Article
Reference
Should preoperative mechanical bowel preparation be abandoned?
BUCHER, Pascal Alain Robert, GERVAZ, Pascal, MOREL, Philippe
BUCHER, Pascal Alain Robert, GERVAZ, Pascal, MOREL, Philippe. Should preoperative
mechanical bowel preparation be abandoned? Annals of Surgery , 2007, vol. 245, no. 4, p. 662
DOI : 10.1097/01.sla.0000259047.43665.04 PMID : 17414618
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http://archive-ouverte.unige.ch/unige:34693
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L
ETTERS TO THEE
DITORShould Preoperative Mechanical Bowel
Preparation Be Abandoned?
To the Editor:
M
echanical bowel preparation (MBP) before elective colorectal surgery is still considered a standard practice by many surgical associations.1However, the results of 7 randomized studies2– 8 have clearly demonstrated the safety of colorec- tal surgery without MBP. In addition, an- other study has recently shown that MBP could be associated with an increased risk of abdominal septic complications after colo-colic or high colorectal anastomo- ses.9Having incorporated the data of re- cently published randomized trials,9 –11we report herein the results of an updated meta-analysis12,13and discuss its implica- tions for the clinical practice.The present meta-analysis included 10 randomized trials, which enrolled a total of 1983 patients (986 with MBP and 997 without MBP); statistical analyses were performed according to the Fleiss approach.14Anastomotic leaks were more frequent in the MBP group (5.1% vs.
2.6%, odds ratio关OR兴 ⫽1.99; 95% con- fidence interval 关CI兴, 1.23–3.23; P ⫽ 0.004). Wound infections were more fre- quent in the MBP group (8.2% vs. 5.5%, OR ⫽ 1.54; 95% CI, 1.08 –2.2; P ⫽ 0.015). The rate of relaparotomy was higher in the MBP group (5.5% vs. 3.2%, OR⫽1.76; 95% CI, 1.03–3.02;P⫽0.035).
A trend toward increased incidence of intra- abdominal abscesses, as well as extradiges- tive complications, was also observed in the MBP group. Finally, 2 studies reported on hospital stay duration, which was signifi- cantly longer in the MBP group.9,11
As the evidence-based data con- tinue to accumulate suggesting that MBP before colorectal surgery is not only useless, but potentially harmful, there are two issues that remain to be elucidated: 1) what are the reasons for the deleterious effect of MPB? 2) How should these data be incorporated in the daily practice of colorectal surgeons?
While MBP seem to have little physiologic impact on colonic motility, it seems morphologically associated with in-
flammatory changes in the colonic mu- cosa, which could affect bowel wall heal- ing.15Moreover, in up to 30% of patients, MBP is inadequate and results in large amounts of liquid stools, which seems to increase the risk of intraoperative spill- age.16In many European institutions, it is now recommended to avoid MBP before elective colorectal surgery, and this ap- proach has been adopted as the new stan- dard by the French Digestive Surgical As- sociation.17 Proponents of MBP will rightfully argue that in the majority of trials polyethylene glycol was used and that no antibiotics or antiseptics were added to the solution; however, it has never been demonstrated that other types of preparation were more effective in de- creasing colorectal surgery morbidity in randomized trials.18Other will argue that MBP should be performed before surgery to facilitate palpation and detection of tu- mors, but this is true for a small proportion of patients with small polyps in which we still perform MBP before surgery.
Finally, with the recognition of fast- track perioperative management of pa- tients, it should be repeated that omission of MBP may play a role in accelerated clinical pathway of recovery after colorec- tal surgery, with a potential for decreasing in hospital costs. In 1972, Hughes stated19:
“Omission of enemas and bowel washes from the preoperative procedures will be welcomed by both patients and nursing staff.” Currently, many surgeons are not reluctant to operate on patients who did not receive MBP; this change of practice is now supported by evidence-based data and fits well with recently established clin- ical pathways of accelerated perioperative management, which could be eventually associated with a decrease in hospitaliza- tion cost.
