DOI: 10.1097/SLA.0b013e3181f08099

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PMID: 20739867

Issn Print: 0003-4932

Publication Date: 2010/09/01


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The Influence of Mechanical Bowel Preparation in Elective Lower Colorectal Surgery

Giuseppe Brisinda; Serafino Vanella; Anna Crocco; Giorgio Maria

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Author Information: gbrisin@tin.it

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Excerpt

We read with interest the randomized trial by van't Sant et al.1 This is an excellent article with the aim of investigating the influence of mechanical bowel preparation (MBP) on anastomotic leakage and septic complications in lower colorectal surgery with or without a temporary diverting ileostomy. Although the study is underpowered and is a subgroup analysis, it presents the highest number of anastomoses performed below the level of the peritoneal verge compared with other studies. According to the authors, we believe that symptomatic anastomotic leakage is a severe complication of any intestinal anastomosis. During the past 2 decades, remarkable progress has been made in the treatment of rectal cancer. The main goal of rectal surgery for malignancy is oncologic radicality in an effort to achieve the preservation of sphincters and sexual-urinary function. Sphincter-saving procedures associated with partial or total mesorectal excision (TME) for the treatment of mid and distal rectal cancer have become increasingly prevalent, as their safety and efficacy have been proved. The introduction of circular stapling devices is largely responsible for their increasing popularity and utilization. Furthermore, neoadjuvant radiochemotherapy has become an integral part of the multidisciplinary approach to rectal cancer to reduce the risk of local recurrences.
The meticulous dissection, however, is not without consequence.2 The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage.3,4 The incidence of anastomotic leak varies widely depending on the anastomosis type and the distance from the anal verge. The introduction of the circular stapler reduced technical difficulties and leakage risk. Stapled techniques for colorectal and coloanal anastomosis in anterior resection have gained widespread acceptance over hand-sewn anastomosis. Different randomized studies comparing stapled and hand-sewn anastomosis confirmed the validity of the stapler associated with reduction of sphincter injury, operative time, and risk of abdominal contamination.
For more than a century surgeons believed dogmatically that efficient MBP is an important factor in preventing infectious complications and anastomotic dehiscence after colorectal surgery. Clinical experiences and observational studies have shown that mechanical removal of gross faeces from the colon has been associated with decreased morbidity and mortality in patients undergoing operations of the colon.5 Authors were categorical that the most important factor to affect the outcome of a colonic operation, which is within the control of a surgeon, is the degree of bowel emptiness.6,7 Several clinical trials questioned this dogma and concluded that vigorous MBP was not necessary. The authors of one meta-analysis concurred with this point of view,8,9 whereas in another trial,10 the authors argued that preoperative MBP is time-consuming and expensive, unpleasant to the patients, and completely unnecessary.11
Different MBP methods have been tested and approved. The potential danger of having faeces in contact with a newly performed anastomosis has led to the construction of a defunctioning stoma when the colon is not prepared. Experimental studies12,13 and clinical trials in emergency surgery14,15 have been published to support this theory. In a review of literature in 1998,16 it was concluded that there was limited evidence in the literature to support the use of MBP in patients undergoing colorectal surgery. Several studies evaluating a consecutive series of patients who underwent resection and primary anastomosis concluded that MBP is not essential for safe colorectal surgery.17,18
The authors of a trial that analyzed the bowel contents suggested that participants receiving MBP had a tendency toward a higher incidence of bowel contents spillage compared with participants who did not receive it, but without statistical significance. Spillage of bowel contents into the peritoneal cavity may increase the rate of postoperative complications.
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