients had an anastomosis

All patients receieved oral or IVprophylactic antibiotics

Bowel preparations

Oral (polyethylene glycol or sodiumphosphate)

Some patients had a rectal enema


d t t


17/28

Not statistically significant overall


(n = 686)


Wound infection 7.9% 6.4%

Deep abscess 0.7% 1.7%

Anastomoticdehiscence

1.9% 2.6%

Postoperative

stay

8.6 days 8.8 days


d t t


18/28

Preoperative Oral Antibiotics inColorectal Surgery Increases theRate of Clostridium difficile Colitis

Wren SM, Ahmed N, Jamal A, SafadiBY.

Arch Surg. 2005 Aug;140(8):752-6.


do nstates rgery org


19/28

Retrospective case-controlled

Elective operations

Resections with or without anastomosis

Colostomy formation

Colostomy takedown

Exclusions

C. diff within 30 days prior to surgery

bowel obstruction

< 30 day follow-up (or survival)


www downstatesurgery org


20/28

Bowel Preparation

All patients received mechanical bowelpreparation

All patients received prophylactic IVantibiotics




21/28

Results

Oral antibiotics

(n = 107)

No oralantibiotics

(n = 197)

C. difficile colitis

(p = 0.03)

7.4% 2.6%

Wound infection(p = 0.20)

14.9% 13.2%




22/28

Reasons to continue mechanicalbowel preparation

Need to palpate small tumors

Need for intraoperative colonoscopy

Easier to handle lightweight bowellaparoscopically

Low pelvic anastomosis




23/28

Reasons NOT to continuemechanical bowel preparation

Significant patient discomfort

Causes electrolyte abnormalities

Causes hypovolemia Associated with bacterial translocation

through the bowel wall

A poorly prepped bowel will allow easierspillage of stool than an unprepped bowel




24/28

The Association of Coloproctologyof Great Britain and Ireland

Guidelines for the Management ofColorectal Cancer (2007)

Bowel preparation should not be usedroutinely before colorectal cancerresection. (Recommendation grade B)

http://www.acpgbi.org.uk/assets/documents/COLO_guides.pdf




25/28

Australian Cancer Network

Colorectal Cancer GuidelinesRevision Committee (2005)

Mechanical bowel preparation is notindicated in elective colorectal operationsunless there are anticipated problems with

faecal loading that might create technicaldifficulties with the procedure, e.g.laparoscopic surgery, low rectal cancers.

http://www.nhmrc.gov.au/_files_nhmrc/file/nics/material_resources/epgr_review_chapter_9.pdf




26/28

American Society of Colon andRectal Surgeons




27/28

Werner Formann


http://upload.wikimedia.org/wikipedia/commons/2/2e/Bundesarchiv_B_145_Bild-F006444-0033%2C_M%C3%BCttergenesungswerk_bei_Bundespr%C3%A4sident_Heuss.jpg


28/28

Ignaz Semmelweis

http://upload.wikimedia.org/wikipedia/commons/f/f8/Ignaz_Semmelweis_1860.jpg

bowel preparation colon resection

Documents