and Andrea Bischoff1
(1)
Pediatric Surgery, Colorectal Center for Children Cincinnati Children’s Hospital, Cincinnati, OH, USA
Colorectal operations are considered “contaminated procedures” and represent, by definition, cases with a higher risk of infection. Therefore, patients must be subjected to some forms of bowel preparation prior to the operation. In addition, the use of prophylactic antibiotics must be considered.
Through the last 30 years, we have been following the evolution of the concepts related with the different modalities of bowel preparation, as well as the use of different antibiotics by mouth, intravenously, and pre- and postoperatively.
Most of the literature is related with adults. There are an enormous number of publications related to adult conditions. We selected only a few papers representative of the tendency to avoid mechanical bowel preparation [1–4] and antibiotics. Some surgeons found no evidence to support the use of mechanical bowel preparations. Even more, some publications present data indicating that the bowel preparations seem to result in a higher incidence of infections and dehiscence! The incidence of wound infections in the adult literature varies from 4 to 19 % with minor variations in favor of those patients who did not receive preoperative colonic preparation.
The question for us, pediatric surgeons, is if we should change our routines, based on the information obtained from adult data. Our personal answer is no. The incidence of wound infections reported in adult patients with and without bowel preparations is still much higher than in our cases [5]. If we closed 649 consecutive colostomies without a single case of infection, following preoperative management, we find no convincing reason to change. We understand that perhaps, we could have the same good results without bowel preparation; however, it is not easy to change a routine that resulted in zero infections. We also suspect that a meticulous surgical technique is the key to avoid complications, rather than the bowel preparation or the antibiotics. Interestingly, during the last 30 years, we have changed the type of antibiotics used pre- and postoperatively according to the recommendations of the epidemiology departments of the institutions in which we worked, yet the results were the same: no infections.
According to Breckler et al. [6], the overwhelming majority of pediatric surgeons in the United States still use mechanical bowel preparation and preoperative intravenous antibiotics. Leys et al. [7] found slightly higher number of anastomotic leaks and infections in pediatric patients who underwent a mechanical bowel preparation. Breckler et al. reported 14 % of wound infections in colostomy closures and no differences between those who received antibiotics and those patients who did not [8]. Serrurier et al., also in pediatric cases [9], found significantly higher number of wound infections (14 %) in a series of 272 colostomy closures, of patients who received mechanical bowel preparation, whereas only 5 % of those without preparation suffered from this complication. Similar results were reported by others [10, 11]. Pennington et al. [12] in a retrospective analysis of the series of 42 American Children’s Hospitals, (5,473 patients) not surprising, found that only 22.9 % of all patients received an “evidence-based preparation.” However, the “evidence-based guidelines” that they allude to are related with adult patients. The question comes again: Should we change our routines based on the adult literature? The question is even more difficult to answer when our results are excellent. In summary, we are not convinced that following adult “evidence-based” routines will benefit our patients.
We are very proud of our excellent record of zero wound infections in colostomy closures. We close all wounds primarily and leave no drains. The patients received irrigations of the proximal stoma, with saline solution and intravenous antibiotics during anesthesia and 48 h postoperatively. On the other hand, we had cases of infections or minor dehiscent anoplasties in cases subjected to primary pull-throughs without a colostomy. Those patients received GoLYTELY® (total bowel preparation). The dehiscences that we have seen occurred usually between the 5 and 8 days postoperatively while the patients are still fasting. We take those patients to the operating room, resutured the dehiscent areas, and prolong the period of fasting for 2–3 more days. A complete dehiscence will receive a colostomy, which is a very unusual event. A question to be answered is if a dehiscence, occurring in a case with bowel preparation, has less serious consequences than in cases without bowel preparation. We believe it does.
The type of colonic preparation that we recommend varies, depending on the type of surgical procedure that the patient is going to receive, as well as the specific circumstances of the patient.
