Quality Improvement: Where Are We with Bowel Preps for Patients Undergoing Colon Resection?
Colorectal surgeons have strived for reductions in postoperative septic complication rates and especially the incidence of anastomotic dehiscence since the inception of bowel surgery [1]. Bowel antisepsis as a means to this end was first advocated by Garl
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Quality Improvement: Where Are We with Bowel Preps for Patients Undergoing Colon Resection? Anthony J. Senagore
Introduction Colorectal surgeons have strived for reductions in postoperative septic complication rates and especially the incidence of anastomotic dehiscence since the inception of bowel surgery [1]. Bowel antisepsis as a means to this end was first advocated by Poth in the 1940s [2]. Thirty years later, Barker and Everett advocated for MBP because of their belief that gross fecal loading of the bowel was associated with an increased incidence of wound infection [3, 4]. As a result of this work, MBP became almost uniformly accepted as a dogma going forward [5]. The classic article which codified the role of mechanical bowel prep with oral antibiotics was the three armed study performed by Condon et al. They compared oral mechanical bowel prep with either intravenous cephalothin alone; oral neomycin and erythromycin alone; or both intravenous and oral regimens [6]. Although the intravenous antibiotic chosen was limited in bacterial coverage, the combined strategy was superior nonetheless. Coppa et al. studied 350 patients randomized to intravenous cefoxitin (broader coverage gram negative and anaerobes) with or without oral neomycin and erythromycin in conjunction with a mechanical bowel prep [7]. The dual regimen was superior for superficial wound infection (11 % versus 5 %). Finally, Schoetz et al. performed the reverse study, randomizing 190 patients to receive neomycin and erythromycin orally with and without intravenous cefoxitin. Wound infection and leak rates were higher in the group receiving only oral antibiotics [8]. These data led to the era of combined mechanical bowel prep, with both oral and intravenous prophylactic antibiotics. Over the last decade, the necessity for mechanical bowel prep
A.J. Senagore, MD, MBA Department of Surgery, UTMB- Galveston, Galveston, TX, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_41
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has been questioned along with contemporaneous data reinvestigating the relative role of mechanical prep with or without oral antibiotics. Patients undergoing colon resection
Bowel prep
No bowel prep
SSI, leak rate, dehiscence, complications
Search Strategy Search DATA SOURCES: Embase, PubMed, and the Cochrane Library were searched using the terms oral, antibiotics/antimicrobial, colorectal/rectal/colon/rectum, and surgery/operation. Time frame 2014–2016. MAIN OUTCOME MEASURES: Anastomotic leakage, all-cause mortality, wound infection, peritonitis/intra-abdominal abscess, reoperation, surgical site infection, quality of life, length of stay, and adverse events were measured. Patients Patients undergoing colectomy
Intervention No bowel prep
Comparator Mechanical bowel prep with or without oral antibiotics
Outcomes Anastomotic leak, mortalit
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