Review Article

Preoperative Mechanical Bowel Preparation for Abdominal, Laparoscopic, and Vaginal Surgery: A Systematic Review Amy Arnold, MBBS, BSc*, Lucy P. Aitchison, and Jason Abbott, BMed(Hons), FRANZCOG, FRCOG, PhD From the Royal Hospital for Women (Dr. Arnold), Department of Gynaecological Surgery (Dr. Abbott), and University of New South Wales (Ms. Aitchison), Randwick, New South Wales, Australia.

ABSTRACT Study Objective: Mechanical bowel preparation (MBP) continues to be widely used in gynecologic surgery, with the aim of reducing postoperative complications and improving the viewing and handling conditions in the surgical field. It is reported that MBP is an unpleasant patient experience and may be associated with adverse effects such as dehydration and electrolyte imbalance. This review evaluates the use of preoperative MBP compared with no MBP in adult patients undergoing open abdominal, laparoscopic, or vaginal surgery. Although the focus is on the use of MBP for gynecologic procedures, data from other surgical areas are covered when relevant. Design: A comprehensive search of the databases Medline (from 1946), EMBASE (from 1947), PubMed, Cochrane Library Central (Register of Controlled Trials), and Google Scholar was performed to identify any randomized controlled trials (RCTs) and prospective or retrospective cohort studies comparing preoperative MBP to no MBP. Results: Forty-three studies were identified in various surgical specialties, of which there were 5 RCTs in gynecology. The gynecologic studies reported no benefit for MBP in operative time or improved surgical field of view but did report a more unpleasant patient experience when MBP is used. RCTs from colorectal and urologic surgery were powered for infectious morbidity and anastomotic leak and did not demonstrate improved patient outcomes when MBP was used. Conclusion: Evidence from high-quality trials reports no or few benefits from MBP or rectal enema across surgical specialties. In the field of gynecologic surgery, high-quality evidence supports the view that MBP may be safely abandoned. Journal of Minimally Invasive Gynecology (2015) -, -–- Ó 2015 AAGL. All rights reserved. Keywords:

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Bowel preparation; Surgery; Gynaecology; Laparoscopy

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Mechanical bowel preparation (MBP), including oral or rectal solutions, before surgery has been widely used in many surgical specialties since the 1970s [1–3]. By reducing fecal contents, MBP is theoretically thought to reduce bacterial load and subsequent peritoneal contamination, An unrestricted Australian Gynaecological Endoscopy and Surgery Society (AGES) society educational grant was given to partly fund this project (to Dr. Arnold). Presented in part at the annual meeting of the AAGL, November 17– 24,2014. Corresponding author: Amy Arnold, MBBS, BSc, Royal Hospital for Women, Barker St., Randwick, NSW, Australia. E-mail: [email protected] Submitted March 16, 2015. Accepted for publication April 2, 2015. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2015.04.003

should there be inadvertent bowel entry, with reduced postoperative complications such as anastomotic or surgical site leak or infection. In addition, for minimally invasive gynecologic procedures, MBP is hypothesized to optimize surgical field of view and ease of bowel handling [4], potentially resulting in shorter surgical times. Although there are theoretical advantages, MBP may require preoperative hospitalization, is an unpleasant patient experience [5–7], and may cause dehydration and electrolyte disturbance [8–13]. Studies have been performed in major surgical specialties evaluating the use of MBP. Highquality evidence does not support the use of MBP [14]. Despite these data, surveys in the fields of gynecologic and colorectal surgery report a high percentage of surgeons still routinely use bowel preparation [15–18].

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Previous studies have been specialty specific in evaluating the use of MBP. Outcomes are applicable to all specialties, however, and may be broadly classified as (1) surgeon outcomes, such as surgical field and bowel handling; (2) operative outcomes, such as intraoperative complications and operative times; and (3) patient outcomes, such as postoperative complications, overall morbidity, and duration of postoperative hospital stay. This systematic review evaluates the studies performed on MBP and assesses the outcomes for each of these categories. Evidence from all surgical specialties is assessed and, where possible, applied to make recommendations for gynecologic surgery. Methods A comprehensive search of the databases Medline (from 1946), EMBASE (from 1947), PubMed, Cochrane Library Central (Register of Controlled Trials), and Google Scholar was performed to identify any randomized controlled trials (RCTs) and prospective or retrospective cohort studies comparing preoperative MBP with no MBP. MBP was defined as any oral or liquid preparation taken at least 24 hours before surgery. This was compared with no additional preparation apart from dietary restrictions, preoperative fasting, or a single sodium phosphate enema on the day of rectal surgery to avoid extrusion of stool when using a transanally inserted stapling device. MESH terms were combined with key words: bowel preparation, preoperative bowel preparation, mechanical bowel preparation, bowel cleansing AND laparotomy [MeSH term explode], laparoscop* [MeSH term explode], colorectal surgery [MeSH term explode], urolog* [Mesh Term explode], gynecolog* OR gynaecolog* [MeSH Term explode]. The search included all articles up to June 2014. Additionally, the reference lists of published articles were handsearched, and any additional studies identified were included in the review. Articles to be included in the systematic review were identified according to the PRISMA process [19] outlined in Figure 1 [20–51]. Two reviewers independently reviewed the titles and abstracts of the articles for relevance and then retrieved the full text article to confirm eligibility, according to the inclusion and exclusion criteria outlined in Table 1. Journal articles were independently assessed and assigned a quality of evidence grade score based on the Grading or Recommendations Assessment, Development and Evaluation (GRADE) System [52]. The grading system was rated as high, moderate, low, or very low. Complications were graded according to the Clavien-Dindo grading system [53]. Results Forty-three studies fitting the inclusion criteria and meeting no exclusion criteria were identified: 38 studies

