Bowel Prep Prior to Colon/Rectal Surgery: Valuable vs. Overrated

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1 Bowel Prep Prior to Colon/Rectal Surgery: Valuable vs. Overrated Alian Garay-Valuable Annie Kulungowski-Overrated Department of Surgery Grand Rounds September 24, 2007

2 Bowel Preps are Overrated History of bowel preparation What are bowel preps? How to perform? What do colorectal surgeons in the US do?/what do surgeons at UCH/DHMC do? Bowel preparation for colorectal surgery is overrated-the data do not lie. Closing Remarks

3 Colonic Flora Enormous reservoir Colonic microflora-anaerobic Bacteroides fragilis CFU/g stool Aerobic coliforms 107 CFU/g stool Prior to 1975 postoperative infection-10-40%

4 History Lesson 1898-Halsted-aseptic anastomosis-suture over inflatable cylinder Early methods included: Charcoal, chlorine, salicylates No influence on post-op infection Toxic complications 1953 E.J. Poth proposes neomycin/sulfathalidine for intestinal antisepsis

5 History Lesson Nichols, Condon, Gorbach, et al. Veterans Administration Cooperative study on bowel preparation for elective colorectoal operations. Ann Surg. 1978; 188(2):

6 Nichols-Condon Bowel Prep

7 What is a bowel preparation?

8 Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:

9 Bowel Preparation Old methods-castor oil, senna, dulcolax Side effects-cleaning insufficient Required addition of enemas Mannitol Side effects-dehydration, electrolyte disturbances and colonic explosion

10 Current Agents Polyethylene glycol(peg-els)-1980, osmotically balanced Benefit-less electrolyte/water changes Down side-4 liters salty fluid Nausea, vomiting, fullness At least 5-15% are unable to complete the prep Grundel et al. Improvements in mechanical bowel preparation for elective colorectal surgery. Dis Colon Rectum 1997; 40: Zmora et al. Bowel Preparation for Colorectal Surgery. Dis Colon Rectum 2000; 44:

11 Current Agents Sulfate-free electrolyte lavage solution- (NuLytely, SF-ELS) Benefit-No rotten egg smell Slightly better compliance Reduced Volume Lavage-Bisacodyl 20 mg at 12 p.m. and 6 p.m. 2L SF-ELS Benefit-less fullness, N/V Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:

12 Current Agents Phosphates Oral sodium phosphate(phosphosoda)-45 ml solution with water given evening before surgery and repeated 12 hours later Phosphate tabs-(visicol)-40 tablets with 10 glasses of water Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61:

13 Trends in Preparation for Colorectal Surgery: Survey of the Members of the American Society of Colon and Rectal Surgeons In 2003, 1295 questionnaires were sent out to American colon and rectal surgeons 515 returned questionnaires for a 40% response rate Zmora et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. The American Surgeon 2003; 69:

14 What is the practice of bowel preparation at UCHSC and DHMC?

15 UCHSC/DHMC Bowel Prep On line survey of attendings at UCHSC/DHMC UCHSC-Response rate of 70% DHMC-Response rate of 30%, one physician refused weakest type of evidence, expert opinion and stated he was not in favor that Overall response rate of 56%

16 Usefulness of Bowel Preparation in Infection Prevention

17 Usefulness of Bowel Preparation in Infection Prevention at UCHSC/DHMC Oral Abx IV Abx Bowel Prep Yes Doubtful No

18 National Preparation Methods

19 Preparation Methods at UCHSC/DHMC Oral Abx IV abx Bowel Prep Yes Selective Never

20 Mechanical Bowel Prep Agents

21 Bowel Prep Agents UCHSC/DHMC NaP PEG Diet/Cath

22 IV Antibiotics

23 IV Antibiotics at UCHSC/DHMC Ceph 2 3 2/F PCN+clav Erta

24 Mechanical Bowel Preparation is Overrated

25 Mechanical bowel preparation for colonic resection and anastomosis Type of resection n Elective Emergency Wound Infection Sigmoid/Descending Colon Anterior resection (2 emer, 2 elective) High (elective) Low Right Hemicolectomy (emergent) Totals (8%) Ivring and Scrimgeour. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surgery 1987; 74:

26 Requirement for Bowel Preparation in Colorectal Surgery Bowel Prep n=82 No. of deaths 2 (2%) 0 No Prep n=87 Complications 15 (17%) 16 (18%) Cardi/Pulm 8 (10%) 9 (10%) Wound infection 4 (4%) 3 (3%) Anast. leakage 3 (3%) 4 (4%) Burke, P. Mealy, K. Requirement for bowel preparation in colorectal surgery. Br J Surgery 1994; 81:907-10

27 Bowel Preparation with Oral Polyethylene Glycol Electrolyte Solution vs. No Preparation in Elective Open Colorectal Surgery Pekka, R, Miettinen, J. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery. Dis Colon and Rectum 2000;43:

28 Colon and Rectal Surgery Without Mechanical Bowel Preparation: A Randomized Prospective Trial Zmora, O. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg. 2003; 237:

29 Infectious Complications

30 Mechanical Bowel Preparation for Elective Colorectal Surgery: A Meta-analysis Seven RCT included Total patients 1297 Mechanical bowel prep-642 No bowel prep-655 Bucher, P, Mermillod, B. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surgery. 2004; 139:

31 Received MBP No MBP Anastomotic Dehiscence 36/642 (5.6%) 18/655 (2.8%) P=.03 OR 1.85 Intraabdominal Infection 17/458 (4.7%) 9/461 (2%) P=.18 OR 1.69 (3 excluded) Wound infection 48/642 (7.5%) 36/665 (5.5%) P=.15 OR=1.38 Reoperation (1 excluded) 19/369 (5.2%) 10/369 (2.2%) P=.16 OR=1.72 Mortality (1 excluded) 5/526 (1%) 3/532 (.5%) P=.6 OR=1.42

32 Mechanical Bowel Preparation for Elective Colorectal Surgery Retrospective review of 9 prospective RCT 1592 patients MBP 789 No MBP 803 Main outcome Anastomotic Leakage Secondary outcome Mortality, Peritonitis Reoperation, Wound infection, Infectious extra-abdominal and non-infectious extraabdominal, SSI Guenaga, K. Mechanical bowel preparation for elective colorectal surgery. The Cochrane Collaboration 2007;1-27.

33 The Cochrane Review 2007 Mechanical Bowel Prep No Mechanical Bowel Prep 48/722 (6.2%) 25/777(3.2%) OR=2.03 p=.003 Mortality 5/509 (1%) 3/516 (.6%) OR=1.72 Anastomotic Leak Peritonitis 16/278 (5.7%) 7/275 (2.5%) Reoperation 16/339 (4%) 9/392 (2.2%) OR=2.28 p=.05 OR=1.8 Wound Infection 59/789 (7.4%) 43/803 (5.4%) OR=1.46 p=.07

34 Theories Bowel wall edema Compromises microcirculation ischemia Liquid feces spillage into peritoneum Unprepared bulky stool Bowel handling Bacterial translocation SBP with PEG

35 Preoperative Oral Antibiotics in Colorectal Surgery Increases the Rate of Clostridium difficile Colitis 304 patients given cathartics and IV abx 107 also had po abx C. diff colitis 4.2% Wren, S. et al. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surgery 2005;140:

37 Colonic Ischemia with Laxative Use in Young Adults Two healthy young adults, 33 and 19 Occurred after using Dulcolax for constipation 33 yo took 20 mg 19 yo took 10 mg Increased intraluminal pressure >30 mmhg Blood flow shunts from mucosa to serosa Morra, H. et al. Colonic ischemia with laxative Use in young adults. Am J of Gastro 2005;100:

38 Renal Failure Diabetics receiving oral sodium phosphate risk of renal failure Beware of phosphate preps Using diuretics NSAIDS ARBs/ACEI Ma, Chow, et al. Acute renal failure following oral sodium phosphate bowel preparation in diabetes. Diabetes Care 2007;30:182=83.

39 What can be done to prevent complications during colorectal surgery? Timely administration of PA Within 1 hour of incision Correct antibiotic choice Oral-neo+erythro or neo+metro Parenteral-Cefotetan, Cefoxitin, Cefazolin + metro or amp-sulbactam. Bratzler, D. and Hunt, D. The Surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.clinical Infectious Diseases 2006; 43(3):322-30

40 Closing Remarks Costly Increased complications Anastomotic dehiscence Wound infection Intraabdominal abscess Renal failure/electrolyte imbalance C. diff Diarrhea Uncomfortable Surgical dogma scientific evidence

42 References Bratzler, D. and Hunt, D. The Surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.clinical Infectious Diseases 2006; 43(3): Bucher, P, Mermillod, B. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surgery. 2004; 139: Burke, P. Mealy, K. Requirement for bowel preparation in colorectal surgery. Br J Surgery 1994; 81: Grundel et al. Improvements in mechanical bowel preparation for elective colorectal surgery. Dis Colon Rectum 1997; 40: Guenaga, K. Mechanical bowel preparation for elective colorectal surgery. The Cochrane Collaboration 2007;1-27. Ivring and Scrimgeour. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surgery 1987; 74: Ma, Chow, et al. Acute renal failure following oral sodium phosphate bowel preparation in diabetes. Diabetes Care 2007;30:182=83. Morra, H. et al. Colonic ischemia with laxative use in young adults. Am J of Gastro 2005;100: Nichols, Condon, Gorbach, et al. Veterans Administration Cooperative study on bowel preparation for elective colorectoal operations. Ann Surg. 1978; 188(2): Pekka, R, Miettinen, J. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery. Dis Colon and Rectum 2000;43: Valantas et al. Mechanical bowel preparation in the older surgical patient. Current Surgery. 2004; 61: Wren, S. et al. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surgery 2005;140: Zmora, O. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg. 2003; 237: Zmora et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. The American Surgeon 2003; 69: Zmora et al. Bowel Preparation for Colorectal Surgery. Dis Colon Rectum 2000; 44:

Bowel Preparation for Elective Colorectal Surgery: Helpful or Harmful? Michael J Stamos, MD University of California, Irvine

Bowel Preparation for Elective Colorectal Surgery: Helpful or Harmful? Michael J Stamos, MD University of California, Irvine History of Colon Surgery Early 20 th Century mortality rates for colorectal