Mechanical Bowel Preparation for Children Undergoing Elective Colorectal Surgery Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection Rectal cancer surgery without mechanical bowel preparation Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based? Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study. Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children. Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence? The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial Preoperative mechanical preparation of the colon: the patient's experience Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Survey of pediatric surgeons on current practices of bowel preparation for elective colorectal surgery in children. Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion. Bowel preparation before colonoscopy in the pediatric patient: a randomized study. Evaluation of necessity for mechanical bowel preparation before Milligan-Morgan hemorrhoidectomy: a randomized prospective clinical study. Requirement for bowel preparation in colorectal surgery Bowel Preparation Before Vaginal Prolapse Surgery: A Randomized Controlled Trial Rectal Cancer Surgery With or Without Bowel Preparation: The French Greccar III Multicenter Single-Blinded Randomized Trial
Objectives : Adult literature supports the elimination of mechanical bowel preparation ( MBP ) for elective colorectal surgical procedures . Prospect i ve data for the pediatric population regarding the utility of MBP are lacking . The primary aim of this study was to compare infectious complications , specifically anastomotic leak , intraabdominal abscess , and wound infection in patients who received MBP  with those who did not . Methods : A r and omized pilot study comparing MBP with polyethylene glycol with no MBP was performed . Patients , 0 to 21 years old , undergoing elective colorectal surgery were eligible and r and omized within 4 age strata . Statistical analyses were performed using & khgr;2 or Fisher exact test for categorical data and t test or Wilcoxon 2- sample test for continuous data . Results : Forty-four patients were enrolled in the study from December 2010 to February 2013 , of which 24 ( 55 % ) received  MBP and 20 ( 45 % ) did not . Two patients ( 5 % ) had anastomotic leak , 4 ( 9 % ) had intraabdominal infection , and 7 ( 16 % ) had wound infections . The rate of anastomotic leak , intraabdominal abscess , and wound infection did not differ between the 2 groups . Conclusions : MBP for elective colorectal surgery in children does not affect the incidence of infectious complications . A larger multiinstitutional study is necessary to vali date the results of this single-institution pilot study Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery . This r and omized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery Eight r and omized clinical trials and two meta‐analyses recently question ed the value of preoperative mechanical bowel preparation ( MBP ) in colorectal surgery . However , very few patients having rectal surgery were included in these studies . The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP PURPOSE It is well established through r and omized trials that oral antibiotics given with or without a mechanical bowel preparation ( MBP ) prior to colorectal procedures reduce complications , while MBP given alone provides no benefit . We aim ed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence -based . METHODS Retrospective analysis of patients undergoing colorectal procedures at 42 children 's hospitals ( 1/2/2007 - 12/31/2011 ) was performed . Patients were analyzed for diagnosis , pre-admission status , and inpatient bowel preparation .  Bowel preparation was considered evidence -based if oral antibiotics were utilized with or without a MBP . RESULTS 49 % of all patients were pre-admitted ( n=5,473 ) , and the most common diagnoses were anorectal malformations ( 55 % ) , inflammatory bowel disease ( 26 % ) , and Hirschsprung 's Disease ( 19 % ) . The most common preparation approaches were MBP alone ( 54.3 % ) , MBP+oral antibiotics ( 18.8 % ) , and oral antibiotics alone ( 4.2 % ) , although significant variation was found in hospital-specific rates for each approach ( MBP alone : 0 - 96.1 % , MBP+oral antibiotics : 0 - 83.6 % , orals alone : 0 - 91.6 % , p<0.0001 ) . Only 22.9 % of all patients received an evidence -based preparation ( range by hospital : 0 - 92.3 % , p<0.0001 ) , and this rate decreased significantly during the five-year study period ( 27.6 % in 2007 vs. 17.3 % in 2011 , p<0.0001 ) . CONCLUSION According to the best available clinical evidence , less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications BACKGROUND / PURPOSE Preoperative mechanical bowel preparation ( MBP ) for elective intestinal operations has been a long accepted practice . However , MBP is often unpleasant and time-consuming for patients , and clinical trials in adults have not shown improved outcomes . We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications . METHODS Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children 's hospital between 1990 and 2003 . RESULTS Thirty-three patients ( No PREP ) were managed by a single surgeon who routinely omitted MBP , whereas another 110 patients ( PREP ) were prepared with enemas , laxatives , or both . Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics . The No PREP group had one anastomotic leak and no wound infections , whereas the PREP group had 2 anastomotic leaks and 1 wound infection ( P = .58 ) . These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group . CONCLUSION The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications . Eliminating MBP may reduce health care costs and inconvenience to patients . These findings warrant a large , prospect i ve , r and omized clinical trial to vali date our findings and to investigate further the necessity of MBP in the pediatric population BACKGROUND The utility of mechanical bowel preparation ( MBP ) to minimize infectious complications in elective colorectal surgery is contentious . Though data is scarce in children , adult studies suggest a benefit to MBP when administered with oral antibiotics ( OAB ) . METHODS After IRB approval , the Pediatric Health Information System ( PHIS ) was queried for young children undergoing elective colon surgery from 2011 to 2014 . Patients were divided into : no bowel preparation ( Group 1 ) , MBP ( Group 2 ) , and MBP plus OAB ( Group 3 ) . Statistical significance was determined using univariate and multivariate analysis with GEE models accounting for clustering by hospital . RESULTS One thous and five hundred eighty-one patients met study criteria : 63.7 % in Group 1 , 27.1 % in Group 2 , and 9.2 % in Group 3 .  Surgical complication rate was higher in Group 1 ( 23.3 % ) compared to Groups 2 and 3 ( 14.2 % and 15.5 % ; P<0.001 ) . However , median length of stay was shorter in Group 1 ( 4 , IQR 4days ) compared to Group 2 ( 5 , IQR 3 ) and Group 3 ( 6 , IQR 3 ) ( P<0.001 ) . 30-day readmission rates were similar . In multivariate analysis compared to patients in Group 1 , the odds of surgical complications were 0.72 ( 95 % CI 0.40 - 1.29 , P=0.28 ) with MBP alone ( Group 2 ) , 1.79 ( 95 % CI 1.28 - 2.52 , P=0.0008 ) with MBP+OAB ( Group 3 ) , and 1.13 ( 95 % CI 0.81 - 1.58 , P=0.46 ) for the aggregate Group 2 plus 3 . CONCLUSION Utilization of bowel preparation in children is variable across children 's hospitals nationally , and the benefit is unclear . Given the discrepancy with adult literature , a three-armed pediatric-specific r and omized controlled trial is warranted . LEVEL OF EVIDENCE Level III treatment study - retrospective comparative study PURPOSE Despite rigorous data from adult literature demonstrating that oral antibiotics ( OA ) reduce infectious complications and mechanical bowel preparation ( MBP ) alone does not , MBP alone remains the preferred approach among pediatric surgeons . We aim ed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership . METHODS Surgeons were queried for their choice of bowel preparation , factors influencing their practice , and their impression of the strength and relevance of the adult literature to pediatric practice . RESULTS Surgeons who used MBP alone ( 31 % ) cited a reduction in stool burden and infectious complications as important factors , whereas surgeons choosing not to use OA ( 70 % ) reported a lack of benefit in reducing infectious complications as the primary reason . Although 53 % of surgeons reported that evidence from adult literature was the most important influence , 73 % of surgeons reported there was poor evidence supporting the use of OA ( ±MBP ) , and only 25 % used a preparation supported by adult r and omized data . CONCLUSIONS Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA . Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice , this is not consistent with stated perceptions or practice Objective To compare mechanical bowel preparation ( MBP ) using oral magnesium citrate with sodium phosphate enema to sodium phosphate ( NaP ) enema alone during minimally invasive pelvic reconstructive surgery . Methods We conducted a single-blind , r and omized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery . The primary outcome was intraoperative quality of the surgical field . Secondary outcomes included surgeon assessment of bowel h and ling and patient-reported tolerability symptoms . Results One hundred fifty-three participants were enrolled ; 148 completed the study ( 71 MBP and 77 NaP ) . Patient demographics , clinical and intraoperative characteristics were similar . Completion of assigned bowel preparation was similar between MBP ( 97.2 % ) and NaP ( 97.4 % ) . The MBP group found the preparation more difficult ( P<0.01 ) and reported more overall discomfort and negative preoperative side effects ( all P⩽0.01 ) . Quality of surgical field at initial port placement was excellent/good in 80.0 % of the MBP group compared with 62.3 % in the NaP group ( P=0.02 ) . This difference was not maintained by the conclusion of surgery ( P=0.18 ) . Similar results were seen in the intent-to-treat population . Surgeons accurately guessed preparation 65.7 % of the time for MBP versus 41.6 % for NaP ( P=0.36 ) . At 2 weeks postoperatively , both reported a median time for return of bowel function of 3.0 ( 2.0–4.0 ) days . Conclusions Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field , but this benefit was not sustained . It was associated with an increase in patient discomfort preoperatively , but did not seem to impact postoperative return of bowel function . LEVEL OF EVIDENCE Background Preoperative mechanical bowel preparation can be question ed as st and ard procedure in colon surgery , based on the result from several r and omised trials . Methods As part of a large multicenter trial , 105 patients planned for elective colon surgery for cancer , adenoma , or diverticulitis in three hospitals were asked to complete a question naire regarding perceived health including experience with bowel preparation . There were 39 questions , each having 3 – 10 answer alternatives , dealing with food intake , pain , discomfort , nausea/vomiting , gas distension , anxiety , tiredness , need of assistance with bowel preparation , and willingness to undergo the procedure again if necessary . Results 60 patients received mechanical bowel preparation ( MBP ) and 45 patients did not ( No-MBP  ) . In the MBP group 52 % needed assistance with bowel preparation and 30 % would consider undergoing the same preoperative procedure again . In the No-MBP group 65 % of the patients were positive to no bowel preparation . There was no significant difference between the two groups with respect to postoperative pain and nausea . On Day 4 ( but not on Days 1 and 7 postoperatively ) patients in the No-MBP group perceived more discomfort than patients in the MBP group , p = 0.02 . Time to intake of fluid and solid food did not differ between the two groups . Bowel emptying occurred significantly earlier in the No-MBP group than in the MBP group , p = 0.03 . Conclusion Mechanical bowel preparation is distressing for the patient and associated with a prolonged time to first bowel emptying BACKGROUND Bowel preparation prior to colonic surgery usually includes antibiotic therapy together with mechanical bowel preparation ( MBP ) . Mechanical bowel preparation may cause discomfort to the patient , prolonged hospitalization , and water and electrolyte imbalance . It was assumed that with the improvement in surgical technique together with the use of more effective prophylactic antibiotics , it was possible that MBP would no longer be necessary . HYPOTHESIS There is no statistical difference in the postoperative results of patients who undergo elective colon resection with MBP  as compared with those who have no MBP . DESIGN AND PATIENTS The study includes all patients who had elective large bowel resection at Campus Golda between April 1 , 1999 , and March 31 , 2002 . Emergency operations were not included . The patients were r and omly assigned to the 2 study groups ( with or without MBP ) according to identification numbers . All patients were treated with intravenous and oral antibiotics prior to surgery . The patients in the MBP group received Soffodex for bowel preparation . RESULTS A total of 329 patients participated in the study , 165 without MBP and 164 with MBP . The 2 groups were similar in age , sex , and type of surgical procedure . Two hundred sixty-eight patients ( 81.5 % ) underwent surgery owing to colorectal cancer and 61 patients ( 18.5 % ) owing to benign disease . The hospitalization period was longer in the bowel-prepared group ( mean + /- SD , 8.2 + /- 5.1 days ) as compared with the nonprepared group ( mean + /- SD , 8.0 + /- 2.7 days ) . However , this difference was not statistically significant . The time until the first bowel movement was similar between the 2 groups : a mean + /- SD of 4.2 + /- 1.3 days in the nonprepared group as compared with a mean + /- SD of 4.3 + /- 1.1 days in the prepared group ( P = NS ) . Four patients ( 1.2 % ) died in the postoperative course owing to acute myocardial infa rct ion and pulmonary embolism . Sixty-two patients ( 37.6 % ) of the non-MBP group suffered from postoperative complications as compared with 77 patients ( 46.9 % ) of the MBP group . CONCLUSION Our results suggest that no advantage is gained by preoperative MBP in elective colorectal surgery BACKGROUND Guidelines regarding bowel preparation exist for the adult but not the pediatric population . Our aim was to evaluate the bowel preparation practice s , including antibiotic usage for elective colorectal operations in children . METHODS A survey was design ed and administered to a nationwide group of pediatric surgeons to ascertain current practice s of bowel preparation . RESULTS Four hundred ninety-three surveys were administered , and 136 physicians responded ( 28 % ) .  Mechanical bowel preparation was used by 96 % of the respondents . Preoperative  intravenous antibiotics  were used by 99 % of respondents . The number of years in practice did not significantly affect the use of oral antibiotics  ( P = .62 ) or the duration of intravenous antibiotics  ( P = .78 ) . CONCLUSIONS There is a wide variation in bowel preparation practice s in children . A prospect i ve , r and omized trial would be helpful to identify the role of oral antibiotics and optimal duration of intravenous antibiotics in this population INTRODUCTION The utility of a preoperative mechanical bowel preparation prior to bowel surgery has recently been question ed . The purpose of this study is to compare the perioperative outcomes between patients undergoing cystectomy with urinary diversion with or without preoperative mechanical bowel preparation .  