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Rectal Cancer Surgery With or Without Bowel Preparation: The French Greccar III Multicenter Single-Blinded Randomized Trial

Bretagnol, Frederic MD, PhD*; Panis, Yves MD, PhD*; Rullier, Eric MD; Rouanet, Philippe MD, PhD; Berdah, Stephane MD§; Dousset, Bertrand MD; Portier, Guillaume MD**; Benoist, Stephane MD, PhD††; Chipponi, Jacques MD‡‡; Vicaut, Eric MD, PhD§§the French Research Group of Rectal Cancer Surgery (GRECCAR)

doi: 10.1097/SLA.0b013e3181fd8ea9
Original Articles from the ESA Proceedings: Rectal Cancer Surgery and Bowel Preparation

Objective: To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP).

Background: The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP.

Methods: From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay.

Results: A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups.

Conclusions: This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer. This study is registered with, number NCT00554892.

Collective evidence from literature strongly demonstrated that elective colonic surgery without mechanical bowel preparation (MBP) was safe without compromising postoperative morbidity. By contrast, this first randomized study on rectal cancer suggests that rectal cancer surgery without MBP increased both overall and infectious morbidity rates.

*Department of Digestive Surgery, Beaujon Hospital, Clichy

Department of Digestive Surgery, St-Andre Hospital, Bordeaux

Department of Digestive Surgery, Val d'Aurelle Institute, Montpellier

§Department of Digestive Surgery, North Hospital, Marseilles

Department of Digestive Surgery, Cochin Hospital, Paris

**Department of Digestive Surgery, Purpan Hospital, Toulouse

††Department of Digestive Surgery, Ambroise Paré Hospital, Boulogne Billancourt

‡‡Department of Digestive Surgery, Hotel-Dieu Hospital, Clermont-Ferrand

§§Lariboisière Hospital, Paris.

Reprints: Yves Panis, MD, PhD, Service de Chirurgie Colorectale, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon – Assistance Publique des Hôpitaux de Paris (APHP), Université Paris VII (Denis Diderot), 100 boulevard du Général Leclerc, 92118 Clichy cedex, France. E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.