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108
T. L. Hedrick and S. D. Holubar
effect. As a result, hyperosmotic preparations can be administered in smaller volumes resulting in higher patient satisfaction. However, as opposed to the safer isosmotic solutions, the hyperosmotic solutions can be associated with signicant uid
and electrolyte shifts and renal damage [32–34]. Hence, hyperosmotic bowel preparation solutions are not generally recommended prior to colorectal surgery.
Polyethylene glycol (PEG), an osmotically balanced electrolyte lavage solution,
is the most commonly used agent for MBP in elective colorectal surgery. It is standardly administered in a 4 liter preparation that many patients dislike due to volume
and taste. The major advantage is that the high-molecular weight, nonabsorbable
polymer passes directly through the GI tract without net absorption or secretion.
Fluid and electrolyte shifts are thereby generally avoided. Up to 17% of patients
will experience adverse effects such as nausea and vomiting with PEG [9]. Standard
full-volume PEG preparations include GoLYTELY® (Braintree Laboratories,
Braintree MA, USA), Colyte® (Pendopharm, Montreal, Canada), NuLytely®
(Braintree Laboratories, Braintree, MA, USA), and TriLyte® (Schwarz Pharma,
Milwaukee, WI, USA). Low-volume PEG preparations (HalfLytely® [Braintree
Laboratories, Braintree, MA, USA], MoviPrep® [Salix Pharmaceuticals,
Bridgewater, NJ, USA], MiraLax® [Bayer, Whippany, NJ, USA], and BiPeglyte®
[Pendopharm, Montreal, Canada]) have been developed in combination with other
cathartic agents to make the solution more palatable. There is a paucity of literature
evaluating the efcacy of these low-volume preparations specic to colorectal surgery. However, the low-volume solutions have been demonstrated to result in similar preparation for colonoscopy procedures.
Bowel Preparations andEnhanced Recovery Protocols (ERPs)
To date, limited research has focused on the intersection between the mechanical
bowel preparation and enhanced recovery. Even ERP guidelines from Europe and
North America are contradictory, with the ERAS society advocating for omission of
the MBP, while the aforementioned ASER guideline recommended routine combined MBP+OA prep [35].
The most recent guideline on ERP for colon and rectal surgery was a joint ASCRS/
SAGES publication. That guideline stated that MBP+OA is the preferred preparation and is associated with reduced complication rates (grade of recommendation 2B,
weak recommendation based on moderate quality evidence) [36]. In addition to that
resource, readers are referred to the SAGES SMART Enhanced Recovery Program
(https://www.sages.org/smart-enhanced-recovery-program/). The position that
SAGES has taken is that bowel preparations should be used selectively, but their
recommendations are congruent with the above recommendations. Specically, they
recommend inclusion of oral antibiotics if a mechanical bowel preparation is used, as
this combination has been shown to decrease infections when used. However, a
denitive recommendation was not made for rectal surgery as it was felt more data
are required (https://www.sages.org/enhanced-recovery/bowel-preparation/).
8 Bowel Preparation inColorectal Surgery: Impact onSSIs andEnhanced Recovery…
109
In addition to the bowel preparation itself, one must consider how the preparation affects oral carbohydrate loading. Hendry and coauthors [37] demonstrated the
feasibility of oral carbohydrate loading with MBP in patients undergoing elective
left colon and rectal resections with no adverse events. Subsequently, numerous
successful ERPs have been published incorporating use of an isosmotic MBP with
oral antibiotics. Thiele and colleagues demonstrated that MBP with oral antibiotics
could successfully be incorporated into an ERP, demonstrating a 2.2day reduction
in length of stay and a reduction in overall complications by 48.8% (p<0.0001)
[38]. Likewise, Keenan and colleagues [39] demonstrated a further reduction in
infectious morbidity and length of stay following the addition of a SSI prevention
bundle that included, among various other things, the routine use of a MBP to their
existing successful ER program. These results demonstrate that use of a PEG-based
MBP in the presence of oral antibiotics is not detrimental to an ER program. Finally,
MBP+ OA has been endorsed not only by ASCRS and SAGES but also by the
American Society for Enhanced Recovery (ASER) and Perioperative Quality
Initiative (POQI) to prevent infectious complications following elective colorectal
surgery in the setting of an ERP [40].
