**1.3 MBP in elective rectal surgery**

Data on MBP in patients with rectal surgery are not sufficient. Traditionally rectal washouts were done. The issues related to rectal surgery are different from those of colonic surgery. In low colorectal or coloanal anastomosis (anastomosis within 6 cm from the anal verge), a protective ostomy is often made because of the higher risk of anastomotic leak. A meta-analysis conducted on 28 RCTs and 12 cohort studies with 69,517 patients concluded that a combination of POA with MBP was associated with a significant reduction of SSI (RR = 0.51, p < 0.00001), anastomotic leak (RR = 0.62, p < 0.00001), 30 days mortality (RR = 0.58, p < 0.0001), overall morbidity (RR = 0.67, p < 0.00001), and postoperative ileus (RR = 0.72, p = 0.04) [83]. Anastomotic leak after rectal surgery is higher than that in colonic surgery [91]. Bretagnol et al. conducted a study on the role of MBP in rectal surgery, and they reported a higher infectious morbidity rate in the patient without MBP [92]. In contrast, Mahajna et al. reported that MBP causes liquid bowel contents, which lead to peritoneal spillage three times more frequently than when semisolid stool is present [93]. Results are not uniform regarding the use of oral antibiotics before rectal surgery, and very few studies have been done exclusively on rectal cancer patients [94]. Zmora et al. reported that some form of bowel preparation, such as rectal enema, is required before rectal surgery [14]. Bowel preparation with rectal enema is

less invasive and well-tolerated and has not been associated with increased infectious morbidity [95]. However, more multicenter trials are required to gather evidence for MBP before rectal surgery.
