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ANNSURG-D-15-01413

ORIGINAL ARTICLE

Benefits of Bowel Preparation Beyond Surgical Site Infection

A Retrospective Study
Azah A. Althumairi, MD,
Joseph K. Canner, MHS,y Timothy M. Pawlik, MD,
Eric Schneider, PhD,y
Neeraja Nagarajan, MD,y Bashar Safar, MD,
and Jonathan E. Efron, MD

demonstrated that the use of oral antibiotic bowel preparation

Objectives: To examine whether the administration of mechanical bowel
(OABP) along with MBP decreased infectious complications after
preparation (MBP) plus oral antibiotic bowel preparation (OABP) was
colectomy, combined MBP plus OABP became the standard of care
associated with reduced surgical site infections (SSIs), which in turn leads
for elective colon surgery.
to a reduction of nonSSI-related postoperative complications.
In 1972, Hughes6 questioned the benefit of MBP, when he
Background: Administration of f MBP/OABP before elective colectomy
published data demonstrating that septic and anastomotic compli-
reduces the incidence of SSI. We hypothesized that reduction of SSI is on
cations were not higher among patients with an unprepared bowel.
causal pathway between the use of MBP/OABP and the reduction of other
This perspective was further supported by Irving and Scrimgeour7
postoperative complications.
who reported no anastomotic complications in patients who did not
Methods: The study population consisted of all colectomy cases in the
receive MBP. A recent systematic review included 14 randomized
American College of Surgeons National Surgical Quality Improvement
controlled trials (RCTs) with a total of 2682 patients who received
Program Colectomy Targeted Participant Use Data File for 2012 and
MBP only and 2691 patients who underwent colorectal surgery
2013. Postoperative outcomes were compared based on the type of bowel
without MBP; there was no difference in the incidence of overall
preparation: none, MBP only, OABP only, and MBP plus OABP adjusting for
surgical site infection (SSI) (odds ratio [OR] 1.26, P 0.12),
other covariates.
wound infection (OR 1.21, P 0.05), anastomotic leak (OR
Results: The cohort included 19,686 patients. Of these 5060 (25.7%) patients
1.08, P 0.56), extra-abdominal septic complications (OR 0.98,
did not receive any form of bowel preparation, 8020 (40.7%) received MBP
P 0.81), reoperation (OR 1.11, P 0.42), and death (OR 0.97,
only, 641 (3.3%) received OABP only, and 5965 (30.3%) received MBP plus
P 0.88).8
OABP. Patients who received MBP plus OABP had a lower incidence of
Nevertheless, several large series have suggested a benefit of
superficial SSI, deep SSI, organ space SSI, any SSI, anastomotic leak,
MBP plus OABP.9,10 Morris et al11 demonstrated that patients who
postoperative ileus, sepsis, readmission, and reoperation compared with
received MBP plus OABP had a lower risk of SSI, wound dehiscence,
patients who received neither (all P < 0.01). The reduction in SSI incidence
anastomotic leak, and postoperative ileus. Furthermore, patients
was associated with a reduction in wound dehiscence, anastomotic leak,
treated with MBP plus OABP had a shorter length of stay (LOS),
pneumonia, prolonged requirement of mechanical ventilator, sepsis, septic
and were less likely to require reoperation or readmission. Studies
shock, readmission, and reoperation.
