Annals of Coloproctology

Review

Benign GI diease,Epidemiology & etiology

A Review of Bowel Preparation Before Colorectal Surgery: Yeon Uk Ju, Byung Wook Min; Ann Coloproctol. 2021;37(2):75-84. Published online May 15, 2020; DOI: https://doi.org/10.3393/ac.2020.04.01

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Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.

Citations

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Original Article

Correlation Between Bowel Preparation and the Adenoma Detection Rate in Screening Colonoscopy: Jung Hun Park, Sang Jin Kim, Jong Hee Hyun, Kyung Su Han, Byung Chang Kim, Chang Won Hong, Sang-Jeon Lee, Dae Kyung Sohn; Ann Coloproctol. 2017;33(3):93-98. Published online June 30, 2017; DOI: https://doi.org/10.3393/ac.2017.33.3.93

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Abstract PDF

Purpose

The adenoma detection rate is commonly used as a measure of the quality of colonoscopy. This study assessed both the association between the adenoma detection rate and the quality of bowel preparation and the risk factors associated with the adenoma detection rate in screening colonoscopy.

Methods

This retrospective analysis involved 1,079 individuals who underwent screening colonoscopy at the National Cancer Center between December 2012 and April 2014. Bowel preparation was classified by using the Aronchick scale. Individuals with inadequate bowel preparations (n = 47, 4.4%) were excluded because additional bowel preparation was needed. The results of 1,032 colonoscopies were included in the analysis.

Results

The subjects' mean age was 53.1 years, and 657 subjects (63.7%) were men. The mean cecal intubation time was 6.7 minutes, and the mean withdrawal time was 8.7 minutes. The adenoma and polyp detection rates were 28.1% and 41.8%, respectively. The polyp, adenoma, and advanced adenoma detection rates did not correlate with the quality of bowel preparation. The multivariate analysis showed age ≥ 60 years (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.02–1.97; P = 0.040), body mass index ≥ 25 kg/m² (HR, 1.56; 95% CI, 1.17–2.08; P = 0.002) and current smoking (HR, 1.44; 95% CI, 1.01–2.06; P = 0.014) to be independent risk factors for adenoma detection.

Conclusion

The adenoma detection rate was unrelated to the quality of bowel preparation for screening colonoscopy. Older age, obesity, and smoking were independent risk factors for adenoma detection.

Citations

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Haoxin Xu, Zhu He, Yulin Liu, Hong Xu, Pengfei Liu
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Assessment of the Role of Artificial Intelligence in the Association Between Time of Day and Colonoscopy Quality
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Hamid-Reza Moein, Eskara Pervez, Salina Faidhalla, Heba Habbal, Hajra Khan, Anshu Wadehra, Mahvish Khalid, Diana Kakos, Paul Naylor, Bashar Mohamad
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Case Report

Acute Hyponatremia With Seizure and Mental Change After Oral Sodium Picosulfate/Magnesium Citrate Bowel Preparation: Young Sun Cho, Kyung Min Nam, Jang Ho Park, Sang Hwan Byun, Jin Suck Ryu, Hyun Ju Kim; Ann Coloproctol. 2014;30(6):290-293. Published online December 31, 2014; DOI: https://doi.org/10.3393/ac.2014.30.6.290

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Abstract PDF

Sodium picosulfate/magnesium citrate (Picolight Powder), which is used as a bowel preparation for the colon and the rectum, can cause a severe electrolyte imbalance like hyponatremia. When hyponatremia gets severe or occurs rapidly, it can lead to death due to associated complications. We have experienced a case of hyponatremia associated with seizure and loss of consciousness in a 76-year-old woman, who took sodium picosulfate/magnesium citrate as a bowel preparation for colonoscopy. She was taking thiazide and synthroid for the treatment of hypertension and hypothyroidism, respectively, and she had other underlying medical conditions such as a history of seizure and dementia. Following the diagnosis of hyponatremia, we used an intravenous injection of 3% NaCl to normalize the sodium level in her serum, and her associated symptoms soon disappeared.

