Mechanical Bowel Preparation

Changes in Our Surgical Practice

UK Department of Surgery Grand Rounds

J. S. Hourigan, MD
April 2010
 (2010)

449 Patients Undergoing Low Anterior Resection….

Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg. 2010 Jan;251(1):59-63.
 (2010)

…..MBP Has No Influence on Anastomotic Failure

Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg. 2010 Jan;251(1):59-63.
Objectives….
Briefly Review the Recent History of Mechanical Bowel Preparation
Review the Literature Regarding Mechanical Bowel Preparation
Discuss MBP’s Influence on Anastomotic Leak and Septic Complications
Propose an Evidence-Based Change in Our Surgical Practice
dogma: a point of view or tenet put forth as authoritative
without adequate grounds

Which
Way
To Go?
Doesn’t It Make “Sense” To Us?......

Decrease Volume of Intraluminal Content and Fecal Load

Decrease the Bacterial Counts
Avoid Major Spillage

Improve Healing of Anastomosis

Decrease Infectious Complications
Improve Patient Outcomes
 Mechanical Bowel Prep

2009: Cochrane Review Shows No Benefit of MBP

1994-2000s: Several Other Trials Follow

1994: One of First RCT Showing No Benefit with MBP

1990s: Trauma Literature Accumulates Regarding No MBP

1980: Development of PEG-based Solutions Tolerated Better

1972: Hughes Presents Early Challenge to Dogma of MBP

1971: Nichols and Condon Describe Favorable Clinical Experience with Bowl Prep

1970s: Practice of Routine MBP

Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT
 “Preoperative Preparation of the Colon” (1971)

…Clinical Experience “Demonstrated Decreased M&M with

Mechanical Removal of Gross Feces”

Assumption Was Made That The Benefit Would Come From Significantly
Lowering Nonselective Bacterial Counts

“Controversy Today Concerns Only the Addition of

Antibiotics To Preoperative Mechanical Preparation”…

Nichols R, Condon R. Preoperative preparation of the colon. Sur Gynecol Obstet 1971;132: 323-327.
 Mechanical Bowel Prep

2009: Cochrane Review Shows No Benefit of MBP

1994-2000s: Several Other Trials Follow

1994: One of First RCT Showing No Benefit with MBP

1990s: Trauma Literature Accumulates Regarding No MBP

1980: Development of PEG-based Solutions Tolerated Better

1972: Hughes Presents Early Challenge to Dogma of MBP

1971: Nichols and Condon Described Favorable Clinical Experience with Bowel Prep

1970s: Practice of Routine MBP

Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT
 “Asepsis in Large Bowel Surgery” (1972)

o Mechanical Cleaning “Loads” the Bowel and Is Unnecessary

o Antibiotics Have Restricted Part in Large-Bowel Surgery

…This Has Been Considered the “Challenge” to Nichols’ Views

Hughes ESR. Asepsis in large-bowel surgery; Hunterian Lecture. Ann Roy Coll Surg Eng 1972, v.51; 347-
356.
 Mechanical Bowel Prep

2009: Cochrane Review Shows No Benefit of MBP

1994-2000s: Several Other Trials Follow

1994: One of First RCT Showing No Benefit with MBP

1990s: Trauma Literature Accumulates Regarding No MBP

1980: Development of PEG-based Solutions Tolerated Better

1972: Hughes Presents Early Challenge to Dogma of MBP

1971: Nichols and Condon Described Favorable Clinical Experience with Bowel Prep

1970s: Practice of Routine MBP

Dietary Restriction, Enemas, and Large Volume Saline Irrigation via NGT
1992 2003
1978 1994
1990
1973
2009
1977
1991 1994
2002
2005 1981
2005
1986
19731989 1991
1971 Nichols
1985 1973
1995v. 1978
20061971
1985
1989 1973 1986 1981 1987 1977
Hughes
2006
2003 198719851984
1995 1985 2009 1992
1987 2001 2002 1998
There is Considerable Discordance Between
What We Do and What We Know….

Is It Possible That We Know Something More

Than What the “Literature” Can Tell Us?
First……What Are We Doing?

