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Hassan MM, Ur Rahman S, Hassan MB, Khan T, Alam I, Ahmad A, Samad AU, Khan I. Safety and Efficacy of Polyethylene Glycol Versus Placebo in the Bowel Preparation for Elective Colorectal Surgeries: A Systemic Review and Meta-Analysis. Cureus 2025; 17:e81024. [PMID: 40264632 PMCID: PMC12013462 DOI: 10.7759/cureus.81024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2025] [Indexed: 04/24/2025] Open
Abstract
The most suitable type of preoperative colonic preparation for colorectal surgery is controversial. Polyethylene glycol (PEG) has been widely used and some regard it as more suitable for bowel cleansing. However, it also has some limitations, such as nausea and vomiting. These problems have caused surgeons to question whether bowel cleansing offers any benefit at all. This study aims to assess the safety and efficacy of PEG, compare it with other available bowel preparations, conduct a detailed analysis of the available evidence, and inform clinical practice guidelines for bowel preparation before elective colorectal surgeries. MeSH terms and keywords, including "colorectal surgeries", "polyethylene glycol", and "placebo", were used to run a literature search on PubMed, Embase, Cochrane, and Clinicaltrials.gov from inception to January 2025. Randomized controlled trials (RCTs) comparing PEG with placebo for patients undergoing colorectal surgeries were included. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method in RevMan (Cochrane Collaboration, London, UK). Random effects meta-analysis was undertaken. Ten RCTs with a total of 2613 patients were included. Polyethylene showed no significant benefits over placebo regarding quality of bowel preparation (RR = 1.03, 95% CI: 0.91-1.17, p = 0.64) and incidence of surgical site infections (SSIs) (RR = 1.29, 95% CI: 0.95-1.75; p = 0.11). Both groups were comparable in terms of anastomotic leak (RR = 1.14, 95% CI: 0.70-1.85, p = 0.60), intra-abdominal abscess (RR = 0.77, 95% CI: 0.36-1.65, p = 0.50), ileus (RR = 1.16, 95% CI: 0.44-3.05, p = 0.76), anastomotic dehiscence (RR = 0.79, 95% CI: 0.39-1.59, p = 0.51), vomiting (RR = 0.54, 95% CI: 0.27-1.09, p = 0.09), and repeated operations (RR = 0.66, 95% CI: 0.20-2.24, p = 0.51). PEG has no significant benefits over placebo for bowel preparation before colorectal surgeries. Further research and RCTs are necessary to identify and explore other therapeutic options for patients undergoing colorectal surgeries.
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Affiliation(s)
| | | | | | - Taimoor Khan
- General Surgery, Saidu Teaching Hospital, Swat, PAK
| | | | - Atizaz Ahmad
- General Surgery, Saidu Teaching Hospital, Swat, PAK
| | - Ata Us Samad
- General Surgery, Saidu Teaching Hospital, Swat, PAK
| | - Imran Khan
- General Surgery, Saidu Teaching Hospital, Swat, PAK
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2
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Palaia I, Caruso G, Perniola G, Di Donato V, Brunelli R, Vestri A, Scudo M, Gentile G, Musella A, Benedetti Panici P, Muzii L. The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section. J Matern Fetal Neonatal Med 2023; 36:2203795. [PMID: 37088567 DOI: 10.1080/14767058.2023.2203795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS). METHODS This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups. RESULTS A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay. CONCLUSIONS Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.
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Affiliation(s)
- Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Maria Scudo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Gabriella Gentile
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Angela Musella
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | | | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
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Yoshida T, Homma S, Ichikawa N, Ohno Y, Miyaoka Y, Matsui H, Imaizumi K, Ishizu H, Funakoshi T, Koike M, Kon H, Kamiizumi Y, Tani Y, Ito YM, Okada K, Taketomi A. Preoperative mechanical bowel preparation using conventional versus hyperosmolar polyethylene glycol-electrolyte lavage solution before laparoscopic resection for colorectal cancer (TLUMP test): a phase III, multicenter randomized controlled non-inferiority trial. J Gastroenterol 2023; 58:883-893. [PMID: 37462794 DOI: 10.1007/s00535-023-02019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND A hyperosmolar ascorbic acid-enriched polyethylene glycol-electrolyte (ASC-PEG) lavage solution ensures excellent bowel preparation before colonoscopy; however, no study has demonstrated the efficacy of this lavage solution before surgery. This study aimed to establish the non-inferiority of ASC-PEG to the standard polyethylene glycol-electrolyte solution (PEG-ELS) in patients undergoing laparoscopic resection for colorectal cancer. METHODS This was a prospective, single-blind, multicenter, randomized, controlled, non-inferiority clinical trial. Overall, 188 patients scheduled for laparoscopic colorectal resection for single colorectal adenocarcinomas were randomly assigned to undergo preparation with different PEG solutions between August 2017 and April 2020 at four hospitals in Japan. Participants received ASC-PEG (Group A) or PEG-ELS (Group B) preoperatively. The primary endpoint was the ratio of successful bowel preparations using the modified Aronchick scale, defined as "excellent" or "good." RESULTS After exclusion, 86 and 87 patients in Groups A and B, respectively, completed the study, and their data were analyzed. ASC-PEG was not inferior to PEG-ELS in terms of effective bowel preparation prior to laparoscopic colorectal resection (0.93 vs. 0.92; 95% confidence interval, - 0.078 to 0.099, p = 0.007). The total volume of cleansing solution intake was lower in Group A than in Group B (1757.0 vs. 1970.1 mL). Two and three severe postoperative adverse events occurred in Groups A and B, respectively. Patient tolerance of the two solutions was almost equal. CONCLUSIONS ASC-PEG is effective for preoperative bowel preparation in patients undergoing laparoscopic resection for colorectal cancer and is non-inferior to PEG-ELS.
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Affiliation(s)
- Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yosuke Ohno
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Yoichi Miyaoka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Hiroki Matsui
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Ken Imaizumi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Hiroyuki Ishizu
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Tohru Funakoshi
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Masahiko Koike
- Department of Surgery, KKR Sapporo Medical Center, Hiragishi 1-jo, 6-chome, Toyohira-ku, Sapporo, Hokkaido, Japan
| | - Hirofumi Kon
- Department of Surgery, KKR Sapporo Medical Center, Hiragishi 1-jo, 6-chome, Toyohira-ku, Sapporo, Hokkaido, Japan
| | - Yo Kamiizumi
- Department of Surgery, Iwamizawa Municipal General Hospital, 9-jo, W7, Iwamizawa, Hokkaido, Japan
| | - Yasuhiro Tani
- Department of Surgery, Iwamizawa Municipal General Hospital, 9-jo, W7, Iwamizawa, Hokkaido, Japan
| | - Yoichi Minagawa Ito
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Kazufumi Okada
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
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Perets M, Yellinek S, Carmel O, Boaz E, Dagan A, Horesh N, Reissman P, Freund MR. The effect of mechanical bowel preparation on postoperative complications in laparoscopic right colectomy: a retrospective propensity score matching analysis. Int J Colorectal Dis 2023; 38:133. [PMID: 37193834 DOI: 10.1007/s00384-023-04409-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE To assess whether full bowel preparation affects 30-day surgical outcomes in laparoscopic right colectomy for colon cancer. METHODS A retrospective chart review of all elective laparoscopic right colectomies performed for colonic adenocarcinoma between Jan 2011 and Dec 2021. The cohort was divided into two groups-no bowel preparation (NP) group and patients who received full bowel preparation (FP), including oral and mechanical cathartic bowel preparation. All anastomoses were extracorporeal stapled side-to-side. The two groups were compared at baseline and then were matched using propensity score based on demographic and clinical parameters. The primary outcome was 30-day postoperative complication rate, mainly anastomotic leak (AL) and surgical site infection (SSI) rate. RESULTS The original cohort included 238 patients with a median age of 68 (SD 13) and equal M:F ratio. Following propensity score matching, 93 matched patients were included in each group. Analysis of the matched cohort showed a significantly higher overall complication rate in the FP group (28 vs 11.8%, p = 0.005) which was mostly due to minor type II complications. There were no differences in major complication rates, SSI, ileus, or AL rate. Although operative time was significantly longer in the FP group (119 vs 100 min, p ≤ 0.001), length of stay was significantly shorter in the FP group (5 vs 6 days, p = 0.001). CONCLUSIONS Aside from a shorter hospital stay, full mechanical bowel preparation for laparoscopic right colectomy does not seem to have any benefit and may be associated with a higher overall complication rate.