Citations

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Hyponatremia‐induced generalized seizure after taking polyethylene glycol for colon preparation—A case report and brief review of the literature
Shiva Seyrafian, Vahid Sebghatollahi, Bahar Bastani
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Hyponatremic Seizure after Ingestion of an Oral Sulfate Tablet for Bowel Preparation for Colonoscopy
Sung Hyun Hong, Dong Seok Lee, Ji Won Kim, Kook Lae Lee, Hyoun Woo Kang, Su Hwan Kim
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Seizure from water intoxication following bowel preparation: a case report
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Krishan Pratap, Manasi Jiwrajka, Liam Weber, Alan Richardson
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Cristiano Spada, Renato Cannizzaro, Maria Antonietta Bianco, Rita Conigliaro, Emilio Di Giulio, Cesare Hassan, Riccardo Marmo, Pietro Occhipinti, Franco Radaelli, Alessandro Repici, Enrico Ricci, Guido Costamagna
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Severe Hyponatremia with Mental Change after Ingestion of Picosulfate Sodium/Magnesium Citrate for Bowel Preparation
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Gyeong Bo Kim, Sung Yeon Hwang, Tae Gun Shin, Tae Rim Lee, Won Chul Cha, Min Seob Sim, Ik Joon Jo, Keun Jeong Song, Joong Eui Rhee, Yeon Kwon Jeong
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Combination could be another tool for bowel preparation?
Jae Seung Soh, Kyung-Jo Kim
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A randomized trial to compare the efficacy and tolerability of sodium picosulfate-magnesium citrate solution vs. 4 L polyethylene glycol solution as a bowel preparation for colonoscopy
Miguel Muñoz-Navas, José Luis Calleja, Guillermo Payeras, Antonio José Hervás, Luis Esteban Abreu, Víctor Orive, Pedro L. Menchén, José María Bordas, José Ramón Armengol, Cristina Carretero, Vicente Pons Beltrán, Inmaculada Alonso-Abreu, Román Manteca, Ad
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Original Articles

Effectiveness of Sodium Picosulfate/Magnesium Citrate (PICO) for Colonoscopy Preparation: Ki Hwan Song, Wu Seok Suh, Jin Sik Jeong, Dong Sik Kim, Sang Woo Kim, Dong Min Kwak, Jong Seong Hwang, Hyun Jin Kim, Man Woo Park, Min Chul Shim, Ja-Il Koo, Jae Hwang Kim, Dae Ho Shon; Ann Coloproctol. 2014;30(5):222-227. Published online October 28, 2014; DOI: https://doi.org/10.3393/ac.2014.30.5.222

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Abstract PDF

Purpose

Bowel preparation with sodium phosphate was recently prohibited by the U.S. Food and Drug Administration. Polyethylene glycol (PEG) is safe and effective; however, it is difficult to drink. To identify an easy bowel preparation method for colonoscopy, we evaluated three different bowel preparation regimens regarding their efficacy and patient satisfaction.

Methods

In this randomized, comparative study, 892 patients who visited a secondary referral hospital for a colonoscopy between November 2012 and February 2013 were enrolled. Three regimens were evaluated: three packets of sodium picosulfate/magnesium citrate (PICO, group A), two packets of PICO with 1 L of PEG (PICO + PEG 1 L, group B), and two packets of PICO with 2 L of PEG (PICO + PEG 2 L, group C). A questionnaire survey regarding the patients' preference for the bowel preparation regimen and satisfaction was conducted before the colonoscopies. The quality of bowel cleansing was scored by the colonoscopists who used the Aronchick scoring scale and the Ottawa scale.

Results

The patients' satisfaction rate regarding the regimens were 72% in group A, 64% in group B, and 45.9% in group C. Nausea and abdominal bloating caused by the regimens were more frequent in group C than in group A or group B (P < 0.01). Group C showed the lowest preference rate compared to the other groups (P < 0.01). Group C showed better right colon cleansing efficacy than group A or group B.

Conclusion

Group A exhibited a better result than group B or group C in patient satisfaction and preference. In the cleansing quality, no difference was noted between groups A and C.

