I thought I would kick off the discussion pages with a question that vexes me:
Do you bowel prep for low anterior resection that you will defunction?
The Cochrane database on bowel prep certainly suggests that it is not necessary in most cases but I must admit that I still do when planning an ultra low anterior resection after radiotherapy that I will definitely defunction. I recently had a case in which the anastomosis was lower than expected and that I defunctioned despite only an enema for bowel prep. I have concerns about the upstream loaded colon in that a loop ileostomy would only mitigate the consequences of an anastomotic leak if the bowel was clean.
What do people think?
In such a situation would you:
defunction with a loop sigmoid colostomy hoping that the left colon is clear from the enema? defunction with a loop ileostomy and assume that the stool in the colon would 'just sit there' as it is defunctioned upstream? on table lavage and loop stoma?
The enema (if given on time) is usually good enough to clear the majority of the left colon. I have not bowel prep'd anything (except Lap Pouches) now for 4-years and have not had a problem. I have also left unpreped colons defunctioned for several months again without a problem
Jason Smith Colorectal Surgeon Chairman ACPGBI IT Committee
No bowel preps for left colons, APER or Ant resections whether defunctioned or not phosphate enemas one the night before and one on arrival on the day of surgery Laparoscopic Reversal of Hartmann's sometimes give trouble if NOT bowel preped as the colon can not be cleared by phosphate enemas and hence leaving the colon sometimes heavy with solid stools to handle laparoscopically
Chris ...I have had the same concerns. For the ultra low anastomosis I was prepping the colon for the same reason as you state, until I was caught out by a very low tumour, despite careful planning and did not have a problem so continued without prep and have so far had no issues of any significance. Now I do as Jason does.
We have had the same discussion in our department in trying to produce a departmental bowel prep protocol. I have used nothing but 2x phosphate enemas for the last 1-2 years irrespective of radiotherapy or prospect of defunctioning stoma (which may be loop colostomy or ileostomy). APERs receive no prep.