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Original Article
quicksearch journal 1365-2168
Prospective study of primary
anastomosis without colonic issn British Journal of blah

lavage for patients with an 99019821

obstructed left colon
Professor V. Naraynsingh *, R. Rampaul, D. Search in this Title
Maharaj, T. Kuruvilla, K. Ramcharan, B.
Pouchet British Journal of Surgery
Department of Surgery, University of the West Enter words or phrases
Indies, General Hospital, Port-of-Spain,
Trinidad, West Indies
All Fields
Correspondence to V. Naraynsingh, Medical
*

Associates, Corner Albert and Abercromby Select a Field

Streets, St Joseph, Trinidad, West Indies
Abstract Bottom of Form

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citation blah 1365-2168
Background:
Traditionally, left-sided colon obstruction is
managed by a multistaged defunctioning Search by Citation
colostomy and resection. However, there is Vol:
growing acceptance of one-stage primary
resection and anastomosis with on-table
antegrade irrigation. This paper presents a
Issue:
series of patients managed prospectively by
primary anastomosis without intraoperative
colonic lavage.
Page:
Methods:
Emergency resection of acutely obstructed left-
sided colonic carcinomas was performed. This
was followed by primary anastomosis without
on-table lavage after bowel decompression Bottom of Form
using a new technique. Top of Form
1

Results:
Bottom of Form
Fifty-eight consecutive, unselected patients Top of Form
underwent bowel decompression, resection and quicksearch WISall
primary colocolic anastomosis. Only one
patient developed a leak at the anastomotic site, Bottom of Form
requiring pelvic abscess drainage and transverse Top of Form
loop colostomy. One death occurred 12 h SEARCH WILEY INTERSCIENCE
following surgery. Autopsy confirmed that this
was due to myocardial infarction. Mean
hospital stay was 9·8 days.
All Content
Conclusion:
Emergency surgery on the obstructed left colon Publication Titles
can be carried out safely after decompression
alone, without intraoperative colonic lavage. ©
1999 British Journal of Surgery Society Ltd Bottom of Form

Accepted: 28 May 1999 • Advanced Search

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1: Br J
Surg. 1999 Oct;86(10):1341-3.

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Comment in:

Br J Surg. 2000 Mar;87(3):376-7.

Prospective study of
primary anastomosis
without colonic lavage for
patients with an
obstructed left colon.
Naraynsingh V, Rampaul R,
Maharaj D, Kuruvilla T,
 Ramcharan K, Pouchet B.

Department of Surgery, University of

the West Indies, General Hospital, Port-
of-Spain, Trinidad.
BACKGROUND: Traditionally, left-
sided colon obstruction is managed by a
multistaged defunctioning colostomy
and resection. However, there is
growing acceptance of one-stage
primary resection and anastomosis with
on-table antegrade irrigation. This paper
presents a series of patients managed
prospectively by primary anastomosis
without intraoperative colonic lavage.
METHODS: Emergency resection of
acutely obstructed left-sided colonic
carcinomas was performed. This was
followed by primary anastomosis
without on-table lavage after bowel
decompression using a new technique.
RESULTS: Fifty-eight consecutive,
unselected patients underwent bowel
decompression, resection and primary
colocolic anastomosis. Only one patient
developed a leak at the anastomotic site,
requiring pelvic abscess drainage and
transverse loop colostomy. One death
occurred 12 h following surgery.
Autopsy confirmed that this was due to
myocardial infarction. Mean hospital
stay was 9.8 days. CONCLUSION:
Emergency surgery on the obstructed
left colon can be carried out safely after
decompression alone, without
intraoperative colonic lavage.
PMID: 10540146 [PubMed - indexed for
MEDLINE]