A sample MBP that can be utilized within an ERP is demonstrated in Box 8.1.
Prophylactic antiemetics may attenuate the postoperative nausea and vomiting associated with the emetogenic nature of the large-volume preparations and high-dose
metronidazole and the prokinetic effects of the high-dose erythromycin. Finally,
patients should be encouraged to drink electrolyte-rich uids throughout their preparation up until 2hours before surgery.
Box 8.1 Sample bowel preparation in enhanced recovery protocol
• Clears starting at 6am in the morning the day before surgery.
• 4 liters of GoLYTELY® (Braintree Laboratories, Braintree, MA, USA) starting at
5:00PM.
• Erythromycin (1g administered orally at 1:00pm, 2:00pm, and 10:00PM)
• Neomycin (1g administered orally at 1:00pm, 2:00pm, and 10:00PM).
• Clear liquids can be consumed ad libitum until 2hours prior to surgery.
• A 20oz Gatorade® (PepsiCo, Chicago, IL, USA) is consumed 2hours prior to surgery.
a
May substitute 1g of metronidazole for the erythromycin
b
Alternative dose/timing 2g of the antibiotics given at 6pm and 10pm
a, b
.
Conclusion
An isosmotic MBP in combination with OAs is associated with the lowest attainable rates of infectious morbidity following elective colorectal surgery. The use of
these preparations can be effectively utilized within an enhanced recovery protocol
without untoward effects on the recovery process. Preparation use may be optimized by addition of simple measures such as use of palatable lower volume solutions, prophylactic antiemetics, and electrolyte-rich drinks.
110
T. L. Hedrick and S. D. Holubar
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13. Guenaga KK, Matos D, Wille-Jorgensen P.Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2009;(1):CD001544.
14. Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jorgensen P.Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2005;(1):CD001544.
15. Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jorgensen P.Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2003;(2):CD001544.
16. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, etal. Guidelines for
perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(R))
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Database Syst Rev. 2009;(1):CD001181.
18. Englesbe MJ, Brooks L, Kubus J, Luchtefeld M, Lynch J, Senagore A, etal. A statewide
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Surg. 2010;252(3):514–9; discussion 9–20
19. Kim EK, Sheetz KH, Bonn J, DeRoo S, Lee C, Stein I, etal. A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Ann Surg.
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20. Moghadamyeghaneh Z, Hanna MH, Carmichael JC, Mills SD, Pigazzi A, Nguyen NT, etal.
Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg.
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21. Toh JWT, Phan K, Ctercteko G, Pathma-Nathan N, El-Khoury T, Richardson A, etal. The
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open elective restorative colorectal surgery with and without faecal diversion. Int J Color Dis.
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22. Kaslow SR, Gani F, Alshaikh HN, Canner JK.Clinical outcomes following mechanical plus
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23. Klinger AL, Green H, Monlezun DJ, Beck D, Kann B, Vargas HD, etal. The role of bowel
preparation in colorectal surgery: results of the 2012-2015 ACS-NSQIP Data. Ann Surg.
2019;269(4):671–7.
24. Koller SE, Bauer KW, Egleston BL, Smith R, Philp MM, Ross HM, et al. Comparative
effectiveness and risks of bowel preparation before elective colorectal surgery. Ann Surg.
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25. Dolejs SC, Guzman MJ, Fajardo AD, Robb BW, Holcomb BK, Zarzaur BL, etal. Bowel preparation is associated with reduced morbidity in elderly patients undergoing elective colectomy.
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26. Al-Mazrou AM, Hyde LZ, Suradkar K, Kiran RP.Effect of inclusion of oral antibiotics with
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27. McSorley ST, Steele CW, McMahon AJ.Meta-analysis of oral antibiotics, in combination
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28. European Society of Coloproctology collaborating g. Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an
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29. Atkinson SJ, Swenson BR, Hanseman DJ, Midura EF, Davis BR, Rafferty JF, etal. In the
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31. Atkinson SJ, Swenson BR, Hanseman DJ, Midura EF, Davis BR, Rafferty JF, etal. In the
absence of a mechanical bowel prep, does the addition of pre-operative oral antibiotics to
parental antibiotics decrease the incidence of surgical site infection after elective segmental
colectomy? Surg Infect. 2015;16(6):728–32.
32. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis
Colon Rectum. 2004;47(8):1397–402.
33. Ackland GL, Harrington J, Downie P, Holding JW, Singh-Ranger D, Griva K, etal. Dehydration
induced by bowel preparation in older adults does not result in cognitive dysfunction. Anesth
Analg. 2008;106(3):924–9, table of contents
34. Ackland GL, Singh-Ranger D, Fox S, McClaskey B, Down JF, Farrar D, etal. Assessment of
preoperative uid depletion using bioimpedance analysis. Br J Anaesth. 2004;92(1):134–6.
35. Slim K, Kartheuser A.Mechanical bowel preparation before colorectal surgery in enhanced
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Feldman LS, Steele SR.Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American
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37. Hendry PO, Balfour A, Potter MA, Mander BJ, Bartolo DC, Anderson DN, etal. Preoperative
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38. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, et al.
Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430–43.
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T. L. Hedrick and S. D. Holubar
Checklist forPatients andOR Team
inPreparation forLaparoscopic
Colorectal Surgery
SamuelEisenstein andAlexisL.Grucela
Introduction andRationale
Preoperative preparation for laparoscopic colon and rectal surgery should include
careful evaluation and planning on the part of the surgeon. Knowledge of comorbidities dictates need for further preoperative testing or intervention in order to prevent complications within the perioperative period. Furthermore, prior pelvic
radiation or pelvic surgery plays an important role in operative planning. Preoperative
mechanical bowel preparation (MBP), judicious use of antibiotics, and prophylaxis
for venous thromboembolic events (VTE) are essential aspects of perioperative
patient care. Once a patient is deemed appropriate and ready for surgery, the surgeon must carefully plan their approach and know what instruments are required to
achieve the desired outcome.
The checklist for the surgeon and OR team can be conceptualized in two phases:
9
1. Preoperative (outpatient) preparation and prevention.
2. Preoperative preparation in the operating room.
S. Eisenstein
University of California San Diego Health Systems, Department of Surgery,
Division of Colon and Rectal Surgery, La Jolla, CA, USA
e-mail: seisenstein@ucsd.edu
A. L. Grucela (
New York University Langone Health, NewYork University, Department of Surgery,
Division of Colon and Rectal Surgery, New York, NY, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_9
*)
113
114
S. Eisenstein and A. L. Grucela
Preoperative Planning, Patient Workup, andOptimization
Preoperative Risk Assessment
A systems-based approach to the preoperative assessment is essential with particular emphasis on cardiac and pulmonary risk factors. There are clinical risk factors
based on patients’ comorbidities which are used to assess perioperative risk of morbidity and mortality. The American Society of Anesthesiologists physical status
classication is used to assess general risk (Table 9.1) [1]. American Society of
Anesthesiologists class III or higher should prompt preoperative risk assessment by
internist or medical subspecialist (i.e., cardiologist, pulmonologist). This provides
dialogue between the surgeon and consultant and determines if further preoperative
diagnostics or interventions are necessary prior to surgery. Box 9.1 lists patient
Table 9.1 American Society of Anesthesiologists physical status classication
ASA PS
classication
ASA I A normal healthy
ASA II A patient with mild
ASA III A patient with severe
ASA IV A patient with severe
ASA V A moribund patient
ASA VI A declared brain-
DM diabetes melitus, HTN hypertension, ESRD end-stage renal disease, MI myocardial infarction,
TIA transient ischemic attack, CVA cerebrovascular accident, DIC disseminated intravascular
coagulation, CAD coronary artery disease
Used with permission of the American Society of Anesthesiologists [1]
Denition
patient
systemic disease
systemic disease
systemic disease that
is a constant threat to
life
who is not expected
to survive without
the operation
dead patient whose
organs are being
removed for donor
purposes
Examples, including, but not limited to:
Healthy, non-smoking, no or minimal alcohol use
Mild diseases only without substantive functional
limitations. Examples include (but not limited to) current
smoker, social alcohol drinker, pregnancy, obesity
(30<BMI<40), well-controlled DM/HTN, mild lung
disease
Substantive functional limitations: one or more moderate
to severe diseases. Examples include (but not limited to)
poorly controlled DM or HTN, COPD, morbid obesity
(BMI ≥40), active hepatitis, alcohol dependence or
abuse, implanted pacemaker, moderate reduction of
ejection fraction, ESRD undergoing regularly scheduled
dialysis, premature infant PCA<60weeks, history
(>3months) of MI, CVA, TIA, or CAD/stents.