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Affiliation(s)
- Michal Perets
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Shlomo Yellinek
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofra Carmel
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Elad Boaz
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Dagan
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nir Horesh
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Affiliated with the Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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The necessity of preoperative enema preparation for hemorrhoidal surgery: a single-center comparative study. Langenbecks Arch Surg 2022; 407:3005-3012. [PMID: 35729398 DOI: 10.1007/s00423-022-02587-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids. The necessity of preoperative enema preparation (PEP) in hemorrhoidal surgery is inconclusive. This study aims to evaluate the benefit and safety of PEP in hemorrhoidal surgery. METHODS This comparative study analyzed data from electronic medical record database and outpatient questionnaire archive. Data of patients who underwent hemorrhoidal surgery from March 2020 to February 2021 were obtained. Patients were allocated to either the PEP or non-PEP group. Primary outcome measurements were postoperative pain and oral analgesic use. Secondary outcomes were the number of days until first defecation, length of hospital stay, time to return to work, incidence of urinary retention, delayed bleeding, and local infection. RESULTS Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups, respectively, who underwent hemorrhoidal surgery were analyzed. Most patients underwent stapled hemorrhoidopexy, with 106 (81.54%) in PEP group and 113 (80.71%) in non-PEP group. The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups. CONCLUSION Our findings revealed that performing PEP before hemorrhoidal surgery produced no benefit when compared with not performing PEP. Typically, the procedure of PEP is inconvenient and discomforting for patients. Therefore, we suggest that it can be omitted in hemorrhoidal surgery.
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Ohta K, Ikenaga M, Ueda M, Iede K, Tsuda Y, Nakashima S, Tanida T, Nojiri T, Matsuyama J, Endo S, Yamada T. Preoperative Oral-Bowel Preparation Using Sodium Picosulfate and Magnesium Citrate Combination Powder for Left-Sided Colorectal Cancer: A Prospective Study. Int Surg 2022; 106:67-74. [DOI: 10.9738/intsurg-d-20-00038.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
ObjectiveThis study aimed to determine if induction of sodium picosulfate and magnesium citrate (SPMC) preparation leads to adequate surgery for left-sided colorectal cancer (CRC).Summary of Background DataAdequate bowel cleansing is vital for safe and accurate colorectal surgery. Ingestion of laxatives for bowel cleansing may be associated with a broad spectrum of adverse effects during surgical intervention.MethodsA single-center prospective study was conducted with hospitalized patients scheduled operation for left-sided CRC. All enrolled patients were instructed to consume normal diet until before preparation. Twenty-seven patients underwent preoperative SPMC preparation.ResultsThe primary endpoint of this study was the 30-day postoperative morbidity rate, which was 23%, and no postoperative complication was higher than Clavien-Dindo grade 3. The primary anastomosis rate was 100%, and there was no anastomotic leakage. The colonic cleansing grades were 1 or 2 according to the bowel preparation scale for surgical assessment in 89% of the patients. The acceptability of the cleansing procedure by the patients assessed by a questionnaire was 85%, and the acceptability of the SPMC preparation by the medical staff was 93%. The surgical procedures included 18 laparoscopies, 6 robotic surgeries, and 3 laparotomies. The median operation time was 165 minutes, and the median blood loss was <50 cc. The median sodium serum concentration was significantly decreased after surgery.ConclusionIngestion of an SPMC preparation as a cleansing procedure was judged to be adequate for curative surgery in patients with left-sided colorectal cancer.
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Affiliation(s)
- Katsuya Ohta
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
- 2 Department of Gastroenterological Surgery, Kindai University, Nara Hospital, Ikoma, Japan
| | - Masakazu Ikenaga
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Masami Ueda
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Kiyotsugu Iede
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Yujiro Tsuda
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Shinsuke Nakashima
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Tsukasa Tanida
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Takashi Nojiri
- 3 Department of Thoracic Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Jin Matsuyama
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Shunji Endo
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
- 4 Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Terumasa Yamada
- 1 Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
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Preoperative low-residue diet in gynecological surgery. Eur J Obstet Gynecol Reprod Biol 2022; 271:172-176. [DOI: 10.1016/j.ejogrb.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/21/2022]
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Kathopoulis N, Chatzipapas I, Valsamidis D, Samartzis K, Kipriotis K, Loutradis D, Protopapas A. Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice? J Obstet Gynaecol Res 2021; 47:1487-1496. [PMID: 33559272 DOI: 10.1111/jog.14674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/12/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
AIM To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures. METHODS A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function. RESULTS One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group. CONCLUSION Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned. CLINICAL TRIAL REGISTRATION ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).
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Affiliation(s)
- Nikolaos Kathopoulis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Chatzipapas
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Samartzis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kipriotis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Protopapas
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Apte SS, Moloo H, Jeong A, Liu M, Vandemeer L, Suh K, Thavorn K, Fergusson DA, Clemons M, Auer RC. Prospective randomised controlled trial using the REthinking Clinical Trials (REaCT) platform and National Surgical Quality Improvement Program (NSQIP) to compare no preparation versus preoperative oral antibiotics alone for surgical site infection rates in elective colon surgery: a protocol. BMJ Open 2020; 10:e036866. [PMID: 32647023 PMCID: PMC7351286 DOI: 10.1136/bmjopen-2020-036866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/24/2020] [Accepted: 06/02/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite 40 randomised controlled trials (RCTs) investigating preoperative oral antibiotics (OA) and mechanical bowel preparation (MBP) to reduce surgical site infection (SSI) rate following colon surgery, there has never been an RCT published comparing OA alone versus no preparation. Of the four possible regimens (OA alone, MBP alone, OA plus MBP and no preparation), randomised evidence is conflicting for studied groups. Furthermore, guidelines vary, with recommendations for OA alone, OA plus MBP or no preparation. The National Surgical Quality Improvement Program (NSQIP) has automated data collection for surgical patients. Similarly, the 'REthinking Clinical Trials' (REaCT) platform increases RCT enrolment by simplifying pragmatic trial design. In this novel RCT protocol, we combine REaCT and NSQIP to compare OA alone versus no preparation for SSI rate reduction in elective colon surgery. To our knowledge, this is the first published RCT protocol that leverages NSQIP for data collection. In our feasibility study, 67 of 74 eligible patients (90%) were enrolled and 63 of 67 (94%) were adherent to protocol. The 'REaCT-NSQIP' trial design has great potential to efficiently generate level I evidence for other perioperative interventions. METHODS AND ANALYSIS SSI rates following elective colorectal surgery after preoperative OA or no preparation will be compared. We predict 45% relative rate reduction of SSI, improvement in length of stay, reduced costs and increased quality of life, with similar antibiotic-related complications. Consent, using the 'integrated consent model', and randomisation on a mobile device are completed by the surgeon in a single clinical encounter. Data collection for the primary end point is automatic through NSQIP. Analysis of cost per weighted case, cost utility and quality-adjusted life years will be done. ETHICS AND DISSEMINATION This study is approved by The Ontario Cancer Research Ethics Board. Results will be disseminated in surgical conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03663504; Pre-results, recruitment phase.
