Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial

Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial Wathirada Karnchanabanyong, Irene Ruengkhachorn, Nida Jareemit, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8067937/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Purpose To evaluate whether adding milk of magnesia (MOM) to an enhanced recovery after surgery (ERAS) pathway prevents postoperative ileus (POI) and improves postoperative bowel function. Methods This randomized controlled trial at the Gynecology Unit, Siriraj Hospital (Bangkok, Thailand) enrolled patients undergoing hysterectomy for benign or malignant indications during September 2023 through February 2024. Participants were randomly assigned to ERAS alone ( n = 80) or ERAS plus MOM ( n = 80). The MOM group received 15 mL on postoperative day 0 and then 30 mL twice daily until first flatus or bowel movement. Primary outcomes were POI incidence, time to first flatus, time to solid diet tolerance, patient satisfaction, and MOM-related complications. Results Among 160 patients, 60 (37.5%) had gynecologic malignancies: endometrial cancer ( n = 34), ovarian cancer ( n = 16), cervical cancer ( n = 8), and leiomyosarcoma ( n = 2). ERAS plus MOM reduced POI versus ERAS alone (3.8% vs 27.5%; P < 0.001). It also shortened time to first flatus (17.1 ± 7.9 vs 22.3 ± 10.8 hours; P < 0.001). Time to solid diet tolerance was shorter (20.6 ± 10.9 vs 28.8 ± 16.3 hours; P < 0.001). Patient satisfaction scores for eating and daily activities were significantly higher. No severe adverse events occurred in the MOM group. Conclusion Adding MOM to ERAS reduced POI incidence and enhanced postoperative recovery after hysterectomy for benign or malignant disease. Trial registration: Thai Clinical Trials Registry. Registration number 20230816005. Enhanced recovery after surgery ERAS Gynecologic malignancy Hysterectomy Milk of magnesia MOM Postoperative ileus POI Figures Figure 1 INTRODUCTION Postoperative ileus (POI) is a frequent complication after abdominal surgery, occurring in 10%–30% overall and reaching 40%–51.8% after gynecologic cancer procedures [ 1 – 3 ]. POI increases postoperative morbidity and prolongs the length of hospital stay, constituting a public health concern [ 1 – 3 ]. Symptoms include nausea, vomiting, bloating, delayed passage of flatus and stool, abdominal distention, and abdominal tenderness [ 1 ]. The pathophysiology is multifactorial. Peritoneal irritation, bowel manipulation, intraoperative autonomic stimulation, exposure to opioids and anxiolytics, and postoperative stress reduce bowel smooth-muscle motility, which typically normalizes within 2–3 days [ 1 , 4 ]. Several nonpharmacologic and pharmacologic strategies, including coffee, juice, tea, gum chewing, prokinetic drugs, ginger, and oral magnesium hydroxide, have been investigated to hasten restoration of bowel function and gastrointestinal motility [ 2 , 5 – 10 ]. The enhanced recovery after surgery (ERAS) protocol is now the standard of care for gynecologic surgery for both benign and malignant conditions [ 11 , 12 ]. Milk of magnesia (MOM) is an oral magnesium hydroxide formulation. Each 5 mL contains 400 mg magnesium hydroxide, 0.25 mg each of methylparaben and propylparaben, 0.0025 mL peppermint oil, and purified water to 5 mL. MOM is a low-cost laxative with minimal adverse effects. Therapeutic uses include laxation at 30–60 mL once daily and acid neutralization at 5–15 mL 4 times daily. MOM has shown efficacy in preventing ileus after benign and malignant gynecologic operations [ 2 , 13 ]. In a reported case of radical hysterectomy, 30 mL MOM twice daily with bisacodyl suppositories hastened bowel function recovery and permitted discharge without significant complications [ 13 ]. However, evidence on incorporating MOM into ERAS pathways remains limited. The primary objective was to compare time to solid diet resumption between groups. The secondary outcomes were POI incidence, time to recovery of bowel function, postoperative complications, eating satisfaction score, daily activities satisfaction score, length of hospital stay, and MOM-related complications. METHODS Study design and oversight After authorization from the Siriraj Institutional Review Board (Si-555/2023) and registration with the Thai Clinical Trials Registry (TCTR20230816005), the study was conducted in adherence to the Declaration of Helsinki and the International Council for Harmonization’s Good Clinical Practice (ICH-GCP) guidelines. We performed an investigator-blinded randomized controlled trial. Participants Eligible patients were those undergoing exploratory hysterectomy for benign or malignant conditions. They were recruited during September 2023 through February 2024, with informed consent being obtained from all participants. Exclusion criteria were allergy to MOM; intraoperative complications or comorbidities requiring prolonged restriction of oral intake; gastroesophageal reflux disease, peptic ulcer, chronic constipation, or bowel obstruction; and prior pelvic radiation. Sample size and power For the primary endpoint—time from surgery to resumption of a solid diet—we based the sample size on Schilder et al [ 14 ]. Women who were permitted early sipping resumed a regular diet at 1.88 ± 0.14 days, significantly sooner than controls [ 14 ]. We anticipated that the MOM group would resume solid diet at 1.55 days, or 0.33 days (8 hours) earlier than controls, with a standard deviation of 0.564 days. With 90% power, α = 0.05, β = 0.1, and 20% attrition, the required sample was 160 women. Randomization and interventions After surgery, eligible participants were randomized 1:1 in blocks of 4 into 2 groups by a sequence generated before study initiation, with allocation concealed and no participant interaction. The control group received standard ERAS: postoperative sips of liquids advancing to solids as tolerated in the absence of vomiting. The intervention group received ERAS plus MOM: 15 mL on postoperative day 0, then 30 mL twice daily until first bowel movement or passage of flatus, after which standard ERAS continued. A designated research nurse administered MOM. Outcomes and follow-up We collected demographic characteristics, operative details, and postoperative outcomes, which included bowel function, time from water intake initiation to regular diet, and time to first flatus. We also recorded use of additional bowel stimulants, eating and daily activity satisfaction scores, length of hospital stay, and MOM-related adverse events. Surgical complications were monitored for 30 days. Statistical analysis Analyses used IBM SPSS Statistics version 29 (IBM Corp, Armonk, NY, USA) under an intention-to-treat framework. Results were summarized as counts (percentages) or medians (IQRs). Normality of continuous data was assessed using histogram inspection and the Kolmogorov–Smirnov test. Continuous variables were compared with Student’s t test or the