that noted an improvement in the postoperative outcomes have used
Conclusions: Combined MBP plus OABP before elective colectomy was
the combination of MBP and OABP, in contrast to the studies that
associated with reduced SSI, which ultimately was associated with a reduction
compared MBP only to no preparation and showed no differences in
in nonSSI-related complications.
the outcomes. Moreover, although previous studies have demon-
Keywords: colectomy, mechanical bowel preparation, oral antibiotics bowel strated the benefit of MBP plus OABP on a variety of outcomes, these
preparation, surgical site infection studies have not explored whether MBP plus OABP could influence
outcomes other than SSI.
(Ann Surg 2015;xx:xxxxxx) The differences in the studies outcomes have resulted in
controversy regarding bowel preparation for elective colectomy,
I n 1887, William Halsted was the first to propose the use of
mechanical bowel preparation (MBP) in an attempt to decrease
infectious complications and anastomotic dehiscence in elective
with lack of consensus on whether to administer MBP or not, and
whether concomitant OABP should be administered. The opponents
of MBP believe that it carries risk of electrolyte imbalance with
colectomy.1 Since then different MBP methods have been in practice, dehydration, prolonged ileus, and abdominal pain, all of which might
including special diets, cathartics, enemas and gut lavage,2,3 and the prolong the LOS and increase postoperative morbidity and the risk of
polyethylene glycol solution that is currently the preferred method readmission.12 Meanwhile, the advocates of MPB believe that it
for bowel preparation among surgeons owing to its lower systemic decreases wound and anastomosis-related complications.12,13
effects and impact on electrolytes. 4 When Nichols et al 5 Given the variation in the practice of bowel preparation before
elective colectomy, the objective of the current study was to inves-
From the
Department of Surgery, Johns Hopkins University School of Medicine, tigate the association between the combined use of MBP plus OABP
Baltimore, MD; and yCenter for Surgical Trials and Outcomes Research, Johns and the incidence of SSI. In addition, we sought to determine whether
Hopkins University School of Medicine, Baltimore, MD. this association might explain the reduction in other postoperative
Authors contributionsstudy concept, and design with data acquisition, analysis,
and interpretation: AAA, JKC, ES, NN, JEE. Drafting of the Manuscript:
outcomes, and provide support for the hypothesis that reduction of
AAA, JKC, JEE. Critical revision of the manuscript for important intellectual SSI is on causal pathway between the use of MBP/OABP and the
content: TMP, BS. reduction of other postoperative outcomes.
Disclaimers: The authors declare no conflict of interests.
Reprints: Jonathan E. Efron, MD, Department of Surgery, Johns Hopkins Uni-
versity School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD METHODS
21287. E-mail: jefron1@jhmi.edu.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
The study population consisted of all colectomy cases in the
ISSN: 0003-4932/14/26105-0821 American College of Surgeons National Surgical Quality Improve-
DOI: 10.1097/SLA.0000000000001576 ment Program (ACS NSQIP) Colectomy Targeted Participant Use