Citations

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White Diet with split‐dose Picosalax is preferred, better tolerated, and non‐inferior to day‐before clear fluids with polyethylene glycol plus sodium picosulfate‐magnesium citrate for morning colonoscopy: A randomized, non‐inferiority trial
Jeremy P Dwyer, Jonathan Y C Tan, Eldho Paul, Catherine Bunn, Dileep Mangira, Robyn Secomb, Peter R Gibson, Gregor Brown
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Randomized clinical trial comparing fixed-time split dosing and split dosing of oral Picosulfate regimen for bowel preparation
Jae Hyuck Jun, Koon Hee Han, Jong Kyu Park, Hyun Il Seo, Young Don Kim, Sang Jin Lee, Baek Gyu Jun, Min Sik Hwang, Yoon Kyoo Park, Myeong Jong Kim, Gab Jin Cheon
World Journal of Gastroenterology.2017; 23(32): 5986. CrossRef
Upper airway obstruction resulting from acute mucosal injury induced by direct ingestion of sodium picosulfate/magnesium citrate powder
Gyeong Bo Kim, Sung Yeon Hwang, Tae Gun Shin, Tae Rim Lee, Won Chul Cha, Min Seob Sim, Ik Joon Jo, Keun Jeong Song, Joong Eui Rhee, Yeon Kwon Jeong
Clinical and Experimental Emergency Medicine.2016; 3(2): 109. CrossRef
Combination could be another tool for bowel preparation?
Jae Seung Soh, Kyung-Jo Kim
World Journal of Gastroenterology.2016; 22(10): 2915. CrossRef
Phase II Randomized Controlled Trial of Combined Oral laxatives Medication for BOwel PREParation (COMBO-PREP study)
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Frustration Still Exists
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Annals of Coloproctology.2014; 30(5): 207. CrossRef

Mechanical Bowel Preparation and Prophylactic Antibiotic Administration in Colorectal Surgery: A Survey of the Current Status in Korea: Byung Mo Kang, Kil Yeon Lee, Sun Jin Park, Suk-Hwan Lee; Ann Coloproctol. 2013;29(4):160-166. Published online August 29, 2013; DOI: https://doi.org/10.3393/ac.2013.29.4.160

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Abstract PDF

Purpose

The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery.

Methods

A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics.

Results

A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation.

Conclusion

The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.

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Single-Dose Versus Multiple-Dose Prophylactic Antibiotics in Minimally Invasive Colorectal Surgery: A Propensity Score Matched Analysis
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Mechanical Bowel Preparation Does Not Affect Clinical Severity of Anastomotic Leakage in Rectal Cancer Surgery
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The Impact of Bowel Preparation on Anastomotic Complications after Laparoscopic Colorectal Resection: A Prospective Comparative Study between Oral Polyethylene Glycol and Phosphate Enema.: Baek, Se Jin , Choi, Dong Jin , Kim, Jin , Woo, Si Uk , Min, Byung Wook , Kim, Seon Hahn , Moon, Hong Young; J Korean Soc Coloproctol. 2009;25(5):294-299.; DOI: https://doi.org/10.3393/jksc.2009.25.5.294

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Abstract PDF: PURPOSE
Although most randomized trials demonstrated no advantage of mechanical bowel preparation for colorectal resection, an oral solution is still widely used. The aims of this study were to evaluate whether a single phosphate enema is as effective as oral polyethylene glycol (PEG) solution in preventing anastomotic complications after laparoscopic colorectal surgery and to examine the clinical courses of anastomotic complications.
METHODS
Between September 2006 and December 2007, 309 patients underwent laparoscopic colorectal resection with primary anastomosis. The bowel preparation used was PEG solution during initial period (PEG group), but since February 2007, a single phosphate enema (enema group) was utilized. Postoperative data were prospectively recorded. In patients with anastomotic complications, the clinical course was compared between the two groups.
RESULTS
There were 150 patients in the PEG group and 159 patients in the enema group. Demographics did not differ between the two groups. Anastomotic leakage occurred in 3.3 percent of the patients in the PEG group and 5.7 percent of the patients in the enema group (P=0.326). The rates of anastomotic bleeding were 2.0 and 2.5 percent, respectively (P=0.761). The hospital stays for patients with anastomotic complication were not different between the two groups (P=0.137), but patients in the PEG group (80%) needed reoperation more frequently than those in the enema group (11.1%) (P=0.023).
CONCLUSION
These results suggest that laparoscopic colorectal surgery may be safely performed with a single phosphate enema instead of oral polyethylene glycol.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Polyethylene Glycol and Sodium Phosphate Oral Lavage Solutions.: Yun, Seong Hyeon , Kang, Jung Gu; J Korean Soc Coloproctol. 2004;20(1):27-31.