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About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Colon and Rectal Surgery Without Mechanical Bowel Preparation
A Randomized Prospective Trial
Oded Zmora, MD, Ahmad Mahajna, MD, Barak Bar-Zakai, MD, Danny Rosin, MD, Dan
Hershko, MD, Moshe Shabtai, MD, Michael M. Krausz, MD, and Amram Ayalon, MD
From the Departments of Surgery, Sheba Medical Center and Sackler School of Medicine, Tel
Aviv, and Rambam Medical Center and Rappaport School of Medicine, Haifa, Israel,
This article has been cited by other articles in PMC.
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
Abstract
Objective
To assess whether elective colon and rectal surgery can be safely performed without preoperative
mechanical bowel preparation.
Summary Background Data
Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at
reducing the risk of postoperative infectious complications. However, in cases of penetrating
colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not
prepared.
Methods
Patients undergoing elective colon and rectal resections with primary anastomosis were
prospectively randomized into two groups. Group A had mechanical bowel preparation with
polyethylene glycol before surgery, and group B had their surgery without preoperative
mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic,
and intra-abdominal infectious complications.
Results
Three hundred eighty patients were included in the study, 187 in group A and 193 in group B.
Demographic characteristics, indications for surgery, and type of surgical procedure did not
significantly differ between the two groups. Colo-colonic or colorectal anastomosis was
performed in 63% of the patients in group A and 66% in group B. There was no difference in the
rate of surgical infectious complications between the two groups. The overall infectious
complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic
leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%,
respectively.
Conclusions
These results suggest that elective colon and rectal surgery may be safely performed without
mechanical preparation.
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
In the first half of the 20th century, mortality from colon and rectal surgery often exceeded 20%,
1
mainly attributed to sepsis. Modern surgical techniques and improved perioperative care have
significantly lowered the mortality rate. Infectious complications, however, still are a major
cause of morbidity in colorectal surgery, leading to increased cost, prolonged hospital stay, and
occasional mortality. 2
Mechanical bowel preparation is aimed at cleaning the large bowel of fecal content, thereby
reducing the rate of infectious complications following surgery. Traditionally, bowel cleansing
was achieved using enemas in combination with oral laxatives. 3 More recently, oral cathartic
agents to induce diarrhea and cleanse the bowel from solid feces were developed. These new
bowel preparation agents, such as polyethylene glycol and sodium phosphate, provide superior
cleansing compared to the more traditional methods 4–6 and are used by most surgeons in
preparation for colorectal surgery. 7–9 The practice of bowel cleansing before colorectal surgery
has became a surgical dogma, and primary colonic anastomosis is considered unsafe in the face
of an unprepared bowel. There is, however, a paucity of data showing that mechanical bowel
preparation by itself, separately from other operative and perioperative measures, actually
reduces the rate of infectious complications.
In urgent colon surgery for penetrating trauma, recent studies have shown that primary colonic
anastomosis is safe even though mechanical bowel preparation is not performed before surgery.
10,11
These data therefore may bring into question the utility of mechanical bowel preparation in
elective colon and rectal surgery.
The aim of this study was to assess whether elective colon and rectal surgery may be safely
performed without preoperative mechanical bowel preparation.
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
METHODS
Patients undergoing elective colon and rectal surgery with primary anastomosis in two
university-affiliated departments of surgery between 1997 and 2000 were prospectively
randomized by individual computer-generated randomization into two groups. Patients in Group
A (the “prep” group) received mechanical bowel preparation with one gallon of polyethylene
glycol 12 to 16 hours before surgery, and Group B (the “non-prep” group) had no preoperative
mechanical bowel preparation. All patients were allowed to have a regular diet until midnight the
evening before surgery (patients in the prep group usually took their mechanical preparation after
the last solid meal). All of the patients received preoperative oral antibiotics (three doses of
neomycin and erythromycin), and perioperative broad-spectrum intravenous antibiotics, which
were continued for at least 24 hours postoperatively. Surgeons were allowed to continue the
prophylactic intravenous antibiotics for more then 1 day, and the length of prophylactic treatment
was recorded.
Patients undergoing rectal surgery were given one Fleet enema (C.B. Fleet Inc., Lynchburg, VA)
on the day of surgery to avoid extrusion of stool when using a transanally inserted stapling
device.
Patients with tumors smaller than 2 cm were excluded from the study, as palpation of small
tumors may be difficult in an unprepared bowel, and these patients may require intraoperative
colonoscopy to identify these lesions. Patients who required a diverting stoma proximal to the
anastomosis and those who were found to have an abdominal abscess at the time of surgery were
also excluded from the data analysis.
The study was approved by the Institutional Review Board (Helsinki committee), and all patients
gave their informed consent before randomization in the study.
Data relative to patients’ demographic and clinical characteristics, operative procedures and
findings, and 30-day postoperative follow-up were prospectively entered in a Microsoft Access
database, and main endpoints entry was rechecked for accuracy. The main outcome was the rate
of postoperative infectious complications, such as wound infection, anastomotic leak, and intra-
abdominal abscess. Wound infection was defined as a wound requiring partial or complete
opening for drainage of purulent collection, or erythema requiring initiation of antibiotic
treatment. Anastomotic leak was identified if demonstrated by imaging or documented in
surgery, or if fecal drainage was evident through a perianastomotic drain. Abdominal abscess
was defined as fluid collection demonstrated by computed tomography scan, in conjunction with
elevated temperature or white blood cell count. Secondary outcomes were the overall rate of
complications and the quality of bowel preparation as assessed by the operating surgeon.
Statistical analysis was performed using the Fisher exact test or unpaired t test, as appropriate
(GraphPad InStat, San Diego, CA), and probability values of less than 0.05 were considered
significant.
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
RESULTS
Four hundred fifteen patients were entered into the study between July 1997 and July 2000.
Twenty-nine patients were excluded after randomization due to the intraoperative exclusion
criteria (18 had abdominoperineal resection and 11 had a proximal stoma). Six patients withdrew
their consent before surgery, leaving 380 patients for the data analysis. One hundred eighty-
seven patients had their surgery with preoperative mechanical bowel preparation, while 193 did
not have mechanical preparation. Demographic characteristics, indications for surgery, and type
of surgery did not significantly differ between the two groups (Table 1