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Althumairi et al Annals of Surgery  Volume XX, Number X, Month 2015

Data File (PUF) for 2012 and 2013. Cases that were emergent or Mean patient age was 61.1 years, 9478 (48.1%) were male,
nonelective were excluded, as were cases with missing data for type and 41.9% of the cases were performed for the diagnosis of colon
of preoperative bowel preparation or for covariates included in the cancer (Table 1). Of note, 5060 (25.7%) patients did not receive any
final multivariable model. form of bowel preparation, 8020 (40.7%) received MBP only, 641
The primary outcomes of interest were wound dehiscence, (3.3%) received OABP only, and 5965 (30.3%) received combination
anastomotic leak, pneumonia, prolonged (>48 h) ventilation, urinary MBP plus OABP. Comparing the baseline characteristics across the
tract infection (UTI), systemic sepsis, septic shock, deep vein different types of bowel preparation method (Table 2), there was no
thrombosis (DVT), pulmonary embolism (PE), LOS, unplanned
readmission, unplanned reoperation, and mortality. All outcomes
occurring within 30 days of surgery were reported in the NSQIP
database. TABLE 1. Study Population Characteristics (n 19,686)
The primary independent variable of interest was the type of
preoperative bowel preparation administered. The Colectomy Age (mean), yrs 61.15
Targeted NSQIP includes data on both MBP and OABP. Patients Sex (%)
Male 9478 (48.15)
were divided into 4 groups: (1) no preoperative preparation, (2) MBP Female 10,208 (51.85)
only, (3) OABP only, and (4) MBP plus OABP. Other independent Race
variables of interest included age, sex, race, American Society of White 14,965 (76.02)
Anesthesiologists (ASA) class, smoking status, diabetes, history of African American 1504 (7.64)
congestive heart failure, history of chronic obstructive pulmonary Hispanic 2210 (11.23)
disease, body mass index (BMI), weight loss, indication for surgery, Other/unknown 1007 (5.12)
surgical approach (laparoscopic vs open), type of procedure, and ASA classification (%)
operative time. These variables were chosen based upon clinical ASA 2 10,591 (53.80)
grounds and findings from previous analyses of colectomy outcomes. ASA 3 8465 (43.00)
ASA 4 630 (3.20)
SSI within 30 days of surgery was also included as an independent BMI
variable, as it was hypothesized to be on the causal pathway between <18.5 441 (2.24)
preoperative bowel preparation and the outcomes in this study, 18.524.9 5741 (29.16)
based both on previous studies demonstrating the association 25.029.9 10,804 (54.88)
between preoperative bowel preparation and SSI911 and the associ- 30.0 2700 (13.72)
ation between SSI and other poor postsurgical outcomes.14,15 SSIs >10% weight loss in the last 6 mo (%) 713 (3.62)
were categorized a superficial, deep, or organ space. In addition, a Current smoker (%) 3277 (16.65)
composite dichotomous variable was created which was yes if the Diabetes mellitus (%) 2767 (14.06)
patient had any of the 3 types of SSI, and no if there was no SSI. Hypertension (%) 9282 (47.15)
History of CHF (%) 95 (0.48)
Patient characteristics across the 4 preoperative bowel prep- History of COPD (%) 848 (4.31)
aration groups were analyzed using frequencies for categorical Ascites (%) 61 (0.31)
variables and medians and interquartile ranges for continuous vari- On hemodialysis (%) 76 (0.39)
ables. Chi-square tests and Kruskal-Walli tests were used to test for On steroid use for chronic conditions (%) 1503 (7.63)
differences between the 4 groups. Chi-square tests and Wilcoxon Received >4 units blood transfusion in 155 (0.79)
rank-sum tests were used to test for associations between SSI and 72 h before surgery (%)
other outcomes. Logistic regression was used to fit a multivariable Indication for surgery (%)
model of the relationship between binary outcomes and type of Colon cancer 8252 (41.92)
preoperative bowel preparation, adjusting for other covariates. Sim- Ulcerative colitis 350 (1.78)
Crohn disease 1197 (6.08)
ilarly, negative binomial regression was used to model the relation- Diverticular disease 4565 (23.19)
ship between LOS and type of preoperative bowel preparation. For Other 5322 (27.03)
each outcome, 4 models were fit: (1) type of preoperative bowel Bowel preparation (%)
preparation only, (2) type of preoperative bowel preparation plus SSI, None 5060 (25.70)
(3) type of preoperative bowel preparation plus all covariates except MBP only 8020 (40.74)
for SSI, and (4) model 3 plus any SSI. Model 1 was compared with OABP only 641 (3.26)
model 2, whereas model 3 was compared with model 4. If the P value MBP and OABP 5965 (30.30)
for preoperative bowel preparation went from significant (P < 0.05) Approach
to nonsignificant (P > 0.05) between the 2 models, we concluded that Open 7389 (37.53)
Laparoscopic 12,297 (62.47)
SSI could be on the causal pathway between preoperative bowel Procedure
preparation and that outcome. Ileocolic resection 4284 (21.76)
All analyses were performed using Stata 12.1 (StataCorp, Partial colectomy 8444 (42.89)
College Station, TX). Total colectomy 888 (4.51)
Hartmann/LAR 6070 (30.83)
Stoma
RESULTS Yes 2126 (10.80)
A total of 38,486 colectomy cases were identified in the No 17,560 (89.20)
NSQIP Colectomy Targeted PUF. Of these 11,784 were excluded Operative time
<3 h 11,474 (58.30)
because the cases were emergent or nonelective. An additional 6886 35 h 6231 (31.66)
cases were excluded because they were missing information on >5 h 1977 (10.04)
preoperative bowel preparation, and 130 cases were excluded
because of missing data in the multivariable regression covariates, CHF indicates congestive heart failure, COPD, chronic obstructive pulmonary
disease.
resulting in a study cohort of 19,686 cases.

