Discussion on the influence of optimizing the perioperative management on the recovery after laparoscopic hysterectomy.

Uterine fibroids and adenomyosis are common benign diseases of the female reproductive system. For patients with obvious symptoms, such as excessive menstrual flow followed by anemia, large fibroids that compress the bladder and rectum, causing corresponding symptoms, or dysmenorrhea that is ineffective in drug treatment, surgery is still the main treatment method. Surgery can be performed through the abdomen, vagina, or laparoscopy. In recent years, with the continuous progress and development of minimally invasive technology, laparoscopic surgery has the advantages of minimal trauma and fast recovery compared to open surgery, and is increasingly recognized by more patients. However, laparoscopic total hysterectomy, as a moderate gynecological surgery, still inevitably brings physical and mental trauma and stress damage to patients, especially for patients with preoperative complications. Surgery is undoubtedly a double-edged sword, which can treat diseases, but it cannot completely avoid the occurrence of intraoperative and postoperative complications. Therefore, minimizing surgical trauma and stress reactions to the greatest extent possible, and accelerating postoperative recovery of patients, are the issues that clinical doctors are most concerned about. [ 1 ] The concept of enhanced recovery after surgery (ERAS) was first proposed by Professor Kehlet of the University of Copenhagen in Denmark in 1997. He believed that early postoperative recovery for colorectal cancer patients may shorten their hospital stay. [ 2 ] ERAS is based on interdisciplinary cooperation in surgery, nutrition, anesthesia, nursing, and other fields. Its aim is to optimize multiple perioperative management measures, including strengthening psychological counseling, simplifying intestinal preparation, multimodal postoperative pain relief, encouraging early eating, and getting out of bed as early as possible. It aims to minimize the trauma and stress reactions of surgery on patients’ physical and mental health, promote rapid postoperative recovery, and shorten hospital stay. The purpose of reducing surgical-related costs. [ 3 ] At present, ERAS research mainly involves fields such as gastrointestinal surgery, hepatobiliary surgery, urology, etc, with few applications in gynecology. This study applies perioperative nutrition management measures under the ERAS concept to the treatment of patients undergoing laparoscopic total hysterectomy, and explores whether perioperative nutrition management measures can effectively promote the recovery of postoperative gastrointestinal function and reduce the occurrence of postoperative complications, thereby promoting early recovery of patients.

Conceptualization: Suning Bai, Liyun Song. Data curation: Suning Bai, Qi Wu. Formal analysis: Suning Bai. Funding acquisition: Liyun Song. Investigation: Suning Bai, Liyun Song. Methodology: Suning Bai, Liyun Song. Project administration: Wenfei Wu, Liyun Song. Resources: Suning Bai, Qi Wu, Wenfei Wu, Liyun Song. Software: Suning Bai, Wenfei Wu. Supervision: Qi Wu, Wenfei Wu. Validation: Wenfei Wu. Visualization: Suning Bai. Writing – original draft: Suning Bai. Writing – review & editing: Qi Wu.

90 patients aged 40 to 65 who underwent laparoscopic total hysterectomy for benign gynecological diseases such as uterine fibroids and adenomyosis at Hebei General Hospital from June 2018 to June 2019 were randomly divided into an experimental group and a control group (n = 45) using a random number table method. There was no statistically significant difference in general data between the 2 groups of patients ( P  > .05), two groups are comparable (Table 1 ). This study has been approved by the Medical Ethics Committee of Hebei General Hospital, and all patients have informed consent and signed the informed consent form. Comparison of General Conditions between 2 groups of patients. Inclusion criteria and exclusion criteria Inclusion criteria: Diagnosis of benign uterine fibroids or adenomyosis confirmed through gynecological examination and ultrasound examination, meeting the indications for laparoscopic total hysterectomy, and planned to receive surgical treatment in this hospital; No fertility requirements, agree to undergo laparoscopic total hysterectomy. Exclusion criteria: Suspected of gynecological malignancy; Severe pathological changes in organs such as the heart, liver, and kidneys; Merge related diseases that may affect nutritional status; Previous history of abdominal surgery. Two groups of patients received different management modes. The experimental group applied the concept of accelerated rehabilitation surgery to perioperative intestinal preparation and dietary management, including not using mechanical intestinal preparation before surgery, having a semi-liquid diet for dinner the day before surgery, fasting and uncontrollable water for 6 hours before surgery, and taking oral sugary electrolyte drinks for 2 hours before surgery, with a total amount of ≤400 ml; Drink water and chew chewing gum 4 hours after surgery, and consume liquid food 6 hours to reduce the amount of intravenous fluids. Control group received routine perioperative treatment, including preoperative oral laxatives (compound polyethylene glycol electrolyte powder 137.5g), a semi-liquid diet starting at noon 1 day before surgery, fasting with water after 24:00 in the evening, routine intravenous fluid replacement after surgery, drinking water 6 hours after surgery, and gradually returning to diet after exhaust. Postoperative first exhaust time; Postoperative first defecation time; Postoperative seventh day incision healing condition; Pelvic infection within 1 month after surgery. Statistical analysis was conducted using statistical software SPSS25.0, with measurement data using t/t ‘test, one-way ANOVA or non-parametric test, and counting data using 2-test or Fish exact probability method. Take α = 0.05 is the test level, and P  < .05 can be considered as statistically significant.

