Improved Outcomes in Colon and Rectal Surgery part 3 pptx

 improved outcomes in colon and rectal surgery increased risk. Intermittent pulse oximetry with observation does not provide the same level of safety.(100) Continuous positive airway pressure ventilation (CPAP) is given to all patients using it preoperatively. diabetes The frequency of glucose abnormalities and type II diabetes increases with age; almost 25% of patients aged more than 60 had an abnormal value in one report.(66) The diabetic patient who is recognized and well managed perioperatively can achieve a surgical mortality which is equal to the nondiabetic patient. Protein catabolism after colorectal surgery is increased in patients with type 2 diabetes mellitus.(101) The preoperative assessment should include any complaints of polyuria, polydypsia, or polyphagia. An associated weight loss with any of these could be a sign of diabetes. A fasting blood glucose >140 mg/dl confirms a diagnosis of diabetes. Control of hyperglycemia should be started preoperatively and continued in the postoperative phase. In contrast to past doctrine that mild hyperglycemia is permissible in the perioperative period, newer studies indicate that there is a benefit in tighter glucose control. These intensive insulin strategies result in less hyperglycemia and as a result appear to improve immune function and reduce infectious complications.(102) These intensive strategies require frequent monitoring of blood glucose levels but may result in more hypoglycemia which has serious potential adverse consequences, causing two large scale studies of this method to be stopped.(103) Close monitoring of glucose and avoidance of hyperglycemia has clear benefit, but especially in difficult-to-control diabetics it can be challenging to avoid dangerous hypoglycemia. Renal and cardiovascular disease occurs commonly in diabetics and is a major cause of death in these patients. Compared to the nondiabetic population, cardiovascular disease occurs more frequently at a younger age, and with more severe manifestations. The reasons for this accelerated atherosclerosis are postulated to include the high incidence of hyperlipoproteinemia in diabetic patients, abnormalities of endothelial cell function, increased platelet aggregation, and a high incidence of hypertension in diabetics. age Despite advances in surgery, anesthesia, and perioperative care, increasing age continues to be a risk factor for perioperative complications. There is an increased risk of surgery associated with advancing age. In a 1982 review of 50,000 elderly patients, the risk of mortality with elective surgery increased from 1.3% for those under age 60, to 11.3% in the 80–89 year-old age group. (104) A recent review nearly 20 years later demonstrates an in- hospital mortality of 0.3% for patients 50–59 and increasing to 2.6% for those patients older than 80.(105) Major perioperative complications increased by decade from 4.3% for 50–59, to 5.7% for 60–69, to 9.6% for 70–79 and 12.5% for 80 or older. Surgical procedures and surgery should not be restricted on the basis of age alone.(106) There is clear evidence that age has an effect on physiologic life processes.(107) Maximum heart rate slowly decreases with age (108) and there is an increasing frequency of arrhythmias (109). There is a decline in maximum oxygen consumption except in very active patients.(110) A decrease in ventilatory threshold with age is predominantly due to an age-related decline of skeletal muscle mass.(111, 112) Chronologic age does not always correlate with the more important estimation of physiologic age. Active athletic individuals can maintain lean body mass equal to that of younger athletes well into their 8th decade.(113) Aging is characterized by a decline in renal function and by a sus- ceptibility to renal diseases. Renal function is preserved with aging in healthy subjects at the expense of a complete reduction of renal functional reserve. Proteinuria (114) and bacteriuria (115) increase with the age. Aging is associated with insulin resistance often attrib- utable to obesity and inactivity. Recent evidence suggests that skeletal muscle insulin resistance in aging is associated with mitochondrial alterations. Aging is associated with both whole body and myocardial insulin resistance, independent of obesity and inactivity.