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ORIGINAL/RESEARCH ARTICLES
BOWEL PREPARATION WITH PEGLEC IN INFANTS : A SAFE, EFFECTIVE AND EXPEDITIOUS WAY
DHARMENDRA SINGH*, SANGRAM SINGH*, GADDI DIWAKAR*, SS BHAGWAT**
Peglec (polyethelene glycol) is an oral preparation, which is being widely used in adults for safe and effective bowel preparation (BwP), but very few studies have been done in infants. Authors evaluated 26 female infants born with anorectal malformations whose bowels were prepared with peglec, and who underwent primary corrective surgeries without the cover of proximal diverting clostomy. All the patients were monitored haemodynamically as well as biochemically. Bowel preparation was found to be good in all the 26 cases. There were no adverse statistically significant haemodynamic or biochemical changes. The efficacy of peglec was evaluated by the same operating consultant surgeon as good, fair or poor and in all of our cases it was found to be good.
INTRODUCTION
The most important prerequisite for a safe and successful colorectal surgery is an adequate bowel preparation. Mechanical cleansing of the bowel has been done traditionally by admitting the child 3 days prior to surgery and then keeping the child on clear fluids or nil by mouth, giving oral antibiotics, enemas, and bowel washes. But this traditional method of bowel preparation is very cumbersome, tedious, and causes unwanted anxiety among parents and unnecessary suffering to a hungry child. Mechanical cleansing of the bowel using whole bowel irrigation was first described by Hewitt in 1973.1 In 1980, Devis et al introduced Golytely (Braintree Laboratories, Braintree, MA) as a bowel irrigant.2 This polyethylene glycol electrolyte lavage solution was designed to avoid electrolyte shifts, and dehydration. Many studies in adults have demonstrated its safety and efficacy, and therefore it has been widely used in adults, but there has been some hesitancy in its use in infants and small children.3-5 This study was carried out to assess the safety, and efficacy of peglec in infants.
MATERIAL AND METHODS
The study was conducted in BJ Wadia Hospital for children, Parel, Mumbai, which is a tertiary care teaching institute. From Jan. 2000 to Jan. 2002 we encountered 41 female patients with anorectal malformations (ARM) out of which 26 were picked up for the study. Those excluded from the study were the ones, having high ARM’s, and those who were above 1 year of age. All the patients operated were, less than 1 year of age (Table 1), with various types of ARM’s (Table 2). Out of the 26 patients 17 underwent Stephen’s sacroperineal pull through, and 7 underwent anal transposition. All the patients were admitted a day prior to surgery and BwP was started 20 hours preoperatively by peglec solution. Peglec was administered via nasogastric tube, at a rate of 3 ml/kg/hr, max 30 ml/hr, until a clear effluent was obtained. During BwP repeated
TABLE 1
Age at surgery of the patients included in the study group
Age at surgery
(in months)No. of patients
(n=26)< 3
4
4-6
12
7-9
5
10-12
5
TABLE 2
Various types of ARM’s seen in the study group
Type of ARM
(n=26)Anteposed anus Vestibular anus Anovestibular fistula Rectovestibular fistula Low rectovaginal fistula fistula catheterization was done to ensure proper deflation. Before starting BwP S. electrolytes, pulse, blood pressure, respiratory rate, abdominal girth and weight of the patient were recorded. During BwP all these parameters were recorded every half hourly. S. electrolytes were repeated 2 hours following completion of BwP. At the time of operation adequacy of BP was graded by the same operating consultant surgeon in all the cases, as good (clean preparation), fair (some particulate matter), or poor (gross stools).
Neither preoperative enteral antibiotics, nor enemas were given to any of the patients. After completion of BwP patients were kept nil orally, on maintenance intravenous (I/V) fluids (as N/3 glucose saline (500 ml) + 5 ml KCl). All the patients received parenteral antibiotics (cefotaxime + amikacin + metronidazole) intraoperatively as well as in postoperative period. During postoperative period patients were nursed in lateral position or in Bryant’s traction, so that good care of the neoanus and sacroperineal wound can be done. Oral feeds were started on 5th postoperative day and patients were discharged on 7th postoperative day. Detailed records of wound infection, wound dehiscence, retraction or stenosis of the neoanus
were maintained.