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Affiliation(s)
- Sameer S Apte
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Husein Moloo
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ahwon Jeong
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michelle Liu
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa Vandemeer
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kathryn Suh
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Clemons
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Prevention of Anastomotic Leak Via Local Application of Tranexamic Acid to Target Bacterial-mediated Plasminogen Activation: A Practical Solution to a Complex Problem. Ann Surg 2019; 274:e1038-e1046. [PMID: 31851007 DOI: 10.1097/sla.0000000000003733] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the role of bacterial- mediated plasminogen (PLG) activation in the pathogenesis of anastomotic leak (AL) and its mitigation by tranexamic acid (TXA). BACKGROUND AL is the most feared complication of colorectal resections. The pathobiology of AL in the setting of a technically optimal procedure involves excessive submucosal collagen degradation by resident microbes. We hypothesized that activation of the host PLG system by pathogens is a central and targetable pathway in AL. METHODS We employed kinetic analysis of binding and activation of human PLG by microbes known to cause AL, and collagen degradation assays to test the impact of PLG on bacterial collagenolysis. Further, we measured the ability of the antifibrinolytic drug TXA to inhibit this process. Finally, using mouse models of pathogen-induced AL, we locally applied TXA via enema and measured its ability to prevent a clinically relevant AL. RESULTS PLG is deposited rapidly and specifically at the site of colorectal anastomoses. TXA inhibited PLG activation and downstream collagenolysis by pathogens known to have a causal role in AL. TXA enema reduced collagenolytic bacteria counts and PLG deposition at anastomotic sites. Postoperative PLG inhibition with TXA enema prevented clinically and pathologically apparent pathogen-mediated AL in mice. CONCLUSIONS Bacterial activation of host PLG is central to collagenolysis and pathogen-mediated AL. TXA inhibits this process both in vitro and in vivo. TXA enema represents a promising method to prevent AL in high-risk sites such as the colorectal anastomoses.
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Collins CR, Wick EC. Reflections on the Complexity of Surgical Site Infection Prevention and Detection from an Organizational Lens. Surg Infect (Larchmt) 2019; 20:577-580. [DOI: 10.1089/sur.2019.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Caitlin R. Collins
- Department of Surgery, University of California San Francisco Medical Center at Parnassus, San Francisco, California
| | - Elizabeth C. Wick
- Department of Surgery, University of California San Francisco Medical Center at Parnassus, San Francisco, California
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Ertas IE, Ince O, Emirdar V, Gultekin E, Biler A, Kurt S. Influence of preoperative enema application on the return of gastrointestinal function in elective Cesarean sections: a randomized controlled trial. J Matern Fetal Neonatal Med 2019; 34:1822-1826. [PMID: 31397204 DOI: 10.1080/14767058.2019.1651264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM There is an extensive literature on the mechanical bowel preparation by an enema in colorectal, abdominal, and gynecologic surgeries that provide evidence against the use of enema. There are, however, few studies investigating the effect of enema prior to elective Cesarean sections. The aim of this study is to investigate whether preoperative enema facilitates the return of gastrointestinal activity in pregnant women undergoing elective Cesarean section. MATERIALS AND METHODS The surgeon-blinded prospective randomized controlled study included 225 elective Cesarean patients between the ages of 18 and 44. The patients were randomized into two groups: those who had enema preoperatively (n = 114) and those who did not (n = 111). The outcome measures were first bowel sound time and first flatus time, the length of hospital stay, the rate of mid ileus symptoms, and additional analgesic and antiemetic need. RESULTS In the non-enema group, the time of the first bowel sound, flatus time, length of hospital stay, the rates of additional analgesic need, additional antiemetic need, and mild ileus symptoms were respectively 10.5 ± 5.8 hours, 16.0 ± 7.6 hours, 1.9 ± 0.3 days, 8.1%, 7.2%, and 2.7%. For the enema group, the same parameters were respectively 11.6 ± 4.7 hours, 17.5 ± 6.5 hours, 1.8 ± 0.3 days, 7%, 6.1% ,and 1.8%. For all parameters, the difference between the groups was not statistically significant (p values were respectively .09, .12, .8, .79, .68, and .26). CONCLUSIONS The study suggests that preoperative enema in elective cesarean sections does not prevent postoperative gastrointestinal complications and does not shorten the recovery of bowel movements or length of hospital stay.
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Affiliation(s)
- Ibrahim Egemen Ertas
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Onur Ince
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Volkan Emirdar
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Emre Gultekin
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Alper Biler
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Sefa Kurt
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
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Cawich SO, Mohammed F, Spence R, FaSiOen P, Naraynsingh V. Surgeons' attitudes toward mechanical bowel preparation in the 21st century: A survey of the Caribbean College of Surgeons. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.cmrp.2019.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial. Female Pelvic Med Reconstr Surg 2016; 23:1-7. [PMID: 27782976 DOI: 10.1097/spv.0000000000000346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. METHODS We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. RESULTS One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0-4.0) days. CONCLUSIONS Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE I.
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Bhat AH, Parray FQ, Chowdri NA, Wani RA, Thakur N, Nazki S, Wani I. Mechanical bowel preparation versus no preparation in elective colorectal surgery: A prospective randomized study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kantartzis KL, Shepherd JP. The use of mechanical bowel preparation in laparoscopic gynecologic surgery: a decision analysis. Am J Obstet Gynecol 2015; 213:721.e1-5. [PMID: 25981848 DOI: 10.1016/j.ajog.2015.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 04/26/2015] [Accepted: 05/10/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The use of mechanical bowel preparation prior to laparoscopy is common in gynecology, but its use may affect the rates of perioperative events and complications. Our objective was to compare different mechanical bowel preparations using decision analysis techniques to determine the optimal preparation prior to laparoscopic gynecological surgery. STUDY DESIGN A decision analysis was constructed modeling perioperative outcomes with the following mechanical bowel preparations: magnesium citrate, sodium phosphate, polyethylene glycol, enema, and no bowel preparation. Comparisons were made using published utility values. Secondary analyses included the percentages that had 1 or more preoperative events and 1 or more intra- or postoperative complications. RESULTS Overall, the highest utility values were for no bowel preparation (0.98) and magnesium citrate (0.97), whereas the other values were as follows: enema (0.95), sodium phosphate (0.94), and polyethylene glycol (0.91). The difference between no bowel preparation and magnesium citrate was less than the published minimally important differences for utilities, so there is likely no real difference between these strategies. The probability of having at least 1 preoperative event was lowest for no bowel preparation (1%), whereas the probability of having at least 1 intra- or postoperative complication was lowest with magnesium citrate (8%). CONCLUSION The highest utilities were seen with no bowel preparation, but the absolute difference between no bowel preparation and magnesium citrate was less than the minimally important difference. With similar overall utilities, our model raises questions as to whether mechanical bowel preparation is a necessary step prior to laparoscopic gynecological surgery. However, if a surgeon prefers a bowel preparation, magnesium citrate is the preferred option.
