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Combined Preoperative Mechanical Bowel Preparation with Oral Antibiotics Significantly Reduces Surgical Site Infection, Anastomotic Leak and Ileus After Colorectal Surgery
Ravi P Kiran*, A C Murray*, Cody Chiuzan*, David Estrada*, Kenneth A Forde
New York Presbyterian Hospital, Columbia University, New York, NY

Objective: To clarify whether bowel preparation use, or its individual components (mechanical bowel preparation (MBP) /oral antibiotics) impact specific outcomes after colorectal surgery.
Methods: 2012 National Surgical Quality Improvement Program targeted-colectomy data capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP/ABx+), MBP alone (MBP/ABx-) and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, SSI and ileus was evaluated using multivariable logistic regression analyses.
Results: Of 8,368 patients, 2403 (28.7%) had no-prep, 3700 (44.2%) MBP/ABx- and 2265 (27.1%) MBP/ABx+. Baseline characteristics were similar except prior sepsis and steroid-use, both greater in no-prep patients. MBP with or without antibiotics was associated with reduced ileus (MBP/ABx+: OR=0.57 (95%CI: 0.47-0.68), p<0.0001; MBP/ABx-: OR=0.77 (95%CI: 0.67-0.90), p<0.0001) and SSI (MBP/ABx+: OR=0.39 (95%CI: 0.32-0.48), p<0.0001; MBP/ABx-: OR=0.82 (95%CI: 0.71-0.96), p=0.011) versus no-prep. MBP/Abx+ was also associated with lower anastomotic leak than no-prep (OR=0.44 (95%CI:0.31-0.62), p<0.0001. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR=0.50 (95%CI: 0.35-0.72), p=0.0002), SSI (OR=0.41, 95%CI: 0.33-0.51, p<0.0001) and post-operative ileus (OR=0.65,95%CI: 0.54-0.79, p<0.0001).
Conclusion: These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak and ileus, the most common and troublesome complications after colorectal surgery.
Comparing No prep, MBP/ABX- and MBP/ABX+
CharacteristicsNo-Prep
(N=2403)
MBP/ABX-
(N=3700)
MBP/ABX+
(N=2265)
p-value
Age (years), median (IQR)62 (51-73)62 (52-72)62 (52-71)0.6
Sex (male), n (%)1162 (48.4)1783 (48.2)1141 (50.4)0.2
ASA class, n (%)
2
1140 (47.7)1858 (50.5)1270 (56.3)<0.0001
Total operation time
(≥180 min), n (%)
918 (38.2)1512 (40.9)929 (41.0)0.07
Laparoscopic surgery, n(%)1470 (61.2)2638 (71.3)1674 (73.9)<0.0001
SSI
(superficial/deep/organ space) n (%)
344 (14.3)446 (12.0)139 (6.1)<0.0001
Anastomotic leak, n (%)108 (4.5)132 (3.6)46 (2.0)<0.0001
Post-operative ileus, n(%)360 (15.1)445 (12.1)206 (9.1)<0.0001
30-day mortality, n (%)36 (1.5)23 (0.6)8 (0.4)0.001


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