Surgeons' attitudes toward mechanical bowel preparation in the 21st century: A survey of the Caribbean College of Surgeons

Abstract

BackgroundThe available evidence strongly supports the abolition of routine mechanical bowel preparation (MBP) for prophylaxis against infectious morbidity in elective colorectal surgery, except in very specific circumstances. Despite evidence-based recommendations, there is still great variation in clinical practice. We examined the clinical practices of general surgeons across the Caribbean. MethodsWe carried out a questionnaire study of all practicing surgeons at the annual symposium of the Caribbean College of Surgeons in June 2016. A standardized questionnaire was used as the data collection instrument. We attempted to classify the surgeons' responses into two groups: those who either used MBP inappropriately and/or cited an irrational reason for their choice and those who used MBP appropriately. Statistical analyses were performed using SPSS, version 16.0. ResultsThere was a 53% (82/154) response rate: 46 (56.1%) surgeons used MBP selectively, 22 (26.8%) routinely used MBP, and 14 (17%) routinely omitted MBP. There were 19 (23.2%) surgeons who believed that MBP reduced infectious morbidity: 17 (20.7%) believed it reduced superficial surgical-site infections, 13 (15.9%) believed it reduced organ space infections, 13 (15.9%) believed it reduced anastomotic leaks, and 3 (3.7%) believed it reduced extraabdominal infections. Ten (12.2%) surgeons believed MBP was completely innocuous, and many respondents were unaware of potentially dangerous complications, including liver dysfunction (92.7%), cardiac events (67.1%), acute renal failure (65.9%), fluid shifts (28.1%), dehydration (28.1%), and electrolyte disturbances (18.3%). These findings were disappointing because they are pathophysiologic sequelae that have direct negative impact on patient recovery after colorectal surgery. Surgeons qualified for less than 5 years were likely to use MBP appropriately (87% vs 13%; P < 0.001), but those practicing in a service hospital (with no academic training programs) were more likely to use MBP inappropriately (35% vs 65%; P 0.02225). ConclusionsIt was disappointing that (1) 50% of surgeons used MBP inappropriately for irrational reasons or incorrect indications and (2) despite the knowledge of robust level I evidence not in support of MBP, a further 77% ignored the evidence and still routinely used MBP, citing “individual preference”. An educational campaign may be required to bring about practice change to align clinical practice with best practice recommendations.