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comparing MBP with no preparation and 5 studies comparing MBP with a single rectal enema. Details of the individual studies, including the number of patients, type of surgery, type of bowel preparation used, the statistically significant results, and the grade of evidence are summarized in Tables 2 and 3. For gynecologic surgery, 4 RCTs were identified. Laparoscopic surgery was studied in 4 of these studies, with a total of 645 patients [6,7,55,64], and 1 study of 150 patients was performed on vaginal prolapse [54]. Two studies compared MBP with no MBP [55,64], 1 study compared bowel preparation with 7-day low-fiber diet [6], and 1 study compared no bowel preparation, 2-day low-residue diet, and 2-day low-residue diet in combination with MBP [7]. From other surgical specialties, 23 studies met the inclusion criteria in colorectal surgery comparing MBP with no MBP: 13 RCTs (4932 patients) [57,59–63,65–71], 2 prospective cohort studies (418 patients) [72,74], and 8 retrospective cohort studies (5141 patients) [75,78,81,83– 86,89]. All studies included only elective surgery; however, they were heterogeneous in the types of surgery performed (ileocolic, colocolic, and colorectal) and mode of surgery (laparoscopic or open surgery, or combination of both). For urology, 2 RCTs with total of 126 patients [56,58], 1 prospective cohort study of 62 patients [73], and 2 retrospective cohort studies of 363 patients [80,88] evaluating the use of MBP before radical cystectomy and ileal conduit surgery were identified. Three other studies were found in urology: a retrospective cohort of 2740 patients undergoing laparoscopic nephrectomy [76], a retrospective cohort study on laparoscopic prostatectomy [77], and a retrospective case control study of 151 radical prostatectomy patients where rectal injury occurred [79]. Additionally, 2 retrospective cohort studies reported on 560 patients undergoing thoracic surgery, either unilateral or bilateral thoracotomy [87], and 200 patients undergoing pancreaticoduodenectomy [82]. Furthermore, 5 studies evaluated the use of MBP to a single rectal enema as the comparator group [90–94]. In the studies comparing MBP with no MBP, only the 5 high GRADE studies in gynecology (a total of 795 patients) included assessment of the operative field [6,7,54,55,64] as an outcome. Only 1 of these reported any difference in the surgeon’s rating of the intraoperative field, with MBP in conjunction with low-fiber diet found to have minimal but statistically better surgical views (p , .01) and bowel handling (p 5 .04) by visual analogue scale [7] that was not reproduced on a verbal descriptor scale of the visual field. In a separate high GRADE blinded study [55], surgeons were only able to correctly guess the allocation of the patient approximately 50% of the time, indicating that MBP has minimal impact on the surgical view. In 16 studies [6,7,54,55,58,61,64,66,68,70,72,73,76,77, 80,87] the impact of MBP on duration of surgery was evaluated. Of these studies, only 1 study found a

Arnold et al.

Review of MBP in Gynecologic Surgery

3

Fig. 1 Search strategy and results of studies comparing MBP with no MBP or single rectal enema [19].

significant reduction in operating time from MBP (138 vs 178 minutes, p 5 .017) [72], and 1 moderate quality study [76] found a longer operative time in the group receiving MBP (278 6 94 vs 268 6 121 minutes, p , .004); however, this was not significant on multivariate analysis (p 5 .257). Intraoperative blood loss was examined by 2 high-quality studies [54,55], with no significant difference in blood loss between groups. Patient outcomes that were measured included rate of anastomotic leak, infectious complications (sepsis, surgical site infection, intra-abdominal abscess, peritonitis), length of hospital stay, time to first stool movement, patient discomfort, cardiorespiratory complications, overall morbidity, and mortality. Among the high-quality studies evaluating patient complications, 3 studies (total 490 colorectal patients) found

increased complications from MBP [59,62,66], which included increased rates of anastomotic dehiscence (p 5 .05) [62], increased infectious abdominal complications (p 5 .028) [66], and overall surgical infectious complications (20% vs 11.3%, p 5 .05) [59]. The complications were not subcategorized according to the Clavien-Dindo classification system. Across surgical specialties, only 2 studies reported improved outcomes when using MBP. A high-quality study reported a reduced 30-day morbidity rate (p 5 .018) and infectious complication rate (p 5 .018) without a significant difference in the rate of grade III or higher Clavien-Dindo complications (p 5 .69) [57], and a moderate-quality study found a reduced rate of surgical site infection (5% vs 9.7%, p 5 .0001) and organ space infection (1.6% vs 3.1%, p 5 .024) in patients receiving full MBP [78].

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Table 1 Study selection criteria Inclusion criteria  Randomized controlled trials, clinical control trials, cohort studies, case control studies  Adult human population undergoing surgery  Comparison of use of mechanical bowel preparation versus no mechanical bowel preparation in abdominal (open or laparoscopic) and vaginal surgery  Comparison of use of mechanical bowel preparation versus single rectal enema in abdominal (open or laparoscopic) and vaginal surgery  Measurement of clinical outcomes Exclusion criteria  Articles in a language other than English where no translation was available  Mechanical bowel preparation for colonoscopies or imaging purposes  Studies not comparing mechanical bowel preparation with a control group  Studies measuring only nonclinical outcomes

Length of hospital stay was assessed in 26 studies [6,57– 61,63–70,72–77,79,80,82,83,85,88,89] and 4 studies reported longer hospital stay in patients receiving MBP [66,83,85,88]. The remaining studies reporting no difference between the groups. Of the 5 studies comparing the use of MBP to a rectal enema [90–94], 2 studies reported worse patient outcomes with a single enema [92,93]. A high-quality study of 294 patients reported increased intra-abdominal fecal soiling (p 5 .008) in the enema group, and the surgeons believed that bowel preparation was more likely to be inadequate in this group (25% compared with 6%, p , .05). There was no statistical difference in the incidence of anastomotic leak between these groups; however, there was higher reoperation rate in the enema-only group (6 [4.1%] vs 0, p 5 .013) where leakage was diagnosed [92]. A low GRADE study of 149 patients favored the use of full bowel preparation, finding that although the mortality, anastomotic leakage, frequency of reoperations, and length of hospital stay were comparable for the 2 groups, the overall but poorly defined postoperative morbidity (p 5 .003), specifically wound infections (p 5 .041), was higher in the enema group [93]. Three highquality studies comparing full MBP with a single rectal enema reported significantly higher patient discomfort with full MBP [90–92]. Apart from this, none of the 5 studies found any benefit from rectal enema over full MBP. Six high-quality studies analyzed the impact of MBP on pre- and postoperative patient symptoms such as nausea, weakness, abdominal distention, and overall patient satisfaction. Five of these reported a significant increase in patient discomfort when MBP was administered [6,7,54,60,64]. Other patient factors that were evaluated were rates of prolonged ileus or time to first stool and time to resume

