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Published on: August 1, 2019
Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery: a randomized
Pascal Bucher1, Pascal Gervaz, Jean-François Egger
1Department of Surgery, Clinic of Visceral and Transplantation Surgery, Geneva, Switzerland. Pascal.Bucher@hcuge.ch
Purpose:
The feasibility and safety of left-sided colorectal procedures with avoidance of mechanical bowel preparation has recently been demonstrated. Moreover, mechanical preparation has been associated with an increased risk for abdominal septic complications, including anastomotic leakage. This study was designed to determine whether mechanical bowel preparation is associated with histologic alterations in the colon.
Methods:
Fifty patients (mean age, 61 (range, 45-78) years) scheduled to undergo elective colorectal surgery were prospectively randomized to receive mechanical preparation (polyethylene glycol; Group 1) or no preparation (Group 2) preoperatively. A macroscopically healthy segment of the bowel was excised at the proximal margin of the colectomy piece. A pathologist, blinded to the patient's group allocation, assessed various morphologic parameters.
Results:
Indications for colectomy (cancer and complicated diverticulosis) did not differ between groups. Bowel wall alterations were more frequent in patients who received a preparation. The most striking alterations associated with mechanical preparation were loss of superficial mucus (moderate-to-severe in 96 and 52 percent in Groups 1 and 2, respectively; P < 0.001) and epithelial cells (moderate-to-severe in 88 and 40 percent in Groups 1 and 2, respectively; P < 0.01). In addition, inflammatory changes, i.e., lymphocytes (severe in 48 and 12 percent in Groups 1 and 2, respectively; P < 0.02) and polymorphonuclear cells infiltration (severe in 52 and 8 percent in Groups 1 and 2, respectively; P < 0.02), were more prevalent after mechanical preparation.
Conclusions:
Mechanical bowel preparation is associated with structural alteration and inflammatory changes in the large bowel wall. Although bowel wall inflammation is a known risk factor for anastomotic leak, it remains to be elucidated whether these changes have a direct relation to the deleterious effect of mechanical bowel preparation in terms of abdominal morbidity.
Insights
Mechanical bowel preparation causes significant colon wall alterations, including mucus loss and increased inflammation. These changes may contribute to surgical complications like anastomotic leakage.
Area of Science:
- Colorectal Surgery
- Gastroenterology
- Surgical Pathology
Background:
- Mechanical bowel preparation (MBP) is standard for colorectal surgery.
- MBP has been linked to increased septic complications, including anastomotic leakage.
- The impact of MBP on colonic tissue histology remains unclear.
Purpose of the Study:
- To investigate the association between MBP and histologic alterations in the colon.
- To compare colonic tissue morphology in patients undergoing elective colorectal surgery with or without MBP.
Main Methods:
- Prospective randomized trial of 50 patients undergoing elective colorectal surgery.
- Patients were randomized to receive MBP (polyethylene glycol) or no preparation.
- Colonic tissue samples were assessed by a pathologist blinded to group allocation.
Main Results:
- MBP was associated with significantly more frequent bowel wall alterations.
- Loss of superficial mucus and epithelial cells was more severe in the MBP group (96% vs. 52% and 88% vs. 40%, respectively).
- Increased infiltration of lymphocytes and polymorphonuclear cells was observed in the MBP group (48% vs. 12% and 52% vs. 8%, respectively).
Conclusions:
- Mechanical bowel preparation induces structural changes and inflammation in the colonic wall.
- These MBP-associated histologic changes may be a contributing factor to increased abdominal morbidity.
- Further research is needed to confirm the direct link between MBP-induced inflammation and anastomotic leak risk.
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