Intervention Review

Mechanical bowel preparation for elective colorectal surgery

  1. Katia F Güenaga1,*,
  2. Delcio Matos2,
  3. Peer Wille-Jørgensen3

Editorial Group: Cochrane Colorectal Cancer Group

Published Online: 7 SEP 2011

Assessed as up-to-date: 25 JUN 2011

DOI: 10.1002/14651858.CD001544.pub4

Database Title

Additional Information

How to Cite

Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD001544. DOI: 10.1002/14651858.CD001544.pub4.

Author Information

  1. 1

    Santos, São Paulo, Brazil

  2. 2

    UNIFESP - Escola Paulista de Medicina, Gastroenterological Surgery, São Paulo, São Paulo, Brazil

  3. 3

    Bispebjerg Hospital, Department of Surgical Gastroenterology K, Copenhagen NV, Denmark

*Katia F Güenaga, Rua Ministro João Mendes, 60/31, Santos, São Paulo, 11040-260, Brazil. kfg012@terra.com.br.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 7 SEP 2011

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

The presence of bowel contents during colorectal surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.

An enema before the rectal surgery to clean the rectum and facilitate the manipulation for the mechanical anastomosis is used for many surgeons. This is analysed separately

Objectives

To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.

Search methods

Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, IBECS and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.

Searches were performed December 1, 2010.

Selection criteria

Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections.

Data collection and analysis

Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).

Main results

At this update six trials and a new comparison (Mechanical bowel preparation versus enema) were added. Altogether eighteen trials were analysed, with 5805 participants; 2906 allocated to MBP (Group A), and 2899 to no preparation (Group B), before elective colorectal surgery.

For the comparison Mechanical Bowel Preparation Versus No Mechanical Bowel Preparation results were:

1. Anastomotic leakage for low anterior resection: 8.8% (38/431) of Group A, compared with 10.3% (43/415) of Group B; Peto OR 0.88 [0.55, 1.40].

2. Anastomotic leakage for colonic surgery: 3.0% (47/1559) of Group A, compared with 3.5% (56/1588) of Group B; Peto OR 0.85 [0.58, 1.26].

3. Overall anastomotic leakage: 4.4% (101/2275) of Group A, compared with 4.5% (103/2258) of Group B; Peto OR 0.99 [0.74, 1.31].

4. Wound infection: 9.6% (223/2305) of Group A, compared with 8.5% (196/2290) of Group B; Peto OR 1.16 [0.95, 1.42].

Sensitivity analyses did not produce any differences in overall results.

For the comparison Mechanical Bowel Preparation (A) Versus Rectal Enema (B) results were:

1. Anastomotic leakage after rectal surgery: 7.4% (8/107) of Group A, compared with 7.9% (7/88) of Group B; Peto OR 0.93 [0.34, 2.52].

2. Anastomotic leakage after colonic surgery: 4.0% (11/269) of Group A, compared with 2.0% (6/299) of Group B; Peto OR 2.15 [0.79, 5.84].

3. Overall anastomotic leakage: 4.4% (27/601) of Group A, compared with 3.4% (21/609) of Group B; Peto OR 1.32 [0.74, 2.36].

4. Wound infection: 9.9% (60/601) of Group A, compared with 8.0% (49/609) of Group B; Peto OR 1.26 [0.85, 1.88].

Authors' conclusions

Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found. Further research on patients submitted for elective rectal surgery, below the peritoneal verge, in whom bowel continuity is restored, and studies with patients submitted to laparoscopic surgeries are still warranted.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Mechanical bowel preparation for elective colorectal surgery may not improve outcome for patients

Until recently it was thought that vigorous preoperative mechanical cleansing of the bowel (mechanical bowel preparation), together with the use of oral antibiotics, reduced the risk of septic complications after non-emergency (elective) colorectal operations. Mechanical bowel preparation was performed routinely prior to colorectal surgery until 1972, when this procedure started to be questioned. Well designed clinical trials were published, and their results caused some colorectal surgeons to doubt this traditional belief.

