Effect of non-mechanical bowel preparation on postoperative gastrointestinal recovery after surgery of gynaecological malignant tumours: A randomised controlled trial

Effect of non-mechanical bowel preparation on postoperative gastrointestinal recovery after surgery of gynaecological malignant tumours: A randomised 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of non-mechanical bowel preparation on postoperative gastrointestinal recovery after surgery of gynaecological malignant tumours: A randomised controlled trial ShanShan Wang, Hongyan Xu, XingXia Li, Suwen Feng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1939829/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To investigate the efcacy and safety of Non-mechanical bowel preparation in patients undergoing surgery of gynaecological malignant tumour. Methods: Patients (n=105) were randomized to receive mechanical bowel preparation（MBP）or Non-mechanical bowel preparation (Non-MBP). The primary outcomes were postoperative gastrointestinal function . Secondary outcomes included Postoperative complaints and plasma of D-lactate and diamine oxidase(DAO). Visualisation of the surgical field, involuntary defecation during surgery, operation time, wound healing, surgical site infection, length of hospital stay, andtolerance of mechanical bowel preparation. Results: Participants in the Non-MBP group exhibited shorter times until first bowel movement (27.87 vs. 29.48 h), first passage of flatus (50.96 vs. 55.08 h), and first passage of stool (75.94 vs. 98.50 h);they also exhibited fewer postoperative gastrointestinal symptoms, including nausea (18.9% vs. 38.5%), vomiting (26.4% vs. 51.9%), abdominal pain (34.0% vs. 78.9%), and bloating (3.8% vs.26.9%). The plasma D-lactate and DAO were significantly increased (2.93 vs. 5.68 nmol/mL and 20.46 vs. 54.49 ng/mL) after bowel preparation in the MBP group; but no differences in the Non-MBP group after bowel preparation. Compared with the MBP group, surgical field visualisation was superior (92.45% vs. 78.85%), and the operation time was shorter (173.58 vs. 203.88 min) in the Non-MBP group. Patients undergoing MBP complained of bloating (82.35%), unpleasant taste (78.43%), sleep disturbance (70.59%), nausea (68.63%), abdominal pain (64.71%), vomiting(45.10%), polydipsia (33.33%), dizziness (25.49%), and headache (7.84%). Conclusions: Non-MBP is more conducive to the recovery of postoperative gastrointestinal function after surgery of gynaecological malignant tumour. Trial registration number: Chictr.org.cn.( ChiCTR2200059101). Mechanical bowel preparation gynaecological malignant tumours enhanced recovery after surgery randomised controlled trial Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Gynaecological malignant tumours mainly include cervical cancer, endometrial carcinoma, and ovarian cancer, all of which seriously threaten women's health. For early stage gynaecological malignancies, surgery remains the primary treatment approach,it assists in tumour staging and debulking. Moreover, radical or total hysterectomy, with or without pelvic lymph node dissection, is generally recommended for gynaecological malignancies [ 1 – 3 ]. Mechanical bowel preparation was originally adopted from colorectal surgery for many years, this approach has been the main preoperative preparation method for gynaecological pelvic surgery [ 4 ]. Mechanical bowel preparation is presumed to reduce faecal bulk and bacterial colonisation, thereby facilitating intraoperative bowel management and surgical field visualisation; it also reduces the risks of postoperative complications (e.g. anastomotic leakage and surgical site infection) [ 5 – 6 ]. After abdominal and pelvic surgery, recovery of gastrointestinal function is often delayed, which can affect postoperative rehabilitation [ 7 ]. Delayed gastrointestinal function recovery may cause abdominal distention, abdominal pain, nausea, vomiting, and intestinal paralysis-related bowel ileus; it can also lead to a prolonged hospital stay [ 8 ]. For these reasons, various procedures have been investigated in terms of their ability to promote rapid recovery in the perioperative period. There is increasing interest in the use of enhanced recovery protocols after surgery, i.e. combinations of best practices aimed at standardising perioperative care [ 9 ]. This approach focuses on evidence-based postoperative care and adjustments to presurgical methods, such as the