Editing Intestinal Segments and Urinary Diversion (section)

== Bowel Preparation ==

=== Normal bowel bacterial flora ===
*Consists of:
** Aerobic organisms
*** Most common: Escherichia coli and Enterococcus faecalis
** Anaerobic organisms
*** Most common: Bacteroides and Clostridium
* Bacterial concentration ranges from 
**10-10e5 organisms per gram of fecal content in the jejunum
**10e5-10e7 in the distal ileum
**10e6-10e8 in the ascending colon
**10e10-10e12 in the descending colon

=== Rationale for Bowel Preparation ===
*Solid feces may place strain on the anastomosis in the early phase of healing and result in ischemia with subsequent perforation
*In experimental animals, an anastomosis with vascular compromise at the anastomotic line, which would normally result in perforation, heals if the bowel has been properly prepared with antibiotics
*Infectious complications after radical cystectomy that are a direct result of fecal contamination include 
**Peritonitis
**Intra-abdominal abscesses
**Wound dehiscence
**Anastomotic dehiscence
**Systemic sepsis

=== Classification (2) ===
*'''Mechanical vs. antibiotic'''

==== Mechanical (whole-gut irrigation) ====
* '''<span style="color:#ff0000">Reduces the amount of feces/total number of bacteria but not their concentration'''
* '''Can be done with polyethylene glycol (PEG)–electrolyte solution'''

===== Efficacy =====

*'''<span style="color:#ff00ff">2011 Cochrane review: Mechanical bowel preparation for elective colorectal surgery'''
** '''18 trials with 5,805 participants were analyzed'''
** '''No difference in anastomotic leakage or wound infection rates; important to note that many of these studies involved peri-operative intravenous antibiotics and likely crucial in keeping the complication rate low'''
** '''[https://pubmed.ncbi.nlm.nih.gov/21901677/ Güenaga, Katia F., Delcio Matos, and Peer Wille‐Jørgensen."Mechanical bowel preparation for elective colorectal surgery." Cochrane Database of Systematic Reviews 9 (2011)]'''
* '''No studies have adequately assessed the safety of omitting mechanical bowel preparation in urologic reconstructive surgery'''

===== Contraindications (5): =====
# '''Obstructed bowel'''
# '''Unstable cardiovascular system'''
# '''Congestive heart failure'''
# '''Cirrhosis'''
# '''Severe CKD'''

===== Adverse Events =====

*'''Hypokalemia'''
**'''Vigorous bowel cleansing, even with Go-Lytely or other electrolyte solutions, will often result in low potassium.'''
*** '''Characteristic signs include muscular weakness with poor respiratory effort causing decreased ventilation in the presence of a normal chest x-ray.'''
*'''Diarrhea'''

==== Antibiotic ====
* '''<span style="color:#ff0000">Reduces the bacterial concentration'''
* '''<span style="color:#ff0000">PERIoperative IV antibiotics appear to be the most important means of preventing infectious complications of intestinal surgery.'''
**'''Systemic antibiotics must be given before the operative event if they are to be effective.'''
***A randomized trial in elective colorectal surgery found that PREoperative antibiotics did not reduce the risk of clinical infections[https://www.ncbi.nlm.nih.gov/pubmed/17443852 §]
** '''If perioperative antibiotics are given, they should be effective against anaerobes because it is complications from these organisms against which perioperative antibiotics appear to be particularly effective.'''

===== Adverse Events =====
*'''Diarrhea'''
*'''Pseudomembranous enterocolitis'''
** '''Treatment involves the administration of vancomycin or metronidazole and discontinuance of other antibiotics that the patient is receiving'''