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Lei P, Jia G, Yang X, Ruan Y, Wei B, Chen T. Region-specific protection effect of preoperative oral antibiotics combined with mechanical bowel preparation before laparoscopic colorectal resection: a prospective randomized controlled trial. Int J Surg 2023; 109:3042-3051. [PMID: 37702427 PMCID: PMC10583894 DOI: 10.1097/js9.0000000000000569] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Oral antibiotics (OA) combined with mechanical bowel preparation (MBP) significantly decrease the rate of surgical site infections (SSIs). However, the prophylactic effects in region-specific colorectal surgery have not been assessed. MATERIALS AND METHODS A single-centre, single-blind, randomized controlled trial was conducted from 2019 to 2022. Patients were eligible if they were diagnosed with nonmetastatic colorectal malignancy, and laparoscopic colorectal surgery was indicated. Participants were randomly assigned (1:1) to the experimental (OA+MBP preparation) or control group (MBP preparation). The randomization was further stratified by resected region. The primary outcome was the incidence of SSIs. Patients were followed up for 1 month postoperatively, and all complications were recorded. RESULT Between 2019 and 2022, 157 and 152 patients were assigned to the experimental and control groups, respectively, after 51 patients were excluded. The incidence of SSIs in the control group (27/152) was significantly higher than that in the experimental group (13/157; P =0.013), as was the incidence of superficial SSIs (5/157 vs. 14/152, P =0.027) and deep SSIs (7/157 vs. 16/152, P =0.042). After redistribution according to the resected region, the incidence of SSIs was significantly higher in the control group with left-sided colorectal resection (descending, sigmoid colon, and rectum) (9/115 vs. 20/111, P =0.022) but was similar between the groups with right-sided colon resection (ascending colon) (3/37 vs. 7/36, P =0.286). No differences were noted between the groups in terms of other perioperative complications. CONCLUSION OA+MBP before colorectal surgery significantly reduced the incidence of SSIs. Such a prophylactic effect was particularly significant for left-sided resection. This preparation mode should be routinely adopted before elective left-region colorectal surgeries.
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Affiliation(s)
- Purun Lei
- Department of Gastrointestinal Surgery
| | - Guiru Jia
- Department of Gastrointestinal Surgery
| | | | - Ying Ruan
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Bo Wei
- Department of Gastrointestinal Surgery
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Alverdy JC. Bowel preparation in colorectal surgery: the day of reckoning is here. Br J Surg 2021; 108:340-341. [PMID: 33793758 PMCID: PMC8815791 DOI: 10.1093/bjs/znab021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/13/2022]
Abstract
Before the use of mechanical bowel preparation is either eliminated or subjected to a clinical trial, its scientific premise should be reconsidered, and consensus of its redesign discussed by a panel of experts including surgeons, infectious disease specialists, microbiome scientists, and clinical trialists.
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Affiliation(s)
- J C Alverdy
- Correspondence to: Department of Surgery, University of Chicago, 5841 S Maryland MC 6090, Chicago, Illinois 60647, USA (e-mail: )
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Mangieri CW, Ling JA, Modlin DM, Rose ED, Burgess PL. Utilization of combination bowel preparation (CBP) is protective against the development of post-operative Clostridium difficile infection (CDI), decreases septic complications, and provides a survival benefit. Surg Endosc 2020; 35:928-933. [DOI: 10.1007/s00464-020-07563-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 04/10/2020] [Indexed: 12/13/2022]
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McChesney SL, Zelhart MD, Green RL, Nichols RL. Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members. Surg Infect (Larchmt) 2019; 21:1-8. [PMID: 31361586 DOI: 10.1089/sur.2019.125] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.
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Affiliation(s)
| | | | - Rebecca L Green
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Ronald L Nichols
- Department of Surgery, Tulane University, New Orleans, Louisiana
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Hajjar R, Santos MM, Dagbert F, Richard CS. Current evidence on the relation between gut microbiota and intestinal anastomotic leak in colorectal surgery. Am J Surg 2019; 218:1000-1007. [PMID: 31320106 DOI: 10.1016/j.amjsurg.2019.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/29/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a major complication in colorectal surgery. It worsens morbidity, mortality and oncological outcomes in colorectal cancer. Some evidence suggests a potential effect of the intestinal microbiome on wound healing. This review aims to provide a comprehensive review on historical and current evidence regarding the relation between the gastrointestinal microbiota and AL in colorectal surgery, and the potential microbiota-modifying effect of some perioperative commonly used measures. DATA SOURCES A comprehensive search was conducted in Pubmed, Medline and Embase for historical and current clinical and animal studies addressing perioperative intestinal microbiota evaluation, intestinal healing and AL. CONCLUSIONS Evidence on microbes' role in AL is mainly derived from animal experiments. The microbiota's composition and implications are poorly understood in surgical patients. Elaborate microbiota sequencing is required in colorectal surgery to identify potentially beneficial microbial profiles that could lead to specific perioperative microbiome-altering measures and improve surgical and oncological outcomes.
