BACKGROUND AND PURPOSE:

• Preoperative mechanical bowel preparation (MBP) is common, but its utility is unclear
• Gynecology literature is limited on this topic and clinical use is extrapolated from colorectal data
• Kalogera et al. (AJOG, 2020) examined whether mechanical bowel preparation and oral antibiotics, alone or combined, were associated with improved outcomes following benign or malignant hysterectomy

METHODS:

• Retrospective, inverse propensity score–weighted cohort study
• Data source
  • OptumLabs (large US commercial health plan database)
• Participants
  • Hysterectomy between January 2006 and July 2017
  • Benign or malignant
  • Irrespective of surgical approach
• Study design
  • Primary outcomes adjusted (using multivariate logistic regression for
    • Race | Census region | Household income | Diabetes
    • Other unbalanced variables following propensity score weighting
• Primary outcomes
  • 30-day surgical site infections (SSI)
  • Anastomotic leaks (AL)
  • Major morbidity

RESULTS:

• Total of 224,687 hysterectomies
  • Benign: 186,148
    • Median age: 45 years
    • Laparoscopic/robotic: 27.2%
    • Laparotomy: 32.6%
    • Vaginal: 40.2%
  • Malignant: 38,539
    • Median age: 54 years
    • Laparoscopic/robotic: 28.8%
    • Laparotomy: 47.7%
    • Vaginal: 23.5%
• Bowel resections performed
  • Benign: 0.4%
  • Malignant: 2.8%
• Type of bowl preparation
  • Benign
    • None: 93.8%
    • Mechanical bowel preparation only: 4.6%
    • Oral antibiotics only: 1.1%
    • Mechanical bowel preparation with oral antibiotics: 0.5%
  • Malignant
    • None: 87.2%
    • Mechanical bowel preparation only: 9.6%
    • Oral antibiotics only: 1.8%
    • Mechanical bowel preparation with oral antibiotics: 1.4%
• For both benign and malignant hysterectomy, the use of bowel preparation did not decrease rates of
  • Surgical site infections
  • Anastomotic leaks
  • Major morbidity
• Surgical approach did not alter above morbidities
• Among malignant abdominal hysterectomies, compared to no preparation, there was no difference in the rates of infectious morbidity between
  • Mechanical bowel preparation alone
  • Oral antibiotics alone
  • Mechanical bowel preparation with oral antibiotics

Note: “Even within the subgroup of malignant abdominal hysterectomies combined with bowel resection at time of hysterectomy, which represents the highest risk for postoperative infectious morbidity subgroup of hysterectomies, use of individual types of bowel preparation was not associated with decreased rates of SSI, AL, postoperative ileus, and major morbidity compared to no bowel preparation”

CONCLUSION:

• Bowel preparation, either mechanical or with oral antibiotics or both, did not decrease the risk of surgical site infections, anastomotic leaks, or major morbidities following benign or malignant hysterectomy
• The authors conclude

Bowel preparation may be safely omitted in gynecologic surgery, especially in the context of well-established Enhanced Recovery After Surgery pathways Practices with high baseline rates of surgical site infections may still consider using bowel preparation in the form of oral antibiotics alone or in combination with mechanical bowel preparation rather than mechanical bowel preparation alone

Learn More – Primary Sources:

Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies

Related ObG Topics:

Evidence-Based Gynecologic Surgery Best Practices: The AHRQ Safety Program

ACOG Guidance on Preventing Gynecologic Post-Procedure Infection

Chlorhexidine or Povidone-Iodine for abdominal hysterectomy?