Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort
Authors: Catarci Marco , Guadagni Stefano , Masedu Francesco , Ruffo Giacomo , Viola Massimo Giuseppe , Borghi Felice , Garulli Gianluca , Pirozzi Felice , Delrio Paolo , De Luca Raffaele , Baldazzi Gianandrea , Scatizzi Marco ,   The Italian ColoRectal Anastomotic Leakage (iCral) study group, Ciano Paolo , Benedetti Michele , Montemurro Leonardo Antonio , Clementi Marco , Bertocchi Elisa , Masini Gaia , Altamura Amedeo , Rubichi Francesco , Migliore Marco , Parlanti Daniele , Vago Gabriele , Sciuto Antonio , Pace Ugo , Bucci Andrea Fares , Simone Michele , Cassini Diletta , Pandolfini Lorenzo , Falsetto Alessandro , Ficari Ferdinando , Giudici Francesco , Cianchi Fabio , Patriti Alberto , Ricci Marcella Lodovica , Siquini Walter , Cardinali Alessandro , D’Ugo Stefano , Spampinato Marcello , Scabini Stefano , Aprile Alessandra , Soriero Domenico , Caricato Marco , Capolupo Gabriella Teresa , Pignata Giusto , Andreuccetti Jacopo , Canfora Ilaria , Liverani Andrea , Lamacchia Giuseppe , Franceschilli Claudia , Campagnacci Roberto , Maurizi Angela , Marini Pierluigi , Attinà Grazia Maria , Elmore Ugo , Puccetti Francesco , Corcione Francesco , Bracale Umberto , Peltrini Roberto , Santoro Roberto , Amodio Pietro , Carlini Massimo , Spoletini Domenico , Marcellinaro Rosa , Giuliani Antonio , Del Vecchio Giovanni , Sorrentino Mario , Stefanoni Massimo , Ferrari Giovanni , Lombardi Pietro Maria , Di Leo Alberto , Crepaz Lorenzo , Verzelli Augusto , Budassi Andrea , Sica Giuseppe , Bagaglini Giulia , Rausei Stefano , Tenconi Silvia , Cavaliere Davide , Solaini Leonardo , Ercolani Giorgio , Baiocchi Gian Luca , Molfino Sarah , Milone Marco , De Palma Giovanni Domenico , Ciaccio Giovanni , Locurto Paolo , Tebala Giovanni Domenico , Di Cintio Antonio , Boni Luigi , Cassinotti Elisa , Mancini Stefano , Sagnotta Andrea , Guerrieri Mario , Ortenzi Monica , Persiani Roberto , Biondi Alberto , Lucchi Andrea , Vitali Giulia , Parini Dario , De Luca Maurizio , Spinelli Antonino , Carrano Francesco , Genna Michele , Fior Francesca , Bottino Vincenzo , Ferronetti Antonio , Coratti Andrea , Giuliani Giuseppe , Benigni Roberto , Scala Dario , Puppio Battistino , Vagliasindi Alessio , Muratore Andrea , Marsanic Patrizia , Pipitone Federico Nicoletta Sveva , Pavanello Maurizio , Di Marco Carlo , Rivolta Umberto , Bertoglio Camillo Leonardo , Piccoli Micaela , Pecchini Francesca , Talarico Carlo , Greco Vincenzo , Carrara Alessandro , Motter Michele , Tirone Giuseppe , Totis Mauro , Tamini Nicolò , Roviello Franco , Piagnerelli Riccardo , Anastasi Alessandro , Canonico Giuseppe , Guercioni Gianluca , Cicconi Simone , Ettorre Giuseppe Maria , Colasanti Marco , Montuori Mauro , Pinotti Enrico , Mariani Pierpaolo , Carminati Roberta , de Manzini Nicolò , Osenda Edoardo , Donini Annibale , Graziosi Luigina , Armellino Mariano Fortunato , De Martino Ciro , Taglietti Lucio , Birindelli Arianna , Anania Gabriele , Chiozza Matteo , Di Cosmo Mariantonietta , Zigiotto Daniele , Feo Carlo Vittorio , Pindozzi Fioralba , Millo Paolo , Grivon Manuela , Pedrazzani Corrado , Conti Cristian , Guerriero Silvio , Organetti Lorenzo , Costanzi Andrea , Monteleone Michela , Vettoretto Nereo , Botteri Emanuele , Marchesi Federico , Dalmonte Giorgio , Basti Massimo , Frazzini Diletta , Longo Graziano , Santoni Simone , Cicetti Moreno , La Gioia Gabriele , Brisinda Giuseppe , Berti Stefano 
Published: April 2024

Abstract
Background
Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation.

Methods
A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI).

Results
Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23–2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10–1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25–0.79; p = .008).

Conclusions
MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.