Review
Pre-operative mechanical bowel cleansing or not? an updated
meta-analysis
P. Wille-Jørgensen*, K. F. Guenaga†, D. Matos† and A. A. Castro†
*Department of Surgery K, Bispebjerg Hospital, Copenhagen, Denmark and †Surgical Gastroenterology Department, Universidade Federal de São
Paulo ⁄ Escola Paulista de Medicina, São Paulo, Brazil
Received 17 February 2005; accepted 24 February 2005
Abstract
Objectives Pre-operative mechanical bowel preparation
has been considered an efficient regimen against leakage
and infectious complications, after colorectal resections.
This dogma is based only on observational data and
experts’ opinions. The aim of this study was to evaluate
the efficacy and safety of prophylactic pre-operative
mechanical bowel preparation before elective colorectal
surgery.
Methods EMBASE, LILACS, MEDLINE and The
Cochrane Library and abstracts from major gastro-
enterological congresses were searched. No language
restrictions were applied. The selection criterion used was
randomised clinical trials (RCT) comparing any kind of
mechanical bowel preparation with no preparation in
patients submitted to elective colorectal surgery and
where anastomotic leakage, mortality, and wound infec-
tion were outcome measurements. Data were independ-
ently extracted by the reviewers and cross-checked. The
methodological quality of each trial was assessed by the
same reviewers. For meta-analysis the Peto-Odds ratio
was used.
Introduction
Mechanical bowel preparation has been considered an
important factor in preventing infective complications and
anastomotic dehiscence after colorectal surgery for more
than a century [1,2]. This dogma was based on the
A more comprehensive version of this review will be found the Cochrane
Library as: Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jørgensen P.
(2005) Mechanical bowel preparation for elective colorectal surgery (Cochrane
Review). In: The Cochrane Library, Issue 1. John Wiley & Sons, Ltd., Chichester,
UK.
Correspondence to: Dr Peer Wille-Jørgensen, Chief Surgeon, Department of
Surgical Gastroenterology, K Bispebjerg Hospital, DK-2400 Copenhagen NV
Denmark.
E-mail: pwj01@bbh.hosp.dk
304
Results Of 1592 patients (9 RCTs), 789 were allocated
to mechanical bowel preparation (Group A) and 803 to
no preparation (Group B) before elective colorectal
surgery. Anastomotic leakage developed in 48 (6%) of
772 patients in A compared with 25 (3.2%) of 777
patients in B; Peto OR 2.03, 95% (CI: 1.28–3.26; P ¼
0.003). Wound infection occurred in 59 (7.4%) of 791
patients in A and in 43 (5.4%) of 803 patients in B; Peto
OR 1.46, 95% (CI: 0.97–2.18; P ¼ 0.07);Five (1%) of
509 patients died in group in A compared with 3 (0.61%)
of 516 patients in group B; Peto OR 1.72, 95% (CI:
0.43–6.95; nonsignificant).
Conclusion There is no evidence that patients benefit
from mechanical bowel preparation. On the contrary
taking colorectal surgery as a whole, pre-operative bowel
cleansing leads to a higher rate of anastomotic leakage.
The dogma that mechanical bowel preparation is neces-
sary before elective colorectal surgery has to be recon-
sidered.
Keywords Cleansing, pre-operative, colorectal, bowel
preparation
potential danger of faeces and bacterias in the operation
field – and the hope that the cleansing procedure would
diminish this. Clinical experience and observational studies
have shown that mechanical removal of gross faeces from
the colon has been associated with decreased morbidity
and mortality in patients undergoing operations of the
colon [3], and the recommendations are mainly based on
expert opinions such as the statement by Chung et al. [4]:
Ôone of the most important factors within the control
of the surgeon that affects the outcome of a colonic
operation is the degree of emptiness of the bowelsÕ.
Today the use of systemic antibiotic prophylaxis is a
routine; the efficacy of which is based on solid evidence
[5], but this has not changed the use of mechanical bowel

