A Chinese survey of current practice patterns of preoperative bowel preparation in colorectal surgery
Original Article

A Chinese survey of current practice patterns of preoperative bowel preparation in colorectal surgery

Hong Yu1,2#, Li Xu3#, Songcheng Yin1, Chunhong Hong1, Shaohua Yang1, Jingyao Chen1, Jianfeng Li1, Wenhui Wu1, Changhua Zhang1

1Digestive Diseases Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China; 2Department of Gastrointestinopancreatic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; 3Emergency and Disaster Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China

Contributions: (I) Concept and design: C Zhang, W Wu, H Yu; (II) Administrative support: C Zhang; (III) Provision of study materials or patients: H Yu, L Xu; (IV) Collection and assembly of data: S Yin, C Hong; (V) Data analysis and interpretation: S Yang, J Chen, J Li; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Wenhui Wu, PhD; Changhua Zhang, PhD. Digestive Diseases Center, The Seventh Affiliated of Sun Yat-sen University, Shenzhen, China. Email: doctorwusysu@126.com; zhchangh@mail.sysu.edu.cn.

Background: Bowel preparation has long been considered as the standard preoperative management for colorectal surgery. However, there are still controversies about bowel preparation and the importance of bowel preparation gradually declined.

Methods: An online 10-question anonymous survey was announced by posters to the active members who attended the 14th Chinese Academic Congress of Colorectal Surgery (CACCRS 2021) on October 15–17, 2021. The questionnaire sought information on each surgeon’s current practice of preoperative bowel preparation.

Results: A total of 384 Chinese surgeons from 26 provincial administrative regions took part in this survey. The most common reason for choosing bowel preparation was preventing surgical site infection (SSI). Meanwhile, 74.2% Chinese surgeons believed bowel preparation could avoid anastomotic leakage. Only 33.9% thought that bowel preparation was considered to reduce risk of postoperative bleeding. In terms of bowel preparation methods, 56.5% Chinese surgeons preferred to choose laxatives alone. Regarding the choices of agents, Chinese surgeons were more likely to choose polyethylene glycol-electrolyte lavage solution (PEG-ELS).

Conclusions: Surgeons choose bowel preparation mostly to avoid SSI and anastomotic leakage, and they prefer using laxatives alone. Our study shows that surgeons do not have clear guidelines that can govern their clinical practice and there are still controversies about bowel preparation. Further study is required to provide strong evidences to inform clinical and policy decisions.

Keywords: Preoperative bowel preparation; colorectal surgery; survey

Received: 21 February 2022; Accepted: 18 May 2022; Published: 30 June 2022.

doi: 10.21037/dmr-22-22

Introduction

Bowel preparation has long been considered as the standard preoperative management for colorectal surgery. A clean colon is thought to facilitate colorectal surgery manipulation, allowing the passage and firing of surgical staplers. Inadequately prepared intestinal tract is considered to be an important factor leading to poor wound healing and postoperative infection, namely surgical site infection (SSI). Among all elective surgeries, colorectal surgery has the highest incidence of SSI, with a recent review showing rates ranging from 5.4% to 23.2% (1).

The method and practice of bowel preparation including mechanical bowel preparation (MBP) and oral antibiotics preparation (OAP) vary differently. MBP refers to the use of oral laxatives and enema to reduce intestinal contents preoperatively, so as to provide a relatively clean intestinal cavity for the surgery, decrease intraluminal bacterial concentration and reduce postoperative infections. OAP refers to the prophylactic use of antibiotics before surgery for the reduction of the bacterial load of the whole body and intestines, so as to reduce the incidence of postoperative infections and other complications.

After the enhanced recovery after surgery (ERAS) concept was proposed, the importance of bowel preparation gradually declined. A multicenter randomized trial of 1,354 patients found that it was reasonable to safely perform colorectal surgery without MBP (2). Some meta-analyses concluded that MBP can be safely omitted in colon surgery (3), even increase the risk of SSI (4). On the other hand, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) indicated that the combined use of MBP and OAP was associated with a significantly lower incidence of postoperative complications compared with the use of other bowel preparation strategies (5).

The view on whether the preoperative bowel preparation is necessary remains inconclusive, how surgeons manage bowel preparation in the real life clinical practice may be beneficial to the renewal of ideas. The aim of this study is to describe the current attitudes and practice patterns of preoperative bowel preparation among Chinese surgeons. We present the following article in accordance with the SURGE reporting checklist (available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-22/rc).

