title: Mechanical Bowel Preparation for Children Undergoing Elective Colorectal Surgery Combination of Oral Antibiotics and Mechanical Bowel Preparation Reduces Surgical Site Infection in Colorectal Surgery. Preoperative Bowel Preparation before Elective Bowel Resection or Ostomy Closure in the Pediatric Patient Population Has No Impact on Outcomes: A Prospective Randomized Study Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based? Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence? Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study. Survey of pediatric surgeons on current practices of bowel preparation for elective colorectal surgery in children. Wound Infection After Elective Colorectal Resection Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children.
abstract: Objectives : Adult literature supports the elimination of mechanical bowel preparation ( MBP ) for elective colorectal surgical procedures . Prospect i ve data for the pediatric population regarding the utility of MBP are lacking . The primary aim of this study was to compare infectious complications , specifically anastomotic leak , intraabdominal abscess , and wound infection in patients who received MBP  with those who did not . Methods : A r and omized pilot study comparing MBP with polyethylene glycol with no MBP was performed . Patients , 0 to 21 years old , undergoing elective colorectal surgery were eligible and r and omized within 4 age strata . Statistical analyses were performed using & khgr;2 or Fisher exact test for categorical data and t test or Wilcoxon 2- sample test for continuous data . Results : Forty-four patients were enrolled in the study from December 2010 to February 2013 , of which 24 ( 55 % ) received  MBP and 20 ( 45 % ) did not . Two patients ( 5 % ) had anastomotic leak , 4 ( 9 % ) had intraabdominal infection , and 7 ( 16 % ) had wound infections . The rate of anastomotic leak , intraabdominal abscess , and wound infection did not differ between the 2 groups . Conclusions : MBP for elective colorectal surgery in children does not affect the incidence of infectious complications . A larger multiinstitutional study is necessary to vali date the results of this single-institution pilot study BACKGROUND Surgical site infections ( SSI ) are a common complication after colorectal surgery . An infection prevention bundle ( IPB ) was implemented to improve outcomes . STUDY DESIGN A st and ardized IPB that included the administration of oral antibiotics with a mechanical bowel preparation , preoperative shower with chlorhexidine , hair removal and skin preparation in holding , antibiotic wound irrigation , and a " clean-closure " protocol was implemented in January 2013 . Data from the American College of Surgeons NSQIP were analyzed at a single academic institution to compare pre-IPB and post-IPB SSI rates . In January 2014 , a prospect i ve data base was implemented to determine compliance with individual IPB elements and their effect on outcomes . RESULTS For the 24 months pre-IPB , the overall SSI rate was 19.7 % . During the 30 months after IPB implementation , the SSI rate decreased to 8.2 % ( p < 0.0001 ) . A subset of 307 patients was identified in both NSQIP and our prospect i ve compliance data bases . Elements of IPB associated with decreased SSI rates included preoperative shower with chlorhexidine ( 4.6 % vs 16.2 % ; p = 0.005 ) , oral antibiotics ( 3.4 % vs 15.4 % ; p < 0.001 ) , and mechanical bowel preparation ( 4.4 % vs 14.3 % ; p = 0.008 ) . Patients who received a full bowel preparation of both oral antibiotics and a mechanical bowel preparation had a 2.7 % SSI rate compared with 15.8 % for all others ( p < 0.001 ) . On multivariate analysis , full bowel preparation was independently associated with significantly fewer SSI ( adjusted odds ratio 0.2 ; 95 % CI 0.1 to 0.9 ; p = 0.006 ) . CONCLUSIONS Implementation of an IPB was successful in decreasing SSI rates in colorectal surgery patients . The combination of oral antibiotics with a mechanical bowel preparation was the strongest predictor of decreased SSI The role of preoperative bowel prep in the pediatric surgical population is uncertain . We performed a r and omized prospect i ve study to evaluate noninferiority between the presence or absence of a preoperative bowel prep in  elective pediatric bowel surgery  on postoperative outcomes . Patients aged three months to 18 years were recruited and r and omized to the bowel prep group or the no bowel prep group . Patients were evaluated in-hospital and at postoperative clinic visits . Thirty-two patients were recruited ; 18 in the bowel prep group and 14 in the no bowel prep group . There was no statistical difference ( P > 0.05 ) in complications between the groups . Complications were observed in five patients in each group ( 27.8 % and 35.7 % , respectively ) . In the bowel prep group , two ( 11.1 % ) had wound infection ( vs three , 21.4 % ) , 0 had an intra-abdominal abscess ( vs one , 7.1 % ) , one ( 5.6 % ) had sepsis ( vs one , 7.1 % ) , one ( 5.6 % ) had an anastomotic leak ( vs 0 ) , and three ( 16.7 % ) had a bowel obstruction ( vs one , 7.1 % ) . There were no extra-abdominal complications . There were no significant differences in complications between the two groups . Further research is warranted , but may require a multi-institutional trial to recruit sufficient numbers to make conclusions about the significance of the need for bowel prep PURPOSE It is well established through r and omized trials that oral antibiotics given with or without a mechanical bowel preparation ( MBP ) prior to colorectal procedures reduce complications , while MBP given alone provides no benefit . We aim ed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence -based . METHODS Retrospective analysis of patients undergoing colorectal procedures at 42 children 's hospitals ( 1/2/2007 - 12/31/2011 ) was performed . Patients were analyzed for diagnosis , pre-admission status , and inpatient bowel preparation .  