omission of mechanical bowel preparation [ 10 – 11 ]. There is evidence that mechanical bowel preparation does not provide significant benefits with respect to infection after colon and rectal surgery; moreover, it leads to preoperative discomfort and complications (e.g. nausea, bloating, dehydration, electrolyte imbalances, and perforation risk), especially in older patients [ 12 – 13 ]. Therefore, non-mechanical bowel preparation protocols are increasingly being used, in accordance with the enhanced recovery after surgery approach implemented in colorectal surgery [ 14 ]. Some researchers have also investigated the application of non-mechanical bowel preparation in abdominal and pelvic surgeries for the treatment of gynaecological diseases. Among patients who underwent benign gynaecological laparoscopic procedures, mechanical bowel preparation was not superior to non-mechanical bowel preparation in terms of intraoperative visualisation of the surgical field, ease of bowel management, or overall ease of surgery [ 15 ]. In patients with gynaecological malignant tumours, non-mechanical bowel preparation may be acceptable, considering the low risk of intraluminal entry during surgery [ 16 ]. A previous retrospective analysis suggested that mechanical bowel preparation provides no significant benefit during gynaecological oncology surgery with simultaneous colon or rectal resection [ 17 ]. Furthermore, mechanical bowel preparation was not associated with a lower incidence of postoperative ileus compared to non-mechanical bowel preparation, indicating no specific advantage for postoperative restoration of gastrointestinal function [ 18 ]. These findings suggest that the non-mechanical bowel preparation strategy, based on enhanced recovery after surgery, may improve the outcomes of patients undergoing gynaecological oncology surgeries. However, there remains limited supporting evidence from prospective and randomised clinical trials, especially in China. Here, we conducted a randomised controlled trial to assess the outcomes of mechanical bowel preparation in patients undergoing gynaecological oncology surgeries. We compared the effects of non-mechanical bowel preparation on patient recovery after gynaecological oncology surgeries to conventional mechanical bowel preparation. Our results provide useful insights for optimisation of preoperative bowel preparation methods in clinical practice 2. Methods This randomized trial was performed from from October 2019 to August 2020. after obtaining approval of the the Ethics Committee of Women‘s Hospital School of Medicine Zhejiang university (approval No. 2019003). Written informedconsent was obtained from all enrolled patients. The study was registered with Chictr.org.cn.( ChiCTR2200059101). Participants This study enrolled patients at a University Hospital in Hangzhou who were diagnosed with gynaecological malignancies from October 2019 to August 2020. All enrolled patients were scheduled for a total hysterectomy plus pelvic or para-aortic lymph node dissection under general anaesthesia with tracheal intubation. The inclusion criteria were as follows: age 18–75 years; no history of abdominal surgery; no history of mental illness; and provision of written informed consent. The exclusion criteria were as follows: suspicion of gastrointestinal metastasis based on the preoperative findings; inability to tolerate orally administered intestinal cleansers; inability to tolerate mechanical enema; pregnancy; presence of severe cardiovascular and cerebrovascular diseases, endocrine diseases, mental illness, or chronic intestinal diseases (e.g. intestinal tuberculosis, Crohn’s disease, or chronic non-specific ulcerative colitis); presence of an emergency abdominal condition (e.g. gastrointestinal perforation, gastrointestinal bleeding, intestinal obstruction, or volvulus); and poor compliance with instructions concerning rapid recovery. Randomisation and blinding The research coordinator used a computer to generate 110 random numbers, and then sealed the numbers in an opaque airtight envelope. Each enrolled patient obtained a number from the envelope. The control group (numbers 1–55) comprised patients who underwent mechanical bowel preparation. The experimental group (numbers 56–110) comprised patients who did not undergo mechanical bowel preparation. Data collectors, research coordinators, surgeons, and data analysts were all blinded to the patients’ group