CLINICAL PRACTICE GUIDELINES

The American Society of Colon and Rectal Surgeons

Clinical Practice Guidelines for the Use of Bowel
Preparation in Elective Colon and Rectal Surgery
John Migaly, M.D.1 • Andrea C. Bafford, M.D.2 • Todd D. Francone, M.D., M.P.H.3
Wolfgang B. Gaertner, M.D., M.Sc.4 • Cagla Eskicioglu, M.D., M.Sc., F.R.C.S.C.5
Liliana Bordeianou, M.D., M.P.H.3 Daniel L. Feingold, M.D.6 • Scott R. Steele, M.D., M.B.A.7
On behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons
1 Department of Surgery, Duke University School of Medicine, Durham, North Carolina
2 Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
3 Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
4 Division of Colorectal Surgery, University of Minnesota Health, Minneapolis, Minnesota
5 Department of Surgery, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
6 Department of Surgery, Columbia University Irving Medical Center, New York, New York
7 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio

T
he American Society of Colon and Rectal Surgeons guidelines. It should be recognized that these guidelines
is dedicated to assuring high-quality patient care should not be deemed inclusive of all proper methods of
by advancing the science, prevention, and manage- care or exclusive of methods of care reasonably directed
ment of disorders and diseases of the colon, rectum, and to obtaining the same results. The ultimate judgment re-
anus. The Clinical Practice Guidelines Committee is com- garding the propriety of any specific procedure must be
posed of Society members who are chosen because they made by the physician in light of all of the circumstances
have demonstrated expertise in the specialty of colon and presented by the individual patient.
rectal surgery. This committee was created to lead inter-
national efforts in defining quality care for conditions re-
STATEMENT OF THE PROBLEM
lated to the colon, rectum, and anus. This is accompanied
by developing clinical practice guidelines based on the Bowel preparation has been used in colon and rectal sur-
best available evidence. These guidelines are inclusive and gery for a variety of reasons. A clean colon is thought to
not prescriptive. Their purpose is to provide information facilitate bowel manipulation, enable passage and firing
on which decisions can be made rather than to dictate a of surgical staplers, and allow for intraoperative colonos-
specific form of treatment. These guidelines are intended copy, if needed. The most studied and debated aspect of
for the use of all practitioners, healthcare workers, and bowel preparation, however, is its role in reducing surgi-
patients who desire information about the management cal morbidity, namely surgical site infections (SSIs). Co-
of the conditions addressed by the topics covered in these lon and rectal surgery has among the highest rates of SSIs
reported for all types of elective surgery, with recent re-
views demonstrating rates varying from 5.4% to 23.2%,
Link to access Supplemental Digital Content 1 and 2, evidence tables, with a weighted mean of 11.4%.1 Colorectal SSI rates are
http://links.lww.com/DCR/A794 and search strategy at http://links.lww. of particular interest currently because US hospitals are
com/DCR/A795.
mandated to report rates of colorectal SSIs to the National
Funding/Support: None reported. Healthcare Safety Network.
A complete description of the evolution of bowel
Financial Disclosure: None reported. preparation as a means to reduce SSI is beyond the scope
of this clinical practice guideline. Briefly, although Wil-
Correspondence: Scott R. Steele, M.D., M.B.A., 9500 Euclid Ave/A30, liam Halsted introduced the concept in the late 1800s, an-
Cleveland Clinic, Cleveland, OH, 44915. E-mail: [email protected]
tiseptic technique was not widely adopted until well into
Dis Colon Rectum 2019; 62: 3–8 the 20th century. After the development of aerobic and
DOI: 10.1097/DCR.0000000000001238 anaerobic cell culture, it became increasingly recognized
© The ASCRS 2018 that a high bacterial count in the colon was a source of
DISEASES OF THE COLON & RECTUM VOLUME 62: 1 (2019) 3