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Affiliation(s)
- Roy Hajjar
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
| | - Manuela M Santos
- Nutrition and Microbiome Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montréal, Québec, QC H2X 0A9, Canada; Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - François Dagbert
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Carole S Richard
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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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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Cawich SO, Teelucksingh S, Hassranah S, Naraynsingh V. Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery. World J Gastrointest Surg 2017; 9:246-255. [PMID: 29359030 PMCID: PMC5752959 DOI: 10.4240/wjgs.v9.i12.246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/28/2017] [Accepted: 11/11/2017] [Indexed: 02/06/2023] Open
Abstract
Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Sachin Teelucksingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Samara Hassranah
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
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Giske A, Nymo LS, Fuskevåg OM, Amundsen S, Simonsen GS, Lassen K. Systemic antibiotic prophylaxis prior to gastrointestinal surgery - is oral administration of doxycycline and metronidazole adequate? Infect Dis (Lond) 2017; 49:785-791. [PMID: 28657405 DOI: 10.1080/23744235.2017.1342044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended prior to a wide range of gastrointestinal operations to reduce the rate of surgical site infections (SSIs). Traditional intravenous (IV) drugs are costly and their preparation strains nursing resources at the wards. While oral administration may attenuate these limitations, its use remains limited. We aimed to assess whether a dual oral antibiotic prophylaxis regimen provides adequate serum concentrations throughout the surgical procedure. METHODS We measured serum concentrations of doxycycline and metronidazole following single oral doses of 400 mg doxycycline and 1200 mg metronidazole at first incision and repeated at wound closure in a cohort of patients undergoing elective gastrointestinal surgery. Both drugs were dispensed at least two hours before skin incision. Serum concentrations were compared to minimum inhibitory concentrations (MIC) and epidemiological cut-off values (ECOFFs) for relevant pathogens. RESULTS Mean serum concentrations of doxycycline at first incision and at wound closure were 5.75 mg/L and 4.66 mg/L and of metronidazole 18.88 mg/L and 15.56 mg/L, respectively. Metronidazole concentrations were above ECOFF (2 mg/L) for relevant anaerobic species in 103/104 of patients in both samples. Doxycycline serum concentrations were above the ECOFF for common Enterobacteriaceae species (4 mg/L) in both samples in 58/104 patients (55.8%). CONCLUSIONS A single dose of orally administered metronidazole provides adequate concentrations throughout surgery in a heterogeneous cohort of patients. Uncertainty persists regarding the adequacy of doxycycline concentrations, as the optimal serum level of doxycycline in a prophylactic setting has not been established.
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Affiliation(s)
- Anneli Giske
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway
| | - Linn Såve Nymo
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway
| | - Ole-Martin Fuskevåg
- b Department of Laboratory Medicine , University Hospital of North Norway , Tromsø , Norway
| | - Siri Amundsen
- b Department of Laboratory Medicine , University Hospital of North Norway , Tromsø , Norway.,c Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Gunnar Skov Simonsen
- d Department of Microbiology and Infection Control , University Hospital of North Norway , Tromsø , Norway.,e Research Group for Host-Microbe Interaction, Department of Medical Biology, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Kristoffer Lassen
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway.,f Department of Gastrointestinal Surgery, Hepatopancreatobiliary Section , University Hospital of Oslo at Rikshospitalet , Oslo , Norway
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Zelhart MD, Hauch AT, Slakey DP, Nichols RL. Preoperative antibiotic colon preparation: have we had the answer all along? J Am Coll Surg 2014; 219:1070-7. [PMID: 25260679 DOI: 10.1016/j.jamcollsurg.2014.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 06/16/2014] [Accepted: 07/08/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Matthew D Zelhart
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA.
