What is included in patient preparation for a colon resection (colectomy)?

Updated: Apr 05, 2021
  • Author: David E Stein, MD, MHCM; Chief Editor: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Answer

Classic bowel preparation is becoming controversial. Traditionally, on the day before surgery, patients should drink only clear liquids. Patients should be on nil per os (NPO) status past midnight, except for medications. Polyethylene glycol may be given as a bowel preparation. The authors also prescribe neomycin and erythromycin (Nichols preparation) in order to decrease the intraluminal bacterial counts preoperatively in combination with the mechanical bowel preparation (MBP).

The authors’ current practice is as follows: No dietary changes are required the day before surgery for a right colectomy, and no bowel preparation is needed. For left colectomy, sigmoid colectomy, or low anterior resection (LAR), MBP is prescribed in conjunction with a Nichols preparation. In the operating room after induction, rectal irrigation is performed with dilute povidone-iodine in saline via a mushroom catheter and cystoscopy tubing. The lower colon and rectum must be thoroughly cleansed and emptied just before the start of surgery because the rectum is accessed to perform the anastomosis.

In January 2019, the American Society of Colon and Rectal Surgeons (ASCRS) issued the following recommendations for bowel preparation in elective colon and rectal surgery [25] :

  • MBP combined with preoperative oral antibiotics is typically recommended for elective colorectal resections
  • Preoperative MBP alone, without oral antibiotics, is generally not recommended for patients undergoing elective colorectal surgery
  • Preoperative oral antibiotics alone, without MBP, are generally not recommended for patients undergoing elective colorectal surgery
  • Preoperative enemas alone, without MBP and oral antibiotics, are generally not recommended for patients undergoing elective colorectal surgery

Enhanced recovery after surgery (ERAS) protocols have become mainstream and have been shown to decrease length of stay. ERAS protocols vary from one institution to another, but in general, their hallmarks include the following [26] :

  • Multimodal pain management to decrease the use of narcotics, including transversus abdominis anesthetic blocks
  • Goal-directed fluid therapy intraoperatively using monitors such as the Flotrac (Edwards Lifesciences)
  • Preoperative carbohydrate loading
  • Postoperative early ambulation

Many medications used to treat pain after surgery (eg, acetaminophen, oxycodone, and hydromorphone) are narcotics or opiates. When opiates bind to opiate receptors (eg, mu and delta) on gut smooth muscle, gastrointestinal (GI) motility is decreased. Alvimopan, acting as a mu opioid receptor antagonist, blocks the GI effect of opiates.

Alvimopan is a US Food and Drug Administration (FDA)-approved medication that decreases the length of postoperative ileus after bowel resection, thereby helping the bowel recover more quickly after bowel surgery and allowing the patient to resume eating solid foods and having regular bowel movements. It is usually taken once before surgery and twice a day after surgery for up to 7 days or until hospital discharge.

Efficacy trials have shown that in comparison with placebo, alvimopan reduces postoperative morbidity and lowers the incidence of prolonged hospital stay or readmission. One study showed that alvimopan decreased the length of hospital stay by 18 hours, as measured by time to discharge orders being written. [27]

The authors have added gabapentin and intravenous (IV) acetaminophen to their pain regimen to decrease narcotic dependence.

Preoperative IV antibiotics are given as per the Surgical Care Improvement Project (SCIP) guidelines. The authors also administer heparin subcutaneously (5000 units) 1 hour prior to surgery to aid in the prevention of deep vein thrombosis (DVT).


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