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 4 MIGALY ET AL: ELECTIVE SURGERY BOWEL PREPARATION

SSI. Mechanical bowel preparation (MBP) was used as a tice Guidelines Committee worked in joint ­production
means of decreasing intraluminal bacterial concentration of these guidelines from inception to final publication.
in hopes of reducing infection rates. Eventually, nonab- Recommendations formulated by the subcommittee were
sorbable antibiotics were added to bowel preparations to reviewed by the entire Clinical Practice Guidelines Com-
further reduce intestinal bacterial content. By the 1970s, mittee. Final recommendations were approved by the
use of an MBP with both oral and intravenous antibiotics ASCRS Executive Committee. In general, each ASCRS
was generally accepted.2 Clinical Practice Guideline is updated every 5 years.
In the late 20th century, data emerged suggesting that
elimination of MBP does not lead to increased morbid-
ity. The majority of these studies, however, did not include BOWEL PREPARATIONS
oral antibiotics. Recently, there has been a general trend of
reintroducing oral antibiotics into preoperative MBP. Sev- 1. MBP combined with preoperative oral antibiotics is
eral surgical units have published results showing reduced typically recommended for elective colorectal resections.
SSIs after introducing SSI bundles that include MBP along Grade of Recommendation: Strong recommendation
with oral antibiotics.3–5 This clinical practice guideline re- based on moderate-quality evidence, 1B.
views the evidence for the various methods and strategies Early studies examined the impact of preoperative enter-
for bowel preparation in elective colon and rectal surgery. al preparations on SSI, correlating cultures from colonic
Link to access Supplemental Digital Content 1, Evidence specimens and subsequent wound infections.8–10 It be-
Tables, http://links.lww.com/DCR/A794. came evident that appropriate antibiotic coverage of gut
flora would require both aerobic and anaerobic antisep-
sis.11,12 The landmark prospective, randomized controlled
METHODOLOGY
trial and subsequent retrospective analyses by Nichols et
An organized search of MEDLINE, Embase, and the Co- al13,14 compared MBP with MBP plus nonabsorbable oral
chrane Database of Collected Reviews was performed antibiotics and demonstrated a marked decrease in SSI
for the period of January 1, 1945, to March 1, 2018. The with combination therapy. Thus, for >3 decades the com-
complete search strategy is included (Supplemental Digi- bination of antibiotics and oral purgatives described in the
tal Content 2, http://links.lww.com/DCR/A795). In brief, original article and commonly referred to as the Nichols’
a total of 1516 unique journal titles were identified. Ini- prep has been the most widely used manner of prepara-
tial review of the search results led to the exclusion of 748 tion before bowel surgery.13,14 Clarke et al15 demonstrated
titles based on either irrelevance of the title or the jour- a reduction in postoperative complications in patients
nal. Secondary review resulted in the exclusion of another who received both enteral antibiotics and MBP not only
441 titles considered irrelevant or outdated. A tertiary in overall SSI but also specifically in the incidence of anas-
review of the remaining 307 titles included assessment of tomotic leak. The findings by Nichols et al13,14 and Clarke
the abstract or full-length article. This led to exclusion of et al15 were reproduced in a subsequent trial and were
an additional 240 titles for which similar but higher-level verified in subsequent meta-analyses.16,17 Multiple studies
evidence was available. The remaining 54 titles were con- have also shown the benefit of combined MBP and oral
sidered for grading of the recommendations. A directed antibiotics in reducing SSI rates, hospital length of stay,
search of references embedded in the candidate publica- and readmission rates.18–20
tions was performed. Emphasis was placed on prospec- More recently, a retrospective review from the National
tive trials, meta-analyses, systematic reviews, and practice Surgical Quality Improvement Program (NSQIP) evaluated
guidelines. Peer-reviewed observational studies and retro- 8415 patients who underwent elective colectomy (62.9%
spective studies were included when higher-quality evi- laparoscopic) from 2011 to 2012, comparing those with no
dence was insufficient. The final source material used was bowel preparation (25.6%), MBP alone (44.9%), and oral
evaluated for the methodologic quality, the evidence base antibiotics (29.5%).18 Of note, 92% of patients in the oral
was examined, and a treatment guideline was formulated antibiotic bowel preparation group received both oral an-
by the subcommittee for this guideline. The final grade tibiotics and MBP. The oral antibiotic bowel preparation
of recommendation and level of evidence for each state- group had a statistically significantly lower rate of post-
ment were determined using the Grades of Recommen- operative SSI (6.5% vs 14.9% with no preparation or 12%
dation, Assessment, Development, and Evaluation system with MBP alone; p < 0.001), a shorter hospital length of
(Table 1).6,7 When agreement was incomplete regarding stay (median, 4 vs 5 d; p < 0.001) compared with the other
the evidence base or treatment guideline, consensus from 2 groups, and the lowest readmission rate (8.1% vs 11.8%
the committee chair, vice chair, and 2 assigned reviewers with no preparation or 9.3% with MBP alone; p < 0.001).
determined the outcome. Members of the American Soci- In a retrospective study using data from the Veterans
ety of Colon and Rectal Surgeons (ASCRS) Clinical Prac- Affairs Surgical Quality Improvement Program including

