Best practices in bowel preparation for colorectal surgery: a 2020 overview

ABSTRACT

Introduction

Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted.

Areas covered

This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed.

Expert opinion

The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.

KEYWORDS:

• Bowel preparation
• oral antibiotics preparation
• mechanical bowel preparation
• colorectal surgery
• morbidity
• surgical site infection

Article highlights

• The data of meta-analyses were concordant in favor of the no-MBP strategy in colonic surgery, but no such firm conclusion can be made in rectal surgery.

• The American ACS NSQIP cohort studies have reloaded the debate around bowel preparation.

• Conflicting guidelines have been published, with American guidelines promoting the association of mechanical bowel preparation (MBP) and oral antibiotics (OAB) in colorectal surgery, whereas other countries promote no preparation.

• One recent randomized controlled trial failed to show a benefit of MBP + OAB compared to no preparation in terms of surgical site infection (SSI).

• Another recent randomized controlled trial showed a benefit of OAB alone compared to no preparation (and MBP + OAB compared to MBP in sigmoid and rectal surgery) in terms of SSI.

• Recent meta-analyses are in favor of OAB alone in terms of overall SSI, organ space infection and wound infection.

• Large randomized trials are currently ongoing and may change these conclusions.

• Microbiota is a future lead for an à-la-carte antibiotics preparation.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper is not funded.