Methods

An online 10-question anonymous survey was announced by posters to the active members who attended the 14th Chinese Academic Congress of Colorectal Surgery (CACCRS 2021) on October 15–17, 2021 (Appendix 1). We distributed the questionnaire by Wenjuanxing web-application (https://www.wjx.cn/). The participants could complete the questionnaire during the meeting. No incentives were offered to obtain the survey results. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Medical Ethics Committee of The Seventh Affiliated Hospital of Sun Yat-sen University (No. KY-2020-024-01) and individual consent for this cross-sectional survey was waived. The questionnaire sought information on each surgeon’s current practice of preoperative bowel preparation. In the questionnaire, we collected demographic information, including gender, age, working experience, medical specialty, hospital setting, department volume and monthly number of operations. In terms of bowel preparation, we investigated the reasons for bowel preparation, the methods of preoperative bowel preparation and the choices of agents in the participants’ practice. Among the reasons, we provided options such as preventing SSI, avoiding anastomotic leakage, and reducing risk of postoperative bleeding. Options of bowel preparation methods include using laxatives, enema, OAP and their combinations. We also asked for information on the choices of laxatives, regarding polyethylene glycol-electrolyte lavage solution (PEG-ELS), sodium phosphate (NaP), magnesium sulfate (MgSO4) and mannitol.

We analyzed the data statistically based on the responses obtained. All statistical analyses were performed using STATA version 12.0. Only P value <0.05 was considered statistically significant.

Results

Demographics

A total of 384 Chinese surgeons from 26 provincial administrative regions took part in this survey. The relevant demographic characteristics of the participants are presented in Table 1. Of the 384 participants, 311 (81.0%) were male surgeons. Most of them were between the ages of 40–50 (46.4%), had more than 20 years working experience (62.5%) and worked in general surgery (38.0%). Most of the hospitals were general hospitals (95.3%) and 52.6% department had less than 50 beds. Among the surgeons, 60.9% performed less than 100 operations per month.

Table 1

Characteristics of surgeons

Characteristics Number Percent (%)
Gender
   Male 311 81.0
   Female 73 19.0
Age
   <40 years 84 21.8
   40–50 years 178 46.4
   >50 years 122 31.8
Working experience
   <10 years 35 9.1
   10–20 years 109 28.4
   >20 years 240 62.5
Medical specialty
   Gastrointestinal surgery 110 28.7
   Anorectal surgery 128 33.3
   General surgery 146 38.0
Hospital setting
   General 366 95.3
   Specialized 18 4.7
Department volume
   <50 202 52.6
   50–100 142 37.0
   101–150 22 5.7
   >150 18 4.7
Operations per month
   <100 234 60.9
   100–200 122 31.8
   >200 28 7.3

Bowel preparation reasons, methods and agents

Table 2 shows bowel preparation reasons, methods and agents. The most common reason for choosing bowel preparation was preventing SSI (312/384, 81.3%). Meanwhile, 74.2% Chinese surgeons believed bowel preparation could avoid anastomotic leakage. Only 33.9% thought that bowel preparation was considered to reduce risk of postoperative bleeding (Figure 1).

Table 2

Bowel preparation reasons, methods and agents

Answers Number Percent (%)
Reasons (multiple choice)
   Preventing SSI 312 81.3
   Avoiding anastomotic leakage 285 74.2
   Reducing risk of postoperative bleeding 130 33.9
   Other 61 15.9
Methods (single choice)
   Laxatives 217 56.5
   Laxatives and oral antibiotics 46 12.0
   Laxatives, oral antibiotics and enema 79 20.6
   Enema 30 7.8
   Oral antibiotics 2 0.5
   Other 10 2.6
Agents (multiple choice)
   PEG-ELS 349 90.9
   Mannitol 24 6.3
   NaP 26 6.8
   MgSO4 11 2.9
   Other 19 4.9

SSI, surgical site infection; PEG-ELS, polyethylene glycol-electrolyte lavage solution; NaP, sodium phosphate; MgSO4, magnesium sulfate.

Figure 1 Bowel preparation reasons. SSI, surgical site infection.

In terms of bowel preparation methods, 56.5% (217/384) Chinese surgeons preferred to choose laxatives alone; laxatives and oral antibiotics was used by 12.0%; laxatives and oral antibiotics combined with enema was used by 20.6%. Enema alone, oral antibiotics alone and other methods were only 7.8%, 0.5% and 2.6%, respectively (Figure 2).

Figure 2 Bowel preparation methods.

Regarding the choices of agents, Chinese surgeons were more likely to choose PEG-ELS (349/387, 90.9%). Mannitol and NaP were prescribed by 6.3% and 6.8%, respectively. MgSO4 and other agents were only 2.9% and 4.9% (Figure 3).