(113) The population is steadily aging and geriatric surgical care is likely to increase. As patients enter their 9th decade it will not be uncommon for them to be acceptable candidates for major surgery. Extremely elderly patients are likely to be poorly toler- ant of complications and difficult to salvage once complications occur. “Failure to rescue” is a new quality of care indicator to measure the inability to save a patient once a complication has occurred.(116) It is likely that elderly patients will prove particularly difficult to rescue once a problem has occurred, so it is up to the surgeon to be fastidious in his preoperative preparation and risk assessment, intraoperative technique and postoperative care to avoid complications in this fragile patient population. neurologic system The prevalence of occult cerebrovascular disease in elderly patients is a common problem. An asymptomatic carotid bruit indicates the presence of peripheral vascular disease and is an indication for further evaluation by duplex scanning. However, prophylactic endarterectomy is not indicated usually, as the increased risk of a perioperative stroke compared to the unselected population is small.(118) Symptomatic disease should be treated before elective interventions. Aspirin prophylaxis and occasionally endarterectomy might be indicated to reduce the incidence of cerebrovascular acci- dents (CVA).(119) Patients who have had a stroke in the past are at an estimated 5–15% annual risk of a recurrent event if left untreated. Thus these patients are often maintained on either aspirin or clopidogrel (Plavix) to reduce their risk. While clopidogrel is more effective in high-risk patients, it is associated with a higher incidence of bleeding events. The risk of stroke while stopping the anticoagulation must be weighed against the adverse event of postsurgical bleeding. The decision-making must be tailored to the stroke risk of the individual patient based on their history and the magnitude and bleeding risk of the proposed procedure. For most patients, the interruption in their anticoagulation for 7 days to proceed with surgery is not likely to result in harm. Parkinson’s disease is a progressive degenerative neurologic condition associated with tremor and gait disturbance. In its later stages, aspiration pneumonia is common thus patients with advanced disease having abdominal surgery must have particular attention paid to their postoperative respiratory program. Most anti-Parkinsonian medications are only orally administered so  preexisting conditions they must be withheld after abdominal surgery until oral medications can be given. This can result in rigidity and further wors- ening of airway protection. One author describes use of rectally administered domperidone to patients with Parkinson’s disease having abdominal surgery in an effort to avoid such problems. (120) We have little experience with this, but it may prove useful in a particularly symptomatic patient. hyPerCOAgUAble dISOrderS Management of patients with hypercoaguable syndromes can be especially challenging in the setting where the need to control postoperative bleeding is crucial. Common (factor V Leiden deficiency) and relatively uncommon (antithrombin deficiency, protein C and protein S deficiency) causes of thrombosis have different risk associations. For example, the relative risk of venous thrombosis in the Caucasian population can range from 2.5% for the prothrombin gene mutation to 25% in the presence of antithrombin deficiency.(121) Furthermore, approximately 50% of cases of venous thrombosis associated with these hereditary disorders are provoked by known risk factors such as surgery. Therefore, aggressive prophylaxis with subcutaneous heparin or low-molecular heparin is warranted peri- and postoperatively. By contrast, for those on long-term anticoagulation, the decision to continue treatment for thrombosis should be individualized. In general, warfarin therapy can be switched to low-molecular weight or intravenous heparin 3 to 5 days before surgery.(121) Patients with antiphospholipid antibody syndrome (lupus anticoagulant/anticardiolipin antibodies, history of arterial or venous thrombosis, and/or recurrent fetal loss) deserve special mention. Currently available anticoagulants are effective in reducing the recurrence rate of venous thromboembolism (VTE). VTE is a common complication in cancer patients and can lead to delay in cancer therapy and is predictive of a worse prognosis. Prophylaxis with anticoagulants is recommended for patients hospitalized for surgery or medical conditions, but is not routinely administered in the ambulatory setting.