Mechanical Bowel Preparation

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(No Transcript)
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Mechanical Bowel Preparation
Changes in Our Surgical Practice
UK Department of Surgery Grand Rounds J. S.
Hourigan, MD April 2010
3
(2010)
449 Patients Undergoing Low Anterior Resection.
Van't Sant HP, Weidema WF, Hop WC, et al. The
influence of mechanical bowel preparation in
elective lower colorectal surgery. Ann Surg. 2010
Jan251(1)59-63.
4
(2010)
..MBP Has No Influence on Anastomotic Failure
Van't Sant HP, Weidema WF, Hop WC, et al. The
influence of mechanical bowel preparation in
elective lower colorectal surgery. Ann Surg. 2010
Jan251(1)59-63.
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Objectives.
Briefly Review the Recent History of Mechanical
Bowel Preparation Review the Literature
Regarding Mechanical Bowel Preparation Discuss
MBPs Influence on Anastomotic Leak and Septic
Complications Propose an Evidence-Based Change in
Our Surgical Practice
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dogma a point of view or tenet put forth as
authoritative without adequate grounds
Which Way To Go?
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Doesnt It Make Sense To Us?......
Decrease Volume of Intraluminal Content and Fecal
Load Decrease the Bacterial Counts Avoid Major
Spillage
Improve Healing of Anastomosis Decrease
Infectious Complications Improve Patient Outcomes
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Mechanical Bowel Prep
2009 Cochrane Review Shows No Benefit of MBP
1994-2000s Several Other Trials Follow
1994 One of First RCT Showing No Benefit with
MBP
1990s Trauma Literature Accumulates Regarding
No MBP
1980 Development of PEG-based Solutions
Tolerated Better
1972 Hughes Presents Early Challenge to Dogma
of MBP
1971 Nichols and Condon Describe Favorable
Clinical Experience with Bowl Prep
1970s Practice of Routine MBP Dietary
Restriction, Enemas, and Large Volume Saline
Irrigation via NGT
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Preoperative Preparation of the Colon
(1971)
Clinical Experience Demonstrated Decreased MM
with Mechanical Removal of Gross Feces
Assumption Was Made That The Benefit Would Come
From Significantly Lowering Nonselective
Bacterial Counts
Controversy Today Concerns Only the Addition of
Antibiotics To Preoperative Mechanical
Preparation
Nichols R, Condon R. Preoperative preparation of
the colon. Sur Gynecol Obstet 1971132 323-327.
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Mechanical Bowel Prep
2009 Cochrane Review Shows No Benefit of MBP
1994-2000s Several Other Trials Follow
1994 One of First RCT Showing No Benefit with
MBP
1990s Trauma Literature Accumulates Regarding
No MBP
1980 Development of PEG-based Solutions
Tolerated Better
1972 Hughes Presents Early Challenge to Dogma
of MBP
1971 Nichols and Condon Described Favorable
Clinical Experience with Bowel Prep
1970s Practice of Routine MBP Dietary
Restriction, Enemas, and Large Volume Saline
Irrigation via NGT
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(1972)
Asepsis in Large Bowel Surgery

• Mechanical Cleaning Loads the Bowel and Is
  Unnecessary
• Antibiotics Have Restricted Part in Large-Bowel
  Surgery

This Has Been Considered the Challenge to
Nichols Views
Hughes ESR. Asepsis in large-bowel surgery
Hunterian Lecture. Ann Roy Coll Surg Eng 1972,
v.51 347-356.
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Mechanical Bowel Prep
2009 Cochrane Review Shows No Benefit of MBP
1994-2000s Several Other Trials Follow
1994 One of First RCT Showing No Benefit with
MBP
1990s Trauma Literature Accumulates Regarding
No MBP
1980 Development of PEG-based Solutions
Tolerated Better
1972 Hughes Presents Early Challenge to Dogma
of MBP
1971 Nichols and Condon Described Favorable
Clinical Experience with Bowel Prep
1970s Practice of Routine MBP Dietary
Restriction, Enemas, and Large Volume Saline
Irrigation via NGT
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2003
1973
1978
1992
1994
2009
1990
1977
1994
1991
2005
2002
1981
2005
1986
1989
1973
1991
1971
1973
1985
Nichols v. Hughes
1971
1978
1995
1985
1989
2006
1973
1981
1986
1977
1987
2003
1984
2006
1987
1985
1992
1995
2001
2009
1998
1985
2002
1987
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There is Considerable Discordance Between What
We Do and What We Know.
Is It Possible That We Know Something More Than
What the Literature Can Tell Us?
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FirstWhat Are We Doing?
A Collection of Surveys.
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(1990)