assignments. Interventions All surgeries were performed by the same group of surgeons. Patients in the control group were instructed to eat a low fibre diet provided by the hospital, along with oral intake of intestinal cleansing agents (four bags of polyethylene glycol electrolyte powder dissolved in water) 1 day before surgery; subsequently, they fasted for 8 h and did not drink any liquid for 4 h before the induction of anaesthesia. The cleansing agent (polyethylene glycol electrolyte powder) was prepared as follows: each bag was mixed with 1,000 ml of warm water and then stirred to completely dissolve the powder. Patients were instructed to rapidly drink 600 ml, followed by 250 ml at intervals of 15 min, such that all cleansing agent preparations were consumed within 3 h. If a patient experienced severe abdominal bloating, intake could be slowed or stopped until symptoms resolved. On the day of surgery, each patient’s intestinal cleanliness was assessed by the charge nurse at 6:00 am. If the patient exhibited residual or turbid stool, a mechanical enema procedure was conducted through the anus to ensure that no stool remained in the bowel. Patients in the experimental group were required to adhere to a preoperative dietary and fasting protocol identical to that for the control group, but mechanical bowel preparation was not performed on the day of surgery. Measurements The following patient information was collected through a questionnaire upon study enrolment: age, education level, body mass index, and diagnosis. Clinical data (e.g. wound healing progress, incidence of surgical site infection, and length of hospital stay) were obtained from medical records. Primary outcomes The primary outcomes were postoperative gastrointestinal function parameters To evaluate postoperative gastrointestinal recovery, a datasheet was used including the times to first bowel movement, first passage of flatus, first passage of stool after surgery, and incidence of bowel obstruction. Two well-trained nurses collected the data through discussions with the patients, as well as auscultation; they recorded all information within 6 h after surgery. Secondary outcomes Postoperative gastrointestinal symptoms, and plasma concentrations of D-lactate and diamine oxidase. Postoperative gastrointestinal symptoms were evaluated by the Common Adverse Events Evaluation Criteria 4.0 (Chinese version), as recommended by the US Health and Public Service (2009); these symptoms included postoperative nausea, vomiting, bloating, abdominal pain, and related gastrointestinal symptoms. All symptoms and types of discomfort were recorded by two well-trained nurses within 48 h after surgery. To evaluate intestinal barrier function and integrity, plasma D-lactate and diamine oxidase concentrations were measured using the Human D-lactate Assay Kit (ab83429; Abcam, Cambridge, UK) and Human Diamine Oxidase ELISA Kit (E-EL-H1241c; Elabscience, Houston, TX, USA), in accordance with the manufacturers’ instructions. Briefly, 3–5 mL of peripheral venous blood was collected from each patient into plastic whole blood tubes coated with K 2 EDTA at 6:30 am, 1 day before surgery, and after the patient entered the operating room on the day of surgery; each sample was centrifuged at 1,600 × g for 15 min. The plasma was then aliquoted and frozen at -80℃ for subsequent use. Plasma was pre-treated with the 10 kD Spin Column (ab93349; Abcam) for deproteinisation, and then mixed with D-Lactate Enzyme Mix and Substrate Mix in 50-µL reaction wells. Next, 50 µL of Reaction Mix was added to each well and incubated for 30 min; the optical density was assessed at 450 nm using a microplate reader. For plasma diamine oxidase enzyme-linked immunosorbent assay analysis, 100 µL of plasma was added to each well of a pre-coated microplate and incubated at room temperature for 90 min. Then, sequential incubations of 1× biotinylated detection antibody, 1× horseradish peroxidase conjugate, and tetramethylbenzidine substrate solution were performed; a wash step was conducted after incubation with each solution. The optical density was also assessed at 450 nm using a microplate reader. The final plasma D-lactate and diamine oxidase concentrations were calculated based on the standard curve generated during each assay. Surgery-related assessment criteria included visualisation of the surgical field (good, fair, or poor), injuries to anatomical structures, involuntary defecation during