normal diet [6,7,54–56,58,59,61,64–67,69,70,73,80,83,88]. The only difference between groups was in 2 separate studies that found a higher incidence of diarrhea (p 5 .0003) in the MBP group [63] and a slower return to normal diet (3.9 vs 3.5 days, p 5 .004) and first bowel movement (3.9 vs 2.5 days, p 5 .001) [66]. Discussion It is imperative that any intervention administered to patients should only occur when there is clear evidence of a beneficial effect. MBP has been given routinely before gynecologic and other abdominal surgery for many decades; however, theories for its use are not proven by high-quality scientific studies. Nearly half of all gynecologic surgeons routinely order MBP and cite the most common reasons for use as improved visualization and decreased risk of anastomotic leak, despite the bowel not being routinely entered at this type of surgery [18]. These data suggest a significant concern by gynecologists of the small but extremely serious risk of inadvertent bowel injury during surgery for benign procedures. With complicated bowel injuries often requiring resection and reanastomosis, anastomotic leakage is considered an important morbidity to avoid by all surgical specialties. There are no gynecologic studies powered to address this outcome; however, evidence from colorectal studies suggests no benefit from preoperative bowel preparation in either decreasing anastomotic leakage or infectious complications [59–63,65–67,69– 72,74,75,81,83–86]. Furthermore, by altering fecal consistency, use of MBP has the potential to increase peritoneal contamination, although this has not been shown to significantly increase the risk of infections [69]. Open abdominal procedures are increasingly less common in gynecology (and other surgical specialties), as minimally invasive surgery by conventional laparoscopy and robotic-assisted approaches confer many benefits for the patient. Seven studies have evaluated the use of MBP in laparoscopic-only surgery (4 gynecologic [6,7,55,64], 3 urologic [76,77], and 1 colorectal surgery [86]). In laparoscopic procedures, fecal loading and distended loops of bowel have the potential to compromise the surgeon’s view, particularly in the deep pelvic space, making the operation potentially more difficult and prolonged. Only 1 study in gynecologic laparoscopy [7] reported an improvement in the surgical field of view in the group receiving MBP. However, this was a difference of 1 point on a 10-point Likert scale, which is likely to have little clinical significance. Additionally, when the field of view was rated verbally on a scale of excellent to poor, there was no significant difference in the verbal ratings allocated by the surgeons between the groups, indicating MBP does not have any clinical advantage. In this study, more than 80% of patients in all 3 groups received ratings of good or excellent for surgical field of view, and there was no statistical difference between the groups that received a rating of a poor surgical field.

Arnold et al.

Table 2 RCTs and prospective and retrospective cohort studies included comparing MBP with no MBP

RCTs Ballard 2014 [54]

Siedhoff 2014 [55]

Won 2013 [7]

Hashad 2012 [56]

No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

High Decreased patient satisfaction in MBP group Increased abdominal fullness, cramping, fatigue, anal irritation and hunger pains in the MBP group High No difference in postoperative constipation or patient rating of symptoms (cramps, hunger, bloating, embarrassment, weakness, dizziness, thirst, nausea, incontinence, constipation) Increased insomnia in no MBP High No difference in complications Increased patient symptoms in MBP group (headache, thirst, weakness, tiredness, overall discomfort) by VAS No difference in anxiety by VAS Low No significant difference in postoperative complications, rates or prolonged ileus

150 (75/75)

Vaginal prolapse

Clear diet, saline enema !2

No difference in assessment of surgical field

No difference in operative time or blood loss

146 (73/73)

Laparoscopic hysterectomy

Sodium phosphate enema the night before surgery All patients clear fluids 24 hr preoperatively

No difference in assessment of surgical field

No difference in operative time and estimated blood loss

3 groups: fasting alone/liquid diet for 2 days preop and clear fluids day before surgery/ liquid diet for 2 days preop and oral sodium picosulfate !2 the day before surgery 3-day preparation Day 1: liquid diet, oral bisacodyl Day 2: liquid diet, castor oil, normal saline enema Day 3: liquid diet, castor oil, saline enema

Better surgical view with minimal residue diet and MBP

No difference in operative time

N/A

N/A

254 (87 MBP, Benign gynecologic laparoscopy 84 minimal residue only, 86 fasting only)

40 (20/20)

Radical cystectomy urinary diversion

GRADE

Review of MBP in Gynecologic Surgery

Study

(Continued )

5

6

Table 2 Continued

Study

No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

No difference in length of hospital stay or overall anastomotic leakage rate Significantly higher 30-day morbidity in no MBP Significantly higher infectious complications in no MBP No difference in postoperative ileus, wound infection, anastomotic leak, sepsis, mortality, or length of hospital stay No difference in surgical infectious complication rate, clinical anastomotic leak, days to first bowel movement, length of hospital stay Higher overall infectious complication rate in the MBP group Increased patient preoperative discomfort (nausea, vomiting, abdominal pain) in MBP group No difference in anastomotic leak, wound infections, or length of hospital stay Abdominal distension and overall discomfort more frequent in MBP group No difference in postoperative pain, nausea, abdominal swelling, length of ileus, and postoperative hospital stay

High

Bretagnol 2010 [57] 178 (89/89)

Sphincter-saving rectal resection

120 mg (1 or 2) Senna solution with 1 L of povidone iodine enema

N/A

No significant difference in intraoperative fecal spillage

Xu 2010 [58]

Radical cystectomy and ileal diversion

Fleet phosphosoda for 2 days All patients fluid diet for 24 hr preoperative

N/A

No difference in operative time

Polyethylene glycol 12–16 hr before surgery

N/A

N/A

Scabini 2010 [59]

86 (47/39)

244 (120/124) Elective colorectal surgery with primary anastomosis

60 (29/31)

Elective left colon and rectal surgery

Mannitol every 6 hr and enema every 6 hr on day before surgery Enema given to patients in no MBP group if planned for rectal surgery

N/A

N/A

Lijoi 2009 [6]

83 (41/42)

Benign gynecologic laparoscopy

4 doses of 58.32 g polyethylene glycol and 5.69 g sodium sulfate, 1.69 g sodium bicarbonate, 1.46 g sodium chloride, .74 g potassium chloride dissolved in 1 L of water per dose the day before surgery vs low fiber diet for 7 days

No difference in grading of surgical field

No difference in operative time

High

High

High

(Continued )

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Balbaa 2010 [60]

High

Arnold et al.