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Annals of Surgery  Volume XX, Number X, Month 2015 Benefits of Bowel Preparation

TABLE 2. Patient Characteristics According to Preoperative Bowel Preparation

None, MBP Only, OABP Only, MBP and OABP,
N 5060 N 8020 N 641 N 5965
(25.70%) (40.74%) (3.26%) (30.30%) P
Median (IQR) age (yrs) 62 (5273) 62 (5272) 60 (4670) 62 (5271) <0.001
Sex (%)
Male 2397 (25.29) 3872 (40.85) 309 (3.26) 2900 (30.60) 0.614
Female 2663 (26.09) 4148 (40.63) 332 (3.25) 3065 (30.03)
Race
White 3626 (24.23) 6030 (40.29 80 (3.21) 4829 (32.27) <0.001
African American 396 (26.33) 618 (41.09) 56 (3.72) 434 (28.86)
Hispanic 815 (36.88) 929 (42.04) 66 (2.99) 400 (18.10)
Other/unknown 223 (22.14) 443 (43.99) 39 (3.87) 302 (29.99)
ASA classification (%)
ASA 2 2611 (24.65) 4282 (40.43) 362 (3.42) 3336 (31.50) <0.001
ASA 3 2265 (26.76) 3495 (41.29) 255 (3.01) 2450 (28.94)
ASA 4 184 (29.21) 243 (38.57) 24 (3.81) 179 (28.41)
BMI
<18.5 142 (32.20) 159 (36.05) 21 (4.76) 119 (26.98) <0.001
18.524.9 1578 (27.49) 2283 (39.77) 220 (3.83) 1660 (28.91)
25.029.9 2700 (24.99) 4433 (41.03) 323 (2.99) 3348 (30.99)
30.0 640 (23.70) 1145 (42.41) 77 (2.85) 838 (31.04)
>10% weight loss in the last 6 mo (%) 206 (28.89) 269 (37.73) 30 (4.21) 209 (29.17) 0.074
Current smoker (%) 833 (25.42) 1306 (39.85) 108 (3.30) 1030 (31.43) 0.46
Diabetes mellitus (%) 667 (24.11) 1184 (42.79) 76 (2.75) 840 (30.36) 0.028
Hypertension (%) 2342 (25.23) 3920 (42.23) 269 (2.90) 2751 (29.64) <0.001
History of CHF (%) 32 (25.66) 37 (39.95) 1 (1.05) 25 (26.32) 0.22
History of COPD (%) 219 (25.83) 349 (41.16) 20 (2.36) 260 (30.66) 0.52
Ascites (%) 31 (50.82) 25 (40.98) 0 (0) 5 (8.20) <0.001
On hemodialysis (%) 27 (35.53) 32 (42.11) 2 (2.63) 15 (19.74) 0.12
On steroid use for chronic conditions (%) 491 (32.67) 452 (30.07) 100 (6.65) 460 (30.61) <0.001
Received >4 units blood transfusion in 72 h before surgery (%) 58 (37.42) 65 (41.94) 7 (4.52) 25 (16.13) <0.001
Indication for surgery (%)
Colon cancer 2105 (25.51) 3542 (42.92) 217 (2.63) 2388 (28.94) <0.001
Ulcerative colitis 135 (38.57) 86 (24.57) 23 (6.57) 106 (30.29)
Crohn disease 424 (35.42) 324 (27.07) 110 (9.19) 339 (28.32)
Diverticular disease 788 (17.26) 1968 (43.11) 135 (2.96) 1674 (36.67)
Other 1608 (30.21) 2100 (39.46) 156 (2.93) 1458 (27.40)
Approach (%)
Open 2196 (29.72) 2838 (38.41) 234 (3.17) 2121 (28.70) <0.001
Laparoscopic 2864 (23.29) 5182 (42.14) 407 (3.31) 3844 (31.26)
Procedure
Ileocolic resection 1502 (35.06) 1475 (34.43) 184 (4.30) 1123 (26.21) <0.001
Partial colectomy 1981 (23.46) 3438 (40.72) 250 (2.96) 2775 (32.86)
Total colectomy 290 (32.66) 299 (33.67) 39 (4.39) 260 (29.28)
Hartmann/LAR 1287 (21.20) 2808 (46.26) 168 (2.77) 1807 (29.77)
Stoma
Yes 677 (31.84) 807 (37.96) 83 (3.90) 559 (26.29) <0.001
No 4383 (24.96) 7213 (41.08) 558 (3.18) 5406 (30.79)
Operative time
<3 h 3056 (26.63) 4680 (40.79) 362 (3.15) 3376 (29.42) 0.004
35 h 1509 (24.22) 2547 (40.88) 218 (3.50) 1957 (31.41)
>5 h 493 (24.94) 792 (40.06) 60 (3.03) 632 (31.97)
CHF indicates congestive heart failure, COPD, chronic obstructive pulmonary disease, IQR, interquartile range.

difference in sex distribution among the 4 groups; patients with ASA
classification 1 to 3 were more likely to have received MBP only vs
patients with ASA classification 4 to 5, and patients with a lower
BMI were more likely to have received no bowel preparation
compared with patients who had a higher BMI. Bowel preparation
did vary by surgical indication. For example, 42.9% of patients with
colon cancer and 43.11% of patients with diverticular disease
received MBP only, whereas 38.6% of patients with ulcerative colitis
and 35.4% of patients with Crohn disease did not receive any bowel
preparation (P < 0.001). Among patients who underwent laparo-
scopic surgery, 42.1% received MBP only, 31.3% received MBP plus
OABP, whereas 23.3% did not receive any bowel preparation.
On univariable analysis comparing postoperative outcomes
based on the type of bowel preparation, several factors were associ-
ated with improved outcomes (Table 3). Specifically, better outcomes
in superficial SSI, deep SSI, organ space SSI, any SSI, anastomotic
leak, postoperative ileus, sepsis, readmission, and reoperation
were noted among patients who received MBP plus OABP vs no

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Althumairi et al Annals of Surgery  Volume XX, Number X, Month 2015