Pascal Bucher, MD Pascal Gervaz, MD Philippe Morel, MD Department of Surgery Geneva University Hospital Geneva, Switzerland Pascal.Bucher@hcuge.ch REFERENCES
1. Guenaga K, Matos D, Castro A, et al. Me- chanical bowel preparation for elective colo- rectal surgery.Cochrane Database Syst Rev.
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2. Brownson P, Jenkins SA, Nott D, et al.
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tal surgery: results of a prospective random- ized trial.Br J Surg. 1992;79:461– 462.
3. Burke P, Mealy K, Gillen P, et al.
Requirement for bowel preparation in colorec- tal surgery.Br J Surg. 1994;81:907–910.
4. Santos JC Jr, Batista J, Sirimarco MT, et al.
Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colo- rectal surgery.Br J Surg. 1994;81:1673–1676.
5. Fillmann E, Fillmann H, Fillmann L. Elective colorectal surgery without mechanical pre- pare.Rev Bras Coloproct. 1995;15:70 –71.
6. Miettinen RP, Laitinen ST, Makela JT, et al.
Bowel preparation with oral polyethylene gly- col electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum. 2000;
43:669 – 675; discussion 675– 677.
7. Tabusso F, Zapata J, Espinoza F, et al.
Mechanical preparation in elective colorectal surgery, a useful practice or need?Rev Gas- troenterol Peru. 2002;22:152–158.
8. Zmora O, Mahajna A, Bar-Zakai B, et al.
Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial.Ann Surg. 2003;237:363–367.
9. Bucher P, Gervaz P, Soravia C, et al.
Randomized clinical trial of mechanical bowel preparation versus no preparation be- fore elective left-sided colorectal surgery.
Br J Surg. 2005;92:409 – 414.
10. Fa-si-Oen P, Roumen R, Buitenweg J, et al.
Mechanical bowel preparation of not? Out- come of a multicenter, randomized trial in elective open colon surgery.Dis Colon Rec- tum. 2005;48:1509 –1516.
11. Ram E, Sherman Y, Weil R, et al. Is mechan- ical bowel preparation mandatory for elective colon surgery? A prospective randomized study.Arch Surg. 2005;140:285–288.
12. Bucher P, Mermillod B, Gervaz P, et al.
Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surg. 2004;139:1359 –1364.
13. Bucher P, Mermillod B, Morel P, et al. Does mechanical bowel preparation have a role in preventing postoperative complications in elective colorectal surgery.Swiss Med Wkly.
2004;134:69 –74.
14. Fleiss JL. The statistical basis of meta-analy- sis.Stat M Med Res. 1993;2:121–145.
15. Bucher P, Gervaz P, Egger J, et al.
Morphologic alteration associated with me- chanical bowel preparation before elective colorectal surgery: a randomized trial. Dis Colon Rectum. 2006;49:109 –112.
16. Mahajna A, Krausz M, Rosin D, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery.Dis Co- lon Rectum. 2005;48:1626 –1631.
17. Mariette C, Alves A, Benoist S, et al. Soins perioperatoires en chirurgie digestive: recom- mendations de la Societe Francaise de Chirurgie Digestive (SFCD).J Chir. 2005;142:14 –28.
18. Slim K, Vicaut E, Panis Y, et al. Meta-analysis of randomized clinical trials of colorectal sur- gery with or without mechanical bowel prepa- ration.Br J Surg. 2004;91:1125–1130.
