Title: EAES, SAGES, ESCP and ESCMID Rapid Guideline: Bowel preparation for minimally invasive colorectal resection
Edition: Original
Classification: Rapid advice guideline
Field: Treatment
Countries and regions: Netherlands
Guidelines users: The guideline aims to inform the practice and decisions of minimally invasive general and colorectal surgeons, anesthetists, and patients. A patient version of the manuscript written in lay language will accompany the guideline report.
Evidence classification method: Results of evidence syntheses will be summarized in evidence tables on MAGICapp. We will use the CINeMA software to summarize risk of bias according to the contribution of each study to the network for the respective outcome. The overall risk of (within study) bias will be based upon the highest proportion of risk of bias contributed to the network, as per CINeMA methodology. Judgements on publication (reporting) bias will be based on comparison-adjusted funnel plots. Judgements on indirectness will be based on conceptual differences between the study populations, settings and interventions, and the presence of direct evidence; if only indirect evidence will be present (which does not allow for assessment of inconsistency), we will downgrade the evidence certainty by one level. Heterogeneity judgements will be based upon statistical calculations of heterogeneity and consistency. If substantial heterogeneity or inconsistency will be found, we will downgrade the certainty in the evidence by one or two levels. Judgements on imprecision will be based upon minimal important differences that will be set by majority voting of the guideline panel in advance, according to principles of a fully contextualized approach (minimal important differences for each outcome were based upon the assumption that each outcome is the only outcome of interest). For each outcome, we will stratify interventions by certainty (moderate-to-high or low-to-very low). We will then group interventions within each stratum into 3 groups according to their statistical ranking: among the best, inferior to the best/better than the worst, and among the worst. The classified rankings were considered by panel members as complementary to the GRADE evidence tables. This process facilitates assessment of both the certainty of the evidence on each intervention along with their ranking [24]. Evidence to decision framework The guideline panel will review the evidence tables and the stratified rankings. In an in-person consensus meeting, panel members will provide their judgements on: the magnitude of benefit of each intervention the magnitude of harm of each intervention the certainty of the evidence for each intervention any variability in patients' values and preferences costs or savings related to each intervention effect of each intervention on equity acceptability of each intervention feasibility of each intervention Following the in-person meeting, panel members will vote on the direction and the strength of the recommendations in an online voting and will formulate the recommendation through a Delphi process. Modifications to the formulation of the recommendations will have to agree with the GRADE methodology to be considered. Consensus will be defined as agreement above 80% among panel members.
Development unit: European Association for Endoscopic Surgery and Other Interventional Techniques
Registration time: 2023-01-23
Registration number: PREPARE-2023CN045
Purpose of the guideline: Bowel preparation has been an integral part of the preoperative workup before colorectal surgery. It consists of a bundle of measures, that include mechanical bowel cleansing, oral or intravenous antibiotics, enemas, or a combination. The expected benefit is a decrease in the incidence of infectious complications, such as superficial surgical site infection and organ space infection. Mechanical bowel preparation may cause discomfort to the patient, loss of significant amount of fluids that may lead to dehydration, with implications on the intraoperative and perioperative management. With the advent of minimally invasive surgery and enhanced recovery programs, the clinical merit of bowel preparation has been questioned. National and international guidelines have recommended using a combination of oral antibiotics with mechanical bowel preparation. These were based upon head-to-head comparisons between options, which, however, does not allow for assessment of intervention effects within the same analysis model. Advanced meta-analytical techniques allow for comparison of multiple interventions, enhancing the precision of effect estimates, potentially resulting in higher certainty of the evidence compared to pairwise comparisons. Members of the European Association for Endoscopic Surgery (EAES) have prioritized bowel preparation for minimally invasive colorectal surgery in a survey of the EAES Guidelines Subcommittee (31.8% among respondents; 95% confidence interval, 25.9%-37.7%) [Outcome of the EAES poll to prioritize topics for future guidelines. Available in: https://eaes.eu/wp-content/uploads/2022/05/2022-05-09-poll.pdf. Accessed October 15, 2022.]. The aim of this rapid guideline is to provide evidence-informed, state-of-the-art, trustworthy recommendations on bowel preparation prior to minimally invasive colorectal surgery, with the objective to support general and colorectal surgeons, other healthcare professionals, and patients in clinical decision making, and ultimately improve patient outcomes and experience.