The experimental group had shorter postoperative first exhaust time and first bowel movement time compared to the control group ( P  < .05) (Table 2 ), with statistically significant differences. Comparison of perioperative related indicators between 2 groups of patients ( x ¯ ± s ). The incidence of poor wound healing 7 days after surgery in the experimental group was lower than that in the control group ( P   .05) (see Table 3 ). Comparison of postoperative complications between 2 groups of patients.

Uterine fibroids and adenomyosis are currently common gynecological diseases that affect women health and quality of life, and surgical treatment is still the main treatment method. With the development of minimally invasive technology, laparoscopic surgery has become a surgical method that patients are willing to accept. Laparoscopic surgery not only has the advantages of small incision and beautiful appearance, but also has the advantages of fast recovery of gastrointestinal function and short hospitalization time without affecting the treatment effect. [ 4 ] The concept of ERAS was first proposed by Professor Kehlet from the University of Copenhagen in Denmark in 1997. The aim is to optimize multiple perioperative management measures, promote rapid postoperative recovery, shorten hospital stay, and reduce surgical-related costs. The ERAS pathway mainly includes 4 important components: pre-adaptation, preoperative, intraoperative, and postoperative. ERAS is based on evidence-based medicine. Up to now, more and more evidence has shown that implementing ERAS plans can significantly shorten hospital stay, reduce the incidence of complications, and more importantly, significantly improve patient treatment outcomes, reduce overall treatment costs, and increase patient satisfaction compared to previous routine perioperative management. In recent years, with the gradual deepening of the concept of ERAS by gynecologists, the application of ERAS in gynecology has also been gradually increasing. However, in specific clinical practice, some processes are not implemented in detail enough, or due to the objective conditions of the hospital itself, every aspect of ERAS cannot be fully implemented. However, as long as we adhere to the ERAS concept in clinical work and continuously follow the Plan, Do, Check and Action is used to improve the ERAS plan, and surgical patients will benefit from it. Marie Claude Renaud conducted a single-center prospective cohort study at a tertiary gynecological oncology center, indicating that even partially implemented ERAS programs can significantly shorten hospital stay without affecting patient care. [ 5 ] The results of this study indicate that optimizing perioperative intestinal preparation and dietary management can promote the recovery of postoperative gastrointestinal function and promote wound healing in patients. The traditional perioperative concept believes that mechanical intestinal preparation, including oral administration of laxatives such as polyethylene glycol electrolyte powder and enema, can reduce food reflux and aspiration during anesthesia, avoid the risk of intraoperative intestinal injury and surgical site infection caused by intestinal bloating during surgery. However, in fact, mechanical intestinal preparation cannot reduce the incidence of surgical site infection. Currently, research has shown that mechanical bowel preparation may lead to nutrient loss, dehydration, electrolyte and acid-base balance disorders in patients, leading to anxiety, which is particularly evident in elderly patients. [ 6 ] The ERAS concept is to avoid mechanical intestinal preparation before surgery as much as possible. Dietary management or oral enteral nutrition can be used to reduce the production of fecal residue and avoid stress reactions caused by mechanical enema. The guidelines of the International ERAS Association point out that preoperative intestinal preparation is not recommended for minimally invasive gynecological surgery and gynecological open surgery. [ 7 ] Studies have shown that patients with gynecological malignancies undergoing colon or rectal resection who do not undergo mechanical bowel preparation before surgery have a higher level of comfort and can accelerate postoperative recovery, reduce postoperative complications and infection rates. [ 8 ] Bisch's research suggests that implementing perioperative management measures guided by the ERAS concept can reduce the incidence of complications during hospitalization from 53.3% to 36.2%. [ 9 ] The research results of this article confirm that not using mechanical intestinal preparation before surgery does not increase the incidence of postoperative pelvic infection, and there is no statistically significant difference compared to conventional preoperative intestinal preparation. However, no conclusion has been drawn that it can reduce postoperative infection rate, which may be related to the small