Until recently it was thought that vigorous preoperative mechanical cleansing of the bowel (mechanical bowel preparation), together with the use of oral antibiotics, reduced the risk of septic complications after non-emergency (elective) colorectal operations. Mechanical bowel preparation was performed routinely prior to colorectal surgery until 1972, when this procedure started to be questioned. Well designed clinical trials were published, and their results caused colorectal surgeons to doubt this traditional belief. Preoperative bowel preparation is time-consuming and expensive, unpleasant to the patients, and even dangerous on occasion (increased risk for inflammatory processes). This review has identified all known trials that compared any kind of mechanical bowel preparation with no preparation in patients receiving elective colorectal surgery. Five new trials have been included in this second update of the review, bringing the total number of included trials to 14 (4821 participants). Analysis of these 14 trials showed no statistically significant differences in how well the two groups of patients (mechanical bowel preparation group and the no preparation group) did after surgery in terms of leakage at the surgical join of the bowel, mortality rates, peritonitis, need for reoperation, wound infection, and other non-abdominal complications. Consequently, there is no evidence that mechanical bowel preparation improves the outcome for patients. Further research on mechanical bowel preparation versus no preparation in patients submitted for elective colorectal surgery is warranted.
"The results show that the amount of water in the body was favorably maintained in the ERAS group compared with the control group, encouraging the introduction of the two procedures, “shortened fasting time” and “reduced laxative medication” as the preoperative patient management. Beneficial effects and safety of ERAS protocol have been reported in many studies 9-11. "
[Show abstract][Hide abstract] ABSTRACT: Aim: Preoperative fasting is an established procedure to be practiced for patients before surgery, but optimal preoperative fasting time still remains controversial. The aim of this study was to investigate the effect of “shortened preoperative fasting time” on the change in the amount of total body water (TBW) in elective surgical patients. TBW was measured by multi-frequency impedance method.
Methods: The patients, who were scheduled to undergo surgery for stomach cancer, were divided into two groups of 15 patients each. Before surgery, patients in the control group were managed with conventional preoperative fasting time, while patients in the “enhanced recovery after surgery (ERAS)” group were managed with “shortened preoperative fasting time” and “reduced laxative medication.” TBW was measured on the day before surgery and the day of surgery before entering the operating room. Defecation times and anesthesia-related vomiting and aspiration were monitored.
Results: TBW values on the day of surgery showed changes in both groups as compared with those on the day before surgery, but the rate of change was smaller in the ERAS group than in the control group (2.4±6.8% [12 patients] vs. −10.6±4.6% [14 patients], p<0.001). Defecation times were less in the ERAS group. Vomiting and aspiration were not observed in either group.
Conclusion: The results suggest that preoperative management with “shorted preoperative fasting time” and “reduced administration of laxatives” is effective in the maintenance of TBW in elective surgical patients.
International journal of medical sciences 09/2012; 9(7):567-74. DOI:10.7150/ijms.4616 · 2.00 Impact Factor
"It can cause dehydration and electrolyte abnormalities , it can prolong postoperative ileus  and increases the risk of inflammatory processes. There is some evidence that preoperative bowel preparation increases the risk of wound infections and anastomotic leakage   . "
[Show abstract][Hide abstract] ABSTRACT: Background: Randomized controlled trials have demonstrated that the rate of anastomotic leakage after laparoscopic colorectal surgery does not differ between patients with or without preoperative bowel preparation. There is, however, still an ongoing discussion that infectious complications consequential to anastomotic leakage, in particular sepsis, are more severe in patients without preoperative bowel cleaning. The aim of this study is to evaluate the assumption that postoperative sepsis in patients undergoing colorectal surgery without mechanical preoperative bowel irrigation is more severe compared to patients with bowel preparation. Methods: In the surgical unit in a teaching hospital in Zurich pa-tients undergoing laparoscopic colorectal surgery were consecutively included in the study. 367 patients with colorectal surgery between December 2000 and April 2004 underwent preoperative mechanical bowel irrigation. From May 2004 until April 2008 colorectal surgery was performed in 367 patients without bowel irrigation. Outcomes of interest are: Severity of sepsis in patients with postoperative anastomotic leakage, assessed by the necessity of referral to ICU, length of stay in the ICU and total length of hospital stay. Results: 734 patients were included in the study, 367 patients with and 367 without preoperative bowel preparation. In 43 patients an anastomotic insufficiency was diagnosed, 26 in the group with and in 17 patients without preoperative irrigation. 14 of these cases developed sepsis and were referred to ICU, 8 (31%) in the group with and 6 (35%) in the group without preparative irrigation. Between the two groups there were no significant differences in mortality, length of stay on ICU and total length of hospital stay. Conclusions: The results of our study provide no indication that the course of sepsis, associated with anastomotic leakage after laparoscopic colorectal surgery, is more severe in patients without preoperative bowel preparation, compared to those with bowel cleaning.
"In case of fibrin glue application, we perform no pre-operative bowel preparation. This strategy is in the same context as for all colonic operations in our department: intact colonic flora offers better healing . Immediately, before the fibrin glue application we like to perform a new fistulography. "
[Show abstract][Hide abstract] ABSTRACT: Individuals with impaired immunity are at higher risk of perianal diseases. Concerning complex anal fistulas impaired healing and complication rates are also higher. Definitive treatment of a fistula aims controlling the purulent discharge and prevents its recurrence. It depends mainly on the trajectory of the fistula and the underlying disease. We present a case of a HIV-positive patient with a complex extrasphincteric anal fistula who was treated successfully with fibrin glue application. We further, discuss tips and tricks when applying fibrin glue as plugging material in complex anal fistulas.
A sixty-one-year-old HIV-positive male referred to us for warts and extrasphincteric fistula. Because of the patients' immunological status, we opted against surgery and recommended fibrin glue plugging. The patient was discharged the same day. A follow-up examination was performed 5 days after the initial fibrin glue application showing that the fistula canal was obstructed. Three months and a year post-intervention the fistula tract remains closed.
The best treatment for a disease gives at least the same result with the other treatments with minimised risk for the life of the patient and minimal application effort. Conservative closure of fistula with fibrin plugging is simple, safe and with less morbidity than surgery. Our patient was successfully treated without endangering his life despite his precarious medical state. Not everybody believes in the effectiveness of fibrin glue application, however we consider this solution in cases of complex fistulas at least as primary procedure in special populations such as the immunosupressed.
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