surgery, total operation time, and length of hospital stay. These criteria were measured using a self-administered questionnaire completed immediately after the procedure by the chief surgeon. Although the participants could not be blinded to their allocation, they were asked not to reveal it to the chief surgeon. A previously published questionnaire [ 19 ] was used to measure patient tolerance of bowel preparation. It included nine items: unpleasant smell and taste, polydipsia, nausea, vomiting, bloating, abdominal pain, headache, dizziness, and sleep disturbance. Each item was assigned one of five grades (none, very mild, mild, moderate, or severe). Patients completed the questionnaire immediately before surgery with assistance from a well-trained research nurse. Wound healing and surgical site infection were assessed by surgeons in accordance with diagnostic criteria established by the China Hospital Infection Professional Committee. These assessments were recorded by a specialist nurse. Statistical analysis Analyzed by PASS2021, we estimated that a sample size of 100 (each group sample size of 50), which could achieve 90% power to reject the null hypothesis of equal means when the population mean difference of time to first passage of flatus was µ1 - µ2 = 55 − 50 = 5 with a standard deviation for both groups of 7.6 and with a significance level (alpha) of 0.05 using a two-sided two-sample equal-variance t-test. Assuming a loss to follow-up rate of 10%, the final overall sample size was set at 110. For continuous data that exhibited a normal distribution and homogeneity of variance, differences were assessed using independent samples t-tests; other data were compared using non-parametric tests. Categorical data were compared by chi-squared, adjusted chi-squared, or Fisher's exact tests. Statistical analysis was performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA) and p-values < 0.05 were considered statistically significant. 3. Results Patient baseline characteristics Between October 2019 and August 2020, 110 patients were randomly allocated to the experimental group (n = 55) or control group (n = 55); most patients were diagnosed with cervical or endometrial cancer. Of the 110 patients, five dropped out or were excluded during the study (n = 1 per group cancelled surgery for personal reasons; n = 1 per group had missing data; and n = 1 could not tolerate mechanical bowel preparation). The remaining 105 patients were included in the final analysis (n = 53 in the experimental group and n = 52 in the control group). The study flow chart is shown in Fig. 1 . The two groups were comparable in terms of age, education level, body mass index, diagnosis, and surgical approach (P > 0.05); these data are presented in Table 1 . All surgeries were performed for the treatment of gynaecological malignancies. Cervical cancer was the most common diagnosis (68 cases, 64.76%), followed by endometrial cancer (34 cases, 32.28%). The most common treatment was laparoscopic surgery (91 cases, 86.67%); open surgery was performed in the remaining 14 cases (13.33%). The most common surgical approach was sub-radical hysterectomy and pelvic lymph node dissection (54 cases, 51.42%), followed by radical hysterectomy and pelvic lymph node dissection (43 cases, 40.95%). No cases involved bowel resection. Table 1 Patient demographic and clinical characteristics Variable Total (n = 105) Control group (n = 53) Experimental group (n = 52) Statistics P Age(years) 501.25 ± 10.05 50.90 ± 10.86 51.60 ± 9.24 t = -0.356 0.723 BMI(kg/m 2 ) 24.2 ± 3.40 24.26 ± 3.60 23.81 ± 3.19 Z = 0.276 0.783 Education χ²= 1.885 0.907 Primary school or below 31(29.52%) 16 (30.77%) 15 (28.84%) High school 56(53.33%) 29 (55.77%) 27(51.94%) Bachelor degree or above 17(16.19%) 7 (13.46%) 10 (19.23%) Type of disease χ²= 2.743 0.481 Cervical cancer 68(64.76%) 35 (67.31%) 33 (62.31%) Endometrial carcinoma 34(32.38%) 16 (30.77%) 18 (33.96%) Ovarian cancer 1(0.95%) 1 (1.92%) 0 (0.00) Gestational Trophoblastic tumor 2(1.90%) 0 (0.00) 2 (3.77%) Surgical approach χ²= 0.720 0.985 Laparoscopic total hysterectomy 2(1.90%) 1 (1.92%) 1 (1.89%) Laparotomy sub-radical hysterectomy and pelvic lymph node dissection 8(7.61%) 4 (7.69%) 4 (7.55%) Laparotomy radical hysterectomy and pelvic lymph node dissection 6(5.71%) 3 (5.77%) 3 (5.66%) Laparoscopic sub-radical hysterectomy and pelvic lymph node dissection 54(51.42%) 28 (53.85%) 26 (49.06%) Laparoscopic