A Collection of Surveys….
 (1990)

o 352 Board-Certified Colon and Rectal Surgeons Surveyed

… 100% Routinely Used Mechanical Bowel Preparation

PEG Solution Used Most Commonly (58%)

Solla JA, Rothenberger DA. Preoperative bowel preparation. A survey of colon and rectal surgeons. Dis Colon Rectum. 1990 Feb;33(2):154-9.
 “Current Practices….Among North
American Colorectal Surgeons”
(1997)

… 100% Routinely Used Mechanical Bowel Preparation

PEG Solution Used Most Commonly (70%)

Nichols RL, Smith JW, et al. Current practices of preoperative bowel preparation among North American colorectal surgeons. Clin Infect Dis. 1997 Apr;24(4):609-19.
 “Trends in Preparation for Colorectal Surgery” (2003)

o 515 ASCRS Members With on Average 14 Years Experience Each

….Survey Results Indicated

99% Routinely Used Mechanical Bowel Preparation
98% Routinely Used Intravenous Antibiotics
75% Routinely Used Oral Antibiotics

Zmora O, Wexner SD, et al. “Trends in preparation for colorectal surgery: survey of the members of the ASCRS. Am Surg. 2003 Feb;69(2):150-4.
 (2007)

“Cathartic Bowel Preparation: A Thing of the Past?”

James McCormick, DO

….Most ASCRS Attendees Polled Admitted to Using MBP

McCormick J. “Cathartic bowel preparation: a thing of the past?” ASCRS 2007 Meeting. Technologic and Pharmacologic Advances for Enhanced Recovery after Colectomy Symposium.
 (2007)

And...ACPGBI Guidelines for Management of Colorectal Cancer

Bowel Preparation Should Not Be Used Routinely Before

Colorectal Cancer Resection

Guidelines for the Management of Colorectal Cancer 3rd edition (2007). Issued by The Association of Coloproctology of Great Britain and Ireland; 30-31.
 (2010)

In Follow-Up…..A Survey of Its Members Indicated the Following:

% Patients Receiving Full

Bowel Prep
Right Colectomy 10%
Left Colectomy 40%
Low Anterior Resection 22%
APR 72%

Drummond R, McKenna R, Wright D. Current Practice in Bowel Preparation for Colorectal Surgery: A Survey of the Members of The Association of Coloproctology of GB & Ireland.
Colorectal Dis. 2010 Feb 20.
 “Mechanical Bowel Preparation and Antibiotic Prophylaxis
in Colorectal Surgery:
Use By and Opinions of Spanish Surgeons” (2009)

o 131 Spanish Colon and Rectal Surgeons Surveyed

….Survey Results Indicated

87% Routinely Use Mechanical Bowel Preparation
(60% for Right Colon…90% for Left Colon…99% for Rectum)

Roig JV, García-Fadrique A, et al. Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons. Colorectal Dis. 2009 Jan;11(1):44-
8.
 (2004)

Recognizes That No Clear Evidence Exists That MBP Reduces

Infectious Complications, Anastomotic Leak, or Mortality

Data Lacks Statistical Power to Exclude Type II Error

Otchy D, Hyman N, et al. The Standards Practice Task Force. Practice Parameters for Colon Cancer. Dis Colon Rec August 2004; 1269-1284
 (2004)

However, Bowel Preparation Is Justified Based On…..

o Ease of Handling Bowel
o Safety of Bowel Preparation
o Low Cost

Otchy D, Hyman N, et al. The Standards Practice Task Force. Practice Parameters for Colon Cancer. Dis Colon Rec August 2004; 1269-1284
Second……What Do We Know?

The Literature….
Let’s First Assume MBP Is Actually a
“Good Thing”….

If MBP Is So Critical to Operative “Success”,

Why Do We Rarely Talk About the Adequacy of
Bowel Preparation?

Do We Routinely Cancel or Postpone Elective

Cases if A Patient Does Not Finish MBP?
 “Inadequate Bowel Preparation and Spillage”
(2005)

o MBP Causes Significantly Higher Incidence of Liquid Contents

o Spillage with Bowel Prep (17%) v. NO Bowel Prep (12%)

Liquid (31%) SemiSolid (10%) Solid (3%)

MBP “Loads” the Bowel (Hughes)

Mahajna A, Krausz M, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005; 48:1626-31.
 Tendency Toward More Infectious Complications

Anastomotic Leak (6.2% v. 3.8%)

Wound Infection (12.5% v. 6.7%)
Mahajna A, Krausz M, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005; 48:1626-31.
Let’s Then Assume MBP is Not Such
A “Good Thing”

Does the Literature Support Not Using MBP

Routinely in Elective Colorectal Surgery?

Two Large Meta-Analyses….