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Abstract PDF: PURPOSE
This study was undertaken to determine whether a mechanical bowel preparation with 90 ml of sodium phosphate (NaP) solution (Group II) increased the acceptability of bowel preparation and reduced discomfort compared with 2 liters of polyethylene glycol (PEG) combined with a bisacodyl 20 mg (Group I).
METHODS
We conducted a prospective, randomized, single-blinded study. Forty-four patients undergoing elective colorectal surgery in the National Health Insurance Corporation Ilsan Hospital from March 2002 to November 2002 were included in this study. We assessed the patients' tolerance and cleansing ability, as well as the surgeon's satisfaction, by using a structured questionnaire. Postoperative complications were also evaluated.
RESULTS
Patient tolerance to NaP was higher than it was to PEG (P=0.034). The cleansing ability and the surgeon's satisfaction were not different between the two groups (P=0.217, P=0.349). There is no significant postoperative complication except for 1 case of wound infection in both group.
CONCLUSIONS
Both oral solutions proved to be equally effective and safe. However, patient tolerance to the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Two Liters and Four Liters of Polyethylene Glycol-Based Oral Lavage Solutions.: Cho, Shin Il , Yun, Seong Hyun , Park, Jae Kun , Kim, Nam Kyu , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(6):383-387.

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Abstract PDF: PURPOSE
This study was undertaken to determine whether a mechanical bowel preparation with 2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg (Group II) increases the acceptability of bowel preparation and reduces discomfort compared with 4 liters of polyethylene glycol solution (Group I).
METHODS
We conducted a prospective randomized single-blinded study. Eighty patients undergoing an elective colorectal surgery in Severance hospital from April 1999 to September 1999 were included in this study. The patients' tolerance, cleansing ability and surgeon's satisfaction were assessed by a structured questionnaire. Postoperative complications were also evaluated.
RESULTS
The patients' tolerance of the group II (2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg) was better than that of the groups I (4 liters of polyethylene glycol solution). The cleaning ability and surgeon's satisfaction were not different between two groups (p=0.225, p=0.322). The incidence of postoperative complications was 2.3 percent in Group I and 2.7 percent in Group II.
CONCLUSIONS
The mechanical bowel preparation with two liters of polyethylene glycol solution with a Bisacodyl 20 mg was more comfortable to patients and equally efficient compared with the mechanical bowel preparation with the 4 liters of polyethylene glycol solution regimen before elective colorectal surgery.

Randomized Controlled Trial

A Comparison of Oral Sodium Phosphate and Polyethylene Glycol Solution for.: Cho, Hang Jun , Kang, Yoon Sik , Kim, Tae Soo , Jung, Seung Yong , Kim, Do Sun; J Korean Soc Coloproctol. 1997;13(2):223-228.

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Abstract PDF: BACKGROUND
Polyethylene glycol(PEG) has been the most widely used colonic lavage solution. But large volume and salty taste of PEG solution is a problem which can lead to the noncompliance and the poor bowel cleansing. Recent reports have suggested that sodium phosphate solution of much smaller volume is more effective in colon cleansing ability and more easier to complete. Therefore, this study was designed to compare two solutions for colonoscopy and to determine the differences in either patient compliance or cleansing ability.
METHOD
Eighty-two patients were randomized to take either oral sodium phosphate solution or 2 liter of PEG solution. Patient's discomfort and tolerance during ingestion was asessed by questionnaire and one colonoscopist who did not know the type of solution, assessed colonic preparation status.
RESULTS
Among 25 patients experiencing two separate colonoscopies with PEG solution and sodium phosphate solution respectively, 19(76%) patients preferred sodium phosphate solution. Sodium phosphate solution was found to be easier to take. Sodium phosphate caused thirst more frequently(p=0.013) than PEG solution. Particulate stool and water retention status were similar in two groups. Gas bubble formation that disturbs luminal observation was more frequently found in sodium phosphate preparation group(P=0.00). Sodium phosphate was more effective in right colon cleansing ability than PEG preparation(P=0.04). The Colonoscopist assessed sodium phosphate as "good" in 47.2% vs 58.6% after PEG preparation as a whole, but there was no statistical difference. CONSLUSION: Sodium Phosphate solution is better tolerated and more easier to take than PEG solution. Gas bubble formation is a correctable problem, but right colonic cleansing effect is not. Our results showed that sodium phosphate is likely to be more effective in colonic cleansing effect comparing to polyethylene glycol solution.

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