TABLE 3. Event Rates According to Preoperative Bowel Preparation

None, MBP Only, OABP Only, MBP and OABP,
N 5060 (25.70%) N 8020 (40.74%) N 641 (3.26%) N 5965 (30.30%) P
Superficial SSI 378 (7.47) 532 (6.63) 29 (4.52) 187 (3.13) <0.001
Deep SSI 69 (1.36) 84 (1.05) 5 (0.78) 39 (0.65) 0.002
Organ space SSI 272 (5.38) 336 (4.19) 22 (3.43) 166 (2.78) <0.001
Any SSI 692 (13.68) 922 (11.50) 54 (8.42) 374 (6.27) <0.001
Wound dehiscence 45 (0.89) 66 (0.82) 1 (0.16) 34 (0.57) 0.055
Anastomotic leak 220 (4.38) 288 (3.60) 18 (2.81) 139 (2.33) <0.001
Postoperative ileus 703 (13.96) 981 (12.26) 67 (10.47) 584 (9.80) <0.001
Pneumonia 90 (1.78) 113 (1.41) 7 (1.09) 63 (1.06) 0.012
Prolonged ventilation 67 (1.32) 77 (0.96) 5 (0.78) 48 (0.80) 0.044
UTI 119 (2.35) 208 (2.59) 16 (2.50) 130 (2.18) 0.459
Sepsis 175 (3.46) 214 (2.67) 21 (3.28) 125 (2.10) <0.001
Septic shock 66 (1.30) 96 (1.20) 5 (0.78) 47 (0.79) 0.034
DVT 55 (1.09) 68 (0.85) 3 (0.47) 70 (1.17) 0.115
PE 23 (0.45) 42 (0.52) 1 (0.16) 36 (0.60) 0.411
Readmission 550 (10.87) 739 (9.21) 57 (8.89) 485 (8.13) <0.001
Reoperation 245 (4.84) 372 (4.64) 29 (4.52) 202 (3.39) <0.001
Mortality 57 (1.13) 51 (0.64) 3 (0.47) 26 (0.44) <0.001
Median (IQR) LOS (d) 5 (47) 5 (47) 5 (47) 5 (36) <0.001
IQR indicates interquartile range.

preparation, MBP only, or OABP only (all P < 0.05). In most cases,
MBP plus OABP was better than OABP only, which was better than
MBP only, and all types of bowel preparation were better than no
bowel preparation. Outcomes not associated with bowel preparation
included wound dehiscence, UTI, DVT, and PE. Based on these
results and data from previous studies,9 11 subsequent analyses
were focused on the comparison between MBP plus OABP vs no
preoperative bowel preparation.
Using univariable analysis to examine the relationship
between SSIs and postoperative outcomes, occurrence of superficial
SSI was associated with worse overall outcomes except for failure
to wean from mechanical ventilator, PE, and mortality. A similar
association was noted with the occurrence of deep SSI, which was
associated with worse outcomes except for DVT and mortality. In
addition, occurrence of organ space SSI and any SSI was associated
with poor outcomes (Table 4). Based on these results, we then
analyzed SSI as a composite variable (ie, superficial, deep, organ
space).
Table 5 shows the results of the 4 models that were fit in
this study. These models are summarized below. In model 1, the
univariable association between preoperative bowel preparation and
each outcome was assessed. The use of MBP plus OABP was
associated with a marked reduction in all adverse outcomes except
for UTI, DVT, and PE. In most cases, these associations were highly
significant (P < 0.001), with the exception of wound dehiscence
(P 0.049), prolonged ventilation (P 0.008), and septic shock
(P 0.008).
In model 2, when the composite SSI variable was added to
model 1, the use of preoperative bowel preparation was no longer
associated with wound dehiscence, anastomotic leak, prolonged
ventilation, systemic sepsis, septic shock, unplanned readmission,
and unplanned reoperation. In addition, the increase in the ORs for
these outcomes ranged from 37% to 146%. Only ileus, pneumonia,
death, and LOS remained associated with preoperative bowel prep-
aration after adding SSI to the model. Although pneumonia was still
associated with preoperative bowel preparation, the association was
much weaker than in model 1 (P 0.038 vs P < 0.001).
In model 3, most of the outcomes that were associated with
preoperative bowel preparation in model 1 remained so after the
addition of other covariates, with the exception of prolonged
ventilation and septic shock, both of which had P value just above
0.05 (P 0.061 and P 0.11, respectively). As noted above, both of
these outcomes had the weakest association with preoperative bowel
preparation in model 1 (both P 0.008).
Finally, in model 4, similar to the pattern observed between
model 1 and model 2, after adding SSI to model 3, only ileus, death,
and LOS remained associated with preoperative bowel preparation
and all of the other outcomes were no longer associated with
preoperative bowel preparation. The increases in the ORs for these
outcomes ranged from 24% to 76%. Pneumonia was the only out-
come that showed a different pattern from the previous models.
Between models 1 and 2, the association between pneumonia and
preoperative bowel preparation went from highly significant to
marginally significant (P 0.001 to P 0.038), whereas between
models 3 and 4, the association went from marginally significant to
not significant (P 0.048 to P 0.31).
Missing Data
Of the 6886 patients excluded from this study because of
missing information on preoperative bowel preparation, 1720 were
only missing information on MBP, 1550 were only missing infor-
mation on antibiotic use, and 3616 were missing both. To assess the
possible bias associated with missing data, we repeated the analysis
twice: (1) assuming that patients with missing bowel preparation data
did not have that type of bowel preparation, and (2) assuming that
patients with missing data did have that type of bowel preparation.
The results based on this imputation were very similar to the main
results, both with respect to the relationship between preoperative
bowel preparation and each of the outcomes, and the relationship
between SSI and each of the outcomes. The multivariable models
based on imputation differed in a number of ways from the corre-
sponding results in Table 5; however, when comparing model 2 to
model 1 and model 4 to model 3, the imputed results consistently
showed a lowering of significance when adding SSI to the model,
consistent with the main results.
Subgroup Analysis
Based on the results from Table 2, which show a wide variety
of practices surrounding preoperative bowel preparation by indica-
tion for surgery, procedure type, and surgical approach (open or

