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Improved Outcomes in Colon and Rectal Surgery part 8

Improved Outcomes in Colon and Rectal Surgery part 8. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | IMPROVED OUTCOMES IN COLON AND RECTAL SURGERY The specific type of fecal diversion ileostomy versus colostomy does not influence anastomotic related outcomes. 25 MECHANICAL BOWEL PREPARATION Mechanical bowel preparation before elective resection has been surgical dogma since Halsted s description of intestinal anastomosis in 1887. Empiric-based practice relies on mechanical bowel preparation together with oral antibiotics to reduce the bacterial load of the bowel and in theory to decrease the risks of anastomotic leak and surgical site infection. Bowel preparation far from innocuous is inconvenient and unpleasant for patients and is associated with potentially harmful metabolic and fluid disturbances. For these reasons and because the purported benefits of bowel preparation remain unproven the utility of mechanical preparation has been questioned. A Cochrane review evaluating the efficacy of bowel preparation in its ability to reduce postoperative complications included 1 592 patients from nine randomized controlled trials stratified to a colectomy group and a low anterior resection group. 26 The clinical leak rate in the colectomy group with and without bowel preparation was 2.9 and 1.6 respectively p value not significant . The clinical leak rate in the low anterior resection group with and without bowel preparation was 9.8 and 7.5 respectively p value not significant . When the surgical groups were combined the 6.2 clinical leak rate in the prepared group was significantly higher than the 3.2 rate in the unprepared group p 0.003 . Meta-analysis of all other infectious complication rates including surgical site infection demonstrated no protective effect of mechanical bowel preparation. Despite significant evidence that bowel preparation before elective colorectal resection does not influence infectious complications and may actually increase the anastomotic leak rate surgical tradition and medico-legal pressure continue to heavily influence the practice of .