Are bowel preps really necessary before abdominal operations in children?

It’s 11pm, and a 12 YO girl is sitting teary-eyed with a tube hanging form her nose. She tried her best to drink that “stuff” but finally gave up and asked for the naso-gastric tube so she can get her bowel prep. Why is she getting her bowel prep? well, apparently, someone in the 1970’s thought it was a good idea!

The current data on the need for bowel preparations before elective colorectal surgery in the adult literature overwhelmingly contradicts the dogma that a bowel preparation is necessary for a safe operation, with a decreased risk of anastomotic leak and wound infection.

Recently, a pilot study by Leys et al, from Vanderbilt University Medical Center, showed findings in the pediatric population consistent with those in the adult literature. The study, which was retrospective in nature, compared the outcomes between 33 patients who did not undergo a bowel prep (No Prep) and 110 who did (Prep).

The study results showed that, despite the Prep group receiving postoperative antibiotics for a longer duration than the No Prep group, as well as greater incidence of delayed wound closure, the two groups did not have any significant difference in anastomotic leaks or wound infection rates.

The rationale behind bowel preps is that they decrease the fecal and bacterial load inside the lumen of the bowel, and thus decrease the risk of infectious complications. Some studies, which have found an increased risk of infectious complications with patients undergoing bowel preps, theorize that the liquid bowel content that results from the bowel prep is more difficult to manage, spills more easily and thus may explain the increased risk of infectious complications.

Despite the retrospective nature of this study by Leys et al, one cannot help but suspect that the results of the research in the adult literature should apply to this younger and generally healthier patient population. Obviously, and before any recommendations can be made about the need to omit bowel preps, a multi-center randomized prospective study with sufficient patients is needed.

Leys C M, Austin M T, Pietsch J B, Lovvorn H N, Pietsch J B. Elective intestinal operations in infants and children without mechanical bowel preparations; A pilot study. J Pediatr Surg 2001;40:978-82

Avoiding placement of implanted central venous catheters in neutropenic patients decreases complication rates

The authors of this study evaluated the outcome of the implementation of a protocol that restricts the placement of implanted central venous catheters to patients with an ANC greater or equal to 500. This was based on previous findings that suggested that placement of implantable central venous devices in neutropenic patients is associated with higher rate of complications.

The authors found a higher rate of complications (infectious and technical) in neutropenic patients. Additionally, the rate of these complications was substantially decreased after implementation of a protocol that excludes neutropenic from device placement.

Gollin G, Gutierrez I. Exclusion of neutropenic children form implanted central venous catheter placement: impact on early catheter removal. J Pediatr Surg 2010;45:1115-1119