Mechanical Bowel Preparation for Children Undergoing Elective Colorectal Surgery Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based? Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence? Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children. Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Rectal cancer surgery without mechanical bowel preparation 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 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 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 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 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 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 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 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 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 .