#1
2009

“Mechanical Bowel Preparation for Elective

Colorectal Surgery”
 “Mechanical Bowel Preparation for Elective
Colorectal Surgery” (2009)

o Second Update (v.3) with Five Additional New Trials Included

o 14 RCTs with 4776 Participants
o Anastomotic Leakage was Primary Outcome Measure
o Secondary Outcome Measures Included Wound Infection
o Prophylactic Antibiotics Used In Both Treatment Groups

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
 Anastomotic Leak
4.2% v 3.4%

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
 Wound Infection

9.6% v. 8.3%

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
 No Statistically Significant Difference
Between MBP and No-MBP (2009)

….This Represented a “Change” From 2005

2005
2003 Statistically Significant 2009
No Difference Increase in Anastomotic No Difference
Leak with MBP

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
 The Lack of Proven Benefit for MBP Allowed Authors
To Suggest the Abandonment of MBP….

….Except When Needed To Identify Pathology or

Perform Intra-Op Colonoscopy

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
 Finland (1)

UK (1) Sweden (1)

Ireland (1) Nether (2)
Germany (1)
Belgium (1)
Switzerland (1)
Spain (1)
Israel (2)

Peru (1) Brazil (2)

Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
#2

2009

“Updated Systematic Review and Meta-Analysis of

Randomized Clinical Trials on the Role of Mechanical
Bowel Preparation Before Colorectal Surgery”
 (2009)

“Updated Systematic Review and Meta-Analysis of

Randomized Clinical Trials on the Role of Mechanical
Bowel Preparation Before Colorectal Surgery”
(2003: Significant Increase in Anastomotic Leak with PEG MBP; 5.3% v. 3.2%)

14 Randomized Clinical Trials with 4859 Participants

Slim K, Vciaut E, et al. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg Feb 2004; 91:1125-30.
Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009; 249:2; 203-09.
 …No-MBP Was Favored for “All SSI” with Statistical Significance

All SSI 15.7% v. 14.5%

Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
 Two Interesting Side Notes With Conflicting
Preference for MBP Were Recognized in This MA….

Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
First,….

…Bucher et al Demonstrated the Negative Effects of MBP

Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation v. no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92: 409-414.
Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
 Bucher et al (MBP n = 78/No-MBP n = 75) for Left Colon
(2005)

o Overall Infectious Complications MBP 22% No-MBP 8%

p=0.028
o Anastomotic Leak MBP 6% No-MBP 1%
p=0.021
o Extra-Abdominal Complications MBP 24% No-MBP 11%
p=0.034
o Hospital Stay (Days) MBP 15 No-MBP 10
p=0.024

Therefore, Reduced Post-Operative Morbidity with No-MBP

Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation v. no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92: 409-414.
 Second,….

….A Statistically Significant Difference Was Demonstrated

In Favor of Mechanical Bowel Preparation

Therefore, Reduced Post-Operative Morbidity with MBP

Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
 (2009)

Overall, The Authors Made the Following Conclusions….

o Higher Risk of Anastomotic Leakage is NOT Suggested

o Harmful Effect of MBP Was Not Evident (As Suggested by Bucher)
o MBP Does Not Reduce Infectious Morbidity of Colon Surgery…

Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
 (2009)

….And Suggested MBP Should Be Abandoned

“At Least From the Patients’ Perspective”

o Quality of Life and Patient Preference

o Unwillingness To Have the Same Procedure Again?
o Dehydration and Electrolyte Disturbance
o Bacterial Translocation

Slim K, Vciaut E, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb
2009; 249:2; 203-09.
 Within Both Large Meta-Analyses…

Two “Large Trials” are Important to Note….

Contant et al
And
Jung et al
 (2007)

o
Anastomotic Leak MBP (4.8%) v. No-MBP (5.4%)
o
Abscess with Leak MBP (0.3%) v. No-MBP (2.5%)
p = 0.001

….Abscesses Not Considered to Be of Major Clinical

Importance

Contant ME, Hop W. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112-17.
 The Authors Made the Following Conclusions….

o No Difference Exists Between MBP and No-MBP

o MBP Does Not Decrease/Prevent Infectious Complications
o Negative Side-Effects Without Evidence of Benefit

… MBP Before Elective Colorectal Surgery Should Be Abandoned

Contant ME, Hop W. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112-17.
 (2007)

o Randomized to MBP (n=686) and No-MBP (n=657)

o 324 Patients (24%) Overall Had At Least One Complication
o No Significant Difference Between Groups in Complication Rates
o No Benefit in Anastomotic Healing or Infection Rates with MBP
o No Improvement in Overall Post-Op Course or Patient Outcome