radical hysterectomy and pelvic lymph node dissection 35(33.33%) 16 (30.77%) 19 (35.85%) Primary outcomes Time to gastrointestinal function recovery after surgery Gastrointestinal function recovery after surgery is reflected in the time to first bowel movement, time to first passage of flatus, and time to first passage of stool. Patients in the experimental group achieved first bowel movement, first passage of flatus, and first passage of stool within mean intervals of 27.87, 50.96, and 75.94 h; these intervals in the control group were 29.48 h (Z = -0.660, P = 0.509), 55.08 h (Z = -1.331, P = 0.183), and 98.50 h (Z = -4.264, P < 0.001), respectively (Fig. 2 A–C). There was no case of bowel obstruction occurred in either group. Secondary outcomes Gastrointestinal symptoms after surgery Compared with the control group, patients in the experimental group experienced significantly fewer postoperative gastrointestinal symptoms, including postoperative nausea (18.9% vs. 38.5%, P = 0.026), vomiting (26.4% vs. 51.9%, P = 0.007), and abdominal pain (34.0% vs. 78.9%, P < 0.001) (Fig. 3 A–C). No participants reported moderate or severe bloating in either group after surgery. However, the incidence of mild bloating was significantly lower in the experimental than control group (3.8% vs. 26.9%, P = 0.001) (Fig. 3 D). Concentrations of plasma D-lactate and diamine oxidase before and after bowel preparation The concentrations of plasma D-lactate and diamine oxidase were assessed to determine intestinal barrier function and integrity. As shown in Fig. 4 , the concentrations of plasma D-lactate (3.87 vs. 4.07 nmol/mL) and diamine oxidase (20.56 vs. 21.72 ng/mL) in the experimental group did not significantly differ before and after bowel preparation. Conversely, the concentrations of plasma D-lactate (2.93 vs. 5.68 nmol/mL, Z = -5.428, P < 0.001) and diamine oxidase (20.46 vs. 54.49 ng/mL, Z = -6.193, P < 0.001) significantly increased after bowel preparation in the control group, implying that the intestinal barrier had been compromised. Operation-related assessment criteria Intraoperative visualisation of the surgical field was more frequently rated as “satisfactory ” or “fair” in the experimental than control group (92.45% vs. 78.85%, χ² = 3.969, P = 0.046). No injuries to anatomical structures occurred during surgery in either group. Moreover, no involuntary defecation occurred in the experimental group, while it occurred in three cases in the control group; however, the incidence did not significantly differ between the groups. The mean total operation time was 173.58 ± 37.40 min in the experimental group and 203.88 ± 35.40 min in the control group ( P < 0.001). Two cases of surgical site infection were observed in the control group, but there were none in the experimental group. The rate of wound healing after surgery did not significantly differ between the two groups (χ² = 2.078, P = 0.243). Additionally, the length of hospital stay did not significantly differ between the groups (12.69 vs. 12.30 days, Z = -0.755, P = 0.450). Table 2 Comparison of operation-related assessment criteria between the groups Operation-related assessment criteria Control group (n = 52) Experimental group (n = 53) Statistics P Intraoperative visualisation of the surgical field χ²=3.969 0.046 Good. 41 (78.85%) 49(92.45%) Fair 10(19.23%) 4(7.54%) Poor 1(1.92%) 0 Involuntary bowel movements during surgery 3 0 χ²= 1.412 0.235 Operation time(min) 203.88 ± 35.40 173.58 ± 37.40 t = 4.262 < 0.001 Wound healing χ²= 2.078 0.243 Grade A 50(96.15%) 53(100%) Grade B 1(1.92%) 0 Grade C 1(1.92%) 0 Surgical site infection χ²= 2.078 0.243 No infection 50(96.15%) 53(100%) Superfical infection 1(1.92%) 0 Deep infection 1(1.92%) 0 Cleanser-related symptoms in the control group After mechanical bowel preparation, patients in the control group complained of bloating (82.35%), unpleasant taste (78.43%), sleep disturbance (70.59%), nausea (68.63%), abdominal pain (64.71%), vomiting (45.10%), polydipsia (33.33%), dizziness (25.49%), and headache (7.84%) (Fig. 5 ). 