). Nearly two thirds of the patients in both groups had surgery with colo-colonic, colorectal, or
coloanal anastomosis (63% in the prep group and 66% in the non-prep group). The median
length of postoperative antibiotic treatment was 2.0 days in the prep group and 2.5 days in the
nonprep group (P = NS). The distribution of length of antibiotic prophylaxis is shown in Figure 1
.
Table 1. DEMOGRAPHIC AND CLINICAL CHARACTERISTICS

Figure 1. Length of prophylactic antibiotic treatment. The bars represent the

percentage of the patients in each group. Prep, with mechanical bowel
preparation (n = 187); Non-prep, without mechanical bowel preparation (n =
193).

Solid content in the colon was found in surgery in nearly a quarter of the patients in the non-prep
group, and liquid and semiliquid contents were the most common findings in the prep group.
Spillage of bowel content during surgery was significantly more common in the prep compared
to the non-prep group (Table 2

).
Table 2. BOWEL CLEANSING ASSESSMENT

When assessing the main outcomes of this study, there was no significant difference in the rate
of postoperative wound infections, clinical anastomotic leaks, or intra-abdominal abscesses
between the prep and the non-prep group (Table 3

). The surgical infectious complications rate was 10.2% in the prep group and 8.8% in the non-
prep group. The overall complications rate was not significantly different between the two
groups (28.3% in the prep group, 28.0% in the non-prep group;Table 4
). Diarrhea in the early postoperative period was significantly more common in the prep group
compared to the non-prep group (P = .0003).
Table 3. INFECTIOUS COMPLICATIONS

Table 4. NONSURGICAL INFECTIOUS COMPLICATIONS

There was no significant difference in the average days to the first bowel movement and the
length of hospital stay between the prep group and the non-prep group (3.8 days vs. 4.2 days, and
8.2 days vs. 8.1 days, respectively).
Mortality occurred in three patients in each group (1.6% in the prep group, and 1.55% in the non-
prep group). One patient in each group died due to sepsis from an anastomotic leak. Although
none of these patients underwent an autopsy, none of the other four deaths was attributed to
surgical infectious complications (1 cardiac, 3 respiratory).
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
DISCUSSION
Preparation for elective colon and rectal surgery with mechanical cleansing and antibiotic
prophylaxis, in conjunction with improved surgical techniques and advances in perioperative
care, served to reduce the rate of infectious complications in colorectal surgery. Although
mechanical bowel preparation before elective colorectal surgery has become a surgical dogma,
there is a paucity of scientific evidence demonstrating the efficacy of this practice in reducing the
rate of infectious complications.
Whereas some animal studies have shown that mechanical preparation improved anastomotic
bursting strength 12,13 and decreased septic complications, 12 others failed to find a difference
between groups of animals with or without bowel preparation. 14 Further evidence questioning
the utility of mechanical bowel preparation in colorectal surgery comes from the literature
regarding the management of urgent cases, such as patients with penetrating colonic trauma or
acute colonic obstruction. In cases of penetrating trauma, prospective randomized studies have
shown that primary colonic anastomosis is safe 15,16 even though the colon is not prepared, the
mechanism of injury is not as controlled as in elective cases, and there is often a delay between
the injury and the repair. These studies have led to a change in the standard of care of penetrating
colonic trauma toward primary colonic repair. 10,11
In cases of acute colonic obstruction, resection with primary anastomosis in one stage is not the
common practice, as the colon is not prepared. Advanced techniques, such as on-table bowel
lavage 17,18 or colonic metallic stents, 19,20 have been used in an effort to allow mechanical bowel
cleansing before primary anastomosis. Few authors, however, have challenged the dogma that
colon resection with primary anastomosis is unsafe in patients with obstructing colon lesions.
Few series suggested that anastomosis between the small bowel and the colon, as performed in
right or subtotal colectomy, may be safe without mechanical preparation, 21,22 since this type of
anastomosis avoids the stool column proximal to the anastomosis. In a multicentric trial, 23 97
patients with malignant left colonic obstruction were randomized to have either a segmental
colon resection with on-table bowel lavage or a subtotal colectomy. The rates of intra-abdominal
sepsis and anastomotic leaks did not significantly differ between the two groups. Other authors
have suggested that colo-colonic anastomosis may also be safe in an unprepared bowel in the
face of an obstructed colon. 24–26 Recently, Naraynsingh et al. 27 reported a prospective series of
58 unselected patients with left colonic obstruction. All underwent segmental colon resection
with primary colo-colonic anastomosis, without a proximal diverting stoma. There was one case
of anastomotic leak and one mortality unrelated to infection.
Four published studies 28–31 have prospectively randomized patients undergoing elective colon
and rectal surgery to having mechanical bowel preparation or no mechanical preparation.
Although all of the prior studies are smaller in numbers then the current study, they also failed to
show a benefit to mechanical bowel preparation in reducing the rate of infectious complications
and anastomotic leaks (Table 5

