By Will Boggs MD
NEW YORK (Reuters Health) - 16/8/2019
Mechanical and oral antibiotic bowel preparation (MOABP) does not reduce surgical site infections (SSIs) or overall morbidity after elective colectomy, compared with no bowel preparation, according to results from the MOBILE trial.
"Many earlier retrospective studies had found profound benefits of mechanical and oral antibiotics bowel preparation, so we were also expecting to see an effect," Dr. Laura Koskenvuo from Helsinki University Hospital in Finland told Reuters Health by email. "It was surprising to see that we could not find differences in any of the outcomes we assessed."
Based on findings from large retrospective series, the American Society of Colon and Rectal Surgeons, the Society of American Gastrointestinal and Endoscopic Surgeons, the American Society for Enhanced Recovery, and the Perioperative Quality Initiative all recommend MOABP over no bowel preparation (NBP). No prospective randomized trials have compared the two approaches.
Dr. Koskenvuo and colleagues from four hospitals in Finland compared SSIs and Comprehensive Complication Index (CCI) scores within 30 days after surgery in their randomized trial of 196 patients assigned to MOABP and 200 patients assigned to NBP before elective colon resection.
SSI followed surgery in 7% of patients in the MOABP group and 11% of patients in the NBP group (odds ratio, 1,65; 95% confidence interval, 0.80 to 3.40), the team reports in The Lancet, August 8.
Similar numbers of patients in the MOABP group (16/196, 8%) and NBP group (13/200, 7%) required reoperation.
Overall, 53% of MOABP patients and 58% of NBP patients had no postoperative complications; 27% of MOABP patients and 27% of NBP patients developed grade 1 complications; 24% and 18%, respectively, developed grade 2 complications; and small but similar proportions developed grade 3 or 4 complications. There were no deaths in either group.
"The current practice in Europe is not to prepare the bowel, whereas in the United States bowel preparation is more common," Dr. Koskenvuo said. "Based on our results, we find that Europe's current clinical practice of not preparing the bowel is best supported by the evidence at the moment, and guidelines should be updated to reflect this change in evidence."
"That being said, this only applies to colon resections at the moment, as rectal resections were not studied in the current trial," she said. "That will be the topic of our next trial."
Dr. Steven D. Wexner from Cleveland Clinic Florida, in Weston, who co-authored a linked editorial, told Reuters Health by email, "The authors chose to focus on lower-risk anastomoses. Additional studies would be beneficial to confirm or refute these findings, in particular, to answer the question about whether or not failure to administer oral mechanical cathartic and oral antibiotic bowel preparation results in an increased incidence of SSIs."
"In my opinion, (these findings) will not change either clinical practice or guidelines for high-risk anastomoses, but offer some level of comfort that oral mechanical cathartic and oral antibiotic bowel preparation may potentially be safely omitted in low-risk anastomoses," he said. "Moreover since intraoperative endoscopy may be needed, failure to preoperatively provide the patient with a mechanical cathartic bowel preparation may limit or prevent the performance of intraoperative endoscopy."
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