Bowel preparation was considered evidence -based if oral antibiotics were utilized with or without a MBP . RESULTS 49 % of all patients were pre-admitted ( n=5,473 ) , and the most common diagnoses were anorectal malformations ( 55 % ) , inflammatory bowel disease ( 26 % ) , and Hirschsprung 's Disease ( 19 % ) . The most common preparation approaches were MBP alone ( 54.3 % ) , MBP+oral antibiotics ( 18.8 % ) , and oral antibiotics alone ( 4.2 % ) , although significant variation was found in hospital-specific rates for each approach ( MBP alone : 0 - 96.1 % , MBP+oral antibiotics : 0 - 83.6 % , orals alone : 0 - 91.6 % , p<0.0001 ) . Only 22.9 % of all patients received an evidence -based preparation ( range by hospital : 0 - 92.3 % , p<0.0001 ) , and this rate decreased significantly during the five-year study period ( 27.6 % in 2007 vs. 17.3 % in 2011 , p<0.0001 ) . CONCLUSION According to the best available clinical evidence , less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications PURPOSE Despite rigorous data from adult literature demonstrating that oral antibiotics ( OA ) reduce infectious complications and mechanical bowel preparation ( MBP ) alone does not , MBP alone remains the preferred approach among pediatric surgeons . We aim ed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership . METHODS Surgeons were queried for their choice of bowel preparation , factors influencing their practice , and their impression of the strength and relevance of the adult literature to pediatric practice . RESULTS Surgeons who used MBP alone ( 31 % ) cited a reduction in stool burden and infectious complications as important factors , whereas surgeons choosing not to use OA ( 70 % ) reported a lack of benefit in reducing infectious complications as the primary reason . Although 53 % of surgeons reported that evidence from adult literature was the most important influence , 73 % of surgeons reported there was poor evidence supporting the use of OA ( ±MBP ) , and only 25 % used a preparation supported by adult r and omized data . CONCLUSIONS Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA . Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice , this is not consistent with stated perceptions or practice BACKGROUND / PURPOSE Preoperative mechanical bowel preparation ( MBP ) for elective intestinal operations has been a long accepted practice . However , MBP is often unpleasant and time-consuming for patients , and clinical trials in adults have not shown improved outcomes . We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications . METHODS Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children 's hospital between 1990 and 2003 . RESULTS Thirty-three patients ( No PREP ) were managed by a single surgeon who routinely omitted MBP , whereas another 110 patients ( PREP ) were prepared with enemas , laxatives , or both . Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics . The No PREP group had one anastomotic leak and no wound infections , whereas the PREP group had 2 anastomotic leaks and 1 wound infection ( P = .58 ) . These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group . CONCLUSION The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications . Eliminating MBP may reduce health care costs and inconvenience to patients . These findings warrant a large , prospect i ve , r and omized clinical trial to vali date our findings and to investigate further the necessity of MBP in the pediatric population BACKGROUND Guidelines regarding bowel preparation exist for the adult but not the pediatric population . Our aim was to evaluate the bowel preparation practice s , including antibiotic usage for elective colorectal operations in children . METHODS A survey was design ed and administered to a nationwide group of pediatric surgeons to ascertain current practice s of bowel preparation . RESULTS Four hundred ninety-three surveys were administered , and 136 physicians responded ( 28 % ) .  