Mann–Whitney U test, and categorical variables with the chi-square or Fisher’s exact test. A P value < 0.05 indicated statistical significance. Operational definitions POI diagnosis. POI was diagnosed using Vather criteria [ 15 ], which require at least 2 of 5 findings: (1) nausea with or without vomiting; (2) inability to tolerate a solid or semi-liquid diet for 24 hours or longer; (3) no flatus or defecation for 24 hours or more; (4) abdominal distention; (5) radiological evidence of ileus. Well-tolerated solid diet. Defined as ability to consume at least half of a solid meal without vomiting. Discharge criteria. Defined as independent ambulation, tolerance of a solid diet, and pain control with oral analgesics. Length of stay. Time from the end of surgery until all discharge criteria were met. Patient-reported outcomes. Eating satisfaction and daily activities satisfaction were each assessed using a visual analog scale (0–10). Severe adverse events related to MOM. Severe events included diarrhea more than 6 times per day; dehydration indicated by urine output < 0.5–1 mL/kg/day; and hypotension (blood pressure < 90/60 mm Hg). Hypermagnesemia symptoms included muscle weakness, arrhythmia, and respiratory rate < 12 breaths per minute. RESULTS Participant flow and baseline characteristics Of 172 eligible patients, 12 were excluded, as shown in Fig. 1 . One hundred sixty participants were randomized equally to 2 arms ( n = 80 per arm). Baseline characteristics, surgical methods, and perioperative medications are summarized in Table 1 . The majority had benign gynecologic conditions (62.5%; n = 100). Malignancies comprised 37.5% ( n = 60): endometrial cancer ( n = 34), ovarian cancer ( n = 16), cervical cancer ( n = 8), and leiomyosarcoma ( n = 2). There were no between-group differences in preoperative care, including use of analgesics, proton pump inhibitors, antiemetics, bowel preparation, or fasting duration. Similarly, intraoperative drug use, anesthetic methods, and postoperative antiemetic or opioid administration did not differ. The groups were comparable in surgical approach (midline or transverse incision), operative time, and intraoperative blood loss; no participant developed hypothermia. Table 1 Baseline characteristics, surgical methods, and perioperative medications by randomized group (standard ERAS vs ERAS with MOM) Variables Control group n = 80 MOM group n = 80 P value Age, y 51.61 ± 12.151 51.44 ± 10.520 0.923 BMI, kg/m 2 23.365 ± 4.392 25.405 ± 5.931 0.014 Diseases Benign 50 (62.5) 50 (62.5) 1.000 Malignant 30 (37.5) 30 (37.5) ASA classification I 26 (32.5) 24 (30.0) 0.515 II 48 (60.0) 53 (66.3) III 6 (7.5) 3 (3.8) IV 0 0 Comorbidities Diabetes mellitus, n = 18 10 (12.5) 8 (10.0) 0.617 Hypertension, n = 44 20 (25.09) 24 (30.0) 0.497 Dyslipidemia, n = 40 18 (22.5) 22 (27.5) 0.465 Stroke, n = 6 6 (7.5) 0 0.028 Alcohol, current user 0 7 (8.8) 0.026 Smoking, current user 0 1 (1.3) 0.316 Preoperative hemoglobin, g/dL 11.898 ± 1.535 12.109 ± 1.501 0.674 Preoperative painkillers within 2 wk 6 (7.5) 5 (6.3) 0.755 Preoperative proton pump inhibitor 29 (36.3) 28 (35.0) 0.869 Preoperative antiemetic 23 (28.7) 20 (25.0) 0.593 Preoperative bowel preparation 10 (12.5) 8 (10.1) 0.631 Fasting time, h From regular diet 17.422 ± 1.680 17.577 ± 1.995 0.595 From sip water 4.268 ± 1.4939 4.502 ± 1.6358 0.345 Incision type 0.990 Midline 37 (46.3) 38 (47.6) Transverse 43 (53.8) 42 (52.6) Adhesiolysis 17 (21.3) 18 (22.5) 0.848 Surgical drain 2 (2.5) 0 0.155 Surgical time, min 143.65 ± 54.828 144.73 ± 49.112 0.896 Estimated blood loss, mL 276.19 ± 276.503 329.88 ± 314.270 0.253 General anesthesia component 37 (46.3) 38 (45.7) 0.732 Intravenous fluid positive, mL 2160.05 ± 976.23 2221.41 ± 1045.61 0.702 Intraoperative paracetamol 5 (6.3) 8 (10.0) 0.385 Intraoperative morphine 9 (11.3) 10 (12.5) 0.807 Intraoperative morphine, mg 5.39 ± 2.826 15.5 ± 3.300 0.938 Intraoperative fentanyl 71 (88.8) 66 (82.5) 0.260 Intraoperative fentanyl, mg 69.01 ± 32.034 65.08 ± 28.494 0.450 Intraoperative xylocaine 5 (6.3) 6 (7.5) 0.755 Intraoperative ondansetron 58 (72.5) 51 (63.7) 0.235 Intraoperative ondansetron, mg 7.9 ± 0.7888 7.88 ± 0.621 0.918 Intraoperative metoclopramide 5 (6.3) 8 (10.0) 0.385 Postoperative opioids 8 (10.0) 11 (13.8) 0.463 Postoperative antiemetics 42 (52.5) 39 (48.8) 0.635 Postoperative simethicone 47 (58.8) 47 (58.8) 0.603 Routine per physician preference 46 47 On patient request 1 0 Routine postoperative omeprazole 15 (18.8) 16 (20.0) 0.841 Unless otherwise indicated, data are mean (SD) or n (%). P values compare groups. Student’s t test or the Mann–Whitney U test was used for continuous variables, and the chi‑square or Fisher’s exact test for categorical variables. Preoperative analgesic use was assessed within 2 weeks before surgery. Fasting time reflects hours since last regular diet and last sip of water. “General anesthesia component” indicates use of general anesthesia within a multimodal anesthetic technique. “Intravenous fluid positive” denotes intraoperative intravenous fluid volume administered. Postoperative outcomes Postoperative outcomes (Table 2 ) showed significantly lower rates of nausea, vomiting, and abdominal distention with MOM than with standard ERAS. The incidence of POI was 3.8% with MOM versus 27.5% with standard ERAS ( P < 0.001). Time to first flatus was shorter with MOM (17.1 ± 7.9 hours vs 22.3 ± 10.8 hours; P < 0.001). Time to tolerate a solid diet was also shorter with MOM (20.6 ± 10.9 hours vs 28.8 ± 16.3 hours; P < 0.001). No MOM participants required additional bowel stimulants, whereas 66.3% of standard ERAS participants did. Length of stay was shorter with MOM (72.7 ± 22.7 vs 81.6 ± 49.8 hours) but not statistically significant ( P = 0.149). Patient-reported outcomes favored MOM, with higher eating satisfaction (8.7 ± 0.8 vs 7.8 ± 1.3; P < 0.001) and daily activities satisfaction (8.9 ± 0.8 vs 8.3 ± 1.0; P < 0.001). Table 2 Postoperative outcomes by randomized group (standard ERAS vs ERAS with MOM) Variables Control group n = 80 MOM group n = 80 P value Postoperative nausea 44 (55.0) 30 (37.5) 0.026 Emesis 30 (37.5) 14 (17.5) 0.005 Bloating 30 (37.5) 14 (17.5) 0.005 POI occurrence 22 (27.5) 3 (3.8) < 0.001 Upper 20 2 Lower 2 1 Time to first flatus (h) 22.309 ± 10.8827 17.101 ± 7.9619 0.001 Time to first belch (h) 15.391 ± 10.9448 12.482 ± 7.565 0.051 Additional bowel stimulants 53 (66.3) 0 < 0.001 Time to first soft diet (h) 12.001 ± 6.698 13.093 ± 6.444 0.295 Time to well‑tolerated solid diet (h) 28.800 ± 16.3435 20.691 ± 10.9635 < 0.001 Time to off IV fluids (h) 18.104 ± 4.914 17.765 ± 5.231 0.673 Time to off Foley catheter (h) 25.969 ± 20.967 23.826 ± 16.891 0.480 Pain score, maximum level of the day POD 0 2.9 ± 2.004 3.13 ± 1.885 0.466 POD 1 1.91 ± 1.314 2.24 ± 1.204 0.105 Eating satisfaction score 7.81 ± 1.342 8.71 ± 0.860 < 0.001 Daily activities satisfaction score 8.35 ± 1.02 8.98 ± 0.811 < 0.001 Length of hospital stay (h) 81.602 ± 