| | - Adam T Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Douglas P Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Ronald L Nichols
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
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He Q, Wang L, Wang F, Wang C, Tang C, Li Q, Li J, Zhao Q. Microbial fingerprinting detects intestinal microbiota dysbiosis in Zebrafish models with chemically-induced enterocolitis. BMC Microbiol 2013; 13:289. [PMID: 24325678 PMCID: PMC4029296 DOI: 10.1186/1471-2180-13-289] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 10/16/2013] [Indexed: 02/08/2023] Open
Abstract
Background Inflammatory bowel disease (IBD) involves a breakdown in interactions between the host immune response and the resident commensal microbiota. Recent studies have suggested gut physiology and pathology relevant to human IBD can be rapidly modeled in zebrafish larvae. The aim of this study was to investigate the dysbiosis of intestinal microbiota in zebrafish models with IBD-like enterocolitis using culture-independent techniques. Results IBD-like enterocolitis was induced by exposing larval zebrafish to trinitrobenzenesulfonic acid (TNBS). Pathology was assessed by histology and immunofluorescence. Changes in intestinal microbiota were evaluated by denaturing gradient gel electrophoresis (DGGE) and the predominant bacterial composition was determined with DNA sequencing and BLAST and confirmed by real-time polymerase chain reaction. Larval zebrafish exposed to TNBS displayed intestinal-fold architecture disruption and inflammation reminiscent of human IBD. In this study, we defined a reduced biodiversity of gut bacterial community in TNBS-induced coliitis. The intestinal microbiota dysbiosis in zebrafish larvae with IBD-like colitis was characterized by an increased proportion of Proteobacteria (especially Burkholderia) and a decreased of Firmicutes(Lactobacillus group), which were significantly correlated with enterocolitis severity(Pearson correlation p < 0.01). Conclusions This is the first description of intestinal microbiota dysbiosis in zebrafish IBD-like models, and these changes correlate with TNBS-induced enterocolitis. Prevention or reversal of this dysbiosis may be a viable option for reducing the incidence and severity of human IBD.
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Affiliation(s)
| | | | | | | | | | - Qiurong Li
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No,305 East Zhongshan Road, Nanjing 210002, China.
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Voice Reconstruction with Free Ileocolon Flap Transfer: Implications for the Lower Respiratory Tract. Plast Reconstr Surg 2011; 127:1916-1924. [DOI: 10.1097/prs.0b013e31820cf282] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yeom CH, Cho MM, Baek SK, Bae OS. Risk Factors for the Development of Clostridium difficile-associated Colitis after Colorectal Cancer Surgery. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2010; 26:329-33. [PMID: 21152135 PMCID: PMC2998023 DOI: 10.3393/jksc.2010.26.5.329] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 07/26/2010] [Indexed: 11/09/2022]
Abstract
Purpose Clostridium difficile (C. difficile)-associated colitis, a known complication of colon and rectal surgery, can increase perioperative morbidity and mortality, leading to increased hospital stay and costs. Several contributing factors, including advanced age, mechanical bowel preparation, and antibiotics, have been implicated in this condition. The purpose of this study was to determine the clinical features of and factors responsible for C. difficile-associated colitis after colorectal cancer surgery. Methods The medical records of patients who had undergone elective resection for colorectal cancer from January 2008 to April 2010 were reviewed. Cases that involved procedures such as transanal excision, stoma creation, or emergency operation were excluded from the analysis. Results Resection with primary anastomosis was performed in 219 patients with colorectal cancer. The rate of postoperative C. difficile-associated colitis was 6.8% in the entire study population. Preoperative metallic stent insertion (P = 0.017) and aged sixty and older (≥ 60, P = 0.025) were identified as risk factors for postoperative C. difficile-associated colitis. There were no significant differences in variables such as preoperative oral non-absorbable antibiotics, site of operation, operation procedure, and duration of prophylactic antibiotics. Conclusion Among the potential causative factors of postoperative C. difficile-associated colitis, preoperative metallic stent insertion and aged sixty and older were identified as risk factors on the basis of our data. Strategies to prevent C. difficile infection should be carried out in patients who have undergone preoperative insertion of a metallic stent and are aged sixty and older years.
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Affiliation(s)
- Chang Ho Yeom
- Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
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Hayashi MS, Wilson SE. Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? Surg Infect (Larchmt) 2009; 10:285-8. [PMID: 19485781 DOI: 10.1089/sur.2008.9958] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In numerous scientific studies, oral antibiotic bowel preparation has reduced surgical site infections in patients undergoing colorectal surgery. The historical evolution of antibiotic bowel preparation is presented with a review of the scientific basis of its effectiveness. METHODS Review of the pertinent English language literature. RESULTS Successful oral antibiotic bowel preparation requires effective mechanical preparation. The progressive shift of preoperative preparation to the outpatient setting has led to a reduction in the use of oral antibiotics. Such preparation, however, continues to be effective although in current surgical practice is often augmented with perioperative, parenteral antimicrobials. CONCLUSION Oral antibiotic bowel preparation has a role in the prevention of surgical site infection in the patient undergoing colorectal surgery.
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Affiliation(s)
- Michael S Hayashi
- Department of Surgery, University of California-Irvine School of Medicine, Orange, California 92868, USA
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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: 67] [Impact Index Per Article: 3.9] [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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Roig JV, García-Armengol J, Alós R, Solana A, Rodríguez-Carrillo R, Galindo P, Fabra MI, López-Delgado A, García-Romero J. Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición? Cir Esp 2007; 81:240-6. [PMID: 17498451 DOI: 10.1016/s0009-739x(07)71312-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.