• 352 Board-Certified Colon and Rectal Surgeons
  Surveyed

100 Routinely Used Mechanical Bowel
Preparation PEG Solution Used Most Commonly (58)
Solla JA, Rothenberger DA. Preoperative bowel
preparation. A survey of colon and rectal
surgeons. Dis Colon Rectum. 1990 Feb33(2)154-9.
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Current Practices.Among North American
Colorectal Surgeons (1997)
100 Routinely Used Mechanical Bowel
Preparation PEG Solution Used Most Commonly (70)
Nichols RL, Smith JW, et al. Current practices of
preoperative bowel preparation among North
American colorectal surgeons. Clin Infect Dis.
1997 Apr24(4)609-19.
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Trends in Preparation for Colorectal Surgery
(2003)

• 515 ASCRS Members With on Average 14 Years
  Experience Each

.Survey Results Indicated 99 Routinely Used
Mechanical Bowel Preparation 98 Routinely Used
Intravenous Antibiotics 75 Routinely Used Oral
Antibiotics
Zmora O, Wexner SD, et al. Trends in preparation
for colorectal surgery survey of the members of
the ASCRS. Am Surg. 2003 Feb69(2)150-4.
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(2007)
Cathartic Bowel Preparation A Thing of the
Past?
James McCormick, DO
.Most ASCRS Attendees Polled Admitted to Using
MBP
McCormick J. Cathartic bowel preparation a
thing of the past? ASCRS 2007 Meeting.
Technologic and Pharmacologic Advances for
Enhanced Recovery after Colectomy Symposium.
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(2007)
And...ACPGBI Guidelines for Management of
Colorectal Cancer
Bowel Preparation Should Not Be Used Routinely
Before Colorectal Cancer Resection
Guidelines for the Management of Colorectal
Cancer 3rd edition (2007). Issued by The
Association of Coloproctology of Great Britain
and Ireland 30-31.
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(2010)
In Follow-Up..A Survey of Its Members Indicated
the Following
Drummond R, McKenna R, Wright D. Current Practice
in Bowel Preparation for Colorectal Surgery A
Survey of the Members of The Association of
Coloproctology of GB Ireland. Colorectal Dis.
2010 Feb 20.
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Mechanical Bowel Preparation and Antibiotic
Prophylaxis in Colorectal Surgery Use By and
Opinions of Spanish Surgeons (2009)

• 131 Spanish Colon and Rectal Surgeons Surveyed

.Survey Results Indicated 87 Routinely Use
Mechanical Bowel Preparation
(60 for Right Colon90 for Left Colon99 for
Rectum)
Roig JV, García-Fadrique A, et al. Mechanical
bowel preparation and antibiotic prophylaxis in
colorectal surgery use by and opinions of
Spanish surgeons. Colorectal Dis. 2009
Jan11(1)44-8.
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(2004)
Recognizes That No Clear Evidence Exists That MBP
Reduces Infectious Complications, Anastomotic
Leak, or Mortality
Data Lacks Statistical Power to Exclude Type II
Error
Otchy D, Hyman N, et al. The Standards Practice
Task Force. Practice Parameters for Colon Cancer.
Dis Colon Rec August 2004 1269-1284
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(2004)
However, Bowel Preparation Is Justified Based
On..

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

Otchy D, Hyman N, et al. The Standards Practice
Task Force. Practice Parameters for Colon Cancer.
Dis Colon Rec August 2004 1269-1284
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SecondWhat Do We Know?
The Literature.
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Lets First Assume MBP Is Actually a Good
Thing.
If MBP Is So Critical to Operative Success,
Why Do We Rarely Talk About the Adequacy of
Bowel Preparation?
Do We Routinely Cancel or Postpone Elective Cases
if A Patient Does Not Finish MBP?
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Inadequate Bowel Preparation and Spillage
(2005)

• MBP Causes Significantly Higher Incidence of
  Liquid Contents
• Spillage with Bowel Prep (17) v. NO Bowel Prep
  (12)