(122) However, anticoagulant treatment is associated with an increased risk for bleeding complications and needs to be discontinued when benefit of treatment no longer clearly outweigh its risks.(123) The incidence of recurrent VTE can be estimated through a two-step decision algorithm. First, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) provide essential infor- mation on the risk for recurrence after anticoagulant treatment discontinuation. Second, at time of anticoagulant treatment discontinuation, D-dimer levels and residual thrombosis have been indicated as predictors of recurrent VTE. Current evidence suggests that the risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effec- tively treated and by the patient’s intrinsic risk of having a new episode of VTE. All patients with acute VTE should receive oral anticoagulant treatment for 3 months. At the end of this treatment period, physicians should decide for withdrawal or indefinite anticoagulation. Based on intrinsic patient’s risk for recurrent VTE and for bleeding complications and on patient preference, selected patients could be allocated to indefinite treatment with scheduled periodic reassessment of the benefit from extending anticoagulation. Cancer patients should receive low-molecular weight heparin over warfarin in the long-term treatment of VTE. These patients should be considered for extended anticoagulation at least until resolution of underlying disease.(123) conclusion The history and physical examination is the most important part of the preoperative evaluation and can be used to guide further workup and testing. Multiple scoring systems are available to quantify risk of postoperative complications and mortality based on preoperative conditions. Optimization of these conditions will increase the likelihood of a successful outcome. references 1. Wilson ME, NB WI, Baskett PJ, Bennett JA, Skene AM. Assessment of fitness for surgical procedures and the vari- ability of anesthetists’’ judgments. Br Med J 1980; 280(6213): 509–12. 2. Parker BM, Tetzlaff JE, Litaker DL, Maurer WG. Redefining the preoperative evaluation process and the role of the anes- thesiologist. J Clin Anesth 2000; 12(5): 350–6. 3. Arvidsson S OJ, Sjostedt L, Svardsudd. Predicting postoperative adverse events. 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J Thomb Thrombolysis 2008; 25: 33–36. 123 Agnelli G, Becattani C. Treatment of DVT: how long is enough and how do you predict recurrence. J Throm Thrombolysis 2008; 25: 37–44.  2 Preoperative bowel preparation David A Margolin and Sean Mayfield CHALLENGING CASE A 57-year-old gentleman with a sigmoid colon cancer found via colonoscopy for a history of anemia and weight loss is awaiting surgery. You stop by the pre-op holding area to see the patient where he tells you, “I tried drinking that prep last night and after only half a glass I got sick and threw up. I just couldn’t take it.” Do you perform elective surgery? CASE MANAGEMENT Yes. Multiple studies have demonstrated the safety of elective bowel surgery in the absence of a mechanical bowel preparation. INTRODUCTION The objectives of preoperative bowel preparation in elective colon and rectal surgery include decreasing the bacterial count in the colon, decreasing the wound infection rate, decreasing the rate of anastomotic leaks, improving interoperative bowel handling, and facilitating interoperative endoscopy if necessary. Aside from the medical reasons for a patient undergoing a bowel prep, there is surgical tradition as well as the medicolegal implications of deviations from the perceived norm. We know that there are a variety of well-documented factors that play a role in infectious compilations in colon and rectal surgery most notably, increased American Society of Anesthesiologists (ASA) classification, obesity, diabetes, prolonged surgical time, interoperative hypotension, excessive blood loss, surgical intervention for bowel obstruction, whether partial or complete, and emergency surgery. (1–5) We as surgeons also try to adhere the dictum of primum non nocere. With those thoughts in mind, preoperative bowl preparation has become the standard before elective colon