I think this is a good debate.currently some people think and support no need of gut preparation ,but we still feel more comfortable doing anastmosis in a prepared gut and literature also support.we still need some more comparative studies before quitting gut preparation.

There is a reasonable body of literature in support of 'not' needed bowel prep.. HOWEVER, in my humble opinion, it makes complete sense to clear/ appropriately prepare the bowel (i.e. to minimize the bacterial load/ potential for contamination). Put another way, if I were to receive bowel surgery, I would certainly prefer the relative inconvenience of bowel prep in order to reduce the risk of intra- and post- operative contamination/ infection.

The Sept 2011 Cochrane Review (an evidence-based meta-analysis and review) determined no benefit of mechanical bowel preparation for elective colon surgery. The analysis was indeterminate for elective rectal surgery. See Abstract at:

http://www.ncbi.nlm.nih.gov/pubmed/21901677

Dr Gondal / Dr Sivathasan

-What kind of bowel prep - glycol / mech wash outs / total gut irrigation / enemas ?

-Is it the gross fecal residue we are wanting to avoid or the morbidity -wound infec/dehiscence, anas leak ?

Thanks Dr Bowman for pointing out the evidence. We have had several literature coming out favouring no prep / 'limited' prep leading the way to fast track the patients.

I do not believe there is any 'significant' body of evidence favouring a particular type of prep. - the patient's factors and acceptability would be my guidance; for example, ambulation-status to be able to go to the toilet after an osmotic prep..

My reasons for wanting to clear the bowel (in elective surgery) are as you said:

1) Clear field, i.e. no faecal residue;

2) No peritoneal contamination;

3) Reduced risk of would infection and dehiscence.

It is believed that bowel prep can make things 'worse' during surgery, esp when the prep makes the contents liquidy and makes what would have been a couple of swabs cleaning the solid ones, there is a continuous down pour of turbid / clear liquid content.

Inviting comments.

Dr. Govindarajan, surely the predominant state of the bowel-contents depends on how proximal (or distal) the site of the surgery is; and thus one can, surely, make an argument 'for' the use of bowel prep. in some cases.

I feel arguments and evidences are on both side,will take more evidence/studies to adher to one policy.in elective surgery we feel anastmosis in prepared colon(mechanical preparation ) is better than the loaded one .we in our setup feel more comfortable,however we are conducting a comparative study to see outcome in our setup

Dr Sivathasan, if we consider stoma closure as an example, considering sigmoid stoma, transverse stoma & cecostomy / ileostomy- what would be the approach ?

Dr Iqbal, do you give wash outs, if yes what is the regime followed ?

I know some who always use prep - for elective operations, of course - and others who rarely use it. I guess that as with most things in surgery, the clinician's preference is key when there is no significant body of evidence for any particular approach!

I agree with dr GONDAL in elective cases better to do anastmosis in a prepared gut than loaded one.less morbidity

Dear dr Krishna,in closure of stoma eg elective closure of sigmoid stoma we start oral clear fluid 48hours before surgery then laxative eg oral castroil a day befor followed by enema ,we feel comfortable doing anastmosis in empty prepared colon

in ERAS (Enhanced recovery after surgery) protocol bowel prep is not necessary, there are hundreds of articles in literature stating bowel prep is un necessary burden infact troublesome for patients.

Dear Dr Umair- How often do you come across liquid contents after bowel prep which you mentioned ?

Dr Pirzada thanks for the comment. Trying to see the transition from the evidence to the practical - how many of us do things differently.

Question is which is difficult - solid contents / liquid contents intra op ? Will it change the plan - surgery cancelled / covering stoma ? Some surgeons even do on table washouts till effluent is clear.

Other query is reg anastomosis type - what material, interrupted/cont, any particular method Connell's/ Lembert's, 2 layered /single, hand sewn vs stapled.

In our setup we follow only liquid diet 24 hrs prior to large bowel surgery only, no addition of laxatives or enemas. The only benefit of preparing bowel is easy handling of bowel. Randomised control trials and meta analyses are sufficient body of evidence to prove bowel prep has no role in preventing infections or anastomotic leak.

i am conducting a compaitive study on bowel anastomosis; conventional versus ERAS protocol. till yet favorable results for ERAS.

regarding anastomosis type i must say 'a surgeon should use a method he/she is comfortable in'

stapling is better in any way in terms of time saving as well. i used to do double layer during initial years of my training, now i m much comfortable in Gambee's technique if i have to do hand sewn!

ERAS is on and gut preparation is getting out of fashion. all new evidence supports no bowel preps and early oral intake. so No NGs No long NPO. need to ask every patient to start orally as soon as he or she TOLERATES. plus it is essential to understand that it is ENHANCED recovery not ENFORCED recovery after surgery.

regards

Dr Qureshi well said reg Enhanced vs Enforced recovery !

Oh there isnt such concept as enforced recovery perhaps the concept originated from fast track surgery which shows promising results.

Dr Pirzada, often times on a practical basis, its the washouts which make the stool 'runny' making it difficult to manage than the solid stools which may be 'easier' to tackle.

What about on table lavage - saline / betadine ? Anyone does it routinely ?

Regarding Bowel Prep we had published an article summing current evidence:

Deka P, Negi SS. Role of mechanical bowel preparation before colorectal surgery. National Medical Journal of India 2009;22(1):7-8.

Dear Dr Negi, is the article available online / can you provide the full text article pls ?

Dear Dr Krishna, Its available online at http://www.nmji.in/Volume-22-Issue-2.asp

No