Comparative efficacy of bowel preparation strategies in colorectal surgery: A network meta-analysis of randomized controlled trials

doi:10.4240/wjgs.124318

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Publication Name

World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Meta-Analysis

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Surg. Nov 27, 2026; 18(11): 124318
Published online Nov 27, 2026. doi: 10.4240/wjgs.124318

Comparative efficacy of bowel preparation strategies in colorectal surgery: A network meta-analysis of randomized controlled trials

Maha AbuZarifa, Mesan Hijazy, Asmaa Zakria Alnajjar, Omar Khaled Abdelsalam, Abdalrahman Ajjur, Mariam A Abusalah, Abdallah AbuJlambo, Mohammed B AbuZarifa, Ola AbuZarifa, Hazem Ayesh

Maha AbuZarifa, Faculty of Medicine, Al-Quds University, Al-Azhar Branch, Gaza P850, Palestine

Mesan Hijazy, Asmaa Zakria Alnajjar, Faculty of Medicine, Al-Azhar University, Gaza P850, Palestine

Omar Khaled Abdelsalam, Faculty of Medicine, New Mansoura University, New Mansoura 35742, Egypt

Abdalrahman Ajjur, Mariam A Abusalah, Faculty of Medicine, Al-Quds University, Abu Dis P1441270, Palestine

Abdallah AbuJlambo, Department of Intensive Care Unit, Al-Shifa Hospital, Gaza P850, Palestine

Mohammed B AbuZarifa, Faculty of Medicine, Ain Shams University, Cairo 3753450, Egypt

Ola AbuZarifa, Faculty of Pharmacy, De Montfort University, Leicester LE1, United Kingdom

Hazem Ayesh, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37011, United States

Author contributions: AbuZarifa M contributed to concept and design; AbuZarifa M, Ayesh H, Ajjur A, Alnajjar AZ, and AbuJlambo A contributed to acquisition, analysis, or interpretation of data; Ayesh H did critical revision of the manuscript for important intellectual content and supervision; all authors contributed to drafting of the manuscript, data extraction and management, and approved the final manuscript.

AI contribution statement: No AI tools were used in this study.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Maha AbuZarifa, MD, Faculty of Medicine, Al-Quds University, Al-Azhar Branch, Gaza P850, Palestine. 20200430@student.alazhar.edu.ps

Received: June 12, 2026
Revised: July 21, 2026
Accepted: September 30, 2026
Published online: November 27, 2026
Processing time: 154 Days and 2.4 Hours

Abstract

BACKGROUND

Colorectal surgeries are commonly performed procedures, yet they are associated with a considerable risk of complications such as surgical site infections (SSIs) and anastomotic leaks. Preoperative approaches, including mechanical bowel preparation (MBP) and oral antibiotics (OAB), aim to reduce these risks.

AIM

To comprehensively evaluate and compare the efficacy of various bowel preparation approaches in reducing postoperative complications following colorectal surgery.

METHODS

A thorough literature search was conducted in PubMed, Cochrane Library, Web of Science, and Scopus up to April 28, 2025. A frequentist network meta-analysis with a random-effects model was used to calculate relative risks with 95% confidence intervals (CIs), and interventions were ranked using P scores. Confidence in Network Meta-Analysis assessment was used to evaluate the confidence in the evidence. Primary outcomes included incisional SSI and organ space SSI. Secondary outcomes encompassed anastomotic leakage, postoperative ileus, and Clavien-Dindo I-II complications.

RESULTS

Our analysis, conducted on 38 studies, showed that the combination of MBP and OAB considerably reduced incisional SSI with a relative risk of 0.53 (95%CI: 0.29-0.99, P = 0.04) and organ-space SSI with a relative risk of 0.62 (95%CI: 0.39-0.99, P = 0.04), demonstrating a statistically significant effect. In the secondary outcomes, OAB-containing regimens showed superiority to the other treatments, and they also had the highest P score.

CONCLUSION

Even though the combination of MBP and OAB is strongly supported as the preferred strategy for preventing infectious postoperative complications, these findings are not only in line with current recommendations but also provide a foundation for additional research that will investigate their relevance to a larger variety of surgical procedures.

Keywords: Surgical site infections; Preoperative cleansing; Antimicrobial prophylaxis; Colorectal surgery; Meta-analysis

Core Tip: This network meta-analysis provides a comprehensive comparison of bowel preparation strategies in colorectal surgery using data from 38 randomized controlled trials. Mechanical bowel preparation combined with oral antibiotics (OAB) significantly reduced incisional surgical site infection (relative risk 0.53, 95% confidence interval: 0.29-0.99) and organ-space surgical site infection (relative risk 0.62, 95% confidence interval: 0.39-0.99) compared with other regimens. OAB-containing approaches ranked highest for preventing postoperative infectious complications. These findings reinforce the superiority of combined mechanical bowel preparation + OAB as the optimal strategy and support current clinical recommendations while highlighting areas for further research.