surgery. Preoperative bowel preparation is divided into two parts: antibiotic prophylaxis and mechanical bowel preparation. The use of antibiotic prophylaxis in elective colon surgery is mandatory to minimize infection complications. Unfortunately the choice antibiotic and rout of antibiotic administration is not as clear. The first principle in prophylactic use of antibiotic administration is to provide cover- age for the normal bowel flora. This means choosing antibiotics that cover both aerobic bacteria, especially Escherichia coli and anaerobic species most notably bacteroides sp. Even with appropriately chosen antibiotics the route of antibiotic administration is undergoing a re-evaluation. Oral antibiotics as used in the traditional Nichols- Condon antibiotic preparation have been shown to reduce intralu- minal and mucosal bacterial count while parenteral antibiotics have been shown to reduce systemic bacterial counts at the tissue level. Colorectal surgery performed before 1970 was fraught with infectious complications which occurred in more than 30–50% of all operations. With a better understanding of bacteriology and the availability of an increasing number of antibiotics, surgeons attempted to improve their outcomes with regards to infections. Garlock and Seley in 1939 gave patients sulfanilamides before surgery; unfortunately, there was no real improvement in infectious complications.(6) Dearing in 1951 and Poth in 1960 tied tetracycline and neomycin respectively with only minimal improvement.(7, 8) It was not till the 1970s that a significant improvement in mitigat- ing infectious complications was seen. In a 1977 VA cooperative study, Nichols and Condon showed that by using oral neomycin sulfate and erythromycin base that they were able to decrease the wound infection rate of elective colon resections from 35% to 9%. They also showed that this regimen showed a significant decrease in all septic complications (wound infection, anastomotic leak, and abscess) from 43% to 9%.(9–11) The dosing of 1 g of oral neomycin sulfate and erythromycin base at 2:00 pm, 3:00 pm, and 10:00 pm for an 8:00 am case became and remains a standard oral antibiotic regime for elective surgery. Unfortunately, the Nichols prep has its draw backs. While this antibiotic combination is efficacious, it can cause significant gastrointestinal discomfort severely limiting patient compliance with the remainder of the antibiotic prep and completion of their mechanical preparation. These limitations, along with the significant increase in number and spectrum of paranteral antibiotics, led many investigators to utilize various IV antibiotic combinations to minimize infectious complications. In 1969, Polk demonstrated that cephaloridine ver- sus mechanical prep alone decreased the rate of wound infection in elective colon resections from 30% to 7%.(12) Since that initial study their have been numerous attempts to find the best parenteral antibiotic. From 1983 to 1995 there were more than 150 randomized controlled trials performed (Table 2.1 and 2.2). Finally in 1998, Song and colleagues, in a landmark review in the British Journal of Surgery, codified modern practice and confirmed that parenteral antibiotics alone decrease the rate of wound infection and that no single regimen is superior as long as the antibiotics chosen cover both aerobic and anaerobic bacteria and are given before incision.(13) In 2003, the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW), a project endorsed by both the American College of Surgeons (ACS) and American Society of Colon and Rectal Surgeons (ASCRS), submitted consensus positions for surgical antimicrobial prophylaxis.(3) They stated that the standard for parenteral antibiotic prophylaxis in elective colon resections should include: 1. Timing: Infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision. 2. Duration: Prophylactic antimicrobials should be discontinued within 24 hours following surgery. 3. Dosing: The initial dose should be adequate based on weight, adjusted dosing weight, or BMI. An additional dose should be administered if the operation continues over two half- lives after the initial dose. 4. Selection (Colon Surgery): Cefotetan, cefoxitin, or cefazolin/ metronidazole. – Options for β-lactam allergic patients: – Clindamycin + gentamicin, ciproﬂoxacin, or aztreonam. – Metronidazole + gentamycin or ciproﬂoxacin.  