Thus, the bowel preparation required for a newborn baby that is going to be subjected to a primary, major, colorectal procedure without a colostomy is different than the one required for an older patient.
There is plenty of evidence related with the safety of using GoLYTELY® 1 (polyethylene glycol electrolyte solution) to clean the entire gastrointestinal tract in pediatric patients [13–18].
7.1 Major Procedures
Major procedures include primary or secondary pull-throughs for anorectal malformations, for Hirschsprung’s disease, or for idiopathic constipation, performed without a protective colostomy. Anoplasties and resection of rectal prolapse are also included in this category. These patients must be admitted, most of the time, 24 h before the operation. Severely constipated or fecally impacted patients, sometimes, are admitted 2 days before surgery to be subjected to our protocol of disimpaction before the cleaning of the gastrointestinal tract (See Chap. 25, Sect. 25.7.1). The morning of admission the patient is only allowed to take clear fluids by mouth. Usually around noon time, the administration of GoLYTELY® 2 is started, at the rate of 25 mL/kg/h until clear. Most of the time, this is administered through a nasogastric tube. Occasionally, some adolescents volunteer to drink GoLYTELY® at the right speed, in order to try to avoid a nasogastric tube. Many of them try, yet, usually the attempt is unsuccessful because they do not drink fast enough or they have nausea, and therefore, they need the nasogastric tube. It usually takes about 4 h for the colon to be completely cleaned. Some patients suffer from nausea and vomiting during the administration of GoLYTELY®. When that happens, the patient benefits from the administration of an antiemetic medication, but we continue the administration of the GoLYTELY®, at a slightly slower rate, because we have seen that most of the GoLYTELY® still goes through the pylorus and through the bowel. During the administration of GoLYTELY®, the patient usually suffers from a certain degree of abdominal distention and cramps. Soon enough, they start passing stool through the rectum. Later on, this becomes liquid stool that becomes more and more clear, until it is free of stool. Patients with Hirschsprung’s disease frequently require rectal irrigation to help relieve this distention during the bowel prep. After 4 h of the administration of GoLYTELY®, the nurse or the resident must see what is coming out through the rectum of the patient. A yellow or greenish color represents bile that is excreted in the bowel and is considered acceptable. On the other hand, the presence of particles of fecal matter is considered unacceptable, and therefore, the administration of GoLYTELY® should continue. Subsequently, the resident or the nurse should check what is coming out of the rectum every hour as the prep continues to run, until the goal of a clean colon is achieved. At that point, the nasogastric tube can be pulled out, and the patient is allowed to drink clear fluids. (Clear fluids by mouth are not allowed during the administration of the GoLYTELY® because we were told by the company that produces GoLYTELY® that the glucose contents allow for inflow of fluid into the colon lumen, leading to dehydration.)
Most patients pass clear liquid through the rectum after 4 h, but others require a longer period of time. Occasionally, we see patients that continue having GoLYTELY® through the night, and then come to the operating room, only for us to find out that they are still not clean.
It has been our experience that many patients who received GoLYTELY® the day before an operation come to the operating room suffering from some degree of dehydration and a mild degree of metabolic acidosis. This seems to be more significant in babies. Therefore, it is our routine to administer intravenous fluids during the entire process to patients younger than 2 years of age. In patients older than 2 years of age, intravenous fluids are desirable, but not vital.
In patients with a significant degree of megacolon and chronic fecal impaction, it is very important to go through the process of fecal disimpaction prior to the administration of GoLYTELY®. The administration of GoLYTELY® through a nasogastric tube in patients with fecal impaction and severe megarectosigmoid sometimes makes them feel very uncomfortable. Their abdomen becomes very distended, they complain of severe cramps, and they feel very sick. The protocol of fecal disimpaction consists of the administration of three enemas per day and daily radiologic monitoring, to be sure that the colon is free of fecal impaction (see chapter on Idiopathic constipation). When this is achieved, the patient can be admitted to follow the protocol of administration of GoLYTELY®.
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