RESULTS
Twenty six females ranging in age 1 month to 12 months, were included in the study having low or intermediate ARM’s. Peglec was administered by a nasogastric tube and was well tolerated by all the patients. It took 3.5 to 6 hours, average - 4.5 hours. for complete BwP. BwP as judged by the same operating consultant surgeon on table was found to be good in all the 26 cases. None of our patients developed clinically significant S. elecltrolyte imbalance following BwP, and also none of our patients developed any significant alteration of other parameters (pulse, blood pressure, respiratory rate, abdominal girth and weight gain) recorded before and during the course of BwP. All our patients had an uneventful postoperative period and none of our patients developed wound infection, wound dehiscence and subsequent retraction or stenosis of the neoanus.DISCUSSION
With increasing load of patients on the government hospitals admitting children, a few days prior to surgery not only leads to unnecessary bed occupancy, thereby denying admission to the needy ones, but it also exaggerates the cost of treatment and simultaneously predisposes child to I/V related complications, and unwarranted suffering to not only the child but also to the parents.
solution as it produces luminal hydrogen, this can cause distension of the abdomen.
Previous studies by Tuggle et al,6 Donahue et al7 and Engum et al,8 have documented the safety of polyethylene gastrointestinal lavage solution in paediatric population, but these authors have also used oral antibiotics and enemas, which we havenot, and have found that its not mandatory, especially in infants, to achieve a good BwP, as in our study none of our patients developed wound infection, dehiscence and subsequent bowel retraction or stenosis.
Therefore to summarize BwP using peglec allows dietary freedom till 20 hours prior to surgery. The BwP time is very short and it eliminates the need of adjunct oral antibiotics. With good BwP, single operative procedure is possible without diverting colostomy, and without any risk of wound infection or dehiscence. It also decreases the duration of hospital stay and is cost effective. Spurned by the wonderful results of peglec, we have now started using it for many other indications like Soave’s endorectal pull through, oesophageal substitution with colon and have found the results very satisfying. Hence to conclude, BwP with peglec is safe, effective, expeditious and less costly.
REFERENCES
Hewitt J, Rigby J, Reeve J, et al. Whole gut irrigation in preparation for large bowel surgery. Lancet 1973; 2 : 337-40. Davis GR, Santa Ana CA, Morawski SG, et al. Development of a lavage solution associated with minimal water and electrolyte absorption or secretion. Gastroenterology 1980; 78 : 991-5. Thomas G, Bronzinsky S, Eisenberg J. Patient acceptance and effectiveness of a balanced lavage solution (Golytely) versus the standard preparation for colonoscopy. Gastroenterology 1982; 82 : 435-7. Fleites RA, Marshall JB, Eckhauser ML, et al. The efficacy of polyethylene glycol electrolyte lavage solution versus traditional mechanical bowel preparation for elective colonic surgery: A randomized, prospective, blinded clinical trial. Surgery 1985; 98 : 708-15. Ernstoff JJ, Howard DA, Marshall JB, et al. A randomized blinded clinical trial of a rapid colonic lavage solution (Golytely) compared with standard preparation for colonoscopy and barium enema. Gastroenterology 1983; 84 : 1512-6. Tuggle DW, Hoelzer DJ, Tunnel WP, et al. The safety and cost-effectiveness of polyethelene glycol electrolyte solution bowel preparation in infants and children. J Pediatr Surg 1987; 22 : 513-5. Donahue MC, Evangelista JK, Shamberger RC. Effect of Golytely on serum electrolytes and hydration status of infants. J Pediatr Surg 1994; 29 (8) : 1095-6. Engum SA, Carter ME, Murphy D, et al. Home bowel preparation for elective colonic procedures in children : cost savings with quality assurance and improvement. J Pediatr Surg 2000; 35 (2) : 232-4. younger than 60 years and 65 per cent in older men.
Engl J Med, 2003; 349 (4) : 317.
SCREENING WITH THE PSA TEST
The failure to perform prostate biopsy in all members of a screened population affects the sensitivity
and specificity of the measurement of prostate-specific antigen (PSA). Correction for verification
bias with the use of a mathematical method revealed that the usual threshold value of 4.1 ng of
PSA per milliliter for a recommendation of biopsy misses 82 per cent of prostate cancers in men
younger than 60 years and 65 per cent in older men.
The authors of this provocative study argue that the threshold for prostate biopsy should be lowered,
perhaps to 2.6 ng of PSA per milliliter, especially for men under 60 years of age.
N Engl J Med, 2003; 349 (4) : 317.
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