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Annals of Surgery  Volume XX, Number X, Month 2015 Benefits of Bowel Preparation

<0.001
0.001
<0.001
<0.001
<0.001

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001

<0.001
<0.001
P laparoscopic), we performed a series of subgroup analyses to deter-
mine whether the main results were consistent across the different
subgroups. First, the association between the use of MBP plus OABP
and reduction in SSI was present for all indications for surgery
(10.08)
(0.43)
(0.77)

(1.03)
(0.60)

(1.96)
(0.90)
(0.41)
(0.82)
(0.44)
(6.59)

401 (2.27)

110 (0.62)
5.52 (4.14)
(all P < 0.05) and for both open and laparoscopic approaches (all
No
Any SSI

P < 0.001). This association was also present for all procedure types
76

73

78
1776

1162
135

181
106

345
159

144
except for total colectomy (P < 0.001 and P 0.12, respectively).
N (%)

The association between incidence of SSI and incidence of

other outcomes was nearly universal, with P < 0.001 for most
(26.06)
(27.49)

(18.41)

(32.76)

447 (21.89)
(3.43)

(4.51)
(4.46)

(6.27)

(6.90)
(2.55)
(1.18)

27 (1.32)
10.37 (9.85)
subgroups and most outcomes and P < 0.05 for all outcomes and
subgroups except for pneumonia among patients with total colec-
Yes

tomy (P 0.23).
530
560

128
376
141

669
70

92
91

52
24
The association between preoperative bowel preparation and
outcome (model 1) varied by subgroup and outcome in ways that
were consistent with the overall results and the smaller sample size
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001

<0.001
<0.001
P

for each subgroup. The effect of adding SSI (model 2) varied

accordingly, but in almost every case the OR increased and the
significance level decreased between model 1 and model 2.
(10.79)
Organ Space SSI

(0.64)
(1.02)

(1.15)
(0.68)

(2.17)
(1.33)
(0.54)
(0.84)
(0.46)
(7.61)

499 (2.64)

114 (0.60)
5.69 (4.39)
No

DISCUSSION
2033

1438
120
192

218
128

410
252
102
159
86

Nosocomial infections including SSI, pneumonia, and UTI are

N (%)

the most frequent complications in surgical patients.16 Patients

(59.72)
(37.99)

(35.55)
(14.07)

(49.37)

349 (43.84)

13.90 (12.68)

undergoing colectomy are at increased risk of infectious compli-

(3.27)

(6.91)
(8.67)

(7.91)

(4.65)
(2.01)

23 (2.89)

cations because of the high bacterial load in the colon.17 The role of
Yes

prophylactic MBP plus OABP in reducing SSI after elective colec-

473
302

283
112

393
26

55
69

63

37
16

tomy has been questioned in the last decade. In this study we found
that the use of MBP plus OABP significantly reduced superficial SSI,
deep SSI, organ space SSI, and anastomotic leak, which is consistent
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001
<0.001
<0.001
0.141
0.048
<0.001

<0.001

0.588
<0.001

with the other studies that have shown benefits of preoperative MBP
P

plus OABP. Kim et al10 recently published results from the Michigan
Surgical Quality Collaborative Colectomy Project, and reported that
the administration of MBP plus OABP was associated with lower
(11.66)
(0.57)
(3.20)

(1.33)
(0.94)

(2.36)
(2.58)
(0.98)
(0.99)
(0.51)
(8.95)

788 (4.04)

135 (0.69)
5.96 (5.11)
TABLE 4. Univariable Analysis of the Association Between SSI and Outcomes

incidence of superficial SSI (3.0% vs 6.0%) and organ space

Deep SSI
No

infection (1.6% vs 3.1%). Cannon et al9 reported similar results

2267

1745
122
622

260
184

460
503
191
192
99

from the Veterans Affairs Surgical Quality Improvement Program,

N (%)

where patients receiving MBP plus OABP had a 57% decrease in

SSI. Recent reports by Morris et al11 and Kiran et al18 used the ACS
(17.26)
(22.16)
(34.87)