preoperative bowel preparation Since 1887, when Halsted described intestinal anastomosis, the idea of mechanically preparing the bowel has become accepted surgical practice. The rationale for mechanical bowel prep has been to reduce the risk of infectious complications including wound infection and anastomotic leak. At the beginning of the 20th century, morbidity and mortality secondary to septic complications following colon and rectal surgery was high. However, medical innovations including broad-spectrum oral and intravenous antibiotics, improved surgical techniques and instrumenta- tion, improved anesthetic and perioperative care, and presumably mechanical bowel preparation has resulted in decreased infectious complication rates making elective colorectal surgery safe. Mechanical bowel preparation preceding elective colon and rectal surgery has become surgical dogma, and surgeons are trained that primary colonic anastomosis is unsafe in the presence of an unprepared bowel. Proponents argue that the “clean” bowel has a lower bacterial load and is easier to handle thus reducing the chance of fecal spillage and contamination of the wound and peritoneal cavity during surgery. Mechanical bowel prep is also believed to eliminate the proximal stool column, possibly reducing the chance of anastomotic disruption by the passing stool, and the sequelae should a disruption occur. The merits of this practice however have lacked clear investigational proof and have undergone continued scrutiny over the last decade. In 1973, Hewitt et al. presented whole gut irrigation, using a large volume of isotonic solution, administered via a nasogastric tube.(26) No change in the rate of infection was displayed, although the quality of the prep was improved. A subsequent advance was whole gut lavage using mannitol as an osmotic agent. Mannitol reduced the absorption of water, but was associated with dehydration and loss of electrolytes. Because mannitol is fermented by E. coli into a potentially explosive gas, explosions while using electrocautery were reported. There are two oral preparations routinely used today, polyethylene glycol (PEG) and sodium phosphate (NaP). PEG is an inert osmotically active polymer that is mixed with an electrolyte solution resulting in an isosomotic preparation that acts to lavage stool from the colon lumen. The electrolyte content combined with the osmotic activity of PEG prevents net absorption or excretion or water and electrolytes. Typically, 4 L of PEG is ingested over 2 to 3 hours. This produces good to excellent cleansing in most patients without causing significant fluid or electrolyte derangements. These issues are of particular importance in elderly patients or those with renal insufficiency or congestive heart failure. Nausea, vomiting, and patient compliance are obstacles to achieving adequate results in some patients. This has been addressed by the addition of flavor additives and a reduced volume prep in which patients take 2–4 (10 mg) bisacodyl tablets and ½ the normal volume of PEG (2 L). Some surgeons also prescribe metoclopramide to hasten gastric emptying, or an antiemetic such as promethaz- ine. However, prospective, randomized trials have not confirmed significant benefit from either of these adjuvant medications. NaP is a hypersomolar oral saline laxative. Smaller volumes of hypertonic NaP can produce adequate bowel cleansing with better patient compliance. Patients are instructed to consume 45 ml of sodium phosphate diluted in clear liquids (15 ml NaP in 240 ml) in two doses separated by 10 hours. The timing of this should be such that the patient is not kept awake evacuating the entire night before the procedure. Sodium phosphate tablets are also available and are equally efficacious. Three to four tablets with 8 oz of clear liquid are taken every 15 minutes to a total of 28 tablets. In May 2006, the Federal Drug Administration issued a warning regarding oral NaP for bowel preps in elderly patients or those with underlying kidney disease, dehydration, or those tak- ing medication that affect renal perfusion (diuretics, ACE inhibitors, angiotensin receptor blockers, and NSAIDs).