Figure 3 Bowel preparation agents. PEG-ELS, polyethylene glycol-electrolyte lavage solution; NaP, sodium phosphate; MgSO4, magnesium sulfate.

Analysis of bowel preparation methods

Analysis of bowel preparation methods is summarized in Table 3. The participants’ age and working experience did not show significant differences in the methods of bowel preparation (P value >0.05). In terms of hospitals’ characteristics, there were no significant differences in the use of bowel preparation. Department volume and number of operations also did not significantly affect choosing bowel preparation.

Table 3

Analysis of bowel preparation methods

Characteristics Laxatives Laxatives and OA Laxatives, OA and enema Enema OA Other P value
Age 0.326
   <40 years 53 5 17 8 0 1
   40–50 years 91 25 41 16 1 4
   >50 years 73 16 21 6 1 5
Working experience 0.686
   <10 years 24 1 8 1 0 1
   10–20 years 59 13 25 10 1 2
   >20 years 134 32 46 19 1 7
Medical specialty 0.791
   Gastrointestinal surgery 57 15 23 12 1 2
   Anorectal surgery 77 13 28 6 0 4
   General surgery 83 18 28 12 1 4
Hospital setting 0.308
   General 209 44 75 26 2 10
   Specialized 8 2 4 4 0 0
Department volume 0.220
   <50 118 22 43 15 0 4
   50–100 81 18 27 10 1 5
   101–150 11 2 4 4 0 1
   >150 7 4 5 1 1 0
Operations per month 0.662
   <100 142 26 44 17 1 4
   100–200 60 17 28 11 1 5
   >200 15 3 7 2 0 1

OA, oral antibiotics.

Discussion

Bowel preparation has been controversial for many years, especially in necessity and methods. This survey involved currently the largest number of participants in China. In this study, the characteristics of demographic, hospital and department did not correlate with the methods of bowel preparation. Most of the reasons for bowel preparation were to prevent SSI and avoid anastomotic leakage. Surgeons preferred laxatives when it came to bowel preparation through the data we collected. In terms of laxatives selection, PEG-ELS was mostly used.

Currently, there are only consensuses on bowel preparation before colonoscopy in China, but no guidelines on bowel preparation before colorectal surgery. Chinese surgeons make decisions on management of preoperative bowel preparation for patients based on their own clinical experience or guidelines from other countries. The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend a combination of MBP and OAP in both colonic and rectal surgery in the 2017 clinical practice guidelines (6). Likewise, the ERAS society guidelines recommended the same methods of bowel preparation (7). However, some countries did not recommend either MBP or MBP + OAP, especially with the spreading of ERAS all over the world. The Canadian guidelines, based on a systematic review of 14 randomized trials and 8 meta-analyses, concluded that it was acceptable to omit MBP as it provided no advantage and might trigger discomfort among patients (8). The British guidelines (updated in 2017 and based on Cochrane reviews) also indicated that stopping or reducing the routine use of MBP in patients undergoing elective colorectal surgery was likely to lead to improved quality of patient care, improved patient experience and productivity savings (9). Furthermore, the French ERAS guidelines did not recommend MBP whether in colonic (strong agreement) or in rectal surgery (weak agreement) (10).

There is a continuous debate on the role of bowel preparation in colorectal surgery. Opponents of MBP argue that it can damage the intestinal mucosal barrier and destroy the endogenous microbial barrier, thereby aggravating the damage of intestinal mucosa directly or indirectly (11). In addition, inadequate MBP caused a significantly higher incidence of peritoneal spillage and subsequent postoperative infectious complications (12). MBP might trigger discomfort among patients, including nausea, vomiting, abdominal pain and abdominal bloating (13).

Regardless of the fact that several studies have shown no benefit from MBP in colorectal surgery, the number of cases they studied was small. The largest and most well-documented study to date came from Kiran’s study (14). They collected NSQIP-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. Of 8,442 patients, MBP with OAP was independently associated with reduced anastomotic leak [odds ratio (OR) =0.57, 95% confidence interval (CI): 0.35–0.94], SSI (OR =0.40, 95% CI: 0.31–0.53), and postoperative ileus (OR =0.71, 95% CI: 0.56–0.90), compared with MBP alone and no bowel preparation. The findings of this study support the universal adoption of a simple preoperative bowel preparation regimen that combines MBP and oral antibiotics before elective colorectal resection. Bretagnol’s study, the first randomized trial focused on the postoperative results after sphincter-saving rectal resection for cancer, showed that the overall and infectious morbidity rates were significantly higher in no-MBP vs. MBP group, 44% vs. 27%, P=0.018, and 34% vs. 16%, P=0.005, respectively (15).