).
Table 5. PROSPECTIVE RANDOMIZED SERIES ON MECHANICAL
BOWEL PREPARATION

Although the new agents used for mechanical bowel preparation such as polyethylene glycol and
sodium phosphate are strong cathartic agents, the colon is frequently not completely clean and
dry at the time of surgery. In our study, fluid or semifluid stool was found in 51.3% of the
patients of the prep group. When preparation is done for colonoscopy, liquid stool can be easily
aspirated to provide adequate cleansing for a safe and effective colonoscopy. In contrast, when
used as a preparation for surgery, it is more difficult to control liquid than solid stool, which may
lead to the significantly higher rate of intraoperative spillage of contaminated bowel content.
When mechanical bowel preparation is used, the use of a clear liquid diet before surgery, in
conjunction with the cathartic agent, may potentially improve the quality of the preparation and
reduce the rate of liquid colonic content.
Mechanical bowel preparation is not harmless. It almost invariably causes significant discomfort
to the patient, including nausea, abdominal bloating, and diarrhea. 4–6 Mechanical bowel
preparation is also associated with electrolyte imbalance and dehydration, 4,5,32–34 which may
complicate the induction of anesthesia and perioperative care. Thus, in our view, mechanical
bowel preparation should be treated as a medication and used only when indicated.
Assessing the role of mechanical bowel preparation separately from other measures used to
reduce the rate of infectious complications is a difficult task. Ideally, all the measures, including
the surgical technique, should be maintained constant, while the variable component should be
randomized into “treatment” or “no treatment” groups. Assuming an infectious complications
rate of 10%, for a prospective study that will be able to detect a difference of 5% in infection
rate, in a one-tailed statistical test, assuming an alpha level of 0.05, with a statistical power of
90%, 770 patients are required to be randomized to each group, or a total of 1,540 patients in the
study. It seems impossible for one team to enroll such a number of patients into this kind of
study in a reasonable period. Multicenter studies allow patient accrual but at the expense of
heterogeneous operative and perioperative techniques, which may be the most important factors
influencing the surgical outcome.
The results of this study strongly suggest that elective colon and rectal surgery may be safely
performed without the use of routine mechanical bowel preparation. Bowel cleansing should
therefore be used selectively—for instance, in cases where intraoperative colonoscopy is likely
to be required. Multicenter studies, with their limitation of diversity of techniques, should
provide data on the reproducibility of these results to support a change in this time-honored
surgical practice.

Footnotes
Presented at the Biennial Congress of the International Society of University Colon and Rectal
Surgeons, Osaka, Japan, April 14–18, 2002.
Correspondence: Oded Zmora, MD, Department of Surgery and Transplantation, Sheba Medical
Center, Tel-Hashomer 52621, Isreal.
E-mail: ozmora@post.tau.ac.il
Accepted for publication February 25, 2002.
Top
Abstract
METHODS
RESULTS
DISCUSSION
References
References
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