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To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP).
The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP.
From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay.
A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups.
This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer.
: Eight randomized clinical trials and two meta-analyses recently questioned the value of preoperative mechanical bowel preparation (MBP) in colorectal surgery. However, very few patients having rectal surgery were included in these studies. The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP.
The postoperative course was assessed in 52 consecutive unselected patients who underwent rectal cancer resection and sphincter preservation without MBP. This group was compared with a group of 61 matched patients in whom MBP was performed before surgery.
The overall morbidity rate after rectal resection was higher in patients who had MBP than in those who did not (51 versus 31 per cent; P = 0.036). The incidence of symptomatic anastomotic leakage was similar in the two groups (8 versus 10 per cent respectively; P = 1.000). Although not significant, peritonitis occurred more frequently in the absence of MBP (2 versus 6 per cent; P = 0.294). A trend towards a higher rate of infectious complications was noted in patients who had MBP (23 versus 12 per cent; P = 0.141), but MBP was associated with a significantly higher rate of infectious extra-abdominal complications (11 versus 0 per cent; P = 0.014). Mean hospital stay was significantly longer in the MBP group (12 versus 10 days; P = 0.022).
Elective rectal surgery for cancer without MBP may be associated with reduced postoperative morbidity.