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Affiliation(s)
- Kelly L Kantartzis
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan P Shepherd
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Moghadamyeghaneh Z, Hanna MH, Carmichael JC, Mills SD, Pigazzi A, Nguyen NT, Stamos MJ. Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg 2015; 220:912-20. [PMID: 25907871 DOI: 10.1016/j.jamcollsurg.2015.02.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are limited data comparing the outcomes of preoperative oral antibiotic bowel preparation (OBP) and mechanical bowel preparation (MBP) in colorectal surgery. We sought to identify the relationship between preoperative bowel preparations (BP) and postoperative complications in colon cancer surgery. STUDY DESIGN The NSQIP database was used to examine the clinical data of colon cancer patients undergoing scheduled colon resection during 2012 to 2013. Multivariate regression analysis was performed to identify correlations between BP and postoperative complications. RESULTS We evaluated a total of 5,021 patients who underwent elective colon resection. Of these, 44.8% had only MBP, 2.3% had only OBP, 27.6% had both MBP and OBP, and 25.3% of patients did not have any type of BP. In multivariate analysis of data, MBP and OBP were not associated with decreased risk of postoperative complications in right side (adjusted odds ratio [AOR] 0.80, 0.30, p = 0.08, 0.10, respectively) or left side colon resections (AOR 1.02, 0.68, p = 0.81, 0.24, respectively). However, the combination of MBP and OBP before left side colon resections resulted in a significantly decreased risk of overall morbidity (AOR 0.63, p < 0.01), superficial surgical site infection (AOR 0.31, p < 0.01), anastomosis leakage (AOR 0.44, p < 0.01), and intra-abdominal infections (AOR 0.44, p < 0.01). CONCLUSIONS Our analysis revealed that solitary mechanical bowel preparation and solitary oral bowel preparation had no significant effects on major postoperative complications after colon cancer resection. However, a combination of mechanical and oral antibiotic preparations showed a significant decrease in postoperative morbidity.
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Affiliation(s)
| | - Mark H Hanna
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Joseph C Carmichael
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Steven D Mills
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Ninh T Nguyen
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA.
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Abstract
OBJECTIVE To compare surgeons' intraoperative surgeon acceptability or assessment of the operative field regarding bowel contents and patients' satisfaction with or without a mechanical bowel preparation before reconstructive vaginal prolapse surgery. METHODS In this single-blind, randomized trial, women scheduled to undergo vaginal prolapse surgery with a planned apical suspension and posterior colporrhaphy were allocated using block randomization to an intervention or control group. Surgeons were blinded to patient allocation. One day before surgery, mechanical bowel preparation instructions consisted of a clear liquid diet and two self-administered saline enemas; the participants in the control group sustained a regular diet and nothing by mouth after midnight. The primary outcome was surgeons' intraoperative assessment of the surgical field regarding bowel content as measured on a 4-point Likert scale (1, excellent; 4, poor). Secondary outcomes included participant satisfaction and bowel symptoms. The primary outcome was determined by intention-to-treat analysis and other analyses were per protocol. RESULTS Of the 150 women randomized (75 women to intervention and control group), 145 completed the study. No differences existed in the demographic, clinical, and intraoperative characteristics between groups (P>.05). Surgeons' intraoperative assessment rating was 85% "excellent or good" with bowel preparation compared with 90% for participants in the control group (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.21-1.61; P=.30). The bowel preparation group was less likely to report "complete" satisfaction compared with the participants in the control group (OR 0.11, 95% CI 0.04-0.35; P<.001). Abdominal fullness and cramping, fatigue, anal irritation, and hunger pains were greater in the bowel preparation group (all P<.01). CONCLUSION Before reconstructive vaginal surgery, mechanical bowel preparation conferred no benefit regarding surgeons' intraoperative assessment of the operative field, reflected decreased patient satisfaction, and had increased abdominal symptoms. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT01431040. LEVEL OF EVIDENCE I.
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Sugihara T, Yasunaga H, Horiguchi H, Matsuda S, Fushimi K, Kattan MW, Homma Y. Does mechanical bowel preparation ameliorate damage from rectal injury in radical prostatectomy? Analysis of 151 rectal injury cases. Int J Urol 2013; 21:566-70. [DOI: 10.1111/iju.12368] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 11/10/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Toru Sugihara
- Department of Quantitative Health Sciences; Cleveland Clinic Foundation; Cleveland Ohio USA
- Department of Urology; The University of Tokyo; Fukuoka Japan
| | - Hideo Yasunaga
- Department of Health Economics and Epidemiology Research; The University of Tokyo; Fukuoka Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research; Clinical Research Center; National Hospital Organization Headquarters; Fukuoka Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health; University of Occupational and Environmental Health; Fukuoka Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics; Tokyo Medical and Dental University; Tokyo Japan
| | - Michael W Kattan
- Department of Quantitative Health Sciences; Cleveland Clinic Foundation; Cleveland Ohio USA
| | - Yukio Homma
- Department of Urology; The University of Tokyo; Fukuoka Japan
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Sugihara T, Yasunaga H, Horiguchi H, Fujimura T, Nishimatsu H, Kume H, Ohe K, Matsuda S, Fushimi K, Homma Y. Is mechanical bowel preparation in laparoscopic radical prostatectomy beneficial? An analysis of a Japanese national database. BJU Int 2013; 112:E76-81. [DOI: 10.1111/j.1464-410x.2012.11725.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Hideo Yasunaga
- Department of Health Management and Policy; Graduate School of Medicine; University of Tokyo; Fukuoka; Japan
| | - Hiromasa Horiguchi
- Department of Health Management and Policy; Graduate School of Medicine; University of Tokyo; Fukuoka; Japan
| | | | | | - Haruki Kume
- Department of Urology; University of Tokyo; Fukuoka; Japan
| | - Kazuhiko Ohe
- Department of Medical Informatics and Economics; Graduate School of Medicine; University of Tokyo; Fukuoka; Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health; University of Occupational and Environmental Health; Fukuoka; Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics; Tokyo Medical and Dental University; Tokyo; Japan
| | - Yukio Homma
- Department of Urology; University of Tokyo; Fukuoka; Japan
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Sugihara T, Yasunaga H, Horiguchi H, Fujimura T, Nishimatsu H, Ohe K, Matsuda S, Fushimi K, Kattan MW, Homma Y. Does mechanical bowel preparation improve quality of laparoscopic nephrectomy? Propensity score-matched analysis in Japanese series. Urology 2013; 81:74-9. [PMID: 23273073 DOI: 10.1016/j.urology.2012.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/22/2012] [Accepted: 09/28/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of mechanical bowel preparation (MBP) before laparoscopic nephrectomy in terms of operation time and perioperative complications. MATERIALS AND METHODS Patients undergoing laparoscopic nephrectomy for T1-T3 tumors were identified in the Japanese Diagnosis Procedure Combination database from 2008 to 2010. The patients were stratified into a preoperative MBP group (polyethylene glycol electrolyte, magnesium citrate solution, and sodium picosulfate) and a non-MBP group and were matched using one-to-one propensity score matching according to age, sex, Charlson score, T category, hospital volume, and hospital academic status. The operation time, postoperative length of stay, and overall complication rate were assessed by multivariate regression analyses. RESULTS Of 2740 patients in 355 hospitals, 1110 pairs were generated. The median operation time, postoperative stay, and overall complication rate (MBP vs non-MBP group) was 278 and 268 minutes (P<.004), 10.3 and 10.0 days (P=.695), and 11.8% and 11.4% (P=.740), respectively. The multivariate regression analyses did not find significant superiority of MBP for the 3 endpoints (all P>.05). A shorter operation time was significantly associated with female sex and early-stage tumor. Older age, greater Charlson score, and lower hospital volume adversely affected the postoperative stay and overall complication rate. Stage T3 tumor was unfavorable for the postoperative stay. CONCLUSION Our large-scale propensity score-matched analysis did not demonstrate a benefit for MBP in operation time, postoperative stay, or overall complications. The results suggest that MBP can be safely omitted before laparoscopic nephrectomy for T1-T3 tumors.
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Affiliation(s)
- Toru Sugihara
- Department of Urology, Shintoshi Hospital, Iwata, Japan.