19. Hughes E. Asepsis in large-bowel surgery.
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Annals of Surgery • Volume 245, Number 4, April 2007
662
Prophylactic Ilioinguinal
Neurectomy in Open Inguinal Hernia Repair
To the Editor:
W
e read with great interest the ar- ticle by Mui et al.1 They re- solved that the incidence of chronic groin pain, at 6 months, was signifi- cantly lower in those patients who had prophylactic ilioinguinal neurectomy than in those patients whose ilioinguinal nerve was reserved (8% vs. 28.6%,P⫽ 0.008). The study was conducted on a total of 100 randomized patients (50 patients in each group), based on the assumption that a 20% difference in the incidence of chronic groin pain would have been meaningful.The authors began their work on the wrong assumption that the incidence of chronic pain ranges from 18% to 63%;
while analyzing a larger number of series according to the literature, it is possible to conclude that it ranges from less than 3%
to 12%2– 4 and that it decreases to less than 1% at 1 year.5In our recent report (on 973 cases of hernioplasty) about the influence of preservation versus division of all three inguinal nerves on chronic pain,5 the presence of overall (mild, moderate, and severe) groin pain at 6 months and 1 year of follow-up was 9.7% and 4.1%, respectively.
Considering these data, we think that Mui et al could argue some conclu- sion if they had, in their experience, more than a 30% of chronic pain inci- dence; in addition, considering literature
data, the study does not have substantial statistic power with only 50 patients in each group; moreover, the follow-up at 6 months is too short.
The authors also reported that the ilioinguinal nerve was identified in all patients and that there was extreme care during surgery to avoid nerve tissue in- clusion during suturing and mesh place- ment. We wonder: why did the authors decide to study just and only the ilioin- guinal nerve and not, for example, one of the other two nerves?
They do not give any data concern- ing iliohypogastric and genital nerves: Are they always identified and preserved, or are they resected? Or are they not identi- fied at all? Moreover, their results regard- ing chronic pain may be distorted because these nerves could be unintentionally di- vided or injured, during herniorrhaphy, and, for these reasons, chronic pain could be generated.
Our study, the only one in the literature that evaluates data concerning all three inguinal nerves, clearly demon- strates that pain is not reported in any case of hernia repair, with all three nerves preserved, and that the risk of developing groin pain increases with the number of nerves concomitantly not de- tected: relative risk increases from 2.2 to 19.2 if one or three nerves have not been recognized, respectively.5
Finally, to accept the assumption of Mui et al that prophylactic ilioingui- nal neurectomy should be considered as a routine surgical step during open in- guinal hernia repair, we should extend neurectomy also to the other two sen- sory inguinal nerves (the iliohypogastric and genital nerves) because both cross the inguinal canal and they may come in
contact with the mesh or with the suture.
However, we have no evidence to con- sider surgical triple neurectomy as a standard procedure during inguinal her- nia repair.
On the contrary, considering our results,5we want to emphasize the im- portance of routinely identifying and preserving all three inguinal nerves dur- ing open hernia repair, reserving neurec- tomy only in the case of unintentional nerve division or as a treatment of se- vere chronic pain after 1 year of not responding to medical therapy.
Sergio Alfieri, MD Davio Di Miceli, MD Giovanni Battista Doglietto, MD Istituto di Clinica Chirurgica Universita` Cattolica del Sacro Cuore Rome, Italy s.alfieri@rm.unicatt.it
REFERENCES
1. Mui WL, Ng CS, Fung TM, et al. Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.Ann Surg. 2006;244:27–33.
2. Lichtenstein IL, Shulman AG, Amid PK, et al.
Cause and prevention of postherniorrhaphy neuralgia: proposed protocol for treatment.
Am J Surg. 1988;155:786 –790.
3. Kark AE, Kurzer M, Waters KJ. Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit.Ann R Coll Surg Engl. 1995;77:299 –304.
4. Amid PK, Shulman AG, Lichtenstein IL. Open
‘tension-free’ repair of inguinal hernias: the Lichtenstein technique.Eur J Surg. 1996;162:
447– 453.
5. Alfieri S, Rotondi F, Di Giorgio A, et al.
Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain.Ann Surg.
2006;243:553–558.
Annals of Surgery • Volume 245, Number 4, April 2007