2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 304–310
P. Wille-Jørgensen et al. Pre-operative mechanical bowel cleansing

cleansing, which still is recommended in most guidelines Primary outcomes

[6–9]. The studies should describe:
The first to question this dogma and conclude that • Anastomotic leakage defined as a discharge of faeces
vigorous mechanical bowel preparation is not necessary from the anastomosis with clinical symptoms. It could
was Hughes in 1972 [10]. Omission of enemas and be confirmed by clinical or radiological investigation.
bowel washes from the pre-operative procedures would • The type of surgery and anastomosis site could be
be welcomed by both patients and nursing staff and may stratified in: Rectal surgery (low anterior resections with
even reduce the duration of admission. extraperitoneal anastomosis) or Colonic surgery, intra-
The question has been evaluated in systematic reviews peritoneal anastomosis;
before, both by us and other groups [11,12], all reaching • Overall anastomotic leakage defined as above with no
the conclusion, that cleansing can be omitted. The aim of stratification in colonic and rectal surgery.
this review has been to update the total knowledge on the
subject, as we have been able to identify more clinical and Secondary outcomes
randomized controlled trials. A more comprehensive The studies should describe:
version of this update is published in the Cochrane Library. • Mortality: number of postoperative deaths related to
surgery.
• Wound infection: defined as a discharge of pus from
Search strategy
the abdominal wound.
The basic search strategy is outlined in the module of the
Cochrane Colorectal Cancer Group (http:// Sensitivity and subgroup analysis
www.cccg.dk) and the databases CINAHL, EMBASE, For sensitivity analyses the following parameters were
LILACS, MEDLINE, SCISEARCH and The Cochrane sought, but incomplete information did not make the
Library were searched up to August 2004. The special- study ineglible for primary and secondary outcomes. The
ized register in the Cocchrane Colorectal Cancer Group sensitivity analyses were:
was searched for additional references, as well as confer- • Anastomotic leakage and wound infection in studies
erence proceedings from major gastrointestinal meetings with adequate randomization.
since 1994. No language restrictions were applied. An • Anastomotic leakage and wound infection in studies
example of a search strategy is listed in Table 1. published as full articles.
Authors of studies with incomplete information were • Anastomotic leakage and wound infection exclusively
contacted by mail or personally in order to retrieve dealing with studies including adult patients.
precise and supplementary data.
Exclusion of studies
Studies evaluating two or more different cleansing
Selection of studies and outcomes
methods; studies mixing elective and emergency sur-
Types of interventions gery.
Selected studies should describe any kind of pre-operative
mechanical bowel preparation compared to no mechan-
Method of review
ical bowel preparation.
Identification and selection of studies
Table 1 Search strategy. The reviewers independently selected the trials to be
included in this review. The methodological quality from
#1 Cochrane Collaboration search strategy for
RCTs (Handbook 2004)
an evaluation of allocation method and concealment,
#2 Tw INTESTIN* or Tw BOWEL eventual blinding and follow up of each trial was assessed.
#3 Tw LARGE or Tw GROSSO or Tw GRUESO Disagreements about selection and classification was
#4 #2 and #3 solved by consensus between the reviewers.
#5 Tw COLO* or Tw CECO
#6 Tw RECT* or Tw RET* Data extraction
#7 #4 or #5 or #6 Data were independently extracted by the reviewers and
#8 #3 and #7 crosschecked. The result of each trial was summarized in
#9 Tw PREPARA* 2 · 2 tables for each outcome. Data were entered into
#10 Tw SURGERY or SURGICAL
the Cochrane Software Review Manager 4.2 by single
#11 #8 and #9 and #10
data-entry (KG): all data-entries were controlled by a
#12 #1 and #11
second author (PWJ).