(16.24)
(11.68)

(43.65)

60 (30.46)

12.36 (11.47)
(6.60)
(6.60)

(6.60)

(2.03)
(1.52)

2 (1.02)

NSQIP Targeted Colectomy file to show that MPB plus OABP was
Yes

associated with lower incidence of SSI, anastomotic leak, ileus,

34
43
68
13
13

13
32
23

86
4
3

and readmission.
In contrast, the literature on the role of MBP is mixed. Most
trials are too small to provide definitive conclusions, with some
0.0139

suggesting that MBP is harmful, some showing no benefit, and some

0.043
0.007
<0.001
0.003
0.077

<0.001
<0.001
0.022

0.355
<0.001

0.001

0.157
<0.001

suggesting the MBP may be beneficial.19 21 A 2011 Cochrane

P

review included 18 RCTs with 5805 patients, 2906 who received

MBP and 2899 who did not receive MBP. This review noted no
(11.38)

differences in anastomotic leak and wound infection, and concluded

Superficial SSI

(0.71)
(3.30)

(1.33)
(0.97)

(2.24)
(2.39)
(1.05)
(0.97)
(0.51)
(8.69)

778 (4.19)

133 (0.72)
5.91 (5.18)

that there was no evidence that patients benefit from MBP; as such, it
No

was recommended that MBP could be safely omitted in colon

2107

1612
132
611

246
180

415
443
194
180
94

surgery.22 A similar review by Dahabreh et al23 included 18 RCTs,

N (%)

7 nonrandomized comparative studies, and 6 single-group cohort

studies of at least 200 patients in their analysis. Interventions
(20.30)

(19.45)
(1.24)
(4.80)

(2.40)
(1.51)

(5.15)
(8.17)
(1.78)
(1.42)
(0.71)

70 (6.22)

4 (0.36)
7.94 (5.95)

included MBP only and no MBP. Co-intervention included oral or

Yes

parenteral antibiotics and/or enema. The authors did not find evi-
8
228

219

dence of clear benefit from bowel preparation, based both on the

14
54

27
17

58
92
20
16

pooled results and the fact that the trials were underpowered, with
poorly defined outcomes, and compared different regimens of bowel
Wound dehiscence
Anastomotic leak

preparation that are no longer in use.

Systemic sepsis

readmission

reoperation
ventilation

Although the evidence for MBP is mixed, the evidence

LOS (SD) (d)
Septic shock

supporting the use of MBP plus OABP is more clear. A 2014

Pneumonia

Unplanned

Unplanned
Prolonged
Outcome

Mortality

Cochrane review on antimicrobial prophylaxis for colorectal surgery

found that antibiotics delivered orally or intravenously (or both)
DVT
Ileus

UTI

PE

before colorectal surgery reduce the risk of SSI.24 This is consistent

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Althumairi et al Annals of Surgery  Volume XX, Number X, Month 2015

TABLE 5. Odds Ratio for MBP Plus OABP vs No Bowel Preparation

Model 1 Model 2 Model 3 Model 4
Univariable Model Model 1 Any SSI Multivariable Model Model 3 Any SSI
Outcome OR (P) OR (P) OR (P) OR (P)
Wound ehiscence 0.64 (0.049) 0.86 (0.53) 0.64 (0.040) 0.82 (0.41)
Anastomotic leak 0.52 (<0.001) 0.95 (0.65) 0.54 (<0.001) 0.95 (0.68)
Ileus 0.67 (<0.001) 0.75 (<0.001) 0.74 (<0.001) 0.82 (0.002)
Pneumonia 0.59 (0.001) 0.71 (0.038) 0.71 (0.048) 0.84 (0.31)
Prolonged ventilation 0.60 (0.008) 0.81 (0.26) 0.69 (0.061) 0.90 (0.62)
UTI 0.92 (0.54) 1.06 (0.64) 1.02 (0.87) 1.15 (0.31)
Systemic sepsis 0.60 (<0.001) 1.00 (0.99) 0.64 (<0.001) 1.01 (0.95)
Septic shock 0.60 (0.008) 0.95 (0.81) 0.73 (0.11) 1.15 (0.51)
DVT 1.08 (0.67) 1.24 (0.24) 1.17 (0.40) 1.31 (0.15)
PE 1.33 (0.29) 1.49 (0.14) 1.29 (0.36) 1.41 (0.22)
Unplanned Readmission 0.73 (<0.001) 0.91 (0.16) 0.76 (<0.001) 0.94 (0.37)
Unplanned reoperation 0.69 (<0.001) 0.99 (0.91) 0.71 (0.001) 1.00 (0.97)
Mortality 0.38 (<0.001) 0.41 (<0.001) 0.49 (0.004) 0.52 (0.008)
LOS (IRR) 0.83 (<0.001) 0.88 (<0.001) 0.88 (<0.001) 0.92 (<0.001)