4. Discussion Gastrointestinal dysfunction is a common form of postoperative morbidity after abdominal and pelvic gynaecological cancer surgery, and represents a multifaceted complication that frequently delays hospital discharge after surgery [ 20 ]. The effects of mechanical bowel preparation on the recovery of bowel function remain controversial. In patients undergoing colorectal surgery, a combined mechanical and oral antibiotic bowel preparation strategy was associated with favourable clinical outcomes, including reduced postoperative ileus and shorter hospital stay [ 21 ]. A large-scale retrospective study revealed that the use of a bowel preparation strategy did not reduce the rates of postoperative complications, such as postoperative ileus, after benign or malignant hysterectomy, irrespective of surgical method (minimally invasive approach or laparotomy) [ 18 ]. Generally, the times to first passage of flatus, first passage of stool, and first bowel movement are the measures most frequently used to define gastrointestinal function recovery [ 22 ]. In our study, the mechanical bowel preparation group exhibited delayed gastrointestinal function recovery with prolonged times to first passage of flatus, first passage of stool, and first bowel movement. Postoperative complaints (e.g. nausea, vomiting, abdominal pain, and mild abdominal distension) were also more frequent among patients in the mechanical bowel preparation group. These findings implied that the recovery of bowel function was directly affected by mechanical bowel preparation. Gastrointestinal integrity is critical for bowel function; it ensures a physical barrier against potentially harmful compounds such as bacteria, toxins, and antigens [ 23 ]. Various methods are available for non-invasive assessment of barrier integrity and function. In this study, we assessed the plasma concentrations of D-lactate and diamine oxidase, which have been shown to be inversely associated with the permeability of the small intestine [ 24 ]. As mentioned above, the increased concentrations of D-lactate and diamine oxidase after mechanical bowel preparation suggested that intestinal barrier function had become impaired, leading to delayed recovery of bowel function. Total hysterectomy or radical hysterectomy, with or without pelvic and para-aortic lymph node dissection, are the main surgical procedures for patients with early stage gynaecological malignancies (e.g. endometrial, cervical, and ovarian cancer). Laparoscopic and minimally invasive surgical methods are considered alternatives to laparotomy; they are becoming more common, especially for the treatment of endometrial cancer [ 25 ], although there has been some controversy regarding their use in the treatment of cervical cancer [ 26 ]. An empty bowel may facilitate management and improve visualisation, particularly when working in the deep pelvis during a laparoscopic operation in which the bowel may be difficult to retract. Therefore, mechanical bowel preparation is a standard practice before gynaecological surgery; there is some evidence that mechanical bowel preparation leads to improvements in surgical view and bowel management [ 27 ]. However, some studies have revealed no significant advantages of a mechanical bowel preparation strategy in gynaecological and gynaecological oncology surgeries [ 16 , 28 ]. In contrast to these reports, we found inferior surgical field visualisation and longer surgical times in the mechanical compared to non-mechanical bowel preparation group. Notably, most (86.67%) patients in our cohort underwent laparoscopic surgery; no procedures involved resection or reconstitution of the bowel or other structures. Thus, we conclude that mechanical bowel preparation confers no benefits with respect to surgical field visualisation during gynaecological surgery not involving bowel resection. Another proposed benefit arising from the use of a bowel preparation strategy is a reduction of surgical site infections, because mechanical bowel preparation is presumed to reduce the abundance of intestinal microbiota [ 29 ]. During total laparoscopic hysterectomy, some procedures (e.g. uterine manipulation and specimen delivery via colpotomy) may increase the risk of surgical site infection [ 30 ]. Considering the potential for intraoperative involuntary defecation, vaginal contamination is sometimes inevitable because of the anatomical proximity to the anus. In our study, three cases of involuntary defecation, and two of surgical site infection, occurred in the mechanical bowel preparation group; no such cases occurred in the non-mechanical bowel preparation group. Although these differences were not statistically significant, the findings indicated that the mechanical bowel preparation strategy did not prevent surgical site infection. The underlying mechanism