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Otchy DP, Crosby ME, Trickey AW. Colectomy without mechanical bowel preparation in the private practice setting. Tech Coloproctol 2013; 18:45-51. [PMID: 23467770 DOI: 10.1007/s10151-013-0990-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/11/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting. METHODS This prospective observational study included elective abdominal colorectal operations from one surgeon's practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year. RESULTS A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14). CONCLUSIONS Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.
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Affiliation(s)
- D P Otchy
- Fairfax Colon and Rectal Surgery P.C., 2710 Prosperity Ave., Suite #200, Fairfax, VA, 22031, USA,
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Surgical and Patient Outcomes Using Mechanical Bowel Preparation Before Laparoscopic Gynecologic Surgery. Obstet Gynecol 2013; 121:538-546. [DOI: 10.1097/aog.0b013e318282ed92] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Patel SS, Floyd A, Doorly MG, Ortega AE, Ault GT, Kaiser AM, Senagore AJ. Current controversies in the management of colon cancer. Curr Probl Surg 2012; 49:398-460. [PMID: 22682507 DOI: 10.1067/j.cpsurg.2012.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012; 27:803-10. [PMID: 22108902 DOI: 10.1007/s00384-011-1361-y] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2011] [Indexed: 02/06/2023]
Abstract
PURPOSE Mechanical bowel preparation (MBP) for elective colorectal surgery has been practiced as a clinical routine for many decades. However, earlier randomized clinical trials (RCTs) and meta-analyses suggest that MBP should be abandoned before colorectal surgery because of the futility in reducing postoperative complications and motility. The new published results from three RCTs comparing MBP with no MBP in colorectal surgery in 2010 make the updating of systemic review and meta-analysis necessary. The aim of this study was to estimate efficacy of MBP in prevention of postoperative complications for elective colorectal surgery. METHOD A literature search was performed mainly in electronic database including Cochrane Library, EMBASE, and MEDLINE. The inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. Septic complications, reoperation, and death were recorded as primary and secondary outcomes. The meta-analysis was conducted according to the QUOROM statement. RESULTS Fourteen RCTs were included in our analysis with a total number of 5,373 patients: 2,682 with MBP and 2,691 without. Comparing with no MBP for elective colorectal surgery, our study showed that MBP had not reduce any postoperative complications when concerning anastomotic leak [odds ratio (OR) 95% confidence interval (CI), 1.08 (0.82-1.43); P = 0.56]; overall SSI [OR 95% CI, 1.26 (0.94-1.68); P = 0.12]; extra-abdominal septic complications [OR 95% CI, 0.98 (0.81-1.18); P = 0.81]; wound infections [OR 95% CI, 1.21 (1.00-1.46); P = 0.05]; reoperation or second intervention rate [OR 95% CI, 1.11 (0.86-1.45); P = 0.42]; and death [OR 95% CI, 0.97(0.63-1.48); P = 0.88]. CONCLUSION No evidence was noted supporting the use of MBP in patients undergoing elective colorectal surgery. MBP should be omitted in routine clinical practice.
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Affiliation(s)
- F Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, 100053, Beijing, China
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Ben Chaabane N, Ben Mansour W, Hellara O, Ben Mansour I, Melki W, Loghmeri H, Bdioui F, Safer L, Saffar H. [Bowel preparation before colonoscopy]. Presse Med 2011; 41:37-42. [PMID: 21795010 DOI: 10.1016/j.lpm.2011.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 03/31/2011] [Accepted: 04/05/2011] [Indexed: 01/10/2023] Open
Abstract
Colonoscopy is a routinely performed procedure in adults. Completion of the procedure and proper visualization of the intestinal mucosa are highly dependent on the quality of the bowel preparation. The ideal bowel preparation should be safe, well-tolerated and effective. No bowel preparation method meets the ideal criteria for bowel-cleansing prior to colonoscopy. However, polyethylene glycol-electrolyte lavage solution and sodium phosphate are the most commonly used bowel preparations before colonoscopy and colon surgery. NaP preparations appear more effective and better tolerated than standard PEG solutions but should be administered with caution in patients with preexisting or at an increased risk for electrolyte disturbances. Timing and dose are important considerations regardless of the method used. The last generation of preparations improves safety and acceptability by reducing volume of liquid ingested.
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Yang LC, Arden D, Lee TTM, Mansuria SM, Broach AN, D'Ambrosio L, Guido R. Mechanical bowel preparation for gynecologic laparoscopy: a prospective randomized trial of oral sodium phosphate solution vs single sodium phosphate enema. J Minim Invasive Gynecol 2010; 18:149-56. [PMID: 21167795 DOI: 10.1016/j.jmig.2010.10.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 10/08/2010] [Accepted: 10/14/2010] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To compare the effect of mechanical bowel preparation using oral sodium phosphate (NaP) solution vs single NaP enema on the quality of the surgical field in patients undergoing advanced gynecologic laparoscopic procedures. DESIGN Single-blind randomized controlled trial (Canadian Task Force classification I). SETTING Academic teaching hospital. PATIENTS Women undergoing gynecologic laparoscopic surgery. INTERVENTIONS Administration of either oral NaP solution or single NaP enema for preoperative bowel preparation. MEASUREMENTS AND MAIN RESULTS One hundred fifty-six women were enrolled, and 145 were randomized to receive either oral NaP solution (n = 72) or NaP enema (n = 73). Sixty-eight women in the oral solution group and 65 in the enema group completed the study. Assessment of the quality of the surgical field and bowel characteristics was performed using a surgeon questionnaire using Likert and visual analog scales. No significant differences were observed between the 2 groups in evaluation of the surgical field, bowel handling, degree of bowel preparation, or surgical difficulty. Surgical field quality was graded as excellent or good in 85% of women in the oral solution group and 91% of women in the enema group (p = .43). When surgeons were asked to guess the type of preparation used, they were correct only 52% of the time (κ = 0.04). Assessment of patient quality of life in the preoperative period was performed using a self-administered questionnaire using a visual analog scale. Severity of abdominal bloating and swelling, weakness, thirst, dizziness, nausea, fecal incontinence, and overall discomfort were significantly greater in the oral solution group. Women in the oral solution group also rated the preparation as significantly more difficult to administer, and were significantly less willing to try the same preparation in the future. CONCLUSION Quality of the surgical field in patients undergoing advanced gynecologic laparoscopic procedures is similar after mechanical bowel preparation using either oral NaP solution and NaP enema. Adverse effects are more severe with oral NaP solution compared with NaP enema administration.
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Affiliation(s)
- Linda C Yang
- Program of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Ellis CN. Bowel Preparation Before Elective Colorectal Surgery: What is the Evidence. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Despite emerging evidence from randomized controlled trials and meta-analyses questioning its use, mechanical bowel preparation (MBP) continues to hold an accepted place among surgeons. MBP has been administered to patients for over a century, and though the methods and agents used for intestinal cleansing have evolved over time, many surgeons still embrace MBP as a necessary, essential regimen. The accepted rationale for MBP includes evacuation of stool to allow visualization of the luminal surfaces as well as to reduce the fecal flora, which is believed to translate into lower risk of infectious and anastomotic complications at surgery. The authors describe the history of MBP as it relates to colorectal surgery and review the agents currently used for mechanical bowel preparation. Additionally, they summarize the recent trials, meta-analyses, and other emerging data from the medical literature that suggest MBP offers no benefit as a preoperative measure and question its place in current surgical practice.
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Affiliation(s)
- James E Duncan
- Department of Surgery, National Naval Medical Center (NNMC), Bethesda, MD 20889, USA.