49.837 72.71 ± 22.765 0.149 Unless otherwise indicated, data are mean (SD) or n (%). Times are measured in hours from the end of surgery. “Upper” and “Lower” denote the reported location of POI. Group comparisons used Student’s t test or the Mann–Whitney U test for continuous variables, and the chi-square or Fisher’s exact test for categorical variables. A P value < 0.05 was considered statistically significant. Safety No severe MOM-related adverse events occurred. Some patients experienced 3–4 bowel movements per day; this did not impair daily activities, and no dehydration or hypotension occurred. DISCUSSION Adding MOM to standard ERAS significantly reduced POI and accelerated bowel function recovery, enabling earlier passage of flatus and tolerance of solid food. The MOM group had a markedly lower POI incidence and fewer symptoms of nausea, vomiting, and abdominal distention than standard ERAS. All MOM recipients passed gas and had bowel movements sooner without additional bowel stimulants, whereas several standard ERAS participants required laxatives and some still failed to defecate. This benefit likely reflects MOM’s dual actions. On postoperative day 0, 15 mL administered while patients had nothing by mouth functions as an antacid, lowering gastric acidity and relieving early postoperative bloating. Beginning on postoperative day 1, 30 mL of MOM twice daily acts as a laxative that stimulates bowel activity and reinforces recovery. Our findings align with Fanning et al, who studied 707 major gynecologic operations and administered 30 mL MOM twice daily until bowel movement occurred [ 2 ]. POI occurred in less than 1% of patients (6 of 707) [ 2 ], which is lower than the 3.8% observed in the present trial. Differences likely reflect surgical mix and invasiveness. In Fanning et al, approximately 87% of procedures were laparoscopic, and 29.4% were adnexal surgeries, both of which generally have shorter operative times and less bowel manipulation than hysterectomy [ 2 ]. These factors likely reduced bowel irritation and explain their lower POI rate compared with our cohort. Schilder et al reported that women undergoing major abdominal surgery began a clear liquid diet on postoperative day 1 and advanced to a regular diet after tolerating 500 mL of clear liquids [ 14 ]. This early feeding reduced time to solid diet consumption from 2.72 ± 0.14 days to 1.88 ± 0.14 days ( P < 0.001) [ 14 ]. In our trial, time to solid diet tolerance occurred at 20.6 ± 10.9 hours with MOM versus 28.8 ± 16.3 hours with standard ERAS, with both earlier than in Schilder et al. We attribute this acceleration to standard ERAS elements, including preoperative carbohydrate loading, allowance of clear liquids until 2 hours before surgery, early ambulation, optimal pain control, multimodal analgesia, and reduced opioid exposure [ 11 , 12 ]. Together, these components likely enabled both groups to tolerate solids sooner than in prior reports. Time to first flatus was similarly accelerated in our cohort: 17.1 ± 7.9 hours in the MOM group, which is faster than previous reports. For comparison, a radical hysterectomy series administered 30 mL MOM twice daily starting on postoperative day 1, with a bisacodyl suppository on postoperative day 2 [ 13 ]. The median time to flatus was 3 days (range 2–3 days) [ 13 ]. These data demonstrate that integrating MOM into ERAS pathways expedites bowel function return, enabling earlier flatus and solid diet tolerance. Length of hospital stay was shorter with MOM (72.7 ± 22.7 hours) than with standard ERAS (81.6 ± 49.8 hours), but not significantly so. Our institution routinely discharges hysterectomy patients on postoperative day 3, even when they tolerate solids or pass flatus by day 1 or 2. This practice likely masked between-group differences in length of stay despite earlier bowel recovery with MOM. By contrast, other studies have shown significant length of stay reductions with MOM [ 13 , 16 ]. Eating satisfaction was significantly higher with MOM (8.7 ± 0.8 vs 7.8 ± 1.3; P < 0.001), as was daily activities satisfaction (8.9 ± 0.8 vs 8.3 ± 1.0; P < 0.001). These improvements likely reflect reduced nausea, vomiting, and bloating, plus earlier bowel function return. Earlier flatus and bowel movements facilitated faster solid diet tolerance, improving satisfaction with both eating and daily activities. This study has several strengths. It is a prospective randomized controlled trial of abdominal hysterectomy for benign and malignant conditions, with well-balanced baseline characteristics between groups. MOM is cost-effective and covered by all healthcare plans, enabling universal access without financial burden. Outcomes were clearly defined, including POI, well-tolerated solid diet, discharge criteria, and length of stay. However, certain outcomes were subjective, particularly time to first flatus. Patients may pass flatus during sleep or other unobserved activities, so recorded times may exceed actual times, potentially biasing recovery-time assessments. CONCLUSION Adding MOM to ERAS effectively reduced POI incidence and accelerated bowel function recovery in patients undergoing abdominal hysterectomy for benign or malignant conditions. Declarations Authorship confirmation/contribution statement All authors contributed to study design and conceptualization. WK, IR, NJ, and SK enrolled participants. DA and RS obtained informed consent and administered medication per protocol. NS and JK prepared and stored the study drug. WK and IR performed data retrieval, analysis, and interpretation from medical records. WK and NJ drafted the manuscript. IR and SK provided critical intellectual content through manuscript revision. All authors edited and approved the final version of the manuscript. Data availability Correspondence and requests for materials should be addressed to WK. Acknowledgments The authors gratefully acknowledge Mr Suthipol Udompunturak for statistical assistance and Ms Sarocha Boonkate for oversight of funding management. We would like to thank Mr. David Park for editing the English version of the manuscript. Funding This research project is supported by the Siriraj Research Development Fund, Faculty of Medicine Siriraj Hospital, Mahidol University (grant number R016632024). Potential conflicts of interest The authors declare that there are no conflicts of interest. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 Mar, 2026 Reviews received at journal 22 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 13 Nov, 2025 First submitted to journal 09 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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12:07:27","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84950,"visible":true,"origin":"","legend":"","description":"","filename":"8e1dfe45b1654c74bd5280dfb7c3e8621structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8067937/v1/41d4844bd97fb3d313dc0dc6.xml"},{"id":100421536,"identity":"e5e3a0e6-b39e-4524-84ee-de28fd7b0e5e","added_by":"auto","created_at":"2026-01-16 13:33:22","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97608,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8067937/v1/b870194a8bad69c0654b6da0.html"},{"id":100405404,"identity":"0ee82e15-6e3c-4a97-b49a-f97d442e60c9","added_by":"auto","created_at":"2026-01-16 12:05:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36210,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant flow diagram for the randomized trial, September 2023–February 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ERAS, enhanced recovery after surgery; ICU, intensive care unit; MOM, milk of magnesia; NPO, nothing by mouth\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8067937/v1/e93026abc65293d263a8e6dc.png"},{"id":100546298,"identity":"3dbcbd48-5c9b-4b09-b978-2b9481000e83","added_by":"auto","created_at":"2026-01-19 08:05:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":911624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8067937/v1/603e0535-dec0-4ee8-a2a1-7e8ebc13be78.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePostoperative ileus (POI) is a frequent complication after abdominal surgery, occurring in 10%\u0026ndash;30% overall and reaching 40%\u0026ndash;51.8% after gynecologic cancer procedures [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. POI increases postoperative morbidity and prolongs the length of hospital stay, constituting a public health concern [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Symptoms include nausea, vomiting, bloating, delayed passage of flatus and stool, abdominal distention, and abdominal tenderness [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The pathophysiology is multifactorial. Peritoneal irritation, bowel manipulation, intraoperative autonomic stimulation, exposure to opioids and anxiolytics, and postoperative stress reduce bowel smooth-muscle motility, which typically normalizes within 2\u0026ndash;3 days [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Several nonpharmacologic and pharmacologic strategies, including coffee, juice, tea, gum chewing, prokinetic drugs, ginger, and oral magnesium hydroxide, have been investigated to hasten restoration of bowel function and gastrointestinal motility [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The enhanced recovery after surgery (ERAS) protocol is now the standard of care for gynecologic surgery for both benign and malignant conditions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMilk of magnesia (MOM) is an oral magnesium hydroxide formulation. Each 5 mL contains 400 mg magnesium hydroxide, 0.25 mg each of methylparaben and propylparaben, 0.0025 mL peppermint oil, and purified water to 5 mL. MOM is a low-cost laxative with minimal adverse effects. Therapeutic uses include laxation at 30\u0026ndash;60 mL once daily and acid neutralization at 5\u0026ndash;15 mL 4 times daily. MOM has shown efficacy in preventing ileus after benign and malignant gynecologic operations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In a reported case of radical hysterectomy, 30 mL MOM twice daily with bisacodyl suppositories hastened bowel function recovery and permitted discharge without significant complications [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, evidence on incorporating MOM into ERAS pathways remains limited.\u003c/p\u003e \u003cp\u003eThe primary objective was to compare time to solid diet resumption between groups. The secondary outcomes were POI incidence, time to recovery of bowel function, postoperative complications, eating satisfaction score, daily activities satisfaction score, length of hospital stay, and MOM-related complications.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and oversight\u003c/h2\u003e \u003cp\u003e After authorization from the Siriraj Institutional Review Board (Si-555/2023) and registration with the Thai Clinical Trials Registry (TCTR20230816005), the study was conducted in adherence to the Declaration of Helsinki and the International Council for Harmonization\u0026rsquo;s Good Clinical Practice (ICH-GCP) guidelines. We performed an investigator-blinded randomized controlled trial.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEligible patients were those undergoing exploratory hysterectomy for benign or malignant conditions. They were recruited during September 2023 through February 2024, with informed consent being obtained from all participants.\u003c/p\u003e \u003cp\u003eExclusion criteria were allergy to MOM; intraoperative complications or comorbidities requiring prolonged restriction of oral intake; gastroesophageal reflux disease, peptic ulcer, chronic constipation, or bowel obstruction; and prior pelvic radiation.\u003c/p\u003e\n\u003ch3\u003eSample size and power\u003c/h3\u003e\n\u003cp\u003eFor the primary endpoint\u0026mdash;time from surgery to resumption of a solid diet\u0026mdash;we based the sample size on Schilder et al [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Women who were permitted early sipping resumed a regular diet at 1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 days, significantly sooner than controls [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We anticipated that the MOM group would resume solid diet at 1.55 days, or 0.33 days (8 hours) earlier than controls, with a standard deviation of 0.564 days. With 90% power, α\u0026thinsp;=\u0026thinsp;0.05, β\u0026thinsp;=\u0026thinsp;0.1, and 20% attrition, the required sample was 160 women.\u003c/p\u003e\n\u003ch3\u003eRandomization and interventions\u003c/h3\u003e\n\u003cp\u003eAfter surgery, eligible participants were randomized 1:1 in blocks of 4 into 2 groups by a sequence generated before study initiation, with allocation concealed and no participant interaction. The control group received standard ERAS: postoperative sips of liquids advancing to solids as tolerated in the absence of vomiting. The intervention group received ERAS plus MOM: 15 mL on postoperative day 0, then 30 mL twice daily until first bowel movement or passage of flatus, after which standard ERAS continued. A designated research nurse administered MOM.\u003c/p\u003e\n\u003ch3\u003eOutcomes and follow-up\u003c/h3\u003e\n\u003cp\u003eWe collected demographic characteristics, operative details, and postoperative outcomes, which included bowel function, time from water intake initiation to regular diet, and time to first flatus. We also recorded use of additional bowel stimulants, eating and daily activity satisfaction scores, length of hospital stay, and MOM-related adverse events. Surgical complications were monitored for 30 days.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses used IBM SPSS Statistics version 29 (IBM Corp, Armonk, NY, USA) under an intention-to-treat framework. Results were summarized as counts (percentages) or medians (IQRs). Normality of continuous data was assessed using histogram inspection and the Kolmogorov\u0026ndash;Smirnov test. Continuous variables were compared with Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e test or the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test, and categorical variables with the chi-square or Fisher\u0026rsquo;s exact test. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperational definitions\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003ePOI diagnosis.\u003c/b\u003e POI was diagnosed using Vather criteria [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which require at least 2 of 5 findings:\u003c/p\u003e \u003cp\u003e(1) nausea with or without vomiting;\u003c/p\u003e \u003cp\u003e(2) inability to tolerate a solid or semi-liquid diet for 24 hours or longer;\u003c/p\u003e \u003cp\u003e(3) no flatus or defecation for 24 hours or more;\u003c/p\u003e \u003cp\u003e(4) abdominal distention;\u003c/p\u003e \u003cp\u003e(5) radiological evidence of ileus.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWell-tolerated solid diet.\u003c/b\u003e Defined as ability to consume at least half of a solid meal without vomiting.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDischarge criteria.\u003c/b\u003e Defined as independent ambulation, tolerance of a solid diet, and pain control with oral analgesics.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLength of stay.\u003c/b\u003e Time from the end of surgery until all discharge criteria were met.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatient-reported outcomes.\u003c/b\u003e Eating satisfaction and daily activities satisfaction were each assessed using a visual analog scale (0\u0026ndash;10).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSevere adverse events related to MOM.\u003c/b\u003e Severe events included diarrhea more than 6 times per day; dehydration indicated by urine output\u0026thinsp;\u0026lt;\u0026thinsp;0.5\u0026ndash;1 mL/kg/day; and hypotension (blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90/60 mm Hg). Hypermagnesemia symptoms included muscle weakness, arrhythmia, and respiratory rate\u0026thinsp;\u0026lt;\u0026thinsp;12 breaths per minute.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant flow and baseline characteristics\u003c/h2\u003e \u003cp\u003eOf 172 eligible patients, 12 were excluded, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. One hundred sixty participants were randomized equally to 2 arms (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80 per arm). Baseline characteristics, surgical methods, and perioperative medications are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The majority had benign gynecologic conditions (62.5%; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;100). Malignancies comprised 37.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60): endometrial cancer (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;34), ovarian cancer (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16), cervical cancer (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8), and leiomyosarcoma (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2). There were no between-group differences in preoperative care, including use of analgesics, proton pump inhibitors, antiemetics, bowel preparation, or fasting duration. Similarly, intraoperative drug use, anesthetic methods, and postoperative antiemetic or opioid administration did not differ. The groups were comparable in surgical approach (midline or transverse incision), operative time, and intraoperative blood loss; no participant developed hypothermia.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics, surgical methods, and perioperative medications by randomized group (standard ERAS vs ERAS with MOM)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMOM group\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.61\u0026thinsp;\u0026plusmn;\u0026thinsp;12.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.44\u0026thinsp;\u0026plusmn;\u0026thinsp;10.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.365\u0026thinsp;\u0026plusmn;\u0026thinsp;4.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.405\u0026thinsp;\u0026plusmn;\u0026thinsp;5.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (25.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol, current user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, current user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.316\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hemoglobin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.898\u0026thinsp;\u0026plusmn;\u0026thinsp;1.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.109\u0026thinsp;\u0026plusmn;\u0026thinsp;1.501\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative painkillers within 2 wk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative proton pump inhibitor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (36.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.869\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative antiemetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative bowel preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.631\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFasting time, h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom regular diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.422\u0026thinsp;\u0026plusmn;\u0026thinsp;1.680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.577\u0026thinsp;\u0026plusmn;\u0026thinsp;1.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.595\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom sip water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.268\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.502\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncision type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.990\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhesiolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.848\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical drain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143.65\u0026thinsp;\u0026plusmn;\u0026thinsp;54.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144.73\u0026thinsp;\u0026plusmn;\u0026thinsp;49.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.896\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e276.19\u0026thinsp;\u0026plusmn;\u0026thinsp;276.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e329.88\u0026thinsp;\u0026plusmn;\u0026thinsp;314.270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral anesthesia component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravenous fluid positive, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2160.05\u0026thinsp;\u0026plusmn;\u0026thinsp;976.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2221.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1045.