(27) These patients are at increased risk for developing acute renal failure and nephrocalcinosis due to the relatively large phosphate load, fluid shifts, and decreased intravascular volume associated with NaP preps. However, both the avoidance of this complication as well as improved efficacy can be achieved by appropriate patient selection and consumption of large volumes (2–3 L) of clear liquids as part of this prep. A 2003 survey by Zmora et al. of members of the American Society of Colon & Rectum Surgeons displayed that 99% of respondents routinely use mechanical bowel preparation Table 2.1 Intravenous Antibiotics. Author No. of Pts. Antibiotic Wound Infections Periti 1989 (14) 403 cefoxitin cefotetan 11.0% 9.0% Skipper 1992 (15) cefotetan 14.7% Zanella 2000 (16) 615 cefepime plus metronidazole 7.2% Mosimann 1998 (17) 440 amoxicillin/ clavulanic 11.1% Hall 1989 (18) 237 gentamicin plus metronidazole 14.8% Corman 1993 (19) 907 cefuroxime plus metronidazole 7.3% Table 2.2 Effect of Intravenous Antibiotics. Author Pts. No. Antibiotics Wound Infections Codon 1983 (20) 1082 neo/erythro neo/erythro + cephalothin 8.0 6.0 Coppa 1983 (21) 241 neo/erythro neo/erythro + cefoxitin 18 7 Portnoy 1983 (22) 104 neo/erythro neo/erythro + cefazolin neo/erythro + ticarcillin 27 4.7 2.3 Lau 1988 (23) 194 neo/erythro metronidazole + gentamicin neo/erythro + metronidazole + gentamicin 27.4 11.9 12.3 Schoetz 1990 (24) 197 neo/erythro neo/erythro + cefoxitin 14.6 5 Stellato 1990 (25) 146 neo/erythro cefoxitin only neo/erythro +cefoxitin 11.4 11.7 7.8  improved outcomes in colon and rectal surgery although 10% questioned its use.(28) 47% of the surgeons used sodium phosphate, 32% used polyethylene glycol, and 14% alter- nated between these two options. These results are the same as those reported by Beck et al. in 1990 and are most likely based on surgical tradition rather than evidence-based science.(29) Since 1992, several randomized controlled trials and meta- analyses have studied the influence of mechanical bowel preparation on the outcome of colorectal surgery. Brownson et al. were the first to perform a randomized trial which consisted of 179 patients. Patients were divided into preparation with polyethylene glycol or no mechanical preparation.(30) Interestingly, patients who received a mechanical prep had a higher rate of anastomotic leak and intraabdominal infection. There was no statistically significant difference in wound infection. Burke et al. and Santos et al. in 1994 published similar studies. Neither study showed a significant difference in intraabdominal infection; however, Santos displayed a higher wound infection rate 24% vs. 12% in patients who received mechanical bowel preparation.(31, 32) Miettinen et al. reported the results of a prospective randomized trial in 2000 including patients undergoing rectal surgery. (33) Again, no significant differences in infectious complications were found between the two groups 4% vs. 2% for both wound infections and anastomotic leaks. It was difficult to determine the effect on anastomotic leakage, as this study included patients who did not undergo an anastomosis. Zmora et al. performed the larg- est study thus far, a randomized prospective trial in 2003 which included 415 patients separated into mechanical bowel prep with polyethylene glycol vs. no bowel prep.(34) Once again surgical infectious complications did not significantly differ between the two groups with the wound infection rate 6.4% for patient who underwent a mechanical bowel prep vs. 5.7 for those who did not. Similar results were seen with regards to anastomotic leak rate 3.7% vs. 2.1%. Fa-Si-Oen et al. performed a well-designed multicenter randomized controlled trial published in 2005.(35) Left- sided colonic resections accounted for approximately half of the procedures. This was distinctive, given the current thinking that right-sided anastomosis are generally safe. No significant difference in wound infection or anastomotic leak was detected, but the method of determining a wound infection was performed incor- rectly in 65 patients which might have therefore affected the valid- ity of the results. Bucher et al. published a randomized control study in 2005 which again compared the outcome of patients who underwent left-sided colorectal surgery with or without mechanical bowel prep.