Examples include (but not limited to) recent (<3months)
MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia
or severe valve dysfunction, severe reduction of ejection
fraction, sepsis, DIC, ARD, or ESRD not undergoing
regularly scheduled dialysis
Examples include (but not limited to) ruptured
abdominal/thoracic aneurysm, massive trauma,
intracranial bleed with mass effect, ischemic bowel in
the face of signicant cardiac pathology or multiple
organ/system dysfunction
9 Checklist forPatients andOR Team inPreparation forLaparoscopic Colorectal…
Box 9.1 Patient Factors Associated with Perioperative Complications
115
Patient factors
• Age
• Smoking
• Dyspnea at rest or on exertion
• Poor functional status
• Cerebrovascular accident
• Disseminated cancer
• Preoperative open wound
• Immunosuppression
• Preoperative weight loss >10%
• Preoperative anemia or need for >4 units of PRBC within 72 hours of
surgery
• Body mass index (BMI)
• Preoperative leukocytosis
characteristics shown to be independent risk factors associated with perioperative
complications in patients undergoing surgery.
Extremes of body mass index (BMI) (<20kg/m
2
or>35kg/m2) are associated
with signicant risk of 30-day mortality, and BMI >35kg/m2 is associated with
increase in 30-day morbidity (urinary tract infection, wound infection, sepsis, VTE)
[2, 3]. These patients should undergo nutrition counseling at rst preoperative visit
in order to optimize weight and nutritional status before surgery. A conversation
between the operating surgeon and the morbidly obese patient should occur communicating the increased risk of morbidity and mortality incurred based on the
patient’s BMI. An anesthesia preoperative assessment is also recommended for
these patients, as factors such as challenging airways can exist.
The goal of preoperative cardiac risk assessment is to identify those who have
recently experienced myocardial infarction (MI) and those at high risk of perioperative MI in order to prevent perioperative cardiac complications. Recent MI requiring
percutaneous coronary intervention presents a challenge due to the requirement of
dual antiplatelet therapy (aspirin and clopidogrel) in the post intervention period [4,
5]. Bare-metal stents require antiplatelet therapy for a minimum of 4–6weeks post
procedure and drug-eluting stents a minimum 1year post procedure before stopping
for elective surgery [4, 5]. In the setting of malignancy or acute ulcerative colitis,
one may not have the ability to concede to these time restraints. Therefore, the risk
of perioperative MI versus postoperative bleeding on antiplatelet therapy must be
carefully weighed, and a discussion between cardiologist, surgeon, and patient is of
utmost importance in such circumstances. Some institutions have their own policies
on this and continue at least aspirin throughout the operation on patients with cardiac stents.