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative paracetamol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative morphine, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative fentanyl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (88.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (82.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative fentanyl, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.01\u0026thinsp;\u0026plusmn;\u0026thinsp;32.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.08\u0026thinsp;\u0026plusmn;\u0026thinsp;28.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative xylocaine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative ondansetron\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (63.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative ondansetron, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative metoclopramide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative opioids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.463\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative antiemetics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative simethicone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine per physician preference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn patient request\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine postoperative omeprazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eUnless otherwise indicated, data are mean (SD) or \u003cem\u003en\u003c/em\u003e (%). \u003cem\u003eP\u003c/em\u003e values compare groups. Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e test or the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test was used for continuous variables, and the chi‑square or Fisher\u0026rsquo;s exact test for categorical variables. Preoperative analgesic use was assessed within 2 weeks before surgery. Fasting time reflects hours since last regular diet and last sip of water. \u0026ldquo;General anesthesia component\u0026rdquo; indicates use of general anesthesia within a multimodal anesthetic technique. \u0026ldquo;Intravenous fluid positive\u0026rdquo; denotes intraoperative intravenous fluid volume administered.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes\u003c/h2\u003e \u003cp\u003ePostoperative outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed significantly lower rates of nausea, vomiting, and abdominal distention with MOM than with standard ERAS. The incidence of POI was 3.8% with MOM versus 27.5% with standard ERAS (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Time to first flatus was shorter with MOM (17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 hours vs 22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 hours; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Time to tolerate a solid diet was also shorter with MOM (20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 hours vs 28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3 hours; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No MOM participants required additional bowel stimulants, whereas 66.3% of standard ERAS participants did. Length of stay was shorter with MOM (72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7 vs 81.6\u0026thinsp;\u0026plusmn;\u0026thinsp;49.8 hours) but not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.149). Patient-reported outcomes favored MOM, with higher eating satisfaction (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and daily activities satisfaction (8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative outcomes by randomized group (standard ERAS vs ERAS with MOM)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMOM group\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBloating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOI occurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to first flatus (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.309\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.101\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to first belch (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.391\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.482\u0026thinsp;\u0026plusmn;\u0026thinsp;7.565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional bowel stimulants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to first soft diet (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.001\u0026thinsp;\u0026plusmn;\u0026thinsp;6.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.093\u0026thinsp;\u0026plusmn;\u0026thinsp;6.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to well‑tolerated solid diet (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.800\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.691\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to off IV fluids (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.104\u0026thinsp;\u0026plusmn;\u0026thinsp;4.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.765\u0026thinsp;\u0026plusmn;\u0026thinsp;5.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.673\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to off Foley catheter (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.969\u0026thinsp;\u0026plusmn;\u0026thinsp;20.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.826\u0026thinsp;\u0026plusmn;\u0026thinsp;16.891\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain score, maximum level of the day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEating satisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily activities satisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.602\u0026thinsp;\u0026plusmn;\u0026thinsp;49.837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.71\u0026thinsp;\u0026plusmn;\u0026thinsp;22.765\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eUnless otherwise indicated, data are mean (SD) or \u003cem\u003en\u003c/em\u003e (%). Times are measured in hours from the end of surgery. \u0026ldquo;Upper\u0026rdquo; and \u0026ldquo;Lower\u0026rdquo; denote the reported location of POI. Group comparisons used Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e test or the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for continuous variables, and the chi-square or Fisher\u0026rsquo;s exact test for categorical variables. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSafety\u003c/h2\u003e \u003cp\u003eNo severe MOM-related adverse events occurred. Some patients experienced 3\u0026ndash;4 bowel movements per day; this did not impair daily activities, and no dehydration or hypotension occurred.