Children support of MBP were derived from clinical

Children
provide a different set of diagnosis and colorectal surgical procedures when
compared to adult population. Anorectal malformation(ARM) and hirschsprung
disease constitute a major portion of diagnosis for elective colorectal
procedures in infants and toddlersleys, serrurier. Necrotising
enterocolitis (NEC), colonic atresia, motility disorders are among the other
conditions which would require colorectal surgeries in this age group. Western
literature reports a significant number of elective surgeries done for inflammatory
bowel disease (IBD) in slightly older children. Other rare conditions needing
elective colorectal surgery in older children are trauma and enteric
duplications. Colostomy closure by far is the commonest elective colorectal
surgery performed in children. Different pull through procedures in
Hirschsprung disease namely Duhamel’s procedure, Soave procedure and Swenson’s
pull through and procedures in Anorectal malformation namely Posterior sagittal
anorectoplasty (PSARP), anterior sagittal anorectoplasty (ASARP) and
laparoscopic assisted anorectoplasty (LAARP) are procedures unique to pediatric
population. Procedures for IBD like proctectomy, total colectomy, ileocolectomy
and pull through are more reported by western investigators.
            Early
decades of 20th century saw an increase in number of colorectal
surgeries in adults, but it was associated with high morbidity and mortality. The
increased infectious complications including anastomotic leak and surgical site
infection were attributed to the high bacterial load in the distal bowel and
the rate of surgical site infection as high as 25% was reported with colorectal
surgeries1. Mechanical bowel preparation (MBP) was introduced as a
preoperative measure to keep the bowel clean during the surgery which would
reduce the infectious complications.

Mechanical
bowel preparation remained a surgical dogma among surgeons till the 1970s when
prospective studies started questioning its effectiveness. Till then theories
in support of MBP were derived from clinical experience and expert opinion2.
A good number of randomized trials and meta-analyses were published in the
adult literature during the last two decades. These studies have refuted the
benefits of MBP in reducing the rate of infectious complications. In addition
they have shown that MBP caused patient discomfort and in rare circumstances
morbidity due to electrolyte disturbances 3,4,5.

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Evidence
from pediatric literature is limited to small randomized pilot studies and
retrospective studies. Leys et al and Aldrink et al had published the only
randomized trials in children and reported that there was no statistically
significant difference in infectious complications between patients receiving
MBP and those not receiving MBP. But these studies are limited mainly by their
small sample size. Serrurier et al in their retrospective study had reported a
significantly high wound infection rate in patients who received bowel
preparation.

There
are many choices for preparation of the bowel before elective surgery, which
ranges from various preparations of polyethylene glycol(PEG), bisacodyl
tablets, aqueous and tablet sodium diphosphate (NaP), and saline irrigation
through nasogastric tube. No method was found superior to others, but there is
obvious patient and care taker discomfort associated with total gut irrigation
using nasogastric tube.

Systemic
antibiotic before surgery has been shown to have a protective effect on incidence
of surgical site infection. The late 1980s witnessed concept of the bowel
antisepsis by using oral antibiotics being popularized. Literature supports the
theory that it is the oral antibioitic not the MBP which caused the reduction
of bacterial load in the colon and thus reduction of infectious complications4,6.

Surveys
have revealed that majority of surgeons despite the strong evidence against it,
still follow bowel preparation practices prior to colorectal surgery2,7,8.
So there exists a big gap between the evidence and the practice of surgeons
world wide, the reason for which is largely not understood.

Literature
in pediatric population is rather deficient in number and quality. Randomized
trials are confined to pilot studies in children which also concluded that MBP
did not offer any additional benefits when it comes to post- operative
complications9,10. In a recent survey 96% of pediatric surgeons
revealed that they still follow bowel preparation practices and considered that
the evidence from adult literature may not be extrapolated to the pediatric
population11. There is lack of good quality prospective evidence in
pediatric population and current practice is being driven by expert opinion and
clinical experience12. 