Jung B, Pahlman L, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colon resection. Br J Surgery 2007; 94:689-95.
 Authors Concluded…
Once Again, The Practice of
MBP Should Be Abandoned

Jung B, Pahlman L, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colon resection. Br J Surgery 2007; 94:689-95.
Other “Things” We Know from the Literature
 Side Does Not Matter (Right v. Left, Colon v. Rectum)

Bretagnol et al Produced Similar Results in Their

Assessment of No-MBP and Rectal Cancer
o No Difference in Symptomatic Anastomotic Leak (8% v. 10%)
o Trend Towards Higher Rate of Infectious Complications with MBP
o Significantly Higher Rate of Extra-Abdominal Inf Complications with MBP
o Significantly Higher Overall Morbidity with MBP

Bretagnol F, Alves A, et al. Rectal cancer surgery without mechanical bowel preparation. Br J Surg 2007;94: 1266-1271.
Zmora O, Mahajna A, et al. Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial. Tech Coloproctol 2006;10: 131-35.
Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation v. no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92: 409-414.
Memon MA, Devine J, et al. Is mechanical bowel preparation really necessary for elective left sided colon and rectal surgery. Int J Colorect Dis 1997;12: 298-302.
 No-MBP and Laparoscopy is Feasible and Safe (2006)

Zmora et al Reviewed 200 Laparoscopic Colectomies

n = 68 (MBP) and n = 132 (No-MBP)

o 16 Patients (8%) with Intraoperative Colonoscopy for Localization

o Overall Conversion Rate of 9% (MBP) an 14% (No-MBP)

1 Conversion in No-MBP for Localization

Zmora O, Lebedyev A, Hoffman A, et al. Laparoscopic colectomy without mechanical bowel preparation. Int J Colorectal Dis 2006;21: 683-687.
 No-MBP and Laparoscopy is Feasible and Safe (2006,2005)

Adequate Patient Selection Should Focus On…..

o Small Lesions (< 3cm) Not Properly Marked

o Possibility for Intraoperative Colonoscopy

Zmora O, Lebedyev A, Hoffman A, et al. Laparoscopic colectomy without mechanical bowel preparation. Int J Colorectal Dis 2006;21: 683-687.
Ram E, Sherman Y, Weil R. Is mechanical bowel preparation mandatory for elective colon surgery? Arch Surg March 2005;140: 285-288.
 Finland (1)

UK (1) Sweden (1)

Ireland (1) Nether (2)
Germany (1)
Belgium (1)
Switzerland (1)
Spain (1)
Israel (2)

Peru (1) Brazil (2)

What About the U.S. Literature?

Two Recent Papers….

 Thomas Jefferson University Reported Their Clinical Experience at
Southeastern Surgical in 2009…..

Review of 153 Patients without MBP

o No Benefit Associated with the Use of MBP

o Elective Colorectal Resections Can Safely Omit MBP

Harris LJ, Moudgill N, Hager E, Abdollahi H, Goldstein S. Incidence of anastomotic leak in patients undergoing elective colon resection without mechanical bowel preparation: our updated
experience and two-year review. Am Surg. 2009 Sep;75(9):828-33.
 University of South Alabama

Retrospective Review of 136 Patients +/- MBP

o Overall, SSI Occurred in 23% of Patients
+MBP 46.7% v. –MBP 19.8%

Thus, Supporting the Safe Omission of MBP

Howard DD, White CQ, Harden TR, Ellis CN. Incidence of surgical site infections postcolorectal resections without preoperative mechanical or antibiotic bowel preparation. Am Surg. 2009
Aug;75(8):659-63; discussion 663-4.
So, Who Should Prep?

o Inadequate Localization or Possibility of Intra-Op Colonoscopy

o Low-Level Rectal Resections or IPAAs?
o Defunctionalized Anastomoses?

And, Who Not Should Prep?

o Elective Colon Resections

In Conclusion

o There is Sufficient Evidence to Abandon MBP

o Rare Evidence Demonstrates the Benefit of MBP
o MBP Has Been Shown to be Harmful in Few Studies
o No-MBP Will Eventually Become the Standard for CR Surgery
o Parenteral Antibiotics Continue to Have a Defined Role
o Routine Use of Oral Antibiotic Preparation Should be Revisited