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAdding MOM to standard ERAS significantly reduced POI and accelerated bowel function recovery, enabling earlier passage of flatus and tolerance of solid food. The MOM group had a markedly lower POI incidence and fewer symptoms of nausea, vomiting, and abdominal distention than standard ERAS. All MOM recipients passed gas and had bowel movements sooner without additional bowel stimulants, whereas several standard ERAS participants required laxatives and some still failed to defecate. This benefit likely reflects MOM\u0026rsquo;s dual actions. On postoperative day 0, 15 mL administered while patients had nothing by mouth functions as an antacid, lowering gastric acidity and relieving early postoperative bloating. Beginning on postoperative day 1, 30 mL of MOM twice daily acts as a laxative that stimulates bowel activity and reinforces recovery.\u003c/p\u003e \u003cp\u003eOur findings align with Fanning et al, who studied 707 major gynecologic operations and administered 30 mL MOM twice daily until bowel movement occurred [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. POI occurred in less than 1% of patients (6 of 707) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], which is lower than the 3.8% observed in the present trial. Differences likely reflect surgical mix and invasiveness. In Fanning et al, approximately 87% of procedures were laparoscopic, and 29.4% were adnexal surgeries, both of which generally have shorter operative times and less bowel manipulation than hysterectomy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These factors likely reduced bowel irritation and explain their lower POI rate compared with our cohort.\u003c/p\u003e \u003cp\u003eSchilder et al reported that women undergoing major abdominal surgery began a clear liquid diet on postoperative day 1 and advanced to a regular diet after tolerating 500 mL of clear liquids [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This early feeding reduced time to solid diet consumption from 2.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 days to 1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 days (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In our trial, time to solid diet tolerance occurred at 20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 hours with MOM versus 28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3 hours with standard ERAS, with both earlier than in Schilder et al. We attribute this acceleration to standard ERAS elements, including preoperative carbohydrate loading, allowance of clear liquids until 2 hours before surgery, early ambulation, optimal pain control, multimodal analgesia, and reduced opioid exposure [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Together, these components likely enabled both groups to tolerate solids sooner than in prior reports.\u003c/p\u003e \u003cp\u003eTime to first flatus was similarly accelerated in our cohort: 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 hours in the MOM group, which is faster than previous reports. For comparison, a radical hysterectomy series administered 30 mL MOM twice daily starting on postoperative day 1, with a bisacodyl suppository on postoperative day 2 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The median time to flatus was 3 days (range 2\u0026ndash;3 days) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These data demonstrate that integrating MOM into ERAS pathways expedites bowel function return, enabling earlier flatus and solid diet tolerance.\u003c/p\u003e \u003cp\u003eLength of hospital stay was shorter with MOM (72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7 hours) than with standard ERAS (81.6\u0026thinsp;\u0026plusmn;\u0026thinsp;49.8 hours), but not significantly so. Our institution routinely discharges hysterectomy patients on postoperative day 3, even when they tolerate solids or pass flatus by day 1 or 2. This practice likely masked between-group differences in length of stay despite earlier bowel recovery with MOM. By contrast, other studies have shown significant length of stay reductions with MOM [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEating satisfaction was significantly higher with MOM (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as was daily activities satisfaction (8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These improvements likely reflect reduced nausea, vomiting, and bloating, plus earlier bowel function return. Earlier flatus and bowel movements facilitated faster solid diet tolerance, improving satisfaction with both eating and daily activities.\u003c/p\u003e \u003cp\u003eThis study has several strengths. It is a prospective randomized controlled trial of abdominal hysterectomy for benign and malignant conditions, with well-balanced baseline characteristics between groups. MOM is cost-effective and covered by all healthcare plans, enabling universal access without financial burden. Outcomes were clearly defined, including POI, well-tolerated solid diet, discharge criteria, and length of stay. However, certain outcomes were subjective, particularly time to first flatus. Patients may pass flatus during sleep or other unobserved activities, so recorded times may exceed actual times, potentially biasing recovery-time assessments.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAdding MOM to ERAS effectively reduced POI incidence and accelerated bowel function recovery in patients undergoing abdominal hysterectomy for benign or malignant conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch1\u003eAuthorship confirmation/contribution statement\u003c/h1\u003e\n\u003cp\u003eAll authors contributed to study design and conceptualization. WK, IR, NJ, and SK enrolled participants. DA and RS obtained informed consent and administered medication per protocol. NS and JK prepared and stored the study drug. WK and IR performed data retrieval, analysis, and interpretation from medical records. WK and NJ drafted the manuscript. IR and SK provided critical intellectual content through manuscript revision. All authors edited and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch1\u003eData availability\u003c/h1\u003e\n\u003cp\u003eCorrespondence and requests for materials should be addressed to WK.\u003c/p\u003e\n\u003ch1\u003eAcknowledgments\u003c/h1\u003e\n\u003cp\u003eThe authors gratefully acknowledge Mr Suthipol Udompunturak for statistical assistance and Ms Sarocha Boonkate for oversight of funding management. We would like to thank Mr. David Park for editing the English version of the manuscript.\u003c/p\u003e\n\u003ch1\u003eFunding\u003c/h1\u003e\n\u003cp\u003eThis research project is supported by the Siriraj Research Development Fund, Faculty of Medicine Siriraj Hospital, Mahidol University (grant number R016632024).\u003c/p\u003e\n\u003ch1\u003ePotential conflicts of interest\u003c/h1\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVenara A, Neunlist M, Slim K, Barbieux J, Colas PA, Hamy A, et al. Postoperative ileus: Pathophysiology, incidence, and prevention. J Visc Surg. 2016;153(6):439\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFanning J, Hojat R. Safety and efficacy of immediate postoperative feeding and bowel stimulation to prevent ileus after major gynecologic surgical procedures. J Am Osteopath Assoc. 