(36) 153 patients were randomized into mechanical bowel preparation (MBP) with polyethylene glycol vs. no prep. The overall rate of abdominal infectious complications was 22% in the prepped group vs. 8% in the unprepped. Anastomotic leak occurred in 6% in the prepped group vs. 1%. Interestingly hospital stay was longer for patient who had MBP, 14.9 days vs. 9.9 in the nonprepped. This was a multicenter trial which the authors agree may partially bias the results. The conclusion was that left-sided colorectal surgery could be performed safely without MBP and that MBP might have a nega- tive impact on the complication rate and hospital stay.(Table 2.3) Additional evidence against the use of mechanical bowel prep has arisen from the literature regarding urgent surgery for traumatic colon injuries. A retrospective review by Conrad et al. was performed in 2000 which evaluated 145 patients with penetrat- ing colon injuries.(33) Two separate time periods were compared, the latter of which included a significantly larger number of primary repairs compared to proximal diversions. The colonic injuries were distributed equally between the right and left colon. Anastomosis of the unprepped bowel appeared safe with only one anastomotic leak in the study. Other infectious complications showed no statistical difference between the two periods. The main focus of this study was to evaluate the safety of primary anastomosis vs. fecal diversion; however it also revealed the safety of an anastomosis in unprepped bowel. A Cochrane review was performed in 2004 as a meta-analysis to analyze the effectiveness and safety of prophylactic mechanical bowel preparation for morbidity and mortality rates in elective colorectal surgery.(39) Out of 1159 patients with anastomoses, 576 Table 2.3 Mechanical Bowel Prep Randomized Controlled Trials. Zmora 2003 (34) Fa-Si-Oen 2005 (35) Ram 2005 (37) Bucher 2005 (36) Miettinen 2000 (33) Patients 415 250 329 153 267 Patients (MBP/no MBP) 187/193 125/125 164/165 78/75 138/129 Mean age (MBP/no MBP) 68/68 68/70 68/68 63/63 61/64 Cancer % (MBP/no MBP) 78/78 90/92 75/88 32/28 46/55 L colon surgery % (MBP/no MBP) 68/72 48/58 89/85 100/100 45/47 Type of prep PEG PEG NaPO4 PEG PEG Anastomotic leak % (MBP/no MBP) 3.7/2.1 (NS) 5.6/4.8 (NS) 0.6/1.2 (NS) 6/1 (NS) 4/2 (NS) Wound infection % (MBP/no MBP) 6.4/5.7 (NS) 7.2/5.6 (NS) 9.8/6.1 (NS) 13/4 (NS) 4/2 (NS) Intraabdominal abscess % (MBP/no MBP) 1.1/1 (NS) Not given 0.6/0.6 (NS) 1/3 (NS) 2/3 (NS)  preoperative bowel preparation received mechanical bowel prep and 583 underwent no prep. There was no difference in anastomotic leak rates for low anterior resection (12.5 vs. 12%), or colonic surgery (1.2 vs. 6%) in patients with or without MBP. Anastomotic leak rates were significantly lower overall without MBP (5.5 vs. 2.9%). Wound infection, peritonitis, reoperation, mortality, and extra abdominal complications were similar between groups. The authors’ conclusion was no convinc- ing evidence exists that MBP is associated with reduced rates of anastomotic leakage after elective colorectal surgery and that MBP may be associated with an increased rate of anastomotic leakage and wound complications. No definitive conclusion on complication rates was possible due to the clinical heterogeneity of trial inclusion criteria, poor reporting of concealment and allocation, potential performance biases, and failure-to-treat analyses.(39) One other important consideration when evaluating MBP is the patient’s experience. A 2007 study from Sweden performed by Jung et al. evaluated 105 patients who underwent elective colon surgery.(40) 60 patients received MBP with half receiving polyethylene glycol and the remainder receiving sodium phosphate. 52% in the MBP group required assistance via hospital staff or a relative with the prep. Only 30% of the MBP group would con- sider undergoing the same preoperative procedure. There was no significant difference in postoperative pain and nausea; however, patients in the no MBP group had more pain on postoperative day #4. This was thought to be due to patient’s regaining bowel function earlier compared to the no MBP group. Despite the growing evidence against MBP, there are several benefits unrelated to the risk of infection. A prepped colon is easier to palpate and manipulate, and allows the surgeon to identify smaller tumors and perform intraoperative colonoscopy if required. During laparoscopy, it may reduce the risk of traumatic bowel injury of an otherwise heavy, fecal loaded colon being manipulated by relatively traumatic laparoscopic grasping instruments. However, the overall data from randomized trials and meta-analyses clearly show the safety of performing an anastomosis in unprepared bowel and the lack of benefit of MBP toward infectious complications. REFERENCES 1. Smith RL, Bohl JK, McElearney ST et al. Wound infection after elective colorectal resection. Ann Surg 2004; 239: 599–605. 