2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 304–310 305

Pre-operative mechanical bowel cleansing
Data analysis
The studies were stratified for different meta-analysis
according to the defined outcome parametres. The meta-
analyses were performed (Review Manager 4.2) using
Peto Odds Ratio (fixed effect model) as default. A test for
statistical heterogeneity was performed in each case.
Clinical heterogeneity amongst the studies were des-
cribed in text and analysed in the different sensitivity
analysis. Potential publication bias in the results of the
meta-analysis was assessed by inspection of graphical
presentations of the study weight or sample size against
the Odds Ratio (Ôfunnel-plotÕ) [13].
Description of studies
Fourteen studies were identified of which five trials were
excluded due to the following reasons: Absence of a control
group [14–16], elemental diet in the control-group [17],
and lack of description of the primary outcome and
insufficient description of the secondary outcomes [10].
Seven of the studies were published in English, one in
Portuguese [18] and one in Spanish [19]. Three studies
were published as abstracts only [20–22]. Data from the
latter study were retrieved from another publication [12].
Types of participants
Children were included in one trial [23]. Patients without
anastomosis were included in three studies [18,20,23]
but these patients were excluded when anastomotic
leakage was analysed [20]. In five studies [19,21,24–
26] only patients with anastomosis were included, and
one study [22] did not give information on this.
None of the studies reported on the use of pre-
operative adjuvant chemotherapy or radiation. Prophy-
lactic antibiotics was used in all studies.
Quality assessment of studies
The allocation concealment was not described specifically
in any of the studies. Despite this the allocation proce-
dure was considered adequate in four studies
[18,23,25,26] and unevaluable in the rest of the studies.
Five trials [18,23–26] described the two allocation
groups as being equal according to gender, age, types of
operation, and diagnosis. Three trials [20–22] did not
give details on this. One [19] reported a significant
difference between the two groups regarding age,
haemoglobin level and serum albumin.
One trial [18] was described as a double-blind study as
they used orange juice as placebo. One study [24] was
described as single-blind because the surgeons were aware
of the allocation. The others authors did not mention if
the trial was blinded or not.
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P. Wille-Jørgensen et al.
The exclusion criteria were only described sufficiently
in five trials [18,23–26]. The duration of follow-up was
described distinctly in four studies [18,23,25,26] less
clearly in two [19,24], and remained undescribed in three
[20–22]. In four trials the methodology used for the
diagnostics of the various outcomes [19–22] was consid-
ered insufficiently described.
Outcome measurements
Two of the studies [24,25] stratified the results according
to the location of the anastomosis as being rectal or
colonic. Data of this stratification were obtained by
personal contact to two authors [23,26] (J.C. Santos,
personal communication, 2001; O. Zmora, personal
communication, 2003). The rest of the authors contacted
did not define the site of the anastomosis in their
publication and did not respond to our questions. In two
studies all anastomosis were reported to be left-sided
[21,26]. All studies described the overall leakage rate
whereas mortality was only described in five studies
[18,23–26]. The incidence of wound infection was
reported in all of the included nine studies.
Results
Of the 1592 patients in the nine RCTs, 791 were
allocated for mechanical bowel preparation (Group A)
and 803 for no preparation (Group B) before elective
colorectal surgery.
Primary outcomes
When stratifying for colonic and rectal (outcome no. 1,
Table 2) [23–26] the meta-analysis of results after low
anterior resection showed that 11 (9.8%) of 112 patients
in Group A compared to 9 (7.5%) of 119 patients in
Group B developed leakage (Peto OR 1.45, 95% CI:
0.57–3.67 nonsignificant). There was no statistical het-
erogeneity. This was the same for colonic surgery, where
11 (2.9%) of 367 patients in Group A compared with 6
(1.6%) of 367 patients in Group B developed leakage
(Peto OR 1.80, 95% CI: 0.68–4.75, non significant).
When the colorectum was seen as a whole (outcome no. 2,
Table 3) the meta-analysis of all nine studies showed that
48 (6.2%) of 772 patients in Group A compared to 25
(3.2%) of 777 patients in Group B developed leakage
(Peto OR 2.03, 95% CI: 1.276–3.26) (P ¼ 0.003).
No statistical heterogeneity was found here either.
Secondary outcomes
The mortality (outcome no. 3) was described in five trials
[18,23–26]. Five (1%) of 509 patients in Group A died

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P. Wille-Jørgensen et al. Pre-operative mechanical bowel cleansing

Table 2 Anastomotic leakage in patients having elective colorectal resections with and without pre-operative mechanical bowel
cleansing. Stratified for colonic and rectal surgery.

Study Preparation No preparation Peto OR Weight Peto OR

or sub-category n/N n/N 95% CI % 95% CI

01 Leakage after low anterior resection

Burke 1994 [24] 3/39 4/36 36.02 0.67 (0.14, 3.15)
Santos 1994 [23] 2/21 2/29 20.52 1.42 (0.18, 11.01)
Miettinen 2000 [25] 3/9 2/14 21.86 2.92 (0.40, 21.25)
Zmora 2003 [26] 3/43 1/40 21.59 2.62 (0.36, 19.34)
Subtotal (95% CI) 112 119 100.00 1.45 (0.57, 3.67)
Total events: 11 (Preparation), 9 (No preparation)
Test for heterogeneity: χ² = 1.77, df = 3 (P = 0.62), I² = 0%
Test for overall effect: Z = 0.78 (P = 0.43)

