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On effectiveness in colorectal surgery: mechanical bowel preparation or not in elective colonic surgery and treatment options for elderly patients with rectal cancer
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The management of patients undergoing colorectal surgery has changed in recent decades. Efforts have been made to show that perioperative physiological stress to the patient can be minimised with standardised care programmes and thus improve short term outcome after colorectal surgery. Mechanical bowel preparation (MBP), for instance, has been questioned as part of standard management. There are studies highlighting the effect of cancer treatment and its side effects in the elderly, showing that geriatric patients benefit from oncological therapy in much the same way as younger patients. The impact of this information on surgical and oncological practice in Sweden today is not known. To assess the effectiveness of colorectal surgery we need both randomised controlled trials and population-based cohort studies. We have performed a trial on colonic surgery with and without preoperative mechanical bowel preparation, as well as a nation-wide register study comparing treatment and outcome of rectal cancer in two age groups. In a randomised controlled trial 1505 patients from 21 hospitals were randomised to MBP or no-MBP prior to open elective colonic resection. There were no differences in overall complication rates between the groups: cardiovascular 5.1% with MBP vs. 4.6% without MBP; general infection 7.9% vs. 6.8%; and surgical site complications 15.1% vs. 16.1%. The proportion of patients reaching at least one primary endpoint was 24.5% vs. 23.7% respectively. The patients experience of and postoperative recovery after MBP or no-MBP was evaluated in 105 of the patients in the bowel preparation trial at three of the participating hospitals. Sixty-five patients received MBP and 40 patients did not. In the MBP group 52% needed assistance with bowel preparation. Day 4 postoperatively patients in the no-MBP group perceived more discomfort than patients in the MBP group, p<0.05. Bowel emptying occurred significantly earlier in the no-MBP group than in the MBP group, p<0.05.

In an experimental study the effect of MBP on intramucosal bacterial count was evaluated. Macroscopically normal colon mucosa was collected from 37 patients (20 MBP and 17 No-MBP) undergoing elective colorectal surgery at three hospitals. MBP did not influence the median colony count of E. coli, Bacteroides, or total median colony count, information that was previously unknown. These three studies imply that MBP can be omitted before elective colonic resection. In a population-based register study, treatment for rectal cancer in patients ≥ 75 years and those < 75 years was evaluated using data from the Swedish Rectal Cancer Register 1995-2004 (N=15104). This study revealed that preoperative radiotherapy was used less in patients > 75 years. There was also a higher threshold for surgery in this group, and they more often received a permanent stoma compared to younger patients. Outcome in terms of 5-year local recurrence rate and 5-year cancer-specific survival differed very little between the older and younger patient groups who underwent abdominal tumour resection with curative intent. We suggest future studies focusing on ways of reducing surgical and perioperative stress and on quality of life when assessing suitable treatment modalities for rectal cancer.

Place, publisher, year, edition, pages
Umeå: Kirurgisk och perioperativ vetenskap , 2008. , 74 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1176
Keyword [en]
colorectal surgery, bowel preparation, postoperative outcome, quality of life, cancer survival
National Category
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-1633ISBN: 978-91-7264-561-5 (print)OAI: oai:DiVA.org:umu-1633DiVA: diva2:141618
Public defence
2008-05-16, Sal B, 1D, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2008-05-02 Created: 2008-05-02 Last updated: 2015-09-01Bibliographically approved
List of papers
1. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection
Open this publication in new window or tab >>Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection
2007 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 6, 689-695 p.Article in journal (Refereed) Published
Abstract [en]

Background: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery.

Methods: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days.

Results: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not.

Conclusion: MBP does not lower the complication rate and can be omitted before elective colonic resection.

Place, publisher, year, edition, pages
John Wiley & Sons, 2007
Keyword
adult, aged, aged; 80 and over, anastomosis; surgical, cathartics, colonic diseases, enema, female, humans, male, middle aged, postoperative complications, sepsis, surgical procedures; elective, treatment outcome
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-10617 (URN)10.1002/bjs.5816 (DOI)000247152400007 ()17514668 (PubMedID)
Available from: 2008-10-07 Created: 2008-10-07 Last updated: 2015-09-01Bibliographically approved
2. Preoperative mechanical preparation of the colon: the patient's experience
Open this publication in new window or tab >>Preoperative mechanical preparation of the colon: the patient's experience
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2007 (English)In: BMC Surgery, ISSN 1471-2482, Vol. 7, 5- p.Article in journal (Refereed) Published
Abstract [en]

Background Preoperative mechanical bowel preparation can be questioned as standard procedure in colon surgery, based on the result from several randomised trials.