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30
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Lynch ML, Brand MI. Preoperative evaluation and oncologic principles of colon cancer surgery. Clin Colon Rectal Surg 2010; 18:163-73. [PMID: 20011299 DOI: 10.1055/s-2005-916277] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Colorectal cancer is the third most common malignancy in men and women and accounts for 10% of all cancer deaths. The primary risk factor for colorectal cancer is advancing age, but other factors also play a role in its development, including genetic predisposition, smoking, alcohol consumption, obesity, and high-fat, low-fiber diet. Colon cancer survival is primarily related to the stage of disease at diagnosis. The main screening tests for colon cancer are fecal occult blood testing, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. The pre-operative evaluation should include a complete blood count, carcinoembryonic antigen (CEA), colonoscopy, and chest radiograph. Other preoperative evaluations are patient specific or of unproven benefit. The operative procedure should include a bowel preparation, parenteral antibiotics, and deep venous thrombosis prophylaxis. The procedure performed must be tailored to the location of the colon cancer but should include complete, en bloc resection of the cancer and its lymphatic drainage, including locally invaded structures. The bowel margins of resection should be at least 5 cm from the tumor to minimize anastomotic recurrences. Laparoscopic colectomy has been shown to be as safe and effective as open colectomy for the treatment of colon cancer. The use of sentinel lymph node biopsy is feasible but has not yet been proved clinically useful. Surveillance after surgery for colon cancer is necessary to monitor for metastatic disease or local recurrence. Several groups have made surveillance recommendations including office visits, colonoscopy, and CEA monitoring.
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Affiliation(s)
- Matthew L Lynch
- Department of General Surgery, Rush University Medical Center, Chicago, IL 60612-3817, USA.
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31
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Scabini S, Rimini E, Romairone E, Scordamaglia R, Damiani G, Pertile D, Ferrando V. Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial. World J Surg Oncol 2010; 8:35. [PMID: 20433721 PMCID: PMC2873340 DOI: 10.1186/1477-7819-8-35] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Accepted: 04/30/2010] [Indexed: 02/07/2023] Open
Abstract
Background Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. The aim of the study was to assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. Methods Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. Results Two hundred forty four patients were included in the study, 120 in group A and 124 in group B. Demographic characteristics, type of surgical procedure and type of anastomosis did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups but the overall infectious complications rate was 20.0% in group A and 11.3% in group B (p .05). Wound infection (p = 0.18), anastomotic leak (p = 0.52), and intra-abdominal abscess (p = 0.36) occurred in 9.2%, 5.8%, and 5.0% versus 4.8%, 4.0%, and 2.4%, respectively. No mechanical bowel preparation seems to be safe also in rectal surgery. Conclusions These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.
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Affiliation(s)
- Stefano Scabini
- Unit of Surgical Oncology, Department of Emato-Oncology, San Martino Hospital, Genoa, Italy.
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Fagotti A, Costantini B, Fanfani F, Vizzielli G, Rossitto C, Lecca A, Scambia G. Risk of Postoperative Pelvic Abscess in Major Gynecologic Oncology Surgery: One-Year Single-Institution Experience. Ann Surg Oncol 2010; 17:2452-8. [DOI: 10.1245/s10434-010-1059-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Indexed: 12/30/2022]
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Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta-analysis. Int J Colorectal Dis 2010; 25:267-75. [PMID: 19924422 DOI: 10.1007/s00384-009-0834-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2009] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to estimate efficacy of mechanical bowel preparation with polyethylene glycol (PEG) in prevention of postoperative complications in elective colorectal surgery. METHOD A literature search of MEDLINE (PubMed), EMBASE, and the Cochrane Library was done to identify randomized controlled trials involving comparison of postoperative complications after mechanical bowel preparation with PEG (PEG group) and no preparation (control group). A meta-analysis was set up to distinguish overall difference between the two groups. RESULTS A total of five randomized controlled trials was identified according to our inclusion criteria. The use of PEG for mechanical bowel preparation did not significantly reduce the rate of surgical site infection (SSI; odds ratio (OR) 95% confidence interval (CI), 1.39 (0.85-2.25); P = 0.19) including incisional SSI (OR 95% CI, 1.44 (0.88-2.33); P = 0.15), organ/space SSI (OR 95% CI, 1.10 (0.43-2.78); P = 0.49), anastomotic leak (OR 95% CI,1.78 (0.95-3.33; P = 0.07), mortality (OR 95% CI, 1.24 (0.37-4.14; P = 0.73), infectious complications (OR 95% CI, 1.14 (0.62-2.08); P = 0.67), and hospital stay (weighted mean difference 95% CI, 2.17 (-2.90-7.25); P = 0.40) except main complications (OR 95% CI, 1.76 (1.09-2.85); P = 0.02), of which the rate increased significantly in the PEG group. CONCLUSION The use of mechanical bowel preparation with PEG does not significantly lower postoperative complications in elective colorectal surgery.
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Jain S, Simms MS, Mellon JK. Management of the Gastrointestinal Tract at the Time of Cystectomy. Urol Int 2009; 77:1-5. [PMID: 16825806 DOI: 10.1159/000092925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Radical cystectomy impacts on the gastro-intestinal tract in several ways. Clearly there is the need for bowel mobilisation, resection and anastamosis in order to create a urinary diversion, and the use of bowel preparation or antibiotics are controversial topics. Post-operatively ileus is common and there is debate about the routine use of NG tubes. Early enteral feeding is a modern concept but not yet proven. In the long-term there can be problems such as diarrhoea and B12 deficiency. All of these issues are discussed in this review using the latest available evidence.
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Affiliation(s)
- S Jain
- Urology Group, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK.
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35
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Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009; 249:203-9. [PMID: 19212171 DOI: 10.1097/sla.0b013e318193425a] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Earlier meta-analyses of small randomized trials suggested that mechanical bowel preparation (MBP) should be omitted before colorectal surgery because it does not affect complication rates 0 mortality and may be even harmful; however, more recent large randomized trials suggested an increased occurrence of pelvic abscesses in the absence of MBP. Therefore, an updated large meta-analysis was conducted to re-evaluate the role of MBP in colorectal surgery. Furthermore, the influence of different kind of MBP regimes on infectious outcomes was examined. METHODS The meta-analysis was conducted according to the QUOROM statement; the inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications. RESULTS Fourteen trials were included with a total number of 4859 patients: 2452 in the MBP group and 2407 in the no MBP group. We found no statistical difference between the groups for anastomotic leakage [OR = 1.12 (0.82-1.53), P = 0.46], pelvic or abdominal abscess (P = 0.75), and wound sepsis (P = 0.11). When all surgical site infections were considered, the meta-analysis favored no MBP [OR = 1.40 (1.05-1.87), P = 0.02].Sensitivity analyses showed similar results for all subgroups but when poor or small trials were excluded, there was a slightly higher risk of deep abdominal abscesses with no MBP, however, the number needed to harm was as high as 333 patients, suggesting this difference to be not clinically relevant. The use of different MBP regimes did not influence primary and secondary outcomes. The main limitation concerned rectal surgery for which the limited data preclude any interpretation. CONCLUSION Although it did not confirm the harmful effect of mechanical bowel preparation (suggested by previous meta-analyses), this meta-analysis including almost 5000 patients, demonstrates with a high level of evidence that any kind of mechanical bowel preparation should be omitted before colonic surgery.
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36
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Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon blind, randomized and controlled trial. Arch Gynecol Obstet 2009; 280:713-8. [DOI: 10.1007/s00404-009-0986-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 02/02/2009] [Indexed: 10/21/2022]
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37
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Itani KM, Kim L. Mechanical Bowel Preparation or Not for Elective Colorectal Surgery. Surg Infect (Larchmt) 2008; 9:563-5. [DOI: 10.1089/sur.2008.9957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kamal M.F. Itani
- Veterans Affairs Boston Health Care System and Boston University School of Medicine, Boston, Massachusetts
| | - Lawrence Kim
- Central Arkansas Veterans Affairs Health Care System and University of Arkansas for the Medical Sciences, Little Rock, Arkansas
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38
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Pineda CE, Shelton AA, Hernandez-Boussard T, Morton JM, Welton ML. Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature. J Gastrointest Surg 2008; 12:2037-44. [PMID: 18622653 DOI: 10.1007/s11605-008-0594-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 06/25/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery. METHODS We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio. RESULTS Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899-1.64, P = 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946-1.413, P = 0.155). DISCUSSION This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery. CONCLUSION In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet "standard of care."