02 Leakage after colonic surgery

Burke 1994 [24] 0/43 0/51 Not estimable
Santos 1994 [23] 5/51 2/48 40.08 2.34 (0.51, 10.80)
Miettinen 2000 [25] 2/129 1/115 18.10 1.75 (0.18, 17.02)
Zmora 2003 [26] 4/144 3/153 41.82 1.42 (0.32, 6.37)
Subtotal (95% CI) 367 367 100.00 1.80 (0.68, 4.75)
Total events: 11 (Preparation), 6 (No preparation)
Test for heterogeneity: χ² = 0.21, df = 2 (P = 0.90), I² = 0%
Test for overall effect: Z = 1.19 (P = 0.23)
0.001 0.01 0.1 1 10 100 1000
Favours preparation Favours control

Table 3 Anastomotic leakage in patients having elective colorectal resections with and without pre-operative mechanical bowel
cleansing. Colorectal surgery unstratified.

Study Preparation No preparation Peto OR Weight Peto OR

or sub-category n/N n/N 95% CI % 95% CI

Brownson 1992 [20] 8/67 1/67 12.34 5.23 (1.36, 20.14)

Burke 1994 [24] 3/82 4/87 9.84 0.79 (0.17, 3.58)
Santos 1994 [23] 7/72 4/77 14.95 1.93 (0.57, 6.57)
Fillmann 1995 [18] 2/30 1/30 4.23 1.99 (0.20, 19.94)
Miettinen 2000 [25] 5/138 3/129 1.56 (0.38, 6.36)
11.35 8.54 (1.36, 53.51)
Tabusso 2002 [19] 5/24 0/23
Bucher 2003 [21] 4/47 1/46 6.66 3.43 (0.57, 20.59)
Fa-Si-Oen 2003 [22] 7/125 6/125 18.05 1.18 (0.39, 3.58)
Zmora 2003 [26] 7/187 4/193 15.62 1.81 (0.55, 5.99)

Total (95% CI) 772 777 100.00 2.03 (1.27, 3.26)

Total events: 48 (Preparation), 24 (No preparation)
Test for heterogeneity: χ² = 7.18, df = 8 (P = 0.52), I² = 0%
Test for overall effect: Z = 2.94 (P = 0.003)
0.001 0.01 0.1 1 10 100 1000
Favours preparation Favours control

compared to 3 (0.6%) of 516 patients in Group B (Peto Wound infection (outcome no. 4) was desribed in all
OR 1.72, 95% CI: 0.43–6.95 (nonsignificant with no all studies) (Table 4). Fifty-nine (7.4%) of 791 patients in
statistical heterogeneity)). Group A developed wound infection compared with 43

Table 4 Wound Infections in patients having elective colorectal resection with and without pre-operative mechanical bowel cleansing.
Colorectal surgery – unstratified.

Study Preparation No preparation Peto OR Weight Peto OR

or sub-category n/N n/N 95% CI % 95% CI

Brownson 1992 [20] 5/86 7/93 12.00 0.76 (0.24, 2.45)

Burke 1994 [24] 4/82 3/87 7.20 1.43 (0.32, 6.47)
Santos 1994 [23] 17/72 9/77 23.04 2.28 (0.98, 5.29)
Fillmann 1995 [18] 1/30 2/30 3.09 0.50 (0.05, 5.02)
Miettinen 2000 [25] 5/138 3/129 8.31 1.56 (0.38, 6.36)
Tabusso 2002 [19] 2/24 0/23 2.09 7.40 (0.45, 122.11)
Bucher 2003 [21] 4/47 1/46 5.10 3.43 (0.57, 20.59)
Fa-Si-Oen 2003 [22] 9/125 7/125 16.05 1.30 (0.47, 3.59)
Zmora 2003 [26] 12/187 11/193 23.12 1.13 (0.49, 2.63)

Total (95% CI) 791 803 100.00 1.45 (0.97, 2.18)

Total events: 59 (Preparation), 43 (No preparation)
Test for heterogeneity: χ² = 5.64, df = 8 (P = 0.69), I² = 0%
Test for overall effect: Z = 1.81 (P = 0.07)
0.001 0.01 0.1 1 10 100 1000
Favours preparation Favours control

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Pre-operative mechanical bowel cleansing P. Wille-Jørgensen et al.