with the results from a meta-analysis which concluded that combi-
nation of OABP and intravenous antibiotics significantly lowers the
incidence of SSI compared with intravenous antibiotics alone.25
Fry12 also concluded, based on a review of 70 years of surgical
literature, that MPB alone does not reduce rates of SSI, whereas oral
antibiotics plus intravenous antibiotics is superior to either intra-
venous antibiotics alone or MBP. What is less clear is whether OABP
plus MBP provides any advantage over OABP alone. RCTs have not
examined this question, and observational studies such as the current
study and others using the NSQIP do not have sufficient numbers of
patients on OABP alone to address this question.11,18
The current study extends the findings of previous randomized
and nonrandomized studies by addressing the question of whether
OABP plus MBP can reduce the incidence of systemic complications
such as pneumonia, prolonged intubation, and sepsis. Kiran et al18
observed an association between the use of OABP plus MBP and
reductions in systemic complications, but did not draw any con-
clusions from these findings, nor did they attempt to propose a
mechanism for this association. Many previous studies have shown
the impact of the occurrence of an SSI on prolonged LOS, increased
hospital cost, and increased morbidity.14,15,26 28 Similarly, in this
study we were able to demonstrate that the reduction in SSI associ-
ated with the use of MBP plus OABP was also associated with a
reduction in wound dehiscence, anastomotic leak, pneumonia, pro-
longed ventilation, sepsis, septic shock, and unplanned reoperation
and readmission. This shows that reduction in SSI associated
with preoperative bowel preparation may extend well beyond the
prevention of SSI, perhaps also influencing the incidence of other
complications and potentially reducing the cost and morbidity
associated with readmission and reoperation.
We also observed a reduction in postoperative ileus, mortality,
and LOS in patients who received MBP plus OABP, but the reduction
in SSI seemed to play only a small role in the reduction in these
outcomes that have a complex set of causes. More research is
necessary to determine how much bowel preparation contributes
to improvements in these outcomes in relation to other factors that
are also associated with these outcomes. Furthermore, we found that
there are some postoperative outcomes that were not influenced by
the administration of MBP plus OABP including UTI, DVT, and PE.
Currently, there is no consensus on the optimum bowel
preparation method and whether bowel preparation should be per-
formed or not before elective colectomy. This was demonstrated by
the 2010 survey conducted by the American Society of Colon and
Rectal Surgery, which noted that 76% of surgeons routinely use
MBP, 19% selectively use it, 36% use MBP plus OABP, whereas 4%
do not use any method of bowel preparation.29 The lack of standard-
ization of care and the presence of conflicting evidence in the
literature clearly show the complexity of the problem, and the
difficulty in determining the best preparation method and its impact
on wound and nonwound-related outcomes.
There are some limitations to our study. The design of the
NSQIP data extraction protocol limited our ability to determine
which antibiotic and bowel preparations were used; furthermore,
the bowel preparation data recorded in the database reflect what was
prescribed in the patient medical record, and we cannot determine for
certain whether patients took the preparation or not. In addition, there
may be confounding variables not recorded in this database that may
be associated both to the prescription of antibiotics and bowel
preparation products and also to the development of postoperative
complications. Finally, our analysis depends on the observation of
associations that are not statistically significant. In general, non-
significant association could be due to a lack of statistical power;
however, adding a single variable to a regression variable should not
cause significant changes in significance related to statistical power.
In addition, both the univariable and multivariable models presented
show similar findings, suggesting that statistical power does not play
much of a role in our results.
Despite these limitations, using the NSQIP database provides
a large sample from a diverse selection of hospitals throughout the
United States, which gives the ability to adjust for a number of
confounding factors and draw reasonable conclusions regarding the
impact of an intervention such as bowel preparation on postoperative
outcomes.
CONCLUSIONS
Combined MBP and OABP before elective colectomy is
associated with a decrease in wound-related complications which
is, in turn, associated with a reduction in nonwound-related com-
plications and better overall postoperative outcomes. Continued use
of combined MBP and OABP before elective colectomy is recom-
mended based on our study. Prospective trials are needed to establish
the causal pathway that leads to improvement in nonwound-related
outcomes in patients undergoing bowel preparation.

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CE: ; ANNSURG-D-15-01413; Total nos of Pages: 7;
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Annals of Surgery  Volume XX, Number X, Month 2015
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