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 DISEASES OF THE COLON & RECTUM VOLUME 62: 1 (2019) 5

TABLE 1.   The Grades of Recommendation, Assessment, Development, and Evaluation System Grading Recommendations
Methodologic quality of
Label Description Benefit vs risk and burdens supporting evidence Implications
1A Strong recommendation, Benefits clearly outweigh risk RCTs without important Strong recommendation, can apply to
high-quality evidence and burdens or vice versa limitations or overwhelming most patients in most circumstances
evidence from observational without reservation
studies
1B Strong recommendation, Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, can apply to
moderate-quality and burdens or vice versa (inconsistent results, most patients in most circumstances
evidence methodologic flaws, indirect, without reservation
or imprecise) or exceptionally
strong evidence from
observational studies
1C Strong recommendation, Benefits clearly outweigh risk Observational studies or case Strong recommendation but may
low- or very low– and burdens or vice versa series change when higher-quality
quality evidence evidence becomes available
2A Weak recommendation, Benefits closely balanced RCTs without important Weak recommendation, best
high-quality evidence with risks and burdens limitations or overwhelming action may differ depending on
evidence from observational circumstances or patient or societal
studies values
2B Weak recommendations, Benefits closely balanced RCTs with important limitations Weak recommendation, best
moderate-quality with risks and burdens (inconsistent results, action may differ depending on
evidence methodologic flaws, indirect, circumstances or patient or societal
or imprecise) or exceptionally values
strong evidence from
observational studies
2C Weak recommendation, Uncertainty in the estimates Observational studies or case Very weak recommendations, other
low- or very low– of benefits, risks, and series alternatives may be equally
quality evidence burden; benefits, risk, and reasonable
burden may be closely
balanced
Grading strength of recommendations and quality of evidence in clinical guidelines are from an American College of Chest Physicians Task Force report. Adapted with
permission from Chest 2006;129:174–181.7
RCT = randomized controlled trial.

9940 patients who underwent elective colorectal resec- ­ atients who received no bowel preparation, those who
p
tions, oral antibiotics significantly decreased the SSI rate received combined oral antibiotics and MBP had signifi-
in comparison with no bowel preparation (9.0% vs 18.1%; cantly lower rates of postoperative SSI (3.2% vs 9.0%;
p < 0.0001). Notably, only 7.3% of patients in the oral an- p < 0.001), anastomotic leak (2.8% vs 5.7%; p = 0.001),
tibiotic group did not receive MBP. MPB alone, without and procedure-related hospital readmission (5.5% vs
oral antibiotics, resulted in a similar SSI rate to that seen 8.0%; p = 0.03).23 Interestingly, there were no differences
with no bowel preparation (20.0% vs 18.1%; p = 0.81).20 in outcomes data among those who received no bowel
A similar retrospective study using the Veterans Af- preparation, MBP only, or oral antibiotics only.
fairs Surgical Quality Improvement Program found that In an additional study using data from the NSQIP,
patients who received oral antibiotics, with or without 8442 patients were evaluated for outcomes after under-
MBP, had a significantly lower median length of stay (neg- going elective colorectal surgery. Similarly, after multi-
ative binomial regression estimate = –0.1159; p < 0.0001) variate analysis, MBP with oral antibiotics, but not MBP
and also a lower 30-day readmission rate of 12.7% for oral alone, was independently associated with a reduced rate
antibiotics with or without MBP, 15.0% for MBP only, of anastomotic leak (OR = 0.57 (95% CI, 0.35–0.94)), SSI
and 16.1% with no bowel preparation (p = 0.002).21 In (OR = 0.40 (95% CI, 0.31–0.53)), and postoperative ileus
another randomized controlled trial of patients with ul- (OR = 0.71 (95% CI, 0.56–0.90)).24
cerative colitis undergoing proctocolectomy, the authors A retrospective cohort analysis from the NSQIP tar-
compared 100 patients who received MBP with oral anti- geted outcomes data set examined the impact of bowel
biotics to 100 patients who received MBP alone and found preparation on the severity of colonic anastomotic leak
a significantly lower SSI rate in the group that received oral and found that MBP was not associated with worse pa-
antibiotics (6.1% vs 22.4%; p = 0.001).22 tient outcomes in those patients who go on to develop
Using data from the NSQIP, 4999 patients who un- an anastomotic leak after elective colon resection with
derwent elective colorectal resection were evaluated based primary anastomosis.25 Although the studies enumerated
on preoperative bowel preparation. Compared with above demonstrate that MBP with oral antibiotics reduces

