Published online Jan 28, 2018. doi: 10.3748/wjg.v24.i4.519
Peer-review started: October 5, 2017
First decision: October 18, 2017
Revised: October 25, 2017
Accepted: November 8, 2017
Article in press: November 8, 2017
Published online: January 28, 2018
Processing time: 114 Days and 9.4 Hours
Mechanical bowel preparation for colorectal surgery has been surgical dogma for decades, despite increasing evidence from the 1990s refuting its benefits. The rationale behind the administration of mechanical bowel preparation is that it reduces fecal bulk and, therefore, bacterial colonisation, thereby reducing the risk of postoperative complications such as anastomotic leakage and wound infection, as well as facilitate dissection and allow endoscopic evaluation. Opponents argue that in the 21st century, with rational use of oral and intravenous prophylactic antibiotics there is no longer a place for mechanical bowel preparation, that it may cause marked fluid and electrolyte imbalance in the preoperative period. As a result of this inconclusive evidence, practice varies between countries and even surgeons in the same institution. We conducted a comprehensive meta-analysis encompassing both randomised controlled trials and observational studies. We sought to address deficiencies in previous studies by including all levels of evidence, separating those in which patients received a single rectal enema vs full or no preparation.
The main topics focused on by this meta-analysis are the role of mechanical bowel preparation vs no preparation or rectal enema alone on postoperative infective complications in patients undergoing elective colorectal surgery, as well as in patients undergoing purely rectal resection. This meta-analysis also sought to examine evidence from both randomized controlled trials and observational studies and compare the results of meta-analyses conducted from these evidence sources.
The aims for this meta-analysis were to analyse the effect of mechanical bowel preparation vs no preparation or rectal enema alone on postoperative infective complications in patients undergoing elective colorectal surgery, to examine the differences in results between evidence obtained from randomised controlled trials and observational studies, and to determine what effect, if any, bowel preparation had on postoperative complications in rectal surgery. These aims were all achieved by this meta-analysis.
We performed an electronic search of the PubMed database and the Cochrane Central Register of Controlled Trials to identify studies comparing outcomes in patients undergoing elective colorectal surgery treated with mechanical bowel preparation vs either no preparation or a single rectal enema. We performed this meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We reviewed full text articles for suitability after excluding studies on the basis of title and abstract. Our inclusion criteria specified that studies must have a minimum of two comparator groups and were either designed as randomised controlled trials or observational studies. Relevant outcome measures were anastomotic leak, surgical site infection, intra-abdominal abscess, mortality, reoperation and hospital length of stay. The analysis was performed using RevMan 5.3 software. Continuous variables were calculated as a mean difference and 95% confidence interval using an inverse variance random effects model. Dichotomous variables were analysed using the Mantel-Haenszel random effects model to quote the risk ratio (RR) and 95% confidence interval. These analyses were used to construct forest plots, with statistical significance taken to be a P value of < 0.05 on two tailed testing. A predetermined subgroup analysis was performed for the impact of MBP in rectal surgery specifically using the same methodology.
This meta-analysis of 23 randomised controlled trials and 13 observational studies has demonstrated that, overall, the use of MBP vs either absolutely no bowel preparation or a single rectal enema was not associated with a statistically significant difference in the incidence of anastomotic leak, surgical site infection, intra-abdominal collection, mortality, reoperation or total hospital length of stay. When just randomised controlled trial evidence was analysed, there was again no significant difference by preparation method in any clinical outcome measure. Finally, when observational studies were analysed, the use of full preparation was associated overall with a reduced incidence of anastomotic leak, surgical site infection, intra-abdominal collection and mortality rates, with these results mirrored in patients receiving MBP vs absolutely no preparation, but no significant differences in those receiving MBP vs a single rectal enema.
This study represents the most comprehensive examination of the role of mechanical bowel preparation prior to elective colorectal surgery to date and has demonstrated that, overall, the use of MBP vs either absolutely no bowel preparation or a single rectal enema was not associated with a statistically significant difference in the incidence of anastomotic leak, surgical site infection, intra-abdominal collection, mortality, reoperation or total hospital length of stay. Given the risks of electrolyte disturbance and patient dissatisfaction as well as potentially significant levels of dehydration and requirement for pre-admission prior to surgery, mechanical bowel preparation should no longer be considered a standard of care prior to elective colorectal surgery.
This study represents the most comprehensive meta-analysis to date on mechanical bowel preparation in elective colorectal surgery. It has demonstrated that mechanical bowel preparation vs a single rectal enema or no bowel preparation at all is associated with no difference in any of the clinical outcome measures studied. Mechanical bowel preparation should no longer be considered a standard of care prior to elective colorectal surgery. Emerging evidence, much of which has been derived from the studies based upon NSQIP datasets, has focused upon the combination between intraluminal antibiotics and mechanical bowel preparation and has demonstrated a reduction in SSI rates. However, the data contained within the studies included within this meta-analysis have been scanty regarding the use of intraluminal antibiotics and as such it has not been possible to include these data within the meta-analysis. Further work on this topic should focus upon the role of intraluminal antibiotics in the setting of elective colorectal surgery.