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Persediaan usus dengan kaedah mekanikal untuk pembedahan kolorektal secara elektif

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Abstract

Background

The presence of bowel contents during colorectal surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.

An enema before the rectal surgery to clean the rectum and facilitate the manipulation for the mechanical anastomosis is used for many surgeons. This is analysed separately

Objectives

To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery.

Search methods

Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, IBECS and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.

Searches were performed December 1, 2010.

Selection criteria

Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage ‐ both rectal and colonic ‐ and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra‐abdominal complications, and overall surgical site infections.

Data collection and analysis

Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto‐Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed).

Main results

At this update six trials and a new comparison (Mechanical bowel preparation versus enema) were added. Altogether eighteen trials were analysed, with 5805 participants; 2906 allocated to MBP (Group A), and 2899 to no preparation (Group B), before elective colorectal surgery.

For the comparison Mechanical Bowel Preparation Versus No Mechanical Bowel Preparation results were:

1. Anastomotic leakage for low anterior resection: 8.8% (38/431) of Group A, compared with 10.3% (43/415) of Group B; Peto OR 0.88 [0.55, 1.40].

2. Anastomotic leakage for colonic surgery: 3.0% (47/1559) of Group A, compared with 3.5% (56/1588) of Group B; Peto OR 0.85 [0.58, 1.26].

3. Overall anastomotic leakage: 4.4% (101/2275) of Group A, compared with 4.5% (103/2258) of Group B; Peto OR 0.99 [0.74, 1.31].

4. Wound infection: 9.6% (223/2305) of Group A, compared with 8.5% (196/2290) of Group B; Peto OR 1.16 [0.95, 1.42].

Sensitivity analyses did not produce any differences in overall results.

For the comparison Mechanical Bowel Preparation (A) Versus Rectal Enema (B) results were:

1. Anastomotic leakage after rectal surgery: 7.4% (8/107) of Group A, compared with 7.9% (7/88) of Group B; Peto OR 0.93 [0.34, 2.52].

2. Anastomotic leakage after colonic surgery: 4.0% (11/269) of Group A, compared with 2.0% (6/299) of Group B; Peto OR 2.15 [0.79, 5.84].

3. Overall anastomotic leakage: 4.4% (27/601) of Group A, compared with 3.4% (21/609) of Group B; Peto OR 1.32 [0.74, 2.36].

4. Wound infection: 9.9% (60/601) of Group A, compared with 8.0% (49/609) of Group B; Peto OR 1.26 [0.85, 1.88].

Authors' conclusions

Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found. Further research on patients submitted for elective rectal surgery, below the peritoneal verge, in whom bowel continuity is restored, and studies with patients submitted to laparoscopic surgeries are still warranted.

Ringkasan bahasa mudah

Persediaan usus dengan kaedah mekanikal untuk pembedahan kolorektal secara elektif mungkin tidak membawa lebih manfaat kepada pesakit

Sehingga baru‐baru ini, kaedah pembersihan usus mekanikal yang teliti (persediaan usus kaedah mekanikal), bersama dengan penggunaan ubat makan antibiotik, dianggap berguna untuk mengurangkan risiko komplikasi septik selepas pembedahan kolorektal bukan kecemasan (elektif). Persediaan usus kaedah mekanikal telah dilaksanakan secara rutin sebelum pembedahan kolorektal sehingga tahun 1972, di mana prosedur ini mula dipersoalkan. Kajian‐kajian klinikal yang direka dengan baik telah diterbitkan, dan keputusan yang diperolehi menyebabkan beberapa pakar bedah meragui kepercayaan tradisional ini.

Ulasan ini telah mengenal pasti semua kajian yang membandingkan apa‐apa jenis persediaan usus kaedah mekanikal dengan tiada persediaan langsung (perbandingan 1) dan persediaan usus kaedah mekanikal dengan enema rektal (perbandingan 2) pada pesakit‐pesakit yang menjalani pembedahan kolorektal elektif. Lima kajian yang baru telah dimasukkan dalam kemas kini ketiga ulasan ini, dan membawa jumlah kajian yang termasuk dalam ulasan ini kepada 18 (5805 orang peserta) Analisis 18 kajian ini menunjukkan bahawa tiada perbezaan statistik yang signifikan pada keadaan pesakit dalam tiga kumpulan (kumpulan persediaan usus kaedah mekanikal, kumpulan tiada persediaan langsung dan kumpulan enema rektal) selepas pembedahan dari segi kebocoran di tempat jahitan di antara dua belah usus, kadar kematian, peritonitis, keperluan pembedahan semula, jangkitan di luka dan komplikasi‐komplikasi perut yang lain. Oleh yang demikian, tiada bukti bahawa persediaan usus kaedah mekanikal membawa lebih manfaat kepada pesakit.Penyelidikan yang lanjut dalam persediaan usus kaedah mekanikal atau enema berbanding dengan tiada persediaan untuk pesakit yang menjalani pembedahan rektal elektif atau pembedahan kolorektal laparoskopik adalah wajar.