This review has identified all known trials that compared any kind of mechanical bowel preparation with no preparation (Comparison 1) and mechanical bowel preparation with rectal enema (Comparison 2) in patients submitted to elective colorectal surgery.  Five new trials have been included in this third update of the review, bringing the total number of included trials to 18 (5805 participants). Analysis of these 18 trials showed no statistically significant differences in how well the three groups of patients (mechanical bowel preparation group, no preparation group and rectal enemas) did after surgery in terms of leakage at the surgical seam of the bowel ends, mortality rates, peritonitis, need for reoperation, wound infection, and other non-abdominal complications.  Consequently, there is no evidence that mechanical bowel preparation improves the outcome for patients. Further research on mechanical bowel preparation or enemas versus no preparation in patients submitted for elective rectal surgery and laparoscopic colorectal surgery is warranted.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

選擇性結腸直腸手術的機械性清腸準備

在手術期間腸內容物的出現與吻合處的滲漏有關,根本數據和專家的意見,相信機械性清腸準備能夠有效的防備腸滲漏以及感染合併症. 主旨:在結腸直手術的病態率及死亡率中,確定機械性腸準備的安全性及有效性.

目標

在結腸直手術的病態率及死亡率中,確定機械性清腸準備的安全性及有效性.

搜尋策略

在選擇性結直腸手術前,描述有關於機械性腸準備的出版刊物, MEDLINE, EMBASE, LILACS, 以及Cochrane 圖書館,被搜尋過.也通過了handsearching相關的醫學雜誌和會議,於2008年3月13日被搜尋執行過.

選擇標準

隨機對照試驗(RCTs)，其中參加者包括選擇性直結腸手術.比較符合條件的措施包括任何類型的機械性清腸準備與無機械性清腸準備.主要結果包括吻合口滲漏直腸和結腸及綜合數字.次要成果包括死亡率，腹膜炎，再次手術，傷口感染，額外腹部併發症，整體手術部位的感染

資料收集與分析

數據獨立提取和檢查.評估每個試驗的質量法.隨機的詳情, blinding,分析類型,記錄了數字遺失及追蹤.對於分析,使用 PetoOdds Ratio (OR)為缺失(無統計學異質性觀察).

主要結論

這個更新包括四個新的試驗(總共13個隨機對照試驗4777參與者;在選擇性結腸直腸手術之前2390個同意機械性清腸準備(A組),2387個沒有準備(B組).發生吻合口滲漏:(i)低前位切除術A組 10.0% (14/139),與B組6.6% (9/136)比較; Peto OR 1.73 (95%置信區間 (CI): 0.73 to 4.10).(ii)大腸手術A組2.9% (32/1226)與B組 2.5% (31/1228)比較;Peto OR 1.13 (95% CI: 0.69 to 1.85). 發生總體吻合滲漏, A組4.2% (102/2398)與B組3.4% (82/2378)比較Peto OR 1.26 (95% CI: 0.941 to 1.69).發生傷口感染, A組9.6(232/2417),與B組8.3% (200/2404)比較 Peto OR 1.19 (95% CI: 0.98 to 1.45).在總體成果,敏感性分析並沒有產生任何分歧

作者結論

沒有顯著性的證據證明患者受益於機械性清腸準備. 在直結腸手術前應該慎重考慮機械性清腸準備是必須的. 接受選擇性結直腸手術的患者進一步研究腸道恢復的連續性.與分層的結腸和直腸手術，仍是必要

翻譯人

本摘要由國泰綜合醫院張世昌翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

直到最近，人們認為術前機械性清洗腸道(機械清腸準備),與一起使用口服抗生素,減少敗血性合併症的危險性,在非緊急情況(選擇)的結直腸手術.進行常規結腸手術前接受機械性清腸準備,直到1972年,當這一程序開始受到質疑.當設計了臨床試驗發表,其結果導致直腸外科醫生懷疑這一傳統觀念.手術前機械性清腸準備,費時和昂貴,及患者的不愉快甚至導致危險(增加發炎過程的危險).這一審查確定了所有已知的試驗,在患者接受選擇性結腸直腸手術, 比較任何類型的機械性清腸準備與無機械性清腸準備.包括第二次更新的審查中的五個新的試驗,14個試驗的總數(4821參與者).分析14個試驗顯示兩組患者並無顯著的差異(機械性清腸準備組與無機械性清腸準備組),術後腸道滲漏,死亡率，腹膜炎，需要再次手術,傷口感染，和其他非腹部併發症.因此，沒有任何證據表明"機械性清腸準備"能改善患者的結果.進一步研究選擇性結腸直腸手術患者在機械性清腸準備與無機械性清腸準備是必要的.

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