Is bowel confinement necessary after anorectal reconstructive surgery? A prospective, randomized, surgeon-blinded trial

PURPOSE: The aim of this study was to assess any differences between the in clusion or omission of medical bowel confinement relative to postoperative morbidity and patient tolerance after anorectal reconstructive surgery. MET HODS: Between January 1995 and February 1997 a prospective randomized trial was conducted for patients without stomas who underwent anorectal reconstr uctive surgery. All patients were randomly assigned either to medical bowel confinement (a clear liquid diet with loperamide 4 mg by mouth three times per day and codeine phosphate 30 mg by mouth four times per day until the third postoperative day) or to a regular diet, beginning the day of surgery . AU patients in both groups underwent the identical preoperative oral mech anical preparation, preoperative oral and parenteral antibiotics, and posto perative antibiotics. Wound closure and wound care were identical in both g roups. RESULTS: Fifty-four patients (46 females) were prospectively, random ly assigned to medical bowel confinement (n = 27; 50 percent) or a regular diet (n = 27; 50 percent); the mean ages were 51.0 (range, 28-80) and 47.2 (range, 23-87) years, respectively. Indications for surgery were fecal inco ntinence in 32 patients, complicated fistulas in 17 patients, anal stenosis in 4 patients, a Whitehead deformity in 1 patient, and a chronic unhealed fissure in 1 patient. Fifty-four patients underwent 55 procedures: 32 patie nts underwent sphincteroplasty, 18 patients underwent transanal advancement flaps, and 5 patients underwent anoplasties. There were no differences bet ween the two groups in the incidence of either septic or urologic complicat ions. Nausea and vomiting were recorded in seven (26 percent) medical bowel confinement and three (11 percent) regular-diet patients. The first postop erative bowel movement occurred at a mean of 3.9 days in the medical bowel confinement group and 2.8 days in the regular diet group (P < 0.05). Fecal impaction occurred in seven (26 percent) of the patients in the medical bow el confinement group and two (7 percent) of the patients in the regular die t group. Hospital charges analysis showed a mean cost of hospitalization of $12,586.00 (range, $3,436.00-$20,375.00) for the medical bowel confinement group and $10,685.00 (range, $3,954.00-$18,574.00) in the regular diet gro up, representing a mean difference of $1,901.00 (P = 0.06). Mean follow-up was 13 months for both groups (range, 1-24 months in the regular diet group and 2-25 months in the medical bowel confinement group). No statistical di fference was shown in the functional outcome of sphincteroplasties between the medical bowel confinement group and the regular diet group. CONCLUSIONS : The outcome of reconstructive anorectal surgery was not adversely affecte d by the omission of medical bowel confinement. Moreover, cost savings can be achieved by the omission of routine bowel confinement.