Outcome: 02 Overall anastomotic leakage for colorectal surgery

0.0

0.4
SE(log Peto OR)

0.8

1.2

1.6

0.001 0.01 0.1 1 10 100 1000

Peto OR

Outcome: 04 Wound infection

0.0

0.4
SE(log Peto OR)

0.8

1.2

1.6 Figure 1 Funnel plots of meta-analyses of

anastomotic leakage and wound infection
in patients having elective colorectal
resections with and without pre-operative
0.001 0.01 0.1 1 10 100 1000 mechanical bowel cleansing. Colorectal
Peto OR surgery unstratified.

(5.4%) of 803 patients in Group B (Peto OR 1.45, 95%

CI: 0.97–2.18 (P ¼ 0.07)) There was no statistical
heterogeneity.
Sensitivity analyses
Exclusion of the four studies where the allocation
procedure was considered unclear did not substantially
change the Peto OR for the two most important clinical
outcomes (anastomotic leakage and wound infection),
although the statistical significance disappeared due to a
smaller total sample size (P ¼ 0.1 and 0.14, respectively).
Neither the Peto OR nor the level of significance for the
two analysed outcomes were substantially changed after
exclusion of the three studies only presented as abstracts.
The significantly higher incidence of anastomotic
leakage in the mechanical bowel preparation group did
not change after exclusion of the study which included
children, but the potential negative effect of cleansing on
wound infection became smaller.
Testing for publication bias
A funnel plot of the two outcomes, which included all
studies (overall anastomotic leakage and wound infec-
tion) demonstrated symmetry indicating no publication
bias (Fig. 1).
Discussion
The principle of pre-operative bowel cleansing was first
severely challenged by Irving & Scrimgeour in 1987
[14] who published a case series without cleansning
and without anastomotic leakage. The study was
criticized in an editorial: Ôthe paper which challenges
accepted surgical practice, is a veritable little bomb of a
paper, brief, iconoclastic, and disrespectful of hal-
lowed tradition in colorectal surgeryÕ. That time
mechanical bowel preparation was an incontestable
routine, and still is according to guidelines from some
surgical associations and scientific societies [6,8,9,27],

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P. Wille-Jørgensen et al.
although other guidelines have now become updated
[7].
The problems has been investigated in randomised
trials for more than a decade and there are now several
published meta-analyses [11,12,28] all reaching the
conclusion that there is no evidence for performing pre-
operative bowel cleansing. The present analysis is an
update as new trials have been identified.The included
nine trials were all prospective and randomised. Typical of
studies of surgical practice the allocation procedure was
not well described, but was nevertheless considered
adequate in half of the studies. The importance of
allocation concealment has not become generally appre-
ciated until recently [29], and most of the studies were
conducted before this era. Only one of the studies tried to
use some kind of blinding [18], an almost impossible task
in trials of this kind. Despite these methodological flaws,
the studies must be considered of sufficient scientific value
that their conclusions should be taken seriously.
We found no convincing evidence that mechanical
bowel preparation before elective colorectal surgery
reduces the incidence of postoperative complications.
The primary outcome, anastomotic leakage, showed that
mechanical bowel preparation was significantly dangerous
when analysing colorectal surgery as a whole, and
stratification into colonic and rectal surgery did not
change the Odds Ratio substantially, although the
significance disappeared due to a smaller sample size.
Unfortunately it was only possible to obtain results for
this stratification from four authors [18,24–26]. Con-
tacting to the other authors did not produce more data.
Seven of the studies must be considered underpow-
ered from the beginning. Only the Peruvian study [19]
reported a significant difference in favour of no cleansing.
When pooling results from underpowered studies meta-
analysis is a good tool, and when there is no heterogen-
eity among the studies the overall result can be accepted
as valid.
The funnel-plots in Fig. 1 raise no suspicion of
publication-bias, thus our literature search should be
sufficient.
Although no statistical heterogeneity was found
between the outcomes of the individual studies, some
methodological and clinical heterogeneity exists. Whe-
ther this should change the conclusions is debatable. We
have tried with sensitivity-analyses to elucidate the
consequences of the heterogeneity, and none of these
analyses led to the conclusion that preparation would be
of benefit for the patient. The significance for the primary
outcome although disappears in some of the analyses, but
the tendency is still strong, and always in the same
direction; preparation is associated with a higher rate of
anastomotic leakage. When performing the sensitivity-