The Revised Cardiac Risk Index (RCRI) [6] and Gupta score [7] are two clinical
indices commonly used to assess patients at high risk for experiencing perioperative
cardiac events. Patients with scores predicting higher risk may need more extensive
diagnostic investigation and possible intervention prior to elective surgery. For
116
Box 9.2 Revised Cardiac Risk Index (RCRI)
S. Eisenstein and A. L. Grucela
• Revised Cardiac Risk Index (RCRI): independent risk factors associated
with increased incidence of perioperative cardiac events in patients undergoing non-cardiac surgery
1. High-risk surgery
2. Ischemic heart disease
3. History of congestive heart failure
4. History of cerebrovascular disease
5. Insulin therapy for diabetes
6. Preoperative serum creatinine >2.0mg/dL
Box 9.3 Gupta Score
• Gupta score: independent risk factors associated with greater potential to
identify increased risk of perioperative cardiac event compared with RCRI
– ASA class
– Dependent functional status
– Age
– Abnormal creatinine (>1.5mg/dL)
– Type of surgery
Table 9.2 Recommend time for discontinuation of anticoagulation prior to surgery
Drugs
Heparin Promote antithrombin 6–12hours
Low molecular weight
heparin
Warfarin Vitamin K antagonist 5days
Argatroban Direct thrombin inhibitors 3–9hours
Bivalirudin Direct thrombin inhibitors 1.5–3hours
Dabigatran Direct thrombin inhibitors 24–96hours (more if patient has renal
Rivaroxaban Factor Xa inhibitor 24–48hours
Apixaban Factor Xa inhibitor 24–48hours
Edoxaban Factor Xa inhibitor 48hours
Aspirin Cyclooxygenase inhibitor Unnecessary (7–10days for reversal of
Clopidogrel Platelet P2Y12 receptor
Prasugrel Platelet P2Y12 receptor
Ticagrelor Platelet P2Y12 receptor
Ticlopidine Platelet P2Y12 receptor
Mechanism of action
Factor Xa inhibitor 12–24hours
inhibitor
inhibitor
inhibitor
inhibitor
Hold time
impairment)
effect)
5days
5days
5days
5days
9 Checklist forPatients andOR Team inPreparation forLaparoscopic Colorectal…
117
example, in the RCRI (Box 9.2) for each risk factor, a patient is given a score of 1,
and for those with a total score of ≥2, further testing may be of clinical utility.
Patients with low scores do not need further testing. The Gupta score (Box 9.3) is
scoring index that is also used to identify high-risk patients for perioperative cardiac
complications [7]. This scoring index is reported to be more accurate than RCRI;
however, it is more difcult to calculate and, therefore, less frequently used. Patients
with cardiac risk factors may be on a variety of anticoagulants. Standard recommendations for holding anticoagulants are included in Table9.2.
Special Considerations
Immune Suppression
Patients undergoing colon and rectal surgery may suffer from baseline immunosuppression for a variety of reasons. Patients with inammatory bowel disease (IBD)
are often taking a variety of medications including biologic agents, steroids, and
thiopurines which impair their immune response, cancer patients may have been
exposed to chemotherapy, transplant patients may require long-term immune suppression, and the malnourished may have baseline immune dysfunction. When possible, it is advantageous to stop immune suppression and allow it to wash out of the
system; however, this is not often an option as stopping these medications could
cause the patients to deteriorate and opens up other potential risks.
There is a signicant body of literature demonstrating that steroids signicantly
increase the risk of septic complications during colon and rectal surgery [8–12].
This effect appears to be dose related, and it does seem clear that patients taking less
than 20mg of prednisone daily are at a lower risk of complications than those on
more than 20mg daily. These patients are still, however, at an increased risk of
complications compared to those who are entirely off of steroids [12]. The use of
perioperative stress-dose steroids has also fallen out of favor. Perioperative adrenal
insufciency is an extremely rare condition, and there is a greater risk of steroidrelated complications [13]. Patients have been assessed for mild symptoms such as
orthostasis in the perioperative period, and there is no difference based on whether
they received a stress dose of steroids at the time of surgery [14]. The current recommendation is for the patient to take their standard steroid dose on the day of surgery
and then begin a taper in the postoperative period. Stress-dose steroids should only
be administered in the setting of symptomatic adrenal insufciency. There is also
excellent evidence showing that thiopurines do not appear to increase the risk of
postoperative complications in patients with IBD [15].
There is much greater controversy surrounding the effect that biologics have on
perioperative outcomes in IBD surgery. There have been several papers showing an
increase in perioperative infection rate [16–18] and several and many others showing no increased rate of infection [19–22]. There are valid arguments on both sides
as to whether biologic agents should be stopped or washed out of the system prior
to surgery, but the full argument is well beyond the scope of this chapter. Likely
biologic agents are markers for severity of disease, and patients who have failed