sample size of this study and needs further confirmation from large sample studies. Nutrition is an important component of the ERAS program and requires clinical workers to continue exploring and improving in the practice of perioperative management. The routine dietary management during the perioperative period is to start a semi-liquid diet at noon 1 day before the surgery, and to fast water after 24:00 in the evening. Regular intravenous fluid replacement is performed after the surgery, and water can be consumed 6 hours after the surgery. Gradually, the diet is restored after venting. The perioperative dietary management model under the ERAS concept is to have a semi-liquid diet for dinner the day before surgery, fasting and uncontrollable water for 6 hours before surgery, and taking oral sugary electrolyte drinks for 2 hours before surgery, with a total amount of ≤400 mL. Drink water and chew chewing gum 4 hours after surgery, and consume liquid food 6 hours to reduce the amount of intravenous fluids. A researcher reported a case of hunger ketoacidosis caused by prolonged preoperative fasting. [ 10 ] The patient experienced ketoacidosis due to prolonged preoperative fasting. A study on perioperative dietary management for patients undergoing laparoscopic cholecystectomy showed that implementing ERAS dietary management during the perioperative period not only reduces hunger, thirst, and fatigue compared to standard fasting guidelines and routine perioperative management, but also improves perioperative comfort for patients undergoing laparoscopic cholecystectomy. [ 11 ] A prospective study was conducted at a cancer research center in Bangalore on patients with gastric and esophageal cancer. The study provided perioperative enteral nutrition support to the study group patients, and the results showed that perioperative nutrition support can reduce the incidence of postoperative complications in patients with moderate and severe malnutrition of gastric and esophageal cancer, as well as effectively reduce mortality, Indicating that individual enteral nutrition support can be used to manage malnourished patients undergoing gastric and esophageal surgery. [ 12 ] Other studies have confirmed that early oral and enteral nutrition interventions for postoperative gynecological malignant tumors are safe. Receiving nutritional intervention can reduce the average hospital stay, intestinal recovery time, and postoperative complications in some patients. [ 13 ] This study shows that optimizing perioperative dietary management can significantly improve postoperative incision healing without affecting surgical procedures, indicating that optimizing perioperative dietary management can bring benefits to patients and is worthy of widespread clinical application. Preoperative carbohydrate supplementation is one of the contemporary elements of ERAS. The traditional view is that a long period of fasting is required before anesthesia, which was later questioned. Research has shown that traditional preoperative bowel preparation and fasting do not bring benefits to surgery, but can increase the body metabolic rate, accompanied by excessive insulin compensatory secretion and release, as well as elevated blood sugar, which affects postoperative recovery. [ 14 ] More and more evidence-based medical evidence suggests that preoperative carbohydrate supplementation not only reduces the physiological effects of surgical stress and insulin resistance, but also improves patient satisfaction and happiness without increasing perioperative complications. A study observed 93 patients who underwent selective abdominal and retroperitoneal surgery. In the observation group (47 cases), carbohydrate beverages (containing 33.5 grams of carbohydrates and 4 grams of hydrolyzed protein per 100 milliliters) were prescribed before the surgery, with 400 milliliters at night and 200 milliliters 2 hours before the surgery. The control group consisted of 46 patients who followed the conventional fasting regimen recommended by ASA (eating solid food no later than 6 hours before surgery and clear liquid no later than 2 hours before surgery). The surgical intervention and anesthesia treatment were similar in both groups. The results showed that preoperative carbohydrate load did not affect perioperative blood glucose, reduced intraoperative infusion volume, reduced organ dysfunction and complications, and reduced postoperative nausea and vomiting, Ensure more stable intraoperative hemodynamics and more comfortable subjective sensation in the early postoperative period. [ 15 ] In summary, optimizing perioperative intestinal preparation and dietary management under the ERAS concept can improve the recovery of patients after laparoscopic total hysterectomy and reduce the incidence of poor postoperative incision healing. ERAS is a scientific, reasonable, and safe perioperative management plan that is worthy of clinical promotion and application.