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Affiliation(s)
- Carlos E Pineda
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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39
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Ker TS. Prospective Comparison of Three Bowel Preparation Regimens: Fleet Phosphosoda, Two-Liter and Four-Liter Electrolyte Lavage Solutions. Am Surg 2008. [DOI: 10.1177/000313480807401032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In an attempt to improve patients’ tolerance for colon cleaning, three bowel preparation regimens: 90-mL Fleet phosphosoda (FPS), 2-L electrolyte lavage solution plus 20 mg oral bisacodyl, and 4-L lavage, were compared for efficacy and safety. A total of 912 patients were prospectively nonrandomized into three study groups. In Group A, 304 patients were given 45-mL Fleet phosphosoda at 9 AM and 6 PM the day before colonoscopy. In Group B, 304 patients were given four tablets of 5 mg bisacodyl at 12 PM the day before colonoscopy followed by 2 L electrolyte lavage by mouth at 6:00 PM the evening before colonoscopy. In Group C, 304 patients were given 4 L electrolyte lavage at 6:00 PM the evening before colonoscopy. All patients were kept on a clear liquid diet the day before colonoscopy. The bowel cleanliness was accessed by one colonoscopist. One registered nurse accessed the ease of the patient. In Group A (FPS), every patient finished the 90-mL Fleet phosphosoda. Colon cleanliness was 95.1 per cent. In Group B (2 L), three patients (0.6%) could not finish the laxative. Colon cleanliness was 95.9 per cent. In Group C (4 L), 22 patients (7.3%) could not finish the laxative preparation. Colon cleanliness was 95.3 per cent. The study found these three regimens can achieve equally good results of bowel preparation; however, the small volume laxative (FPS) has been accepted favorably by patients.
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Affiliation(s)
- Tim S. Ker
- Department of Colorectal Surgery, University of Southern California, Los Angeles, California
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40
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Abstract
Bowel preparation has been a much-debated issue for both colonoscopy and for colorectal surgery. While bowel preparation for colonoscopy is clearly mandatory for optimal intraluminal visualization, bowel preparation for surgery has recently been challenged. This review evaluates oral bowel preparation, based on evidence in the literature, in order to provide a practical guide for physicians and practitioners about oral bowel cleansing preparations in current use for both colonoscopy and for colorectal surgery.A MEDLINE search, limited to publications in English language, was done through Ovid including articles published from 1966 to 2007 about bowel preparation using terms 'pre-operative care' and 'colonoscopy' or 'surgical procedure' associated with 'polyethylene glycol' and 'sodium phosphate'. The references lists from the identified articles were also included in the review. No bowel preparation method meets the ideal criteria for bowel cleansing prior to colonoscopy. However, polyethylene glycol-electrolyte lavage solution (PEG-ELS) and sodium phosphate are the most commonly used bowel preparations before colonoscopy and colon surgery. Both preparations are safely used and effective; however, some precautions should be considered, particularly with sodium phosphate. In addition, the efficacy of low-volume PEG-ELS can be improved by the addition of preparation adjuncts. Timing and dose are important considerations regardless of the method used. Mechanical bowel preparation for surgery has been questioned, and shown to have no extra benefits and possibly the association with increased morbidity. Regardless of the evidence, there are many randomized controlled trials showing the lack of benefit of mechanical bowel preparation.
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Affiliation(s)
- Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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41
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Baca B, Aytac E, Apaydin BB, Onur E, Kilic IE, Erdamar S, Uslu E, Uzun H, Koksal S. Mechanical bowel preparation with different solutions in rats with selective left colonic ischemia and reperfusion injury. Am J Surg 2008; 196:418-24. [PMID: 18353271 DOI: 10.1016/j.amjsurg.2007.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 10/30/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effects of preoperative mechanical bowel preparation (MBP) on colonic ischemia/reperfusion (I/R) injury. METHODS Seventy adult male Sprague-Dawley rats were divided randomly into 7 equal groups of 10 rats each. Groups were assigned as follows: group I = sham surgery; group II = I/R of left colon (control group); group III = intravenous heparin and metronidazole followed by I/R of the left colon; groups IV through VII = before I/R of the left colon, heparin and metronidazole and MBP were performed with sodium chloride (NaCl), Na phosphate, polyethylene glycol, and mannitol, respectively. Histopathologic and biochemical parameters were evaluated. RESULTS According to the histopathologic changes, the groups least affected by I/R injury were groups V and VII. Catalase activity was significantly higher in groups V and VII, and copper-zinc superoxide dismutase activity was significantly higher in group VII compared with the control group (P <.002). CONCLUSIONS MBP with sodium phosphate and mannitol appears to be more protective against I/R injury.
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Affiliation(s)
- Bilgi Baca
- Department of Surgery, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey.
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Contant CME, Hop WCJ, van't Sant HP, Oostvogel HJM, Smeets HJ, Stassen LPS, Neijenhuis PA, Idenburg FJ, Dijkhuis CM, Heres P, van Tets WF, Gerritsen JJGM, Weidema WF. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112-7. [PMID: 18156032 DOI: 10.1016/s0140-6736(07)61905-9] [Citation(s) in RCA: 205] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation. METHODS We did a multicentre randomised non-inferiority study at 13 hospitals. We randomly assigned 1431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496. FINDINGS 77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups: 32/670 (4.8%) patients who had mechanical bowel preparation and 37/684 (5.4%) in those who did not (difference 0.6%, 95% CI -1.7% to 2.9%, p=0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3%] vs 17/684 [2.5%], p=0.001). Other septic complications, fascia dehiscence, and mortality did not differ between groups. INTERPRETATION We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.
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Bretagnol F, Alves A, Ricci A, Valleur P, Panis Y. Rectal cancer surgery without mechanical bowel preparation. Br J Surg 2007; 94:1266-71. [PMID: 17657719 DOI: 10.1002/bjs.5524] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND : 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. METHODS 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. RESULTS 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). CONCLUSION Elective rectal surgery for cancer without MBP may be associated with reduced postoperative morbidity.
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Affiliation(s)
- F Bretagnol
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
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44
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Burke CA, Church JM. Enhancing the quality of colonoscopy: the importance of bowel purgatives. Gastrointest Endosc 2007; 66:565-73. [PMID: 17725947 DOI: 10.1016/j.gie.2007.03.1084] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 03/29/2007] [Indexed: 12/13/2022]
Affiliation(s)
- Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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45
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Rex DK. Dosing considerations in the use of sodium phosphate bowel preparations for colonoscopy. Ann Pharmacother 2007; 41:1466-75. [PMID: 17652123 DOI: 10.1345/aph.1k206] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To review dosing considerations and other treatment recommendations to maximize the efficacy, tolerability, and safety of sodium phosphate (NaP) preparations. DATA SOURCES Literature was accessed through PubMed (1990-May 2007) and abstracts from scientific meetings. STUDY SELECTION AND DATA EXTRACTION English-language publications including clinical trials and case reports were evaluated. Recent reports assessing newer bowel preparations containing reduced doses of NaP were reviewed to evaluate efficacy, tolerability, and safety. DATA SYNTHESIS Among commonly administered bowel preparations for colonoscopy, NaP preparations are generally more effective and better tolerated compared with polyethylene glycol electrolyte lavage solution regimens. However, NaP preparations are contraindicated in specific patient populations, and clinicians must use effective screening mechanisms to select proper patients to receive NaP preparation for colonoscopy. Recently, cases of renal failure in patients with previously normal renal function have been reported after NaP preparation for colonoscopy, heightening concerns about the safety of these agents. Newer products contain reduced doses of NaP and may improve the safety and tolerability of NaP purgatives without compromising efficacy of colon cleansing. In addition, accumulating clinical data and/or rationale support split dosing of NaP products, wide intervals between doses, and aggressive hydration before and during bowel preparation and after the colonoscopy procedure. CONCLUSIONS Safe administration of NaP products requires rigorous attention to dosing considerations and other treatment recommendations, including administration of minimally effective doses of NaP, split-dosing schedules, and aggressive hydration.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, Indiana University Medical Center, #4100, 550 North University Blvd., Indianapolis, IN 46202, USA.
