Mechanical Bowel Preparation Before Colorectal Surgery in Enhanced Recovery Programs: Discrepancy Between the American and European Guidelines

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We read with interest the recent guidelines from The American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons for enhanced recovery.1 Our comments focus on the role of mechanical bowel preparation (MBP) before colon surgery. The authors stated, in contrast with the European guidelines,2–4 that MBP should be used (together with oral antibiotics (OAs)). This recommendation is based mainly on 1 systematic review.5 We are faced with a clear discrepancy between the present American and European guidelines recommending no MBP for the colon. In Europe, there is indeed almost unanimous agreement against MBP before colon surgery.6 Because of several meta-analyses, the omission of MBP has become the gold standard since the late 1990s. In the meta-analysis used in the American recommendation,5 there was no control arm without an MBP. Since 2015 there have been >5 reports (references available on demand) on this topic, and some of them did compare no MBP versus MBP with OA. However, these reports are open to criticism: they are mainly retrospective, and some of them used the same database (American College of Surgeons National Surgical Quality Improvement Program) but had different numbers and outcomes with no mention of missing data. Furthermore, the latest Cochrane review published in 20117 suggested, in a subgroup analysis, that the most favorable option for reducing surgical site infections was OA without MBP. Therefore, the grade of the present American recommendation should actually be 2C instead of 2B.
Why is this discrepancy evident between American and European guidelines? In our opinion, the European recommendation is not to be revisited at present.
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