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 6 MIGALY ET AL: ELECTIVE SURGERY BOWEL PREPARATION

the incidence of anastomotic leak, this study implies that MBP alone, and 2899 had no preparation (no MBP). They
the addition of oral antibiotics in the preoperative bowel also included trials comparing MBP with enema. There
preparation does not reduce the severity of an anastomot- were no statistically significant differences in how well the
ic leak. 3 groups of patients (MBP alone, no MBP, and rectal en-
In summary, MBP, in combination with oral antibiot- emas) did postoperatively in terms of anastomotic leak,
ics, reduces the rates of SSI, anastomotic leak, readmission, mortality, peritonitis, need for reoperation, and wound
and length of stay in comparison with other methods of infection.31
bowel preparation. MBP with oral antibiotics should be More recent evaluation using the NSQIP database
modified or omitted in patients who have an allergy to the also found no benefit for MBP alone.32 Of 5021 patients
antibiotics or in those who have a bowel obstruction. who underwent elective colon resection, 44.8% had MBP
As a special consideration, Clostridium difficile colitis only. Multivariate analysis demonstrated that MBP alone
occurs in ≈1% to 7% of patients after colorectal surgery.26 was not associated with a decreased risk of postoperative
A large observational cohort study using data from the complications (anastomotic leakage, superficial SSI, organ
Michigan Surgical Quality Collaborative-Colectomy Best space SSI, wound disruption, deep venous thrombosis,
Practices Project provides granular insight into the effect pneumonia, unplanned intubation, ventilator dependen-
of bowel preparation on rates of C difficile colitis in a study cy >48 h, pulmonary embolism, cardiac arrest requiring
population of 2475 patients. In this study, Kim et al27 cre- cardiopulmonary resuscitation, renal insufficiency, sepsis,
ated a propensity-matched analysis of 957 paired cases (n hemorrhagic complications, return to the operating room,
= 1914) and compared patients receiving full bowel prepa- urinary tract infection, prolonged hospitalization >30 d,
ration (MBP with oral antibiotics) with patients with no or death) after right- or left-sided colon resections. There
bowel preparation. Patients who received oral antibiot- was no association of MBP alone with mortality, morbid-
ics and MBP were actually less likely to develop postop- ity, or any of the aforementioned postoperative compli-
erative C difficile colitis than those who received no bowel cations. This study is consistent with multiple previous
preparation (0.5% vs 1.8%; p = 0.01).26,27 In a retrospective studies showing no benefit of MBP alone in colorectal sur-
study of 219 patients, Yeom et al28 also found no differ- gery, and it also showed a lack of harm. It is important to
ence in rates of C difficile infection in patients receiving note that most studies also do not show a detriment from
nonabsorbable antibiotics versus those who did not (7.3% MBP compared with no MBP.24,32–34
vs 6.4%; p = 0.803). Another small retrospective study in-
3. Preoperative oral antibiotics alone, without mechani-
volving 314 patients demonstrated higher C difficile toxin
cal preparation, are generally not recommended for pa-
detection rates in colectomy patients who received oral
tients undergoing elective colorectal surgery. Grade of
antibiotics in addition to MBP (7.4%) compared with
Recommendation: Weak recommendation based on
those who did not (4.2%; p = 0.03).29 This study was lim-
low-quality evidence, 2C.
ited by the small number of patients and the retrospective
methodology. There are no randomized trials evaluating the use of oral
However, in a recent randomized controlled trial of antibiotics independent of MBP. Retrospective studies,
310 patients divided into 3 groups comparing the use of however, have shown that oral antibiotics alone may have
MBP plus preoperative probiotics only, MBP plus pre- similar efficacy to oral antibiotics plus MBP.18,19 In an
operative oral antibiotics only, and MBP only in elective NSQIP review, patients who received both oral antibiotics
colon cancer operations, there were no differences in the and MBP had a slightly lower SSI rate, although not sta-
rates of detection of C difficile toxin in stool samples ob- tistically significant, when compared with those who re-
tained 1 and 2 weeks postcolectomy in any of the 3 groups ceived oral antibiotics without MBP.19 Others have shown
(7.0% vs 9.1% vs 10.5%; p = 0.69).30 that outcomes in patients receiving MBP alone or oral an-
In limited studies, bowel preparation does not ap- tibiotics alone did not differ significantly from those re-
pear to increase the risk of postcolectomy C difficile colitis. ceiving no preparation at all.20,23
Given the benefits outlined elsewhere in this article, bowel
4. Preoperative enemas alone, without MBP and oral
preparation should not be omitted because of concern re-
antibiotics, are generally not recommended for pa-
garding C difficile infection.
tients undergoing elective colorectal surgery. Grade of
2. Preoperative MBP alone, without oral antibiotics, is gen- Recommendation: Weak recommendation based on
erally not recommended for patients undergoing elective moderate-quality evidence, 2B.
colorectal surgery. Grade of Recommendation: Strong
A number of small studies have evaluated bowel prepara-
recommendation based on high-quality evidence, 1A.
tion using rectal enemas alone.31,34–38 Alcantara Moral et
A Cochrane review from 2011 evaluated 18 randomized al35 studied 193 patients in a single-center, prospective,
controlled trials including 5805 patients; 2906 received randomized study wherein patients were randomly as-