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46
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Jung B, Påhlman L, Nyström PO, Nilsson E. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg 2007; 94:689-95. [PMID: 17514668 DOI: 10.1002/bjs.5816] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery.
Methods
A total of 1505 patients, aged 18–85 years with American Society of Anesthesiologists grades I–III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days.
Results
A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5·1 and 4·6 per cent respectively, general infectious complications in 7·9 and 6·8 per cent, and surgical-site complications in 15·1 and 16·1 per cent. At least one complication was recorded in 24·5 per cent of patients who had MBP and 23·7 per cent who did not.
Conclusion
MBP does not lower the complication rate and can be omitted before elective colonic resection. Registration number: ISRCTN28535118 (http://www.controlled-trials.com).
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Affiliation(s)
- B Jung
- University of Umeå, Department of Surgery, Visby Hospital, Visby, Sweden.
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47
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Jung B, Lannerstad O, Påhlman L, Arodell M, Unosson M, Nilsson E. Preoperative mechanical preparation of the colon: the patient's experience. BMC Surg 2007; 7:5. [PMID: 17480223 PMCID: PMC1884131 DOI: 10.1186/1471-2482-7-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 05/04/2007] [Indexed: 12/24/2022] Open
Abstract
Background Preoperative mechanical bowel preparation can be questioned as standard procedure in colon surgery, based on the result from several randomised trials. Methods As part of a large multicenter trial, 105 patients planned for elective colon surgery for cancer, adenoma, or diverticulitis in three hospitals were asked to complete a questionnaire regarding perceived health including experience with bowel preparation. There were 39 questions, each having 3 – 10 answer alternatives, dealing with food intake, pain, discomfort, nausea/vomiting, gas distension, anxiety, tiredness, need of assistance with bowel preparation, and willingness to undergo the procedure again if necessary. Results 60 patients received mechanical bowel preparation (MBP) and 45 patients did not (No-MBP). In the MBP group 52% needed assistance with bowel preparation and 30% would consider undergoing the same preoperative procedure again. In the No-MBP group 65 % of the patients were positive to no bowel preparation. There was no significant difference between the two groups with respect to postoperative pain and nausea. On Day 4 (but not on Days 1 and 7 postoperatively) patients in the No-MBP group perceived more discomfort than patients in the MBP group, p = 0.02. Time to intake of fluid and solid food did not differ between the two groups. Bowel emptying occurred significantly earlier in the No-MBP group than in the MBP group, p = 0.03. Conclusion Mechanical bowel preparation is distressing for the patient and associated with a prolonged time to first bowel emptying.
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Affiliation(s)
- Barbel Jung
- University of Umeå and Department of Surgery, Visby Hospital, Visby Sweden
| | | | - Lars Påhlman
- Department of Surgery, Colorectal Unit, University Hospital, Uppsala, Sweden
| | - Malin Arodell
- Department of Medicine and Care, Division of Nursing Science, Linköping University, Sweden
| | - Mitra Unosson
- Department of Medicine and Care, Division of Nursing Science, Linköping University, Sweden
| | - Erik Nilsson
- Department of Surgery, University Hospital, Umeå, Sweden
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Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery. Am J Surg 2007; 193:190-4. [PMID: 17236845 DOI: 10.1016/j.amjsurg.2006.08.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Revised: 08/01/2006] [Accepted: 08/01/2006] [Indexed: 02/02/2023]
Abstract
BACKGROUND The type of mechanical bowel preparation (MBP) used before elective colorectal surgery remains controversial. METHODS This post hoc analysis of a prospective randomized controlled antibiotic prophylaxis trial (ertapenem vs. cefotetan) evaluated the effect of polyethylene glycol (PEG) and sodium phosphate (SP) MBPs on the rates of postoperative surgical site infections (SSI). RESULTS Good to excellent MBPs were observed in 281 of 303 (93%) evaluable patients for the PEG and 336 of 367 (92%) for the SP types. A higher rate of SSI was observed in the PEG (34%) than SP (24%) group (difference, 10%; 95% confidence interval, 3.4-17.2). The MBP type was a significant risk factor for SSI, with SP favored over PEG (odds ratio, .6; 95% confidence interval, .43-.85) in univariate analysis; multivariate analysis favored SP, but was not significant (odds ratio, .69; 95% confidence interval, .46-1.02). SSI was lowest with SP and ertapenem (19%) and highest with PEG and cefotetan (44%). CONCLUSIONS SP, coupled with ertapenem antibiotic prophylaxis, may improve outcomes and reduce SSIs in patients undergoing elective colorectal surgery when compared with PEG coupled with cefotetan antibiotic prophylaxis.
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Affiliation(s)
- Kamal M F Itani
- VA Boston Healthcare System and Boston University School of Medicine, 1400 VFW Pkwy. (112), West Roxbury, MA 02132, USA.
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Gmeiner M, Pfeifer J. Management of complications in surgery of the colon. Eur Surg 2007; 39:15-32. [PMID: 32288768 PMCID: PMC7102154 DOI: 10.1007/s10353-007-0311-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/23/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly. METHODS We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads). RESULTS Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery. CONCLUSIONS To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.
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Affiliation(s)
- M. Gmeiner
- />Department of Pulmology, General Hospital Graz-West, Graz, Austria
| | - J. Pfeifer
- />Department of General Surgery, Medical University of Graz, Graz, Austria
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Ker TS. Comparison of Reduced Volume versus Four-Liter Electrolyte Lavage Solutions for Colon Cleansing. Am Surg 2006. [DOI: 10.1177/000313480607201015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In an attempt to improve patient tolerance for colon cleaning, a reduced-volume regimen with a 2-liter electrolyte lavage solution plus 20 mg of oral bisacodyl was compared with the standard 4-liter lavage for efficacy and safety. Three hundred patients were prospectively randomized into two study groups. One group of 150 patients was given four tablets of 5 mg bisacodyl at 12:00 PM the day before their colonoscopy, followed by 2 liters of electrolyte lavage by mouth at 6:00 PM the evening before their colonoscopy. Another group of 150 patients were given 4 liters of electrolyte lavage at 6:00 PM the evening before their colonoscopy. All patients were on a clear liquid diet the day before their colonoscopy. No enema was given in either groups. The bowel cleanliness was accessed by one colonoscopist. One registered nurse accessed the comfort of patient. In the 2-liter group, only one (0.6%) patient could not finish the laxative. Colon cleanliness was 80 per cent to 100 per cent, with an average of 95.9 per cent. In the 4-liter group, 11 (7.3%) patients could not finish the laxative preparation. Colon cleanliness was 78 per cent to 100 per cent, with an average of 95.3 per cent. The study that found the 2-liter electrolyte lavage solution with four tablets of bisacodyl can achieve equally good results in bowel preparation and favorable acceptance by patients compared with the 4-liter lavage.
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Affiliation(s)
- Tim S. Ker
- From the University of Southern California, Los Angeles, California
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