Children
provide a different set of diagnosis and colorectal surgical procedures when
compared to adult population. Anorectal malformation(ARM) and hirschsprung
disease constitute a major portion of diagnosis for elective colorectal
procedures in infants and toddlersleys, serrurier. Necrotising
enterocolitis (NEC), colonic atresia, motility disorders are among the other
conditions which would require colorectal surgeries in this age group. Western
literature reports a significant number of elective surgeries done for inflammatory
bowel disease (IBD) in slightly older children. Other rare conditions needing
elective colorectal surgery in older children are trauma and enteric
duplications. Colostomy closure by far is the commonest elective colorectal
surgery performed in children. Different pull through procedures in
Hirschsprung disease namely Duhamel’s procedure, Soave procedure and Swenson’s
pull through and procedures in Anorectal malformation namely Posterior sagittal
anorectoplasty (PSARP), anterior sagittal anorectoplasty (ASARP) and
laparoscopic assisted anorectoplasty (LAARP) are procedures unique to pediatric
population. Procedures for IBD like proctectomy, total colectomy, ileocolectomy
and pull through are more reported by western investigators.
            Early
decades of 20th century saw an increase in number of colorectal
surgeries in adults, but it was associated with high morbidity and mortality. The
increased infectious complications including anastomotic leak and surgical site
infection were attributed to the high bacterial load in the distal bowel and
the rate of surgical site infection as high as 25% was reported with colorectal
surgeries1. Mechanical bowel preparation (MBP) was introduced as a
preoperative measure to keep the bowel clean during the surgery which would
reduce the infectious complications.

Mechanical
bowel preparation remained a surgical dogma among surgeons till the 1970s when
prospective studies started questioning its effectiveness. Till then theories
in support of MBP were derived from clinical experience and expert opinion2.
A good number of randomized trials and meta-analyses were published in the
adult literature during the last two decades. These studies have refuted the
benefits of MBP in reducing the rate of infectious complications. In addition
they have shown that MBP caused patient discomfort and in rare circumstances
morbidity due to electrolyte disturbances 3,4,5.

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!


order now

Evidence
from pediatric literature is limited to small randomized pilot studies and
retrospective studies. Leys et al and Aldrink et al had published the only
randomized trials in children and reported that there was no statistically
significant difference in infectious complications between patients receiving
MBP and those not receiving MBP. But these studies are limited mainly by their
small sample size. Serrurier et al in their retrospective study had reported a
significantly high wound infection rate in patients who received bowel
preparation.

There
are many choices for preparation of the bowel before elective surgery, which
ranges from various preparations of polyethylene glycol(PEG), bisacodyl
tablets, aqueous and tablet sodium diphosphate (NaP), and saline irrigation
through nasogastric tube. No method was found superior to others, but there is
obvious patient and care taker discomfort associated with total gut irrigation
using nasogastric tube.

Systemic
antibiotic before surgery has been shown to have a protective effect on incidence
of surgical site infection. The late 1980s witnessed concept of the bowel
antisepsis by using oral antibiotics being popularized. Literature supports the
theory that it is the oral antibioitic not the MBP which caused the reduction
of bacterial load in the colon and thus reduction of infectious complications4,6.

Surveys
have revealed that majority of surgeons despite the strong evidence against it,
still follow bowel preparation practices prior to colorectal surgery2,7,8.
So there exists a big gap between the evidence and the practice of surgeons
world wide, the reason for which is largely not understood.

Literature
in pediatric population is rather deficient in number and quality. Randomized
trials are confined to pilot studies in children which also concluded that MBP
did not offer any additional benefits when it comes to post- operative
complications9,10. In a recent survey 96% of pediatric surgeons
revealed that they still follow bowel preparation practices and considered that
the evidence from adult literature may not be extrapolated to the pediatric
population11. There is lack of good quality prospective evidence in
pediatric population and current practice is being driven by expert opinion and
clinical experience12. 

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