Liquid (31) SemiSolid (10) Solid (3)
MBP Loads the Bowel (Hughes)
Mahajna A, Krausz M, et al. Bowel preparation is
associated with spillage of bowel contents in
colorectal surgery. Dis Colon Rectum 2005
481626-31.
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Tendency Toward More Infectious Complications
Anastomotic Leak (6.2 v. 3.8) Wound Infection
(12.5 v. 6.7)
Mahajna A, Krausz M, et al. Bowel preparation is
associated with spillage of bowel contents in
colorectal surgery. Dis Colon Rectum 2005
481626-31.
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Lets Then Assume MBP is Not Such A Good Thing
Does the Literature Support Not Using
MBP Routinely in Elective Colorectal Surgery?
Two Large Meta-Analyses.
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1
2009
Mechanical Bowel Preparation for Elective
Colorectal Surgery
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Mechanical Bowel Preparation for Elective
Colorectal Surgery
(2009)

• Second Update (v.3) with Five Additional New
  Trials Included
• 14 RCTs with 4776 Participants
• Anastomotic Leakage was Primary Outcome Measure
• Secondary Outcome Measures Included Wound
  Infection
• Prophylactic Antibiotics Used In Both Treatment
  Groups

Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
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Anastomotic Leak
4.2 v 3.4
Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
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Wound Infection
9.6 v. 8.3
Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
34
No Statistically Significant Difference Between
MBP and No-MBP
(2009)
.This Represented a Change From 2005
2005 Statistically Significant Increase in
Anastomotic Leak with MBP
2003 No Difference
2009 No Difference
Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
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The Lack of Proven Benefit for MBP Allowed
Authors To Suggest the Abandonment of MBP.
.Except When Needed To Identify Pathology or
Perform Intra-Op Colonoscopy
Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
36
Guenega KKFG, Matos D, Wille-Jorgensen P.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.
CD01544. Pub1-3.
37
2
2009
Updated Systematic Review and Meta-Analysis of
Randomized Clinical Trials on the Role of
Mechanical Bowel Preparation Before Colorectal
Surgery
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(2009)
Updated Systematic Review and Meta-Analysis of
Randomized Clinical Trials on the Role of
Mechanical Bowel Preparation Before Colorectal
Surgery
(2003 Significant Increase in Anastomotic Leak
with PEG MBP 5.3 v. 3.2)
14 Randomized Clinical Trials with 4859
Participants
Slim K, Vciaut E, et al. Meta-analysis of
randomized clinical trials of colorectal surgery
with or without mechanical bowel preparation. Br
J Surg Feb 2004 911125-30.
Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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No-MBP Was Favored for All SSI with
Statistical Significance
All SSI
Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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Two Interesting Side Notes With
Conflicting Preference for MBP Were Recognized in
This MA.
Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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First,.
Bucher et al Demonstrated the Negative Effects
of MBP
Bucher P, Gervaz P, Soravia C, et al. Randomized
clinical trial of mechanical bowel preparation v.
no preparation before elective left-sided
colorectal surgery. Br J Surg 200592 409-414.
Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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Bucher et al (MBP n 78/No-MBP n 75) for Left
Colon
(2005)
p0.028
p0.021
p0.034
p0.024
Therefore, Reduced Post-Operative Morbidity with
No-MBP
Bucher P, Gervaz P, Soravia C, et al. Randomized
clinical trial of mechanical bowel preparation v.
no preparation before elective left-sided
colorectal surgery. Br J Surg 200592 409-414.
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Second,.
.A Statistically Significant Difference Was
Demonstrated In Favor of Mechanical Bowel
Preparation
Therefore, Reduced Post-Operative Morbidity with
MBP
Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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(2009)
Overall, The Authors Made the Following
Conclusions.

• Higher Risk of Anastomotic Leakage is NOT
  Suggested
• Harmful Effect of MBP Was Not Evident (As
  Suggested by Bucher)
• MBP Does Not Reduce Infectious Morbidity of
  Colon Surgery

Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
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(2009)
.And Suggested MBP Should Be Abandoned At
Least From the Patients Perspective

• Quality of Life and Patient Preference
• Unwillingness To Have the Same Procedure Again?
• Dehydration and Electrolyte Disturbance
• Bacterial Translocation

Slim K, Vciaut E, et al. Updated systematic
review and meta-analysis of randomized clinical
trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg
Feb 2009 2492 203-09.
46
Within Both Large Meta-Analyses Two Large
Trials are Important to Note. Contant et
al And Jung et al
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(2007)
.Abscesses Not Considered to Be of Major
Clinical Importance
Contant ME, Hop W. Mechanical bowel preparation
for elective colorectal surgery a multicentre
randomised trial. Lancet 2007 3702112-17.
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The Authors Made the Following Conclusions.