Table 2 Continued

Contant 2007 [61]

No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

1354 (670/684) Elective colorectal resections and primary anastomoses

2–4 L of polyethylene glycol lavage in combination with bisacodyl or sodium phosphate with fluid diet day before operation

N/A

No difference in operative time, incidence of fecal contamination

High

3 L of polyethylene glycol plus conventional enemas over 24 hr

N/A

N/A

Polyethylene glycol or sodium phosphate or enema

N/A

N/A

Oral sodium phosphate

No difference in No difference in operative time grade of operative field and surgical difficulty

2.4 g monobasic sodium phosphate and .9 g dibasic sodium phosphate 1 day before surgery

N/A

No difference in infectious complications but patients with MBP had fewer abscesses after anastomotic leak No difference in rate of anastomotic leak, length of hospital stay, or resumption to normal diet No difference in surgical site infection Increase in anastomotic dehiscence in patients with MBP No difference in cardiovascular complications, infective complications, length of hospital stay No difference in postoperative pain or length of hospital stay Significant discomfort from MBP No difference in length of hospital stay, infectious complications, ileus, abdominal/pelvic collections, and pulmonary complications

Pena Soria 2007 [62] 97 (48/49)

Jung 2007 [63]

Elective colorectal surgery with primary intraperitoneal anastomosis

1343 (686/657) Elective colorectal surgery

Muzii 2006 [64]

162 (81/81)

Benign gynecologic laparoscopy

Ram 2005 [65]

329 (164/165) Elective large bowel resection

N/A

High

Review of MBP in Gynecologic Surgery

Study

High

High

Moderate

(Continued )

7

8

Table 2 Continued

Study

No. patient (MBP/no MBP) Type of surgery

Surgeon findings

Operation findings

3 L of polyethylene glycol 12–16 hr before surgery

N/A

4 L of polyethylene glycol

N/A

High Longer hospital stay and time to first bowel movement and return to normal diet in MBP group Higher overall rate of complications (anastomotic leak, intra-abdominal abscess, peritonitis, wound infection) in MBP group Higher rate of extraabdominal complications in the MBP group (bronchopneumonia, cardiac, sepsis, UTI, cerebral embolism) High N/A No difference in anastomotic leak, wound infection, length of hospital stay, duration of ileus High No difference in No difference in wound operative time infection and dehiscence or length of hospital stay High Spillage of fecal content No difference in infectious much more frequent in complications, anastomotic leak, overall complications, the MBP group days to first bowel movement, length of hospital stay Increased diarrhea in the MBP group High No difference in No difference in operating time anastomotic leak, time to first stool, surgical site infection, length of hospital stay (Continued )

153 (78/75)

Fasi Oen 2005 [67]

250 (125/125) Elective colorectal surgery

Terzi 2005 [68]

N/A Sodium phosphate solution !2 doses and rectal enema on morning of procedure N/A 1 gallon of polyethylene glycol 380 (187/193) Elective colorectal 12–16 hr before surgery resection with primary All patients undergoing rectal anastomosis surgery were given a single Fleet enema on the day of surgery

Zmora 2003 [69]

Pilonidal sinus

Miettinen 2000 [70] 267 (138/129) Elective colorectal surgery

Sodium picosulfate electrolyte solution

N/A

Patient findings

GRADE

No difference in operative time

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Bucher 2005 [66]

108 (52/56)

Elective left-sided colorectal surgery

Method of bowel preparation

Arnold et al.

Table 2 Continued No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

Elective colorectal surgery with primary anastomoses

Sodium picosulfate 10 mg

N/A

N/A

No difference in morbidity rate (anastomotic leak, wound sepsis, cardiorespiratory failure)

High

No difference in length of hospital stay, anastomotic leak No statistical difference in wound infections, anastomotic leak, ileus, mortality, length of hospital stay, or time to oral diet

Low

Burke 1994 [71]

169 (82/87)

Prospective Kolovrat 2012 [72]

85 (46/39)

Elective colorectal surgery

136 g polyethylene glycol and 2 L of water

N/A

Decreased operation time in MBP

Tabibi 2007 [73]

62 (30/32)

Radical cystectomy and urinary diversion

3-day preparation Day 1: soft liquid diet, oral bisacodyl Day 2: soft liquid diet, castor oil !2, normal saline enema until clear Day 3: soft liquid diet, castor oil !2 doses, normal saline enema until clear 1 gallon polyethylene glygcol 1 day before surgery

N/A

No difference in operative time

MBP associated with residual liquid bowel contents

No difference in spillage of bowel contents

Polyethylene glycol evening before surgery

N/A

polyethylene glycol, magnesium citrate, or sodium picosulfate At least one of the following: polyethylene glycol, magnesium citrate, sodium picosulfate

N/A

Low No difference in 30-day postoperative complication rate, infectious morbidity, or length of hospital stay No difference in postoperative Moderate No difference in complications or length operating time on of hospital stay multivariate analysis Low No difference in On multivariate operative time analysis, no difference in overall complications or length of hospital stay (Continued )

Mahajna 2005 [74]

Retrospective Otchy 2014 [75]

333 (181/152) Elective colorectal surgery

165 (86/79)

Elective abdominal colorectal surgery

Sugihara 2014 [76] 2220 (1110/1110)Laparoscopic nephrectomy Sugihara 2013 [77]

734 (580/154) Laparoscopic radical prostatectomy

N/A

No difference in median length of postoperative antibiotic treatment and surgical infectious and noninfectious complications

Low

Review of MBP in Gynecologic Surgery

Study

Low

N/A

9

10

Table 2 Continued

Study Kim 2013 [78]

No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

2475 (1363/1112)Elective colectomy

Polyethylene glycol or sodium phosphate

N/A

N/A

Lower rates of surgical site infection (organ space, superficial and overall), and C. difficile colitis in MBP group No difference in deep incisional SSI No difference in complications, colostomy formation, length of hospital stay, or total cost No difference in Clavien grade III complications, length of hospital stay, and time until normal diet No difference in anastomotic leak, intra-abdominal abscess, and fistula formation, MI, DVT, and PE No difference in perioperative outcomes and length of hospital of stay No difference in anastomotic leak, wound infection, and abdominal collection Longer mean diet resume time in MBP group Shorter hospital stay in the no MBP group Higher incidence of surgical site infection with MBP

