Primary colorectal anastomosis, no preparation, no stoma needed

Abstract

Background: Mechanical bowel preparation was regarded for a long time as a vital prerequisite for successful colorectal surgery; this is now being questioned. The distressful effect of bowel preparation, alongside the safety of primary colorectal anastomosis in emergency cases, has led to a considerable change in the surgical protocol, making primary repair and anastomosis after colon resection safer without bowel preparation, and the role of colostomy has changed from mandatory to optional. Aim: To assess whether colorectal surgery can be performed safely without mechanical bowel preparation or colostomy. Method: A series of 130 patients, who underwent elective and emergency colorectal surgery, were followed prospectively over a three-year period in Al Bashir Teaching Hospital, Amman, Jordan. The patients were randomized into two groups. In one group (preparation group) 66 elective patients were selected from the outpatient department; the bowel was prepared using Fortran’s solution. In the second group (non-preparation group), 64 patients were selected from the emergency and outpatient departments, no bowel preparation was used. Colostomy was omitted in both groups. The main outcomes regarding operative time, hospital stay, rate of postoperative wound infection, anastomotic leak and intra-abdominal abscess were compared between the two groups. Results: Malignancy was the most prevalent pathology in both the preparation and non-preparation groups, 75.7% and 62.5% respectively, while benign diseases were present in up to 24.2% of the preparation group and in 1.5% of the non-preparation group. Anastomosis was ileo-colic in 33.3% and 37.5%, colo-colic or colo-rectal in 66.6% and 62.5% of the preparation and non-preparation groups respectively. There was no significant statistical difference in the overall postoperative complication rates between the two groups, 16.6% in the preparation group and 14% in the non-preparation group. Postoperative wound infection, wound dehiscence, intra-abdominal abscess and anastomotic leak occurred in 9.09%, 1.5%, 1.5% and 4.5% in the preparation group, as compared to 7.8%, 3.1%, 0% and 3.1% in the non-preparation group respectively. The mortality rate was nil in both groups. Conclusion: Resection of colorectal pathology followed by primary anastomosis, without stoma, can be performed safely with the omission of preoperative mechanical bowel preparation.