• No Difference Exists Between MBP and No-MBP
• MBP Does Not Decrease/Prevent Infectious
  Complications
• Negative Side-Effects Without Evidence of
  Benefit

Contant ME, Hop W. Mechanical bowel preparation
for elective colorectal surgery a multicentre
randomised trial. Lancet 2007 3702112-17.
49
(2007)

• Randomized to MBP (n686) and No-MBP (n657)
• 324 Patients (24) Overall Had At Least One
  Complication
• No Significant Difference Between Groups in
  Complication Rates
• No Benefit in Anastomotic Healing or Infection
  Rates with MBP
• No Improvement in Overall Post-Op Course or
  Patient Outcome

Jung B, Pahlman L, et al. Multicentre randomized
clinical trial of mechanical bowel preparation in
elective colon resection. Br J Surgery 2007
94689-95.
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Authors Concluded
Once Again, The Practice of MBP Should Be
Abandoned
Jung B, Pahlman L, et al. Multicentre randomized
clinical trial of mechanical bowel preparation in
elective colon resection. Br J Surgery 2007
94689-95.
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Other Things We Know from the Literature
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Side Does Not Matter (Right v. Left, Colon v.
Rectum)
Bretagnol et al Produced Similar Results in
Their Assessment of No-MBP and Rectal Cancer

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

Bretagnol F, Alves A, et al. Rectal cancer
surgery without mechanical bowel preparation. Br
J Surg 200794 1266-1271.
Zmora O, Mahajna A, et al. Is mechanical bowel
preparation mandatory for left-sided colonic
anastomosis? Results of a prospective randomized
trial. Tech Coloproctol 200610 131-35.
Bucher P, Gervaz P, Soravia C, et al. Randomized
clinical trial of mechanical bowel preparation v.
no preparation before elective left-sided
colorectal surgery. Br J Surg 200592 409-414.
Memon MA, Devine J, et al. Is mechanical bowel
preparation really necessary for elective left
sided colon and rectal surgery. Int J Colorect
Dis 199712 298-302.
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No-MBP and Laparoscopy is Feasible and Safe
(2006)
Zmora et al Reviewed 200 Laparoscopic
Colectomies n 68 (MBP) and n 132 (No-MBP)

• 16 Patients (8) with Intraoperative
  Colonoscopy for Localization
• Overall Conversion Rate of 9 (MBP) an 14
  (No-MBP)

1 Conversion in No-MBP for Localization
Zmora O, Lebedyev A, Hoffman A, et al.
Laparoscopic colectomy without mechanical bowel
preparation. Int J Colorectal Dis 200621
683-687.
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No-MBP and Laparoscopy is Feasible and Safe
(2006,2005)
Adequate Patient Selection Should Focus On..

• Small Lesions (lt 3cm) Not Properly Marked
• Possibility for Intraoperative Colonoscopy

Zmora O, Lebedyev A, Hoffman A, et al.
Laparoscopic colectomy without mechanical bowel
preparation. Int J Colorectal Dis 200621
683-687.
Ram E, Sherman Y, Weil R. Is mechanical bowel
preparation mandatory for elective colon surgery?
Arch Surg March 2005140 285-288.
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What About the U.S. Literature?
Two Recent Papers.
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Thomas Jefferson University Reported Their
Clinical Experience at Southeastern Surgical in
2009..
Review of 153 Patients without MBP

• No Benefit Associated with the Use of MBP
• Elective Colorectal Resections Can Safely Omit
  MBP

Harris LJ, Moudgill N, Hager E, Abdollahi H,
Goldstein S. Incidence of anastomotic leak in
patients undergoing elective colon resection
without mechanical bowel preparation our updated
experience and two-year review. Am Surg. 2009
Sep75(9)828-33.
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University of South Alabama
Retrospective Review of 136 Patients /- MBP

• Overall, SSI Occurred in 23 of Patients

MBP 46.7 v. MBP 19.8
Thus, Supporting the Safe Omission of MBP
Howard DD, White CQ, Harden TR, Ellis CN.
Incidence of surgical site infections
postcolorectal resections without preoperative
mechanical or antibiotic bowel preparation. Am
Surg. 2009 Aug75(8)659-63 discussion 663-4.
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So, Who Should Prep?

• Inadequate Localization or Possibility of
  Intra-Op Colonoscopy
• Low-Level Rectal Resections or IPAAs?
• Defunctionalized Anastomoses?

And, Who Not Should Prep?

• Elective Colon Resections

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In Conclusion

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