2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 304–310
Pre-operative mechanical bowel cleansing
and subgroup- analyses the material of course gets
smaller, leading to a statistical underpower of the analyses
thus enhancing the risk of a type II error when evaluating
the primary outcome. The Peto Odds Ratio remains
almost unchanged strongly supporting the conclusion
that mechanical bowel cleansing leads to a higher
incidence of anastomotic dehiscence in colorectal surgery.
In all selected trials and almost all of the excluded
studies, prophylactic antibiotics were used in both groups
and it was discussed whether this is the reason why no
beneficial effect was found for mechanical bowel prepar-
ation. We are unable to provide any substantial informa-
tion on this matter. One could speculate on changes in
the microcirculation in the bowel, due to the cleansing
procedure leading to relative iscaemia and altered possi-
bilities for bacterial translocation, although no studies
support these theories [22,30]. The problems of the
poorly prepared bowel might be overcomed by omitting
the mechanical preparation totally. A Ôsemi preparedÕ
colon is usually full of liquid faeces that can be difficult to
contain, resulting in spillage into the peritoneal cavity
causing significant contamination. The content of the
bowel (bulky stools) can be manipulated into the bowel
segment to be resected, enough to make the zone of the
anastomosis clear.
In any case the conclusions of this analysis are
supported by many case-series of unprepared patients
published during the last few years [31,32] showing an
acceptable low incidence of leakage in patients without
pre-operative bowel cleansing.
Conclusion
Prophylactic mechanical bowel preparation before colo-
rectal surgery has not been proven beneficial. It seems
that preparation is associated with a higher frequency of
anastomotic leakage – and thus should be omitted.
Future trials should report on rectal and colonic surgery
separately, and authors of previous trials should be
persuaded to give their original data free, so sufficient
stratified meta-analyses can be performed.
Acknowledgements
We thank Dr Oded Zmora and Dr JC Santos for
providing supplementary data. Dr E. Fillmann is thanked
for inspiration. This study was kindly supported by a
grant from the Valerie Jefferson Fund.
References
1 Halsted WS. Circular suture of the intestine: an experimental
study. Am J Med Sci 1887; 94: 436–61.
309
Pre-operative mechanical bowel cleansing
2 Thornton FJ, Barbul A. Healing in the gastrointestinal tract.
Surg Clin North Am 1997; 77: 549–73.
3 Nichols RL, Condon RE. Preoperative preparation of the
colon. Surg Gynecol Obstet 1971; 132: 323–37.
4 Chung RS, Gurll NJ, Berglund EM. A controlled trial of
whole gut lavage as a method of bowel preparation for
colonic operations. Am J Surg 1979; 137: 75–81.
5 Song F, Glenn AM. Antimicrobial prophylaxis in colorectal
surgery: a systematic review of randomized controlled trials.
Br J Surg 1998; 85: 1232–41.
6 The Association of Coloproctology of Great Britain and
Ireland (2001) Guidelines for the Management of Colorectal
Cancer, 2001. The Association of Coloproctology of Great
Britain and Ireland, London.
7 Kronborg O, Burchardt F, Bülow S et al. (2002) Guidelines
for diagnosis and treatment of colorectal cancer, 2 (In
Danish)., Danish Surgical Society, Copenhagen.
8 Scottish. Intercollegiate Guidelines Network (SIGN) &
Scottish Cancer Therapy Network. (1997) Colorectal Cancer,
A National Clinical Guideline Recommended for Use in
Scotland, 16. SIGN, Edinburgh.
9 Otchy D, Hyman NH, Simmang C et al. Practice parameters
for colon cancer. Dis Colon Rectum 2004; 47: 1269–84.
10 Hughes ESR. Asepsis in large-bowel surgery. Ann Roy Coll
Surg Engl 1972; 51: 347–56.
11 Wille-Jorgensen P, Guenaga KF, Castro AA, Matos D.
Clinical value of preoperative mechanical bowel cleansing in
elective colorectal surgery: a systematic review. Dis Colon