2011;111(8):469\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;ng\u0026ouml;rd\u0026uuml;k K, \u0026Ouml;zdemir İ A, G\u0026uuml;ng\u0026ouml;rd\u0026uuml;k \u0026Ouml;, G\u0026uuml;lseren V, Gok\u0026ccedil;\u0026uuml; M, Sancı M. Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial. Am J Obstet Gynecol. 2017;216(2):145\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-.e7\u003c/span\u003e\u003cspan address=\"http://.e1-.e7\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z-L, Zhao B-C, Deng W-T, Zhuang P-P, Liu W-F, Li C, et al. Incidence and risk factors of postoperative ileus after hysterectomy for benign indications. Int J Colorectal Dis. 2020;35(11):2105\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEamudomkarn N, Kietpeerakool C, Kaewrudee S, Jampathong N, Ngamjarus C, Lumbiganon P. Effect of postoperative coffee consumption on gastrointestinal function after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials. Sci Rep. 2018;8(1):17349.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJirawongprapa Y, Chotboon C, Songthamwat S, Summart U, Songthamwat M. Effects of Caffeine Dose on Bowel Function Recovery Following Gynecologic Cancer Surgery: A randomized double-blind controlled trial. Thai Journal of Obstetrics and Gynaecology. 2023;31(4):265\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadirogullari P, Seckin KD, Yalcin Bahat P, Aytufan Z. The effect of chewing gum on bowel function postoperatively in patients with total laparoscopic hysterectomy: a randomised controlled trial. J Obstet Gynaecol. 2022;42(5):1192\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSillapasa C, Jeerasap R, Tangsiriwatthana T. Metoclopramide for Preventing Ileus after Benign Gynecologic Surgery: A randomized controlled trial. Thai Journal of Obstetrics and Gynaecology. 2023;31(3):192\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaiyakunapruk N, Kitikannakorn N, Nathisuwan S, Leeprakobboon K, Leelasettagool C. The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis. Am J Obstet Gynecol. 2006;194(1):95\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePongsupanimit P, Chaikomin R, Tripatara P, Achariyapota V, Viriyapak B, Kanpetpanao S, et al. The Impact of Ginger on Preventing Postoperative Ileus after Hysterectomy Under the Enhanced Recovery after Surgery Protocol: A randomized controlled trial. Thai Journal of Obstetrics and Gynaecology. 2025;33(1):53\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer. 2019;29(4):651\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026oacute;mez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, et al. European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: Status of ERAS protocol implementation across Europe. Int J Gynaecol Obstet. 2023;160(1):306\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFanning J, Yu-Brekke S. Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy. Gynecol Oncol. 1999;73(3):412\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchilder JM, Hurteau JA, Look KY, Moore DH, Raff G, Stehman FB, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecologic oncology. 1997;67(3):235\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVather R, Trivedi S, Bissett I. Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg. 2013;17(5):962\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTatar C, Hinckley S, Holubar SD, L\u0026iacute;ška D, Delaney CP, Steele SR, et al. Does milk of magnesia impact length of hospital stay after major colorectal resection. ANZ Journal of Surgery. 2022;93.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Enhanced recovery after surgery, ERAS, Gynecologic malignancy, Hysterectomy, Milk of magnesia, MOM, Postoperative ileus, POI","lastPublishedDoi":"10.21203/rs.3.rs-8067937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8067937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate whether adding milk of magnesia (MOM) to an enhanced recovery after surgery (ERAS) pathway prevents postoperative ileus (POI) and improves postoperative bowel function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis randomized controlled trial at the Gynecology Unit, Siriraj Hospital (Bangkok, Thailand) enrolled patients undergoing hysterectomy for benign or malignant indications during September 2023 through February 2024. Participants were randomly assigned to ERAS alone (\u003cem\u003en\u003c/em\u003e = 80) or ERAS plus MOM (\u003cem\u003en\u003c/em\u003e = 80). The MOM group received 15 mL on postoperative day 0 and then 30 mL twice daily until first flatus or bowel movement. Primary outcomes were POI incidence, time to first flatus, time to solid diet tolerance, patient satisfaction, and MOM-related complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 160 patients, 60 (37.5%) had gynecologic malignancies: endometrial cancer (\u003cem\u003en\u003c/em\u003e = 34), ovarian cancer (\u003cem\u003en\u003c/em\u003e = 16), cervical cancer (\u003cem\u003en\u003c/em\u003e = 8), and leiomyosarcoma (\u003cem\u003en\u003c/em\u003e = 2). ERAS plus MOM reduced POI versus ERAS alone (3.8% vs 27.5%; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). It also shortened time to first flatus (17.1 ± 7.9 vs 22.3 ± 10.8 hours; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Time to solid diet tolerance was shorter (20.6 ± 10.9 vs 28.8 ± 16.3 hours; \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.001). Patient satisfaction scores for eating and daily activities were significantly higher. No severe adverse events occurred in the MOM group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdding MOM to ERAS reduced POI incidence and enhanced postoperative recovery after hysterectomy for benign or malignant disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Thai Clinical Trials Registry. Registration number 20230816005.\u003c/p\u003e","manuscriptTitle":"Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 10:36:32","doi":"10.21203/rs.3.rs-8067937/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T15:53:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T22:52:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280629054725681107527149576223846387653","date":"2026-01-17T19:27:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289583613182645600217413371089284729580","date":"2026-01-12T20:51:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T17:54:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T20:25:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T01:27:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-11-09T08:42:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cbc7b232-d0ab-4382-81cb-ae76ee9fb1e7","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T19:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 10:36:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8067937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8067937","identity":"rs-8067937","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}