The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial

Abstract

OBJECTIVE To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. METHODS We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. RESULTS 153 participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At two weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0–4.0) days. CONCLUSION MBP with oral magnesium citrate prior to minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE I

Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery

“…Among 60 patients who received polyethylene glycol orally and 60 patients with no bowel preparation preoperatively, no difference was found regarding the cleansing of surgical field. Conversely, adverse effects were significantly higher in the group of patients with intestinal preparation while abdominal distention was reported by 22% and nausea by 8% of patients in the MBP group [13].…”

“…e quality of the surgical field was the same when appreciated in the conclusion of the operation, despite an initial advantage of the MBP group during port placement. Return of bowel function was the same in both groups (2-4 days, median 3 days) [13].…”

“…Most randomized controlled trials (RCTs) compare oral MBP to no preparation regimen, besides fasting or a type of low residue diet [17][18][19][20][21]. Fewer studies compare oral MBP to enema MBP [11,13]. Only a small part of them compare enema use to no MBP [8,12] (Table 1).…”

“…It must be taken into account that some of the studies mentioned above exclude patients with suspected or anticipated malignancy, or with severe endometriosis, mainly in the cul de sac, because of possible enteric resection [8,[11][12][13][17][18][19][20]. Similarly, obese patients that might require an advanced laparoscopic procedure and even patients with prior surgery to the pelvis or the abdomen did not meet the inclusion criteria [18,19].…”

“…Only four randomized controlled studies exist in the literature, one of which refers to a combined laparoscopic and vaginal approach. All evidence is against the use of MBP in vaginal surgery [13][14][15][16]. However, as with laparoscopic surgery, MBP is still used by many surgeons who appear reluctant to omit it from day to day practice, despite the fact that scientific societies have addressed the need of specific guidelines, by issuing recommendations against the use of MBP solely.…”