Rectum 2003; 46: 1013–20.
12 Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of
randomized clinical trials of colorectal surgery with or
without mechanical bowel preparation. Br J Surg 2004;
91: 1125–30.
13 Egger M, Smith GD, Schneider M, Minder M. Bias in meta-
analysis detected by a simple, graphical test. Br Med J 1997;
315: 629–34.
14 Irving AD, Scrimgeour D. Mechanical bowel preparation for
colonic resection and anastomosis. Br J Surg 1987; 74: 580–1.
15 Dorudi S, Wilson NM, Heddle RM. Primary restorative
colectomy in malignant left-sided large bowel obstruction.
Ann R Coll Surg Engl 1990; 72 (393): 395.
16 Duthie GS, Foster ME, Price-Thomas JM, Leaper DJ. Bowel
preparation or not for elective colorectal surgery. J R Coll
Surg Edinb 1990; 35: 169–71.
17 Matheson DM, Arabi Y, Baxter-Smith D, Alexander-Wil-
liams J, Keighley MR. Randomized multicentre trial of oral
bowel preparation and antimicrobials for elective colorectal
operations. Br J Surg 1978; 65: 597–600.
18 Fillmann EEP, Fillmann HS, Fillmann LS. Elective colorectal
surgery without mechanical prepare. Rev Bras Colo-Proct
1995; 15: 70–1.
19 Tabusso FY, Zapata CJ, Espinoza BF, Meza P, Figueroa RE.
Mechanical preparation in elective colorectal surgery, a
310
P. Wille-Jørgensen et al.
usefull pratice or need. Rev Gastroenterol Peru 2002; 22:
152–8.
20 Brownson P, Jenkins AS, Nott D et al. Mechanical bowel
preparation before colorectal surgery: results of a prospective
randomized trial. Br J Surg 1992; 79: 461–2.
21 Bucher P, Soravia C, Gervaz P et al. Post-operative compli-
cations after elective colorectal surgery in regards of bowel
preparation: results of a prospective randomised trial.
Gastroenterology 2003; 124: 817.
22 Fa-Si-Oen PR, Buitenweg JA, van Geldere D et al. (2003)
The effect of preoperative bowel preparation with polyethylene
glycol on surgical outcome in elective open colorectal surgery – a
randomised multicentre trial. Fourth Belgian Surgical Week,
Ostende, Belgium.
23 Santos JMC, Batista J, Sirimarco MT et al. Prospective
randomized trial of mechanical bowel preparation in patients
undergoing elective colorectal surgery. Br J Surg 1994; 81:
1673–6.
24 Burke P, Mealy K, Gillen P et al. Requirement for bowel
preparation in colorectal surgery. Br J Surg 1994; 81:
907–10.
25 Miettinen RPJ, Laitinen ST, Makela JT et al. Bowel prepar-
ation with oral polyethylene glycol electrolyte solution vs. no
preparation in elective open colorectal surgery. Dis Colon
Rectum 2002; 43: 669–77.
26 Zmora O, Mahajna A, Bar-Zakai B et al. Left-Sided
Anastomosis Without Mechanical Bowel Preparation: a
Randomized, Prospective Trial. Dis Colon Rectum 2002;
45: A7–A8.
27 Moore J, Hewet P, Penfold JC. Practice parameters for the
management of colonic cancer I. surgical issues. Recommen-
dations of the colorectal surgical society of Australia. Austr
NZ J Surg 1999; 69: 415–21.
28 Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical
bowel preparation for elective colorectal surgery: a meta-
analysis. Arch Surg 2004; 139: 1359–64.
29 Schulz KF, Grimes DA, Altman DG, Hayes RJ. Blinding and
exclusions after allocation in randomised controlled trials.
survey of published parallel group trials in obstetrics and
gynaecology. Br Med J 1996; 312: 742–4.
30 Kale TI, Kuzu MA, Tikely A, Tanik A, Aksoy M, Cete M.
Aggressive bowel preparation does not enhance bacterial
translocation, provide the mucosal barrier is not disrupted. A
prospective, randomized study. Dis Colon Rectum 1998; 31:
636–41.
31 van Geldere D, Fa-Si-Oen P, Noach LA, Rietra PJ, Peterse
JL, Boom RP. Complications after colorectal surgery without
mechanical bowel preparation. J Am Coll Surg 2002; 194:
40–7.
32 Memon MA, Devine J, Freeney J, From SG. Is mechanical
bowel preparation really necessary for elective left sided
colon and rectal surgery. Int J Colorectal Dis 1997; 12:
298–302.

2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 304–310