Moderate

Sugihara 2014 [79]

151 (73/78)

Radical prostatectomy

Polyethylene glycol, magnesium citrate, or sodium picosulfate

N/A

N/A

Large 2012 [80]

180 (105/75)

Radical cystectomy and ileal conduit

4 L Golytely solution on the day before surgery, both groups liquid diet for 24 hr preop Unspecified

N/A

No difference in operative time

N/A

N/A

Nicholson 2011 [81] 1730 (1460/270) Elective (potentially curable) surgery for colon cancer

200 (100/100) Pancreaticoduodenetomy Sodium phosphate solution day before surgery, clear fluids in both groups

N/A

N/A

Pitot 2009 [83]

186 (127/59)

Elective colorectal with anastomosis

4 L polyethylene glycol Patients scheduled for tran-anally inserted stapling device had one phosphate enema on the day of surgery

N/A

N/A

Howard 2009 [84]

136 (15/121)

Elective colorectal resection

Unspecified

N/A

N/A

Low

Low

Low

Low

Low

(Continued )

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Lavu 2010 [82]

Low

Arnold et al.

Table 2 Continued No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

Bretagnol 2007 [85] 113 (61/52)

Rectal cancer resection and sphincter preservation

Senna solution (X-PREP sarget) 1 or 2 120-mg package with water 24 hr before surgery and 1 L polvidone-iodine enema the evening before and the morning of the surgery

N/A

N/A

Low

Zmora 2006 [86]

Laparoscopic colectomy

1 gallon polyethylene glycol or 2 doses of 45 mL sodium phosphate All patients undergoing rectal surgery were given a single Fleet enema on the day of surgery Oral sennosid night before surgery 1/2 glycerin enema the day of surgery

N/A

N/A

Higher morbidity in MBP with higher rate of extra-abdominal complications No difference in anastomotic leak Longer hospital stay in MBP No difference in postoperative complication rate, anastomotic leak, or infection rate

N/A

No difference in operative time

Low

N/A

N/A

No difference in feeding and bowel movement, abdominal complications, morbidity, or mortality No difference in wound infection, fistula, and anastomotic dehiscence Increased anastomotic dehiscence in MBP group Prolonged postoperative ileus and length of hospital stay in MBP group Slower return to commence oral fluids in the MBP group

200 (68/132)

Yamazaki 2004 [87] 560 (280/280) Thoracotomy, sternotomy

Shafii 2002 [88]

86 (64/22)

Radical cystectomy and ileal diversion

Low-residue diet and 30 mL castor oil 4 days before surgery, water enema 2 days before surgery, and clear fluid only, rectal washouts until clear 1 day before surgery

Low

Review of MBP in Gynecologic Surgery

Study

Very low

(Continued )

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DVT 5 deep vein thrombosis; MI 5 myocardial infarction; N/A 5 not applicable; PE 5 pulmonary embolism; SSI 5 surgical site infection; UTI 5 urinary tract infection; VAS 5 visual analog scale.

Low No difference in incidence of wound infection, wound dehiscence, abdominal or pelvic collections, anastomotic breakdown, and length of hospital stay N/A N/A Phosphate enemas 1/2 rectal washout or phosphate enemas 1/2 Picolax or Picolax alone or oral polyethylene glycol lavage or oral saline lavage 1/2 rectal washout or stoma to rectal saline washout Elective left-sided colorectal procedures 136 (61/75) Memon 1997 [89]

Study

Continued

Table 2

No. patient (MBP/no MBP) Type of surgery

Method of bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

12

The impact of MBP on the surgical field of view seems to remain minimal regardless of whether diagnostic or more challenging laparoscopies are performed. Although most studies in gynecology specifically excluded patients with severe endometriosis, in the high-quality study that included endometriosis resection, MBP still did not offer any significant benefit in optimizing the surgical field, reflected by similar length of procedures and no difference in intraoperative complications. The patient experience is an important aspect of variation in clinical practice. MBP is unpleasant for the patient to endure [5–7]. Patients undergoing MBP have reported significantly higher levels of weakness, abdominal distension, nausea/vomiting, and hunger/thirst, with 90% of patients in 1 study reporting symptoms as moderate or intense [91]. Use of rectal enemas has reduced patient discomfort compared with MBP, but there is no convincing evidence that rectal enemas confer any advantages in nonrectal surgery. Overall patient satisfaction is reported to be lower when bowel preparation is used. Economic costs have not been evaluated at this time; however, because preadmission may be required to administer MBP to patients who are elderly, have comorbidities, or live remotely, additional nursing and medical costs may substantially increase overall healthcare costs. Colorectal surgery differs from gynecologic procedures in that bowel resection and reanastomosis is the norm and colorectal procedures are often performed for malignancy. Despite the evidence regarding a lack of benefit from MBP in improved patient outcomes, a high percentage of colorectal surgeons still routinely use MBP [15–17]. Their preference may now be supported by a recent study reporting on a 10-year follow-up of a cohort of patients randomized to receive MBP or no MBP while undergoing colonic resection for colorectal cancer. Although not statistically significant, there was a higher incidence of cancer recurrence in the group that did not receive MBP (22.5% vs 17.9%, p 5 .093) [95]. Cancerspecific survival was statistically worse in the patients who had omission of MBP (78% vs 84.1%, p 5 .019). However, overall survival was not different between the groups (58.8% vs 56%, p 5 .186). There are no data available on long-term outcomes for patients undergoing bowel resection for urologic malignancy and limited data for gynecologic malignancy. Currently, data only support a cancer-specific improvement but no overall survival improvement when MBP is used, with further data required to establish these parameters more precisely. Although there may be groups not been identified specifically in the 20 RCTs to date (e.g., the morbidly obese, certain cancers), the burden of evidence is to prove an advantage in these groups, because data at this time do not support its usedeven when bowel surgery is routine. Evidence from nonrandomized data reports that for gynecologic oncology patients, omitting routine MBP led to reduced hospitalization and no increase in morbidity [96].

Arnold et al.