METHODS Seventy patients underwent radical cystectomy and urinary diversion between May 2008 and August 2009 for bladder cancer . The first cohort of patients ( n = 37 ) underwent cystectomy and diversion during the period May 2008-December 2008 and underwent a preoperative mechanical bowel preparation including a clear liquid diet , magnesium citrate solution , and an enema before surgery . The second cohort of patients underwent surgery  during the period of January 2009-August 2009 ( n=33 ) . These patients were given a regular diet before surgery and did not undergo a mechanical bowel preparation except for the enema before surgery was performed to decrease rectal/colonic distention . Outcome measures included gastrointestinal and overall complications , and perioperative outcomes including recovery of bowel function . RESULTS There were no differences with regard to recovery of bowel function , time to discharge , or overall complication rates between the 2 groups . More specifically , the rate of GI complications was not different in prepped patients vs. nonprepped patients ( 22 % vs. 15 % ; P = 0.494 ) . There were no occurrences of bowel anastomotic leak , fistula , abscess , peritonitis , or surgical site infection in either group . One perioperative death occurred in the nonprepped group secondary to cardiovascular complications . CONCLUSIONS Preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion does not demonstrate any significant advantage in perioperative outcomes , including gastrointestinal complications . Further studies aim ed at measuring patient satisfaction and larger r and omized trials will be beneficial in evaluating the role of mechanical bowel preparation prior to urinary diversion Flexible fiberoptic colonoscopy is an established diagnostic procedure in the pediatric patient . The approach to the pediatric patient is , however , different from the approach to adults . Bowel preparation must be geared to the age , size , and clinical status of the patient . An effective , palatable , st and ardized bowel preparation has not been determined for the child undergoing a colonoscopy . This study systematic ally evaluated three components of the bowel preparation -- cathartics , diet , and enema use . The bowel preparation of 140 children undergoing colonoscopy at The Children 's Hospital of Philadelphia was evaluated . The effectiveness of the bowel preparation was evaluated by direct visualization during the colonoscopy as to the amount and consistency of the residual stool in the colon . Parents were interviewed to determine adherence to the instructions including tolerance of diet , cathartics , and enema administration . Equipment maintenance was also monitored . An effective bowel preparation was achieved in all groups . As a result of this study , the Division of Gastroenterology and Nutrition at The Children 's Hospital of Philadelphia now uses a less restrictive diet , one enema , and X-Prep to achieve effective bowel preparation for colonoscopy AIM In this r and omized prospect i ve clinical study , we aim ed to evaluate the effect of mechanical bowel preparation ( MBP ) before Milligan-Morgan hemorrhoidectomy on intraoperative procedures and postoperative complication rates to determine whether MBP is adventageous or not before elective anorectal surgeries . METHODS Forty patients who had internal grade III or IV hemorrhoidal disease and who would underwent open hemorrhoidectomy were r and omized into two groups : non-MBP group ( female : male , 11:9 ; mean age , 33.8±9.57 years ) that would not receive MBP before the surgery , and MBP group ( female : male , 12:8 ; mean age , 34.7±11.37 years ) that would be given one Fleet enema on the morning of Milligan-Morgan hemorrhoidectomy . Intraoperative variables and postoperative complications were compared between two groups . RESULTS MPB had no effect on both intraoperative and postoperative variables , such as operating time , intraoperative bleeding , visual analogue scale ( VAS ) score for the comfort of the surgeon during operation , the presence of stool or enema remnants in anal canal , the presence of mucosal edema of the anal canal intraoperatively , the rates of postoperative bleeding and infection , VAS score for the pain on third day postoperatively , time to first stool after the operation , VAS score for the pain during first stool after the operation , and number of analgesics during one week postoperatively ( P>0.05 for all ) . CONCLUSION MBP performed before surgery does not provide introperative or postoperative benefit for Milligan-Morgan hemorrhoidectomy , thus MBP is not necessary before elective anorectal surgeries To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery , 186 patients undergoing elective left colonic or rectal resection were r and omized before surgery to bowel preparation ( n = 89 ) or no bowel preparation ( n = 97 ) . Surgical technique was st and ardized and no patient had a defunctioning colostomy . Seventeen patients were excluded ( seven with preparation , ten without ) . Indications for surgery in the remaining 169 patients were carcinoma ( 133 patients ) , diverticular disease ( 26 ) , inflammatory bowel disease ( six ) and miscellaneous conditions ( four ) . Operations performed were left colonic resection or reversal of Hartmann 's procedure ( 26 with preparation , 28 without ) and anterior resection ( 56 versus 59 ) . The overall morbidity rate ( 18 per cent ) was similar in the two groups . All seven clinical anastomotic leaks occurred after low anterior resection , in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not ( P>0·9 ) . Two deaths occurred , both of patients who had received bowel preparation , one being secondary to anastomotic leakage .  