Mechanical bowel preparation was used by 96 % of the respondents . Preoperative  intravenous antibiotics  were used by 99 % of respondents . The number of years in practice did not significantly affect the use of oral antibiotics  ( P = .62 ) or the duration of intravenous antibiotics  ( P = .78 ) . CONCLUSIONS There is a wide variation in bowel preparation practice s in children . A prospect i ve , r and omized trial would be helpful to identify the role of oral antibiotics and optimal duration of intravenous antibiotics in this population Introduction : Surgical site infection ( SSI ) is a potentially morbid and costly complication following major colorectal resection . In recent years , there has been growing attention placed on the accurate identification and monitoring of such surgical complications and their costs , measured in terms of increased morbidity to patients and increased financial costs to society . We hypothesize that incisional SSIs following elective colorectal resection are more frequent than is generally reported in the literature , that they can be predicated by measurable perioperative factors , and that they carry substantial morbidity and cost . Methods : Over a 2-year period at a university hospital , data on all elective colorectal resections performed by a single surgeon were retrospectively collected . The outcome of interest was a diagnosis of incisional SSI as defined by the Center of Disease Control and Prevention . Variables associated with infection , as identified in the literature or by experts , were collected and analyzed for their association with incisional SSI development in this patient cohort . Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI by univariate analysis to determine their prognostic significance . The incidence of SSI in this study was compared with the rates of incisional SSI in this patient population reported in the literature , predicted by a nationally based system monitoring nosocomial infection , and described in a prospect ively acquired intradepartmental surgical infection data base at our institution . Results : One hundred seventy-six patients undergoing elective colorectal resection were identified for evaluation . The mean patient age was 62 ± 1.2 years , and 54 % were men . Preoperative diagnoses included colorectal cancer ( 57 % ) , inflammatory bowel disease ( 20 % ) , diverticulitis ( 10 % ) , and benign polyp disease ( 5 % ) . SSIs were identified in 45 patients ( 26 % ) . Twenty-two ( 49 % ) SSIs were detected in the outpatient setting following discharge . Of all preoperative and perioperative variables measured , increasing patient body mass index and intraoperative hypotension independently predicted incisional SSI . Although we could not measure statistically increased length of hospital stay associated with SSI , a representative population of patients with SSI accumulated a mean of $ 6200/patient of home health expenses related to wound care . Our rates of SSI were substantially higher than that reported generally in the literature , predicted by the National Nosocomial Infection System , or described by our own institutional surgical infection data base . Conclusions : The incidence of incisional SSI in patients undergoing elective colorectal resection in our cohort was substantially higher than generally reported in the literature , the NNIS or predicted by an institutional surgical infection complication registry . Although some of these differences may be attributable to patient population differences , we believe these discrepancies highlight the potential limitations of systematic outcomes measurement tools which are independent of the primary clinical care team . Accurate surgical complication documentation by the primary clinical team is critical to identify the true frequency and etiology of surgical complications such as incisional SSI , to rationally approach their reduction and decrease their associated costs to patients and the health care system BACKGROUND The utility of mechanical bowel preparation ( MBP ) to minimize infectious complications in elective colorectal surgery is contentious . Though data is scarce in children , adult studies suggest a benefit to MBP when administered with oral antibiotics ( OAB ) . METHODS After IRB approval , the Pediatric Health Information System ( PHIS ) was queried for young children undergoing elective colon surgery from 2011 to 2014 . Patients were divided into : no bowel preparation ( Group 1 ) , MBP ( Group 2 ) , and MBP plus OAB ( Group 3 ) . Statistical significance was determined using univariate and multivariate analysis with GEE models accounting for clustering by hospital . RESULTS One thous and five hundred eighty-one patients met study criteria : 63.7 % in Group 1 , 27.1 % in Group 2 , and 9.2 % in Group 3 .  Surgical complication rate was higher in Group 1 ( 23.3 % ) compared to Groups 2 and 3 ( 14.2 % and 15.5 % ; P<0.001 ) . However , median length of stay was shorter in Group 1 ( 4 , IQR 4days ) compared to Group 2 ( 5 , IQR 3 ) and Group 3 ( 6 , IQR 3 ) ( P<0.001 ) . 30-day readmission rates were similar . In multivariate analysis compared to patients in Group 1 , the odds of surgical complications were 0.72 ( 95 % CI 0.40 - 1.29 , P=0.28 ) with MBP alone ( Group 2 ) , 1.79 ( 95 % CI 1.28 - 2.52 , P=0.0008 ) with MBP+OAB ( Group 3 ) , and 1.13 ( 95 % CI 0.81 - 1.58 , P=0.46 ) for the aggregate Group 2 plus 3 . CONCLUSION Utilization of bowel preparation in children is variable across children 's hospitals nationally , and the benefit is unclear . Given the discrepancy with adult literature , a three-armed pediatric-specific r and omized controlled trial is warranted . LEVEL OF EVIDENCE Level III treatment study - retrospective comparative study
target: Conclusion Based on the current literature , there is insufficient evidence to indicate that the use of MBP leads to a significant difference in the risk of developing infectious complications in pediatric colorectal surgery
background: Objectives To evaluate whether the application of mechanical bowel preparation ( MBP ) before colorectal surgery reduces the risk of developing infectious complications in children .