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 DISEASES OF THE COLON & RECTUM VOLUME 62: 1 (2019) 7

signed to oral MBP or cleansing enemas only. Patients in 12. Finegold SM. Studies on antibiotics and the normal intestinal
the enema group had similar morbidity (wound infection flora. Tex Rep Biol Med. 1951;9:432–444.
or anastomotic dehiscence) as the MBP group.35 Zmora et 13. Nichols RL, Broido P, Condon RE, Gorbach SL, Nyhus LM. Ef-
al39 randomly assigned 380 patients to an MBP group or fect of preoperative neomycin-erythromycin intestinal prepa-
ration on the incidence of infectious complications following
an enema group and also found no significant difference
colon surgery. Ann Surg. 1973;178:453–462.
in the rate of surgical infectious complications between 14. Nichols RL, Schumer W, Nyhus LM. Technique of preoperative
the 2 groups. On the other hand, Bucher et al40 found bowel sterilisation. Lancet. 1973;2:735.
lower rates of overall morbidity and anastomotic leak in 15. Clarke JS, Condon RE, Bartlett JG, Gorbach SL, Nich-

an enema group when 153 patients undergoing low ante- ols RL, Ochi S. Preoperative oral antibiotics reduce
rior resection were randomly assigned to MBP or enemas septic complications of colon operations: results of pro-
only. Platell et al37 found an increased risk of anastomotic spective, randomized, double-blind clinical study. Ann Surg.
leakage with phosphate enema preparation versus oral 1977;186:251–259.
polyethylene glycol. These studies, however, are limited by 16. Matheson DM, Arabi Y, Baxter-Smith D, Alexander-Williams J,
small sample sizes and unclear methodology. The paucity Keighley MR. Randomized multicentre trial of oral bowel prep-
of data for rectal enemas as the only mechanism of pur- aration and antimicrobials for elective colorectal operations. Br
J Surg. 1978;65:597–600.
gative cleansing and the preponderance of data favoring
17. Guglielmo BJ, Hohn DC, Koo PJ, Hunt TK, Sweet RL, Conte
combined mechanical and oral antibiotic bowel prepa- JE Jr. Antibiotic prophylaxis in surgical procedures: a critical
ration further bolster the recommendation of combined analysis of the literature. Arch Surg. 1983;118:943–955.
oral MBP with oral antibiotics. 18. Morris MS, Graham LA, Chu DI, Cannon JA, Hawn MT. Oral
antibiotic bowel preparation significantly reduces surgical site
infection rates and readmission rates in elective colorectal sur-
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