might be related to a reduction of intestinal barrier integrity, as indicated by the plasma concentrations of D-lactate and diamine oxidase. After bowel preparation, these concentrations were significantly elevated in the mechanical, but not in non-mechanical, bowel preparation group. Reduced intestinal integrity has been associated with bacterial translocation and an increased risk of infection. Furthermore, the mechanical bowel preparation procedure causes discomfort for patients. Our questionnaire survey showed that most patients in the control group experienced an unpleasant taste, abdominal distension, abdominal pain, nausea, vomiting, and sleep disturbance. A few patients experienced irritation, thirst, dizziness, and headache. Furthermore, the trans-anal enema undermined patient privacy, led to repeated defecation, and impacted self-esteem; these aspects enhanced preoperative anxiety among affected patients. In addition, the mechanical bowel preparation procedure was time-consuming and increased the treatment cost by 28 USD per patient. Importantly, there were some limitations to our study. Firstly, there may have been selection bias because all patients were treated in a single hospital. Secondly, our patients had early stage gynaecological malignancies that did not require bowel resection. Thirdly, the patients could not be blinded to their group allocation and the evaluation of subjective symptoms may have been affected by psychological factors associated with the allocation. Thus, further multicentre studies with additional patients and late-stage gynaecological malignancies are needed to validate our findings. 5. Conclusions Non-mechanical bowel preparation for patients with gynaecological malignant tumours promotes the recovery of gastrointestinal function after surgery. It also reduces the potential for adverse gastrointestinal symptoms without increasing the likelihood of intraoperative damage to adjacent organs or postoperative complications (e.g. intestinal obstruction and surgical site infection), while conserving medical resources. Overall, non-mechanical bowel preparation before surgery for gynaecological malignancies is safe and feasible for clinical applications. Declarations Acknowledgements : We would like to thankC hangkun Zhu, Songfa Zhang, Xiaofen Luo and Peiyu Feng for their help with data collection and with the operation treatment. Funding: The study was no funding supported. Compliance with ethical standards: The authors declare that they have no conflicts of interest. Ethics approval The study was approved by the Ethics Committee of Women‘s Hospital School of Medicine Zhejiang university (approval No. 2019003) and was performed in line with the Declaration of Helsinki. Informed consent Informed written consent was obtained from all individual participants included in the study. Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests Authors’ contributions ✓ All authors meet the criteria for authorship. ✓ All those entitled to authorship are listed as authors. The detailed contributions of each author were as follows: (1) Shanshan Wang: data collection, analysis and interpretation, paper drafting and revision; (2) Hongyan Xu: study design, data collection, paper drafting and revision; (3)Xingxia Li: data collection and paper revision; (4) Suwen Feng: study design and paper revision. References Cohen PA, Jhingran A, Oaknin A, Denny L, Cervical cancer (2019) Lancet. Jan 12;393(10167):169–182. doi: 10.1016/S0140-6736(18)32470-X . PMID: 30638582 Morice P, Leary A, Creutzberg C, Abu-Rustum N, Darai E (2016) Endometrial cancer. Lancet. Mar 12;387(10023):1094–1108. doi: 10.1016/S0140-6736(15)00130-0 . Epub 2015 Sep 6. PMID: 26354523 Lheureux S, Gourley C, Vergote I, Oza AM (2019) Epithelial ovarian cancer. Lancet. Mar 23;393(10177):1240–1253. doi: 10.1016/S0140-6736(18)32552-2 . PMID: 30910306 Diakosavvas M, Thomakos N, Haidopoulos D, Liontos M, Rodolakis A (2020 Nov) Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature. Arch Gynecol Obstet 302(5):1049–1061. doi: 10.1007/s00404-020-05704-1. Epub 2020 Aug 1. PMID: 32740871 Rollins KE, Javanmard-Emamghissi H, Lobo DN (2018 Jan) Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis. World J Gastroenterol 28(4):519–536. doi: 10.3748/wjg.v24.i4.519. PMID: 29398873; PMCID: PMC5787787 Migaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, Feingold DL, Steele SR, Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