Bowel preparation does not influence outcome after elective colorectal surgery OBJECTIVE : To compare surgeons ' intraoperative surgeon acceptability or assessment of the operative field regarding bowel contents and patients ' satisfaction with or without a mechanical bowel preparation before reconstructive vaginal prolapse surgery . METHODS : In this single-blind , r and omized trial , women scheduled to undergo vaginal prolapse surgery with a planned apical suspension and posterior colporrhaphy were allocated using block r and omization to an intervention or control group . Surgeons were blinded to patient allocation . One day before surgery , mechanical bowel preparation instructions consisted of a clear liquid diet and two self-administered saline enemas ; the participants in the control group sustained a regular diet and nothing by mouth after midnight . The primary outcome was surgeons ' intraoperative assessment of the surgical field regarding bowel content as measured on a 4-point Likert scale ( 1 , excellent ; 4 , poor ) . Secondary outcomes included participant satisfaction and bowel symptoms . The primary outcome was determined by intention-to-treat analysis and other analyses were per protocol . RESULTS : Of the 150 women r and omized ( 75 women to intervention and control group ) , 145 completed the study . No differences existed in the demographic , clinical , and intraoperative characteristics between groups ( P>.05 ) . Surgeons ' intraoperative assessment rating was 85 % “ excellent or good ” with bowel preparation compared with 90 % for participants in the control group ( odds ratio [ OR ] 0.59 , 95 % confidence interval [ CI ] 0.21–1.61 ; P=.30 ) . The bowel preparation group was less likely to report “ complete ” satisfaction compared with the participants in the control group ( OR 0.11 , 95 % CI 0.04–0.35 ; P<.001 ) . Abdominal fullness and cramping , fatigue , anal irritation , and hunger pains were greater in the bowel preparation group ( all P<.01 ) . CONCLUSION : Before reconstructive vaginal surgery , mechanical bowel preparation conferred no benefit regarding surgeons ' intraoperative assessment of the operative field , reflected decreased patient satisfaction , and had increased abdominal symptoms . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT01431040 . LEVEL OF EVIDENCE : Objective : To assess with a single-blinded , multicenter , r and omized trial , the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation ( MBP ) .  Background : The collective evidence from literature strongly suggests that MBP , before elective colonic surgery , is of no benefit in terms of postoperative morbidity . Very few data and no r and omized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP . Methods : From October 2007 to January 2009 , patients scheduled for elective rectal cancer sphincter-saving resection were r and omized to receive preoperative MBP ( ie , retro grade enema and oral laxatives ) or not . Primary endpoint was the overall 30-day morbidity rate . Secondary endpoints included mortality rate , anastomotic leakage rate , major morbidity rate ( Dindo III or more ) , degree of discomfort for the patient , and hospital stay . Results : A total of 178 patients ( 103 men ) , including 89 in both groups ( no-MBP and MBP groups ) , were included in the study . The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group , 44 % versus 27 % , P = 0.018 , and 34 % versus 16 % , P = 0.005 , respectively . Regarding both anastomotic leakage and major morbidity rates , there was no significant difference between no-MBP and MBP group : 19 % versus 10 % ( P = 0.09 ) and 18 % versus 11 % ( P = 0.69 ) , respectively . Moderate or severe discomfort was reported by 40 % of prepared patients . Mortality rate ( 1.1 % vs 3.4 % ) and mean hospital stay ( 16 vs 14 days ) did not differ significantly between both groups . Conclusions : This first r and omized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate . Thus , it suggests continuing to perform MBP before elective rectal resection for cancer . This study is registered with clinical trials.gov , number NCT00554892
Conclusion Based on the current literature , there is insufficient evidence to indicate that the use of MBP leads to a significant difference in the risk of developing infectious complications in pediatric colorectal surgery
Objectives To evaluate whether the application of mechanical bowel preparation ( MBP ) before colorectal surgery reduces the risk of developing infectious complications in children .