Methods As part of a large multicenter trial, 105 patients planned for elective colon surgery for cancer, adenoma, or diverticulitis in three hospitals were asked to complete a questionnaire regarding perceived health including experience with bowel preparation. There were 39 questions, each having 3 – 10 answer alternatives, dealing with food intake, pain, discomfort, nausea/vomiting, gas distension, anxiety, tiredness, need of assistance with bowel preparation, and willingness to undergo the procedure again if necessary.

Results 60 patients received mechanical bowel preparation (MBP) and 45 patients did not (No-MBP). In the MBP group 52% needed assistance with bowel preparation and 30% would consider undergoing the same preoperative procedure again. In the No-MBP group 65 % of the patients were positive to no bowel preparation. There was no significant difference between the two groups with respect to postoperative pain and nausea. On Day 4 (but not on Days 1 and 7 postoperatively) patients in the No-MBP group perceived more discomfort than patients in the MBP group, p = 0.02. Time to intake of fluid and solid food did not differ between the two groups. Bowel emptying occurred significantly earlier in the No-MBP group than in the MBP group, p = 0.03.

Conclusion Mechanical bowel preparation is distressing for the patient and associated with a prolonged time to first bowel emptying.

Place, publisher, year, edition, pages
BioMed Central, 2007
Keyword
Adenoma/*surgery, Aged, Colonic Neoplasms/*surgery, Defecation, Diverticulitis; Colonic/*diagnosis/*surgery, Enema, Female, Humans, Irrigation, Male, Patient Acceptance of Health Care, Patient Satisfaction, Preoperative Care, Recovery of Function, Surgical Procedures; Elective
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-10616 (URN)10.1186/1471-2482-7-5 (DOI)17480223 (PubMedID)
Available from: 2008-10-07 Created: 2008-10-07 Last updated: 2015-09-01Bibliographically approved
3. Mechanical bowel preparation does not affect the intramucosal bacterial colony count
Open this publication in new window or tab >>Mechanical bowel preparation does not affect the intramucosal bacterial colony count
Show others...
2010 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 25, no 4, 439-442 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon.

Materials and methods Macroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection.

Results MBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study.

Conclusions MBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.

Keyword
colorectal surgery, bacteria, colon mucosa, bowel preparation
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-3135 (URN)10.1007/s00384-009-0863-3 (DOI)000275104700004 ()
Note

Ingår i avhandling under titel: Does mechanical bowel preparation affect the intramucosal bacterial colony count?

Available from: 2008-05-02 Created: 2008-05-02 Last updated: 2015-09-01Bibliographically approved
4. Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish Rectal Cancer Registry 1995-2004
Open this publication in new window or tab >>Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish Rectal Cancer Registry 1995-2004
2009 (English)In: BMC Cancer, ISSN 1471-2407, Vol. 9, 68- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Limited information is available regarding the effect of age on choice of surgical and oncological treatment for rectal cancer. The objective of this study was to assess the influence of age on treatment and outcome of rectal cancer. METHODS: We utilized data in the Swedish Rectal Cancer Registry (SRCR) from patients treated for rectal cancer in Sweden in 1995-2004. RESULTS: A total of 15,104 patients with rectal cancer were identified, 42.4% of whom were 75 years or older. Patients > or = 75 years were less likely to have distant metastases than younger patients (14.8% vs. 17.8%, P < 0.001), and underwent abdominal tumor resection less frequently (68.5% vs. 84.4%, P < 0.001). Of 11,725 patients with abdominal tumor resection (anterior resection [AR], abdominoperineal excision [APE], and Hartmann's procedure [HA]), 37.4% were > or = 75 years. Curative surgery was registered for 85.0% of patients > or = 75 years and for 83.9% of patients < 75 years, P = 0.11. Choice of abdominal operation differed significantly between the two age groups for both curative and non-curative surgery, The frequency of APE was similar in both age groups (29.5% vs. 28.6%), but patients > or = 75 years were more likely to have HA (16.9% vs. 4.9%) and less likely to have preoperative radiotherapy (34.3 vs. 67.2%, P < 0.001). The relative survival rate at five years for all patients treated with curative intent was 73% (70-75%) for patients > or = 75 years and 78% (77-79%) for patients < 75 years of age. Local recurrence rate was 9% (8-11%) for older and 8% (7-9%) for younger patients. CONCLUSION: Treatment of rectal cancer is influenced by patient's age. Future studies should include younger and older patients alike to reveal whether or not age-related differences are purposive. Local recurrence following surgery for low tumors and quality of life aspects deserve particular attention.

National Category
Cancer and Oncology
Identifiers
urn:nbn:se:umu:diva-22053 (URN)10.1186/1471-2407-9-68 (DOI)19245701 (PubMedID)
Available from: 2009-04-22 Created: 2009-04-22 Last updated: 2015-09-01Bibliographically approved

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