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Affiliation(s)
- José V Roig
- Servicio de Cirugía General y Digestiva, Consorcio Hospital General Universitario de Valencia, Valencia, España.
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Nichols RL, Choe EU, Weldon CB. Mechanical and Antibacterial Bowel Preparation in Colon and Rectal Surgery. Chemotherapy 2005; 51 Suppl 1:115-21. [PMID: 15855756 DOI: 10.1159/000081998] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Colorectal surgery performed prior to 1970 was fraught with postoperative infectious complications which occurred in more than 30-50% of all operations. Diversion of the fecal stream appeared mandatory when operating on an urgent or emergent basis, thereby requiring the performance of multiple, staged operations instead of a single surgery encompassing resection and primary anastomosis as is performed commonly today. Multiple studies conducted in the early 1970s determined that anaerobic colonic microflora were causative agents in postoperative infections in colon and rectal surgery, and these studies initiated the development of effective oral preoperative antibiotic prophylaxis in combination with preoperative mechanical bowel preparation. This dual-tier regimen significantly reduced the incidence of postoperative infectious complications, thus allowing most uncomplicated colon and rectal surgeries to be performed in a single stage without the need for the diversion of the fecal stream and multiple operations. Therefore, a preoperative mechanical and antibacterial bowel regimen serves as the cornerstone of modern elective colorectal surgery, and these regimens now comprise three therapeutic directives. The first step is preoperative mechanical cleansing of the bowel, which is then followed by preoperative oral antibiotic prophylaxis. Finally, perioperative parenteral antibiotics directed against aerobic and anaerobic colonic microflora are utilized.
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Affiliation(s)
- Ronald Lee Nichols
- Department of Surgery, Tulane University School of Medicine, Tulane University Health Sciences Center, New Orleans, LA 70112-2699, USA.
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Abstract
PURPOSE The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery. METHODS The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered. RESULTS Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory. CONCLUSIONS The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.
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Affiliation(s)
- O Zmora
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Abstract
Specific targeting of drugs to the colon is recognized to have several therapeutic advantages. Drugs which are destroyed by the stomach acid and/or metabolized by pancreatic enzymes are slightly affected in the colon, and sustained colonic release of drugs can be useful in the treatment of nocturnal asthma, angina and arthritis. Treatment of colonic diseases such as ulcerative colitis, colorectal cancer and Crohn's disease is more effective with direct delivery of drugs to the affected area. Likewise, colonic delivery of vermicides and colonic diagnostic agents require smaller doses. This article is aimed at providing insight into the design considerations and evaluation of colonic drug delivery systems. For this purpose, the anatomy and physiology of the lower gastrointestinal tract are surveyed. Furthermore, the biopharmaceutical aspects are considered in relation to drug absorption in the colon and hence various approaches to colon-specific drug delivery are discussed.
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Affiliation(s)
- R Kinget
- Laboratorium voor Farmacotechnologie en Biofarmacie, Katholieke Universiteit Leuven, Belgium
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Bleday R, Braidt J, Ruoff K, Shellito PC, Ackroyd FW. Quantitative cultures of the mucosal-associated bacteria in the mechanically prepared colon and rectum. Dis Colon Rectum 1993; 36:844-9. [PMID: 8375226 DOI: 10.1007/bf02047381] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Little is known about the mucosal microflora of the colon and rectum at the time of elective surgery. Our objective was to determine the concentrations of anaerobic and aerobic bacteria associated with the mucosa of the mechanically prepared large bowel. Ten patients were studied after a standard polyethylene glycol-electrolyte lavage preparation. No patient had taken antibiotics in the preceding four weeks. Sterile wire brushes passed through the colonoscope during advancement were used to culture the rectal, transverse colon, and cecal mucosa. Total anaerobic, aerobic, Gram-positive, and enteric bacterial counts were determined along with specific cultures for Bacteroides fragilis, Clostridium difficile, Escherichia coli, Pseudomonas aeruginosa, enterococcus, and staphylococcus species. The results showed that there was a significant increase (P < 0.01) in aerobes, anaerobes, enterics, Gram positives, B. fragilis, and E. coli mucosal counts with proximal progression. Aerobes showed a steady gradient, while anaerobes demonstrated an increase from the rectum to the transverse colon but no change between the transverse colon and cecum. We conclude that, in the prepared bowel, there is an increase in the mucosal bacterial counts in the more proximal portions of the bowel. The results may serve as a baseline for future studies on the mucosal-associated bacteria of the large intestine.
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Affiliation(s)
- R Bleday
- Department of Surgery, New England Deaconess Hospital, Boston, Massachusetts 02215
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