Table 3 Studies comparing MBP to rectal enema No. patient (MBP/enema)

Type of surgery

Bowel preparation

Surgeon findings

Operation findings

Patient findings

GRADE

Yang 2011 RCT [90]

145 (68/65)

Benign gynecologic laparoscopy

No difference in evaluation of surgical field or ease of bowel handling

N/A

Significantly higher patient discomfort in MBP

High

Moral 2008 [91] RCT

140 (69/71)

Bowel surgery with colocolic or colorectal anastomosis, including 15 laparoscopic cases

Higher rate of liquid feces in MBP

No difference in operative time

No statistical difference in rates of rates of wound infection and anastomotic dehiscence Higher level of patient discomfort in group receiving MBP

High

Platell 2006 [92] RCT

294 (147/147)

Elective colorectal surgery with anastomosis Exclude laparoscopic procedures

Comparison of oral sodium phosphate with single sodium phosphate enema Comparison of phosphosoda and polyethylene glycol day before surgery to cleansing enema at 2100 hr the day before surgery and again 2 hr before surgery Comparison of 3 L of polyethylene glycol vs single phosphate enema

Surgeons rated quality of bowel preparation worse after enema

Increased fecal soiling after enema

High

Veenhof 2007 [93] Prospective cohort

149 (71/78)

Elective colorectal surgery

Comparison of polyethylene glycol vs single phosphosoda enema

N/A

N/A

Radical Cystectomy and urinary diversion

Clear liquids for 24 hr before surgery, oral magnesium citrate plus enema 2 hr before surgery vs enema only 2 hr before surgery

N/A

No difference in operative time or estimated blood loss

No difference in overall anastomotic leak rate Increased severity of anastomotic leakage in enema group requiring reoperation No difference in infectious complications Higher rates of nausea and discomfort in polyethylene glycol group Higher postoperative morbidity in enema group Higher wound infections in enema group Higher intra-abdominal infections in enema group No difference in anastomotic leak rate or length of hospital stay No difference in postop complications, length of stay, time to first bowel movement or flatus

Raynor 2013 [94] Retrospective cohort

70 (37/33)

Review of MBP in Gynecologic Surgery

Study and type

Low

Low

13

Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015

14

Conclusion MBP is an unpleasant and invasive patient experience. Substantial high-quality evidence now exists from gynecologic surgery that MBP does not improve the surgical field of view in minimally invasive procedures or improve patient outcome. From extrapolation of high GRADE colorectal studies, there is no evidence that using MBP confers any benefit if inadvertent bowel injury occurs or if resection and reanastomosis is required. There should now be a requirement to prove efficacy for using MBP in specific patient groups rather than on an historical basis. Therefore, in the absence of any benefit and with the potential for harm, the evidence suggests that routine use of MBP or rectal enemas should now be discarded as a preoperative treatment for patients undergoing gynecologic surgery. References 1. Stearns MW Jr, Schottenfeld D. Techniques for the surgical management of colon cancer. Cancer. 1971;28:165–169. 2. Nichols RL, Condon RE. Preoperative preparation of the colon. Surg Gynecol Obstet. 1971;132:323–337. 3. Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal microflora following preoperative mechanical preparation of the colon. Dis Colon Rectum. 1971;14:123–127. 4. Muzii L, Angioli R, Zullo M, et al. Bowel preparation for gynecological surgery. Crit Rev Oncol Hematol. 2003;48:311–315. 5. Jung B, Lannerstad O, Pahlman L, et al. Preoperative mechanical preparation of the colon: the patient’s experience. BMC Surg. 2007;7:5. 6. Lijoi D, Ferrero S, Mistrangelo E, et al. Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon blind, randomized and controlled trial. Arch Gynecol Obstet. 2009;280:713–718. 7. Won H, Maley P, Salim S, et al. Surgical and patient outcomes using mechanical bowel preparation before laparoscopic gynecologic surgery: a randomized controlled trial. Obstet Gynecol. 2013;121: 538–546. 8. Ezri T, Lerner E, Muggia-Sullam M, et al. Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance. Can J Anaesth. 2006;53:153–158. 9. Keighley MR. A clinical and physiological evaluation of bowel preparation for elective colorectal surgery. World J Surg. 1982;6:464–470. 10. Ambrose NS, Keighley MR. Physiological consequences of orthograde lavage bowel preparation for elective colorectal surgery: a review. J R Soc Med. 1983;76:767–771. 11. Okada M, Bothin C, Kanazawa K, et al. Experimental study of the influence of intestinal flora on the healing of intestinal anastomoses. Br J Surg. 1999;86:961–965. 12. Barker P, Trotter T, Hanning C. A study of the effect of Picolax on body weight, cardiovascular variables and haemoglobin concentration. Ann R Coll Surg Engl. 1992;74:318–319. 13. Yoshioka K, Connolly AB, Ogunbiyi OA, et al. Randomized trial of oral sodium phosphate compared with oral sodium picosulphate (Picolax) for elective colorectal surgery and colonoscopy. Dig Surg. 2000;17: 66–70. 14. Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2011;CD001544. 15. Businger A, Grunder G, Guenin M-O, et al. Mechanical bowel preparation and antimicrobial prophylaxis in elective colorectal surgery in Switzerlandda survey. Langenbecks Arch Surg. 2011;396:107–113. 16. Drummond RJ, McKenna RM, Wright DM. Current practice in bowel preparation for colorectal surgery: a survey of the members of the As-

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31. 32.

33.

34.

35.