In our study, most of Chinese surgeons believed that bowel preparation could prevent SSI (81.3%) and avoid anastomotic leakage (74.2%) by reducing the intraluminal bacterial counts and stool burden. In a retrospective study using data from ACS NSQIP Colectomy Targeted database from 2012 to 2015, combined MBP/OAP resulted in significantly lower rates of SSI (OR =0.56, P<0.001) and anastomotic leak (OR =0.53, P<0.001) than no preparation (16). Toh et al. included in their meta-analysis 38 RCTs and 8,458 patients (17). MBP + OAP was better in terms of SSI and wound infection compared to no preparation (OR =0.60, 95% CI: 0.45–0.79 and OR =0.67, 95% CI: 0.48–0.93, respectively), and in terms of SSI and wound infection compared to MBP alone (OR =0.71, 95% CI: 0.57–0.88, and OR =0.62, 95% CI: 0.49–0.85, respectively). Nevertheless, the disruption of the host colonic microbiome and subsequent clostridium difficile infection remains a problem (18). Kim created a propensity-matched analysis of 957 paired cases (n=1,914) and compared patients receiving MBP + OAP with no bowel preparation (19). MBP + OAB group was less likely to develop postoperative clostridium difficile colitis than those who received no bowel preparation (0.5% vs. 1.8%, P=0.01). Bowel preparation should not be omitted considering the benefits above, especially in high-grade colorectal surgery.

Our results showed that Chinese surgeons preferred PEG-ELS as their first laxatives choice (90.9%). PEG-ELS has been widely used for colorectal surgery since 1980. Because of its isotonic and electrolyte-balanced feature, the patient’s electrolytes and internal environment don’t change much, and it has been shown to be highly effective and well tolerated, especially patients with renal insufficiency, congestive heart failure, and advanced liver disease (20). In spite of its safe and adequate cleansing, large volumes of liquid required and unpleasant taste remain troubling patients (21). Modified regimen (a lower-volume PEG formulation, for instance) and improved taste (PEG-ELS-II, for instance) enhance patients’ tolerance with the progress of technology (22,23). Mannitol and NaP are both hyperosmotic cleansing agents which not only can’t be absorbed from the gastrointestinal tract, but also can attract fluid into the bowel. The disadvantage of mannitol is that it can explode by the catabolism of Escherichia coli (24). The preference for NaP has reduced owing to phosphate-induced renal disease (25).

This survey had some limitations. Firstly, the questionnaire did not ask about bowel preparation in colon surgery and rectal surgery separately, which could lead to further findings. In recent years, bowel preparation for colon surgery has often been omitted. This can influence the accuracy of the survey results. Moreover, questionnaire’s options should be more classified in detail. If responders chose ‘other’ on the multiple choice question, they should give a specific description. Finally, there is no discrimination of open or laparoscopic procedures. The questionnaire should include elective and emergency procedures.

Conclusions

In summary, this present survey describes the current attitudes and practice patterns of preoperative bowel preparation among Chinese surgeons. Our study shows that surgeons choose bowel preparation mostly to avoid SSI and anastomotic leakage, and they prefer using laxatives alone. Surgeons do not have clear guidelines that can govern their clinical practice and there are still controversies about bowel preparation. Further study is required to provide strong evidences to inform clinical and policy decisions.

Acknowledgments

We thank the surgeons who kindly participated in the survey.

Funding: This work was supported by the Sanming Project of Medicine in Shenzhen (No. SZSM201911010), the Shenzhen Key Medical Discipline Construction Fund (No. SZXK016), and Guangdong Provincial Key Laboratory of Digestive Cancer Research (No. 2021B1212040006).

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-22/rc

Data Sharing Statement: Available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-22/dss

Peer Review File: Available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-22/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-22/coif). CZ serves as an unpaid Associate Editor-in-Chief of Digestive Medicine Research. All authors report that this work was supported by the Sanming Project of Medicine in Shenzhen (No. SZSM201911010), the Shenzhen Key Medical Discipline Construction Fund (No. SZXK016), and Guangdong Provincial Key Laboratory of Digestive Cancer Research (No. 2021B1212040006). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Medical Ethics Committee of The Seventh Affiliated Hospital of Sun Yat-sen University (No. KY-2020-024-01) and individual consent for this cross-sectional survey was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/dmr-22-22
Cite this article as: Yu H, Xu L, Yin S, Hong C, Yang S, Chen J, Li J, Wu W, Zhang C. A Chinese survey of current practice patterns of preoperative bowel preparation in colorectal surgery. Dig Med Res 2022;5:22.

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