Mechanical Bowel Preparation in Intestinal Surgery: A Meta-Analysis and Review of the Literature

  • Carlos E. Pineda
  • Andrew A. Shelton
  • Tina Hernandez-Boussard
  • John M. Morton
  • Mark L. Welton
ssat quick shot presentation

Abstract

Introduction

Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery.

Methods

We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio.

Results

Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899–1.64, P = 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946–1.413, P = 0.155).

Discussion

This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery.

Conclusion

In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet “standard of care.”

Keywords

Mechanical bowel preparation Elective intestinal surgery Colon and rectal surgery Meta-analysis Literature review Intestinal preparation 

References

  1. 1.
    Nichols RL, Broido P, Condon RE, Gorbach SL, Nyhus LM. Effect of preoperative neomycin-erythromycin intestinal preparation on the incidence of infectious complications following colon surgery. Am Surg 1973;178:453–62. doi:10.1097/00000658-197310000-00008.Google Scholar
  2. 2.
    Zmora O, Wexner SD, Hajjar L, Park T, Efron JE, Noqueras JJ, Weiss EG. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. Am Surg 2003;69:150–4.PubMedGoogle Scholar
  3. 3.
    McCahill LE, Ahern JW, Gruppi LA, Limanek J, Dion GA, Sussman JA, McCaffrey CB, Leary DB, Lesaqe MB, Single RM. Enhancing compliance with Medicare guidelines for surgical infection prevention: experience with a cross-disciplinary quality improvement team. Arch Surg 2007;142:355–61. doi:10.1001/archsurg.142.4.355.PubMedCrossRefGoogle Scholar
  4. 4.
    Nichols RL, Choe EU, Weldon CB. Mechanical and antibacterial bowel preparation in colon and rectal surgery. Chemotherapy 2005;51(Suppl 1):115–21. doi:10.1159/000081998.PubMedCrossRefGoogle Scholar
  5. 5.
    Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal microflora following preoperative mechanical preparation of the colon. Dis Colon Rectum 1971;14:123–7. doi:10.1007/BF02560057.PubMedCrossRefGoogle Scholar
  6. 6.
    Lindsey JT, Smith JW, McClugage SG Jr, Nichols RL. Effects of commonly used bowel preparations on the large bowel mucosal-associated and luminal microflora in the rat model. Dis Colon Rectum 1990;33:554–60. doi:10.1007/BF02052206.PubMedCrossRefGoogle Scholar
  7. 7.
    Smith MB, Baliga P, Sartor WM, Goradia VK, Holmes JW, Nichols RL. Intraoperative colonic lavage: failure to decrease mucosal microflora. South Med J 1991;84:38–42. doi:10.1097/00007611-199104000-00017.PubMedCrossRefGoogle Scholar
  8. 8.
    Bornside GH, Cohn I Jr. Intestinal antisepsis. Stability of fecal flora during mechanical cleansing. Gastroenterology 1969;57:569–573.PubMedGoogle Scholar
  9. 9.
    Bleday R, Braidt J, Ruoff K, Shellito PC, Ackroyd FW. Quantitative cultures of the mucosal-associated bacteria in the mechanically prepared colon and rectum. Dis Colon Rectum 1993;36:844–9. doi:10.1007/BF02047381.PubMedCrossRefGoogle Scholar
  10. 10.
    Mahajna A, Krausz M, Rosin D, Shabtai M, Hershko D, Ayalon A, Zmora O. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005;48:1626–31. doi:10.1007/s10350-005-0073-1.PubMedCrossRefGoogle Scholar
  11. 11.
    Irvin TT, Goligher JC. Aetiology of disruption of intestinal anastomoses. Br J Surg 1973;60:461–4. doi:10.1002/bjs.1800600612.PubMedCrossRefGoogle Scholar
  12. 12.
    Muzii L, Bellati F, Zullo MA, Manci N, Angioli R, Panici PB. Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril 2006;85:689–93. doi:10.1016/j.fertnstert.2005.08.049.PubMedCrossRefGoogle Scholar
  13. 13.
    Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2006;20:1147–60. doi:10.1007/s00464-006-0152-y.PubMedCrossRefGoogle Scholar
  14. 14.
    Nichols RL, Smith JW, Garcia RY, Waterman RS, Holmes JW. Current practices of preoperative bowel preparation among North American colorectal surgeons. Clin Infect Dis 1997;24:609–19.PubMedGoogle Scholar
  15. 15.
    de Graaf P, Slagt C, de Graaf JL, Loffeld RJ. Fatal aspiration of polyethylene glycol solution. Neth J Med 2006;64:196–8.PubMedGoogle Scholar
  16. 16.
    Oliveira L, Wexner SD, Daniel N, DeMarta D, Weiss EG, Noqueras JJ, Bernstein M. Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions. Dis Colon Rectum 1997;40:585–91. doi:10.1007/BF02055384.PubMedCrossRefGoogle Scholar
  17. 17.
    Mathus-Vliegen EM, Kemble UM. A prospective randomized blinded comparison of sodium phosphate and polyethylene glycol-electrolyte solution for safe bowel cleansing. Aliment Pharmacol Ther 2006;23:543–52. doi:10.1111/j.1365-2036.2006.02777.x.PubMedCrossRefGoogle Scholar
  18. 18.
    Gonlusen G, Akgun H, Ertan A, Olivero J, Truong LD. Renal failure and nephrocalcinosis associated with oral sodium phosphate bowel cleansing: clinical patterns and renal biopsy findings. Arch Pathol Lab Med 2006;130:101–6.PubMedGoogle Scholar
  19. 19.
    Ullah N, Yeh R, Ehrinpreis M. Fatal hyperphosphatemia from a phosphosoda bowel preparation. J Clin Gastroenterol 2002;34:457–8. doi:10.1097/00004836-200204000-00017.PubMedCrossRefGoogle Scholar
  20. 20.
    Aydogan T, Kanbay M, Uz B, Kaya A, Isik A, Bozalan R, Erkman M, Akcay A. Fatal hyperphosphatemia secondary to a phosphosoda bowel preparation in a geriatric patient with normal renal function. J Clin Gastroenterol 2006;40:177. doi:10.1097/01.mcg.0000196408.60851.cf.PubMedCrossRefGoogle Scholar
  21. 21.
    Jung B, Lannerstad O, Pahlman L, Arodell M, Unosson M, Nilsson E. Preoperative mechanical preparation of the colon: the patient’s experience. BMC Surg 2007;7:5. doi:10.1186/1471-2482-7-5.PubMedCrossRefGoogle Scholar
  22. 22.
    Bucher P, Gervaz P, Egger JF, Soravia C, Morel P. Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery: a randomized trial. Dis Colon Rectum 2006;49:109–12. doi:10.1007/s10350-005-0215-5.PubMedCrossRefGoogle Scholar
  23. 23.
    Zwas FR, Cirillo NW, El-Serag HB, Eisen RN. Colonic mucosal abnormalities associated with oral sodium phosphate solution. Gastrointest Endosc 1996;43:463–6.PubMedCrossRefGoogle Scholar
  24. 24.
    LoCicero J 3rd, Tajima T, Drapanas T. A half-century of experience in the management of colon injuries: changing concepts. J Trauma 1975;15:575–9. doi:10.1097/00005373-197507000-00003.PubMedGoogle Scholar
  25. 25.
    Duthie GS, Foster ME, Price-Thomas JM, Leaper DJ. Bowel preparation or not for elective colorectal surgery. J R Coll Surg Edinb 1990;35:169–71.PubMedGoogle Scholar
  26. 26.
    Brownson P, Jenkins SA, Nott D, Ellenbogen S. Mechanical bowel preparation before colorectal surgery: results of a prospective randomized trial. Br J Surg 1992;79:461–2.Google Scholar
  27. 27.
    Burke P, Mealy K, Gillen P, Joyce W, Traynor O, Hyland J. Requirement for bowel preparation in colorectal surgery. Br J Surg 1994;81:907–10. doi:10.1002/bjs.1800810639.PubMedCrossRefGoogle Scholar
  28. 28.
    Santos JC Jr, Batista J, Sirimarco MT, Guimaraes AS, Levy CE. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg 1994;81:1673–6. doi:10.1002/bjs.1800811139.PubMedCrossRefGoogle Scholar
  29. 29.
    Fillmann EEP, Fillmann HS, Fillmann LS. Elective colorectal surgery without prepare [Cirugia colorretal eletiva sem preparo]. Rev Bras Colo-Proct 1995;15:70–1.Google Scholar
  30. 30.
    Miettinen RP, Laitinen ST, Makela JT, Paakkonen ME. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum 2000;43:669–75. discussion 75–77. doi:10.1007/BF02235585.PubMedCrossRefGoogle Scholar
  31. 31.
    Tabusso FY, Zapata JC, Espinoza FB, Meza EP, Figueroa ER. Mechanical preparation in elective colorectal surgery, a useful practice or need. Rev Gastroenterol Peru 2002;22:152–8. Preparación mecánica en cirugía electiva colo-rectal ¿Costumbre o necesidad?Google Scholar
  32. 32.
    Zmora O, Mahajna A, Bar-Zakai B, Rosin D, Hershko D, Shabtai M, Krausz MM, Ayalon A. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg 2003;237:363–7. doi:10.1097/00000658-200303000-00010.PubMedCrossRefGoogle Scholar
  33. 33.
    Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92:409–14. doi:10.1002/bjs.4900.PubMedCrossRefGoogle Scholar
  34. 34.
    Fa-Si-Oen P, Roumen R, Buitenweg J, van de Velde C, van Geldere D, Putter H, Verwaest C, Verhoef L, de Waard JW, Swank D, D’Hoore A, Croiset van Uchelen F. Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum 2005;48:1509–16. doi:10.1007/s10350-005-0068-y.PubMedCrossRefGoogle Scholar
  35. 35.
    Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 2005;140:285–8. doi:10.1001/archsurg.140.3.285.PubMedCrossRefGoogle Scholar
  36. 36.
    Zmora O, Mahajna A, Bar-Zakai B, Hershko D, Shabtai M, Krausz MM, Ayalon A. Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial. Tech Coloproctol 2006;10:131–5. doi:10.1007/s10151-006-0266-1.PubMedCrossRefGoogle Scholar
  37. 37.
    Pena-Soria MJ, Mayol JM, Anula-Fernandez R, Arbeo-Escolar A, Fernandez-Represa JA. Mechanical bowel preparation for elective colorectal surgery with primary intraperitoneal anastomosis by a single surgeon: interim analysis of a prospective single-blinded randomized trial. J Gastrointest Surg 2007;11:562–7. doi:10.1007/s11605-007-0139-6.PubMedCrossRefGoogle Scholar
  38. 38.
    Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surg 2004;139:1359–64. discussion 65. doi:10.1001/archsurg.139.12.1359.PubMedCrossRefGoogle Scholar
  39. 39.
    Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005, CD001544.Google Scholar
  40. 40.
    Jung B, Pahlman L, Nystrom PO, Nilsson E. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg 2007;94:689–95. doi:10.1002/bjs.5816.PubMedCrossRefGoogle Scholar
  41. 41.
    Contant CM, Hop WC, van’t Sant HP, Oostvoqel HJ, Smeets HJ, Stassen LP, Neijenhuis PA, Idenburg FJ, Dijkhuis CM, Heres P, van Tets WF, Gerritsen JJ, Weidema FF. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007;370:2112–7. doi:10.1016/S0140-6736(07)61905-9.PubMedCrossRefGoogle Scholar
  42. 42.
    Vlot EA, Zeebregts CJ, Gerritsen JJ, Mulder HJ, Mastboom WJ, Klaase JM. Anterior resection of rectal cancer without bowel preparation and diverting stoma. Surg Today 2005;35:629–33. doi:10.1007/s00595-005-2999-2.PubMedCrossRefGoogle Scholar
  43. 43.
    Bretagnol F, Alves A, Ricci A, Valleur P, Panis Y. Rectal cancer surgery without mechanical bowel preparation. Br J Surg 2007;94:1266–71. doi:10.1002/bjs.5524.PubMedCrossRefGoogle Scholar
  44. 44.
    Eagle KA, Garson AJ Jr, Beller GA, Sennett C. Closing the gap between science and practice: the need for professional leadership. Health Aff (Millwood) 2003;22:196–201. doi:10.1377/hlthaff.22.2.196.CrossRefGoogle Scholar
  45. 45.
    Feld AD. Medicolegal implications of colon cancer screening. Gastrointest Endosc Clin N Am 2002;12:171–9. doi:10.1016/S1052-5157(03)00065-5.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • Carlos E. Pineda
    • 1
  • Andrew A. Shelton
    • 1
  • Tina Hernandez-Boussard
    • 1
  • John M. Morton
    • 1
  • Mark L. Welton
    • 1
  1. 1.Department of SurgeryStanford University School of MedicineStanfordUSA

Personalised recommendations