Mechanical bowel preparation for elective colorectal surgery
ABSTRACT The presence of bowel contents during surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.
To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.
Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.Searches were performed March 13, 2008.
Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections.
Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).
Four new trials were included at this update (total 13 RCTs with 4777 participants; 2390 allocated to MBP (Group A), and 2387 to no preparation (Group B), before elective colorectal surgery) .Anastomotic leakage occurred:(i) in 10.0% (14/139) of Group A, compared with 6.6% (9/136) of Group B for low anterior resection; Peto OR 1.73 (95% confidence interval (CI): 0.73 to 4.10).(ii) in 2.9% (32/1226) of Group A, compared with 2.5% (31/1228) of Group B for colonic surgery; Peto OR 1.13 (95% CI: 0.69 to 1.85). Overall anastomotic leakage occurred in 4.2% (102/2398) of Group A, compared with 3.4% (82/2378) of Group B; Peto OR 1.26 (95% CI: 0.941 to 1.69). Wound infection occurred in 9.6% (232/2417) of Group A, compared with 8.3% (200/2404) of Group B; Peto OR 1.19 (95% CI: 0.98 to 1.45). Sensitivity analyses did not produce any differences in overall results.
There is no statistically significant evidence that patients benefit from MBP. The belief that MBP is necessary before elective colorectal surgery should be reconsidered. Further research on patients submitted for elective colorectal surgery in whom bowel continuity is restored, with stratification for colonic and rectal surgery, is still warranted.
SourceAvailable from: Judith Tanner[Show abstract] [Hide abstract]
ABSTRACT: Care bundles are a strategy that can be used to reduce the risk of surgical site infection (SSI), but individual studies of care bundles report conflicting outcomes. This study assesses the effectiveness of care bundles to reduce SSI among patients undergoing colorectal surgery. We performed a systematic review and meta-analysis of randomized controlled trials, quasi-experimental studies, and cohort studies of care bundles to reduce SSI. The search strategy included database and clinical trials register searches from 2012 until June 2014, searching reference lists of retrieved studies and contacting study authors to obtain missing data. The Downs and Black checklist was used to assess the quality of all studies. Raw data were used to calculate pooled relative risk (RR) estimates using Cochrane Review Manager. The I(2) statistic and funnel plots were performed to identify publication bias. Sensitivity analysis was carried out to examine the influence of individual data sets on pooled RRs. Sixteen studies were included in the analysis, with 13 providing sufficient data for a meta-analysis. Most study bundles included core interventions such as antibiotic administration, appropriate hair removal, glycemic control, and normothermia. The SSI rate in the bundle group was 7.0% (328/4,649) compared with 15.1% (585/3,866) in a standard care group. The pooled effect of 13 studies with a total sample of 8,515 patients shows that surgical care bundles have a clinically important impact on reducing the risk of SSI compared to standard care with a CI of 0.55 (0.39-0.77; P = .0005). The systematic review and meta-analysis documents that use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of SSI. Copyright © 2015 Elsevier Inc. All rights reserved.Surgery 04/2015; 149. DOI:10.1016/j.surg.2015.03.009 · 3.11 Impact Factor
Indian Journal of Surgery 01/2015; DOI:10.1007/s12262-015-1212-0 · 0.27 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Adult literature supports the elimination of mechanical bowel preparation (MBP) for elective colorectal surgical procedures. Prospective data for the pediatric population regarding the utility of MBP are lacking. The primary aim of this study was to compare infectious complications, specifically anastomotic leak, intraabdominal abscess, and wound infection in patients who received MBP with those who did not. A randomized pilot study comparing MBP with polyethylene glycol with no MBP was performed. Patients, 0 to 21 years old, undergoing elective colorectal surgery were eligible and randomized within 4 age strata. Statistical analyses were performed using χ or Fisher exact test for categorical data and t test or Wilcoxon 2-sample test for continuous data. Forty-four patients were enrolled in the study from December 2010 to February 2013, of which 24 (55%) received MBP and 20 (45%) did not. Two patients (5%) had anastomotic leak, 4 (9%) had intraabdominal infection, and 7 (16%) had wound infections. The rate of anastomotic leak, intraabdominal abscess, and wound infection did not differ between the 2 groups. MBP for elective colorectal surgery in children does not affect the incidence of infectious complications. A larger multiinstitutional study is necessary to validate the results of this single-institution pilot study.Journal of pediatric gastroenterology and nutrition 04/2015; 60(4):503-507. DOI:10.1097/MPG.0000000000000651 · 2.87 Impact Factor