2. National Academy of Science NRC. Postoperative wound infections: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964; 160: 1–132. 3. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. CID 2004; 38: 1706–15. 4. Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989; 106: 750–6. 5. Perncevich E, Sands K, Cosgrove S et al. Health and eco- nomic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003; 9: 196–203. 6. Garlock JH, Seley GP. The use of sulfanilamide in surgery of the colon and rectum. A preliminary report. Surgery 1939; 5: 787. 7. Dearing WH, Needham GM. The effect of terramycin on the intestinal bacterial flora of patients being prepared for intestinal surgery. Proc Staff Meet Mayo Clin 1951; 26(3): 49–52. 8. Poth EJ. The role of intestinal antisepsis in the preoperative preparation of the colon. Surgery 1960; 47: 1018–28. 9. Clarke JS, Condon RE, Bartlett JG et al. Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized, double-blind clinical study. Ann Surg 1977; 186: 151. 10. Bartlett JG, Condon RE, Gorbach SL et al. Veterans administration cooperative study on bowel preparation for elective colorectal operations: impact of oral antibiotic regimen on colonic flora, wound irrigation cultures and bacteriology of septic complications. Ann Surg 1978; 188(2): 249–54. 11. Condon RE, Bartlett JG, Nichols RL et al. Preoperative prophylactic cephalothin fails to control septic complications of colorectal operations: results of controlled clinical trial. A Veterans Administration Cooperative Study. Am J Surg 1979; 137: 68. 12. Polk HC, Zeppa R, Warren WD. Surgical significance of dif- ferentiation between acute and chronic pancreatic collec- tions. Ann Surg 1969; 169(3): 444–6. 13. Song F, Glenny A. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg 1998; 85: 1232–41. 14. Periti P, Mazzei T, Tonelli F. Single-dose cefotetan vs. multiple-dose cefoxitin antimicrobial prophylaxis in colorectal surgery. Results of a prospective, multicenter, randomized study. Dis Colon Rectum 1989; 32(2): 121–7. 15. Skipper D, Karran SJ. A randomized prospective study to compare cefotetan with cefuroxime plus metronidazole as prophylaxis in elective colorectal surgery. J Hosp Infect 1992; 21(1): 73–7. 16. Zanella E, Rulli F. A multicenter randomized trial of prophylaxis with intravenous cefepime + metronidazole or ceftri- axone + metronidazole in colorectal surgery. The 230 Study Group. J Chemother 2000; 12(1): 63–71. 17. Mosimann F, Cornu P. Are enemas given before abdominal operations useful? A prospective randomised trail. Eur J Surg 1998; 164(7): 527–30. 18. Hall C, Curran F, Burdon DW, Keighley MR. A randomized trial to compare amoxycillin/clavulanate with metronidazole plus gentamicin in prophylaxis in elective colorectal surgery. J Antimicrob Chemother 1989; 24 (Suppl B): 195–202. 19. Corman M, Robertson W, Lewis T et al. A controlled clinical trial. Cefuroxime, metronidazole, and cefoxitin as prophylactic therapy for colorectal surgery. Complications in Surgery 1993; 12: 37–40. 20. Condon RE, Bartlett JG, Greenlee H et al. Efficacy of oral and systemic antibiotic prophylaxis in colorectal operations. Arch Surg 1983; 118(4): 496–502. 21. Coppa GF, Eng K, Gouge TH, Ranson JH, Localio SA. Parenteral and oral antibiotics in elective colon and rectal surgery. A prospective, randomized trial. Am J Surg 1983; 145(1): 62–5. 22. Portnoy J, Kagan E, Gordon PH, Mendelson J. Prophylactic antibiotics in elective colorectal surgery. Dis Colon Rectum 1983; 26(5): 310–13. . preparation in elective colon and rectal surgery include decreasing the bacterial count in the colon, decreasing the wound infection rate, decreasing the rate of anastomotic leaks, improving interoperative. and rectal surgery was high. However, medical innovations including broad-spectrum oral and intravenous antibiotics, improved surgical techniques and instrumenta- tion, improved anesthetic and. reported the results of a prospective randomized trial in 2000 including patients undergoing rectal surgery. (33 ) Again, no significant differences in infectious complications were found between

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