36.

sociation of Coloproctology of GB, Ireland. Colorectal Dis. 2011;13: 708–710. Zmora O, Wexner SD, Hajjar L, et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons. Am Surg. 2003;69:150–154. Wells T, Plante M, McAlpine JN. Preoperative bowel preparation in gynecologic oncology: a review of practice patterns and an impetus to change. Int J Gynecol Cancer. 2011;21:1135–1142. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8:336–341. Reddy BS, Macfie J, Gatt M, et al. Randomized clinical trial of effect of synbiotics, neomycin and mechanical bowel preparation on intestinal barrier function in patients undergoing colectomy. Br J Surg. 2007; 94:546–554. Sasaki J, Matsumoto S, Kan H, et al. Objective assessment of postoperative gastrointestinal motility in elective colonic resection using a radiopaque marker provides an evidence for the abandonment of preoperative mechanical bowel preparation. J Nippon Med Sch. 2012; 79:259–266. Kale TI, Kuzu MA, Tekeli A, et al. Aggressive bowel preparation does not enhance bacterial translocation, provided the mucosal barrier is not disrupted: a prospective, randomized study. Dis Colon Rectum. 1998; 41:636–641. Watanabe M, Murakami M, Nakao K, et al. Randomized clinical trial of the influence of mechanical bowel preparation on faecal microflora in patients undergoing colonic cancer resection. Br J Surg. 2010;97: 1791–1797. Bucher P, Gervaz P, Egger JF, et al. Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery: a randomized trial. Dis Colon Rectum. 2006;49:109–112. Jung B, Matthiessen P, Smedh K, et al. Mechanical bowel preparation does not affect the intramucosal bacterial colony count. Int J Colorectal Dis. 2010;25:439–442. Mardini S, Chen HC, Salgado CJ, et al. Bowel preparation before microvascular free colon transfer for head and neck reconstruction: is it necessary? Plast Reconstr Surg. 2004;113:1916–1922. Ahmad M, Abbas S, Asghar MI. Is mechanical bowel preparation really necessary in colorectal surgery? J Coll Physicians Surg Pak. 2003;13: 637–639. Vlot EA, Zeebregts CJ, Gerritsen JJ, et al. Anterior resection of rectal cancer without bowel preparation and diverting stoma. Surg Today. 2005;35:629–633. Jansen JO, O’Kelly TJ, Krukowski ZH, et al. Right hemicolectomy: mechanical bowel preparation is not required. J R Coll Surg Edinb. 2002; 47:557–560. Harris LJ, Moudgill N, Hager E, et al. Incidence of anastomotic leak in patients undergoing elective colon resection without mechanical bowel preparation: our updated experience and two-year review. Am Surg. 2009;75:828–833. Irving AD, Scrimgeour D. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surg. 1987;74:580–581. Ciga M, Oteiza F, Fernandez L, et al. Comparative study of one-stage colectomy of the descending colon in emergency and elective surgery without mechanical preparation. Dis Colon Rectum. 2010;53: 1524–1529. Van Geldere D, Fa-Si-Oen P, Noach LA, et al. Complications after colorectal surgery without mechanical bowel preparation. J Am Coll Surg. 2002;194:40–47. Lins-Neto MA, Leao MJ, Alves EC, et al. Colon mechanical preparation is necessary as routine in medical care? Arq Bras Cir Dig. 2012; 25:25–28. Duthie GS, Foster ME, Price-Thomas JM, et al. Bowel preparation or not for elective colorectal surgery. J R Coll Surg Edinb. 1990;35: 169–171. Eskicioglu C, Gagliardi A, Fenech DS, et al. Can a tailored knowledge translation strategy improve short term outcomes? A pilot study to

Arnold et al.

37.

38. 39.

40.

41.

42.

43. 44.

45.

46.

47.

48.

49.

50.

51.

52.

53. 54.

55.

56. 57.

58.

Review of MBP in Gynecologic Surgery

increase compliance with bowel preparation recommendations in general surgery. Surgery. 2011;150:68–74. Barker K, Graham NG, Mason MC, et al. The relative significance of preoperative oral antibiotics, mechanical bowel preparation, and preoperative peritoneal contamination in the avoidance of sepsis after radical surgery for ulcerative colitis and Crohn’s disease of the large bowel. Br J Surg. 1971;58:270–273. Le TH, Timmcke AE, Gathright JB Jr, et al. Outpatient bowel preparation for elective colon resection. South Med J. 1997;90:526–530. O’Connell JR, Johnson DE, Rather J, et al. Rapid preoperative bowel preparation for patients undergoing radical cystectomy. Urology. 1983;21:245–247. Santos JC Jr, Batista J, Sirimarco MT, et al. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg. 1994;81:1673–1676. Casperson KJ, Fronczak CM, Siparsky G, et al. Ventriculoperitoneal shunt infections after bladder surgery: is mechanical bowel preparation necessary? J Urol. 2011;186:1571–1575. Smith JT, Smith MS. Does a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study. J Pediatr Orthop. 2013;33:e69–e71. Tahirkheli MUIS, Iqbal RA. Anastomotic leak in preparated versus unprepared bowel. Gomal J Med Sci. 2013;11:5. Arumainayagam N, McGrath J, Jefferson KP, et al. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008; 101:698–701. Arnspiger RC, Helling TS. An evaluation of results of colon anastomosis in prepared and unprepared bowel. J Clin Gastroenterol. 1988; 10:638–641. Brownson PJ, Nott D, Ellenbogen S. Mechanical bowel preparation before colorectal surgery: results of a prospective randomised trial. Br J Surg. 1992;79:2. Burke P, Mealy KG, Traynor O, et al. Anastomotic dehiscence in colorectal surgery: is bowel preparation still relevant? Int J Colorectal Dis. 1993;8:239. Zmora O, Mahajna A, Bar-Zakai B, et al. Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial. Tech Coloproctol. 2006;10:131–135. Van’t Sant HP, Slieker JC, Hop WCJ, et al. The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis. Tech Coloproctol. 2012;16:309–314. van’t Sant HP, Weidema WF, Hop WC, et al. Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation. Am J Surg. 2011;202:321–324. Van’t Sant HP, Weidema WF, Hop WCJ, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg. 2010;251:59–63. Atkins D, Best D, Briss PA, et al. GRADE Working Group. Grading quality of evidence and strength of recommendations. Br Med J. 2004;328:1490. Dindo DDN, Clavien PA. Classification of surgical complications. Ann Surg. 2004;240:9. Ballard AC, Parker-Autry CY, Markland AD, et al. Bowel preparation before vaginal prolapse surgery: a randomized controlled trial. Obstet Gynecol. 2014;123:232–238. Siedhoff MT, Clark LH, Hobbs KA, et al. Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2014;123:562–567. Hashad MM, Atta M, Elabbady A, et al. Safety of no bowel preparation before ileal urinary diversion. BJU Int. 2012;110:E1109–E1113. Bretagnol F, Panis Y, Rullier E, et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial. Ann Surg. 2010;252:863–868. Xu R, Zhao X, Zhong Z, et al. No advantage is gained by preoperative bowel preparation in radical cystectomy and ileal conduit: a randomized controlled trial of 86 patients. Int Urol Nephrol. 2010;42:947–950.

15 59. Scabini S, Rimini E, Romairone E, et al. Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial. World J Surg Oncol. 2010;8:35. 60. Balbaa MASH, El-Sisy A, Abdel-Latif M, Zeid N. Non mechanical bowel preparation for elective left sided colorectal cancer surgery. Egypt J Surg. 2010;29:5. 61. Contant CM, Hop WC, van’t Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet. 2007;370:2112–2117. 62. Pena-Soria MJ, Mayol JM, Anula R, et al. Single-blinded randomized trial of mechanical bowel preparation for colon surgery with primary intraperitoneal anastomosis. J Gastrointest Surg. 2008;12:2103–2108. discussion 2108–2109. 63. Jung B, Pahlman L, Nystrom PO, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg. 2007;94:689–695. 64. Muzii L, Bellati F, Zullo MA, et al. Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril. 2006;85:689–693. 65. Ram E, Sherman Y, Weil R, et al. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg. 2005;140:285–288. 66. Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective leftsided colorectal surgery. Br J Surg. 2005;92:409–414. 67. Fa-Si-Oen P, Roumen R, Buitenweg J, et al. Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum. 2005;48:1509–1516. 68. Terzi C, Canda AE, Unek T, et al. What is the role of mechanical bowel preparation in patients with pilonidal sinus undergoing surgery? Prospective, randomized, surgeon-blinded trial. World J Surg. 2005;29: 1465–1471. 69. 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. 70. Miettinen RP, Laitinen ST, Makela JT, et al. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum. 2000;43:669–675. discussion 675–667. 71. Burke P, Mealy K, Gillen P, et al. Requirement for bowel preparation in colorectal surgery. Br J Surg. 1994;81:907–910. 72. Kolovrat M, Busic Z, Lovric Z, et al. Mechanical bowel preparation in colorectal surgery. Coll Antropol. 2012;36:1343–1346. 73. Tabibi A, Simforoosh N, Basiri A, et al. Bowel preparation versus no preparation before ileal urinary diversion. Urology. 2007;70:654–658. 74. Mahajna A, Krausz M, Rosin D, et al. Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum. 2005;48:1626–1631. 75. Otchy DP, Crosby ME, Trickey AW. Colectomy without mechanical bowel preparation in the private practice setting. Tech Coloproctol. 2014;18:45–51. 76. Sugihara T, Yasunaga H, Horiguchi H, et al. Does mechanical bowel preparation improve quality of laparoscopic nephrectomy? Propensity score-matched analysis in Japanese series. Urology. 2013;81:74–79. 77. Sugihara T, Yasunaga H, Horiguchi H, et al. Is mechanical bowel preparation in laparoscopic radical prostatectomy beneficial? An analysis of a Japanese national database. BJU Int. 2013;112:E76–E81. 78. Kim EK, Sheetz KH, Bonn J, et al. A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Ann Surg. 2014;259:310–314. 79. Sugihara T, Yasunaga H, Horiguchi H, et al. Does mechanical bowel preparation ameliorate damage from rectal injury in radical prostatectomy? Analysis of 151 rectal injury cases. Int J Urol. 2014;21: 566–570. 80. Large MC, Kiriluk KJ, DeCastro GJ, et al. The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion. J Urol. 2012;188:1801–1805.

16 81. Nicholson GA, Finlay IG, Diament RH, et al. Mechanical bowel preparation does not influence outcomes following colonic cancer resection. Br J Surg. 2011;98:866–871. 82. Lavu H, Kennedy EP, Mazo R, et al. Preoperative mechanical bowel preparation does not offer a benefit for patients who undergo pancreaticoduodenectomy. Surgery. 2010;148:278–284. 83. Pitot D, Bouazza E, Chamlou R, et al. Elective colorectal surgery without bowel preparation: a historical control and case-matched study. Acta Chir Belg. 2009;109:52–55. 84. Howard DD, White CQ, Harden TR, et al. Incidence of surgical site infections postcolorectal resections without preoperative mechanical or antibiotic bowel preparation. Am Surg. 2009;75:659–663. discussion 663–654. 85. Bretagnol F, Alves A, Ricci A, et al. Rectal cancer surgery without mechanical bowel preparation. Br J Surg. 2007;94:1266–1271. 86. Zmora O, Lebedyev A, Hoffman A, et al. Laparoscopic colectomy without mechanical bowel preparation. Int J Colorectal Dis. 2006;21: 683–687. 87. Yamazaki K, Takeo S, Maehara Y. Preoperative mechanical bowel preparation unnecessary in patients undergoing thoracic surgery. Jpn J Thorac Cardiovasc Surg. 2004;52:407–410. 88. Shafii M, Murphy DM, Donovan MG, et al. Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion? BJU Int. 2002;89:879–881.

Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015 89. Memon MA, Devine J, Freeney J, et al. Is mechanical bowel preparation really necessary for elective left sided colon and rectal surgery? Int J Colorectal Dis. 1997;12:298–302. 90. Yang LC, Arden D, Lee TT, et al. Mechanical bowel preparation for gynecologic laparoscopy: a prospective randomized trial of oral sodium phosphate solution vs single sodium phosphate enema. J Minim Invasive Gynecol. 2011;18:149–156. 91. Moral MAA, Junca JB, Lopez LM, et al. A prospective randomised, controlled study on the need to mechanically prepare the colon in scheduled colorectal surgery. Cirurg Espanola. 2009;85:6. 92. Platell C, Barwood N, Makin G. Randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery. Br J Surg. 2006;93:427–433. 93. Veenhof AA, Sietses C, Giannakopoulos GF, et al. Preoperative polyethylene glycol versus a single enema in elective bowel surgery. Dig Surg. 2007;24:54–57. discussion 57–58. 94. Raynor MC, Lavien G, Nielsen M, et al. Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion. Urol Oncol. 2013;31:32–35. 95. Collin A, Jung B, Nilsson E, et al. Impact of mechanical bowel preparation on survival after colonic cancer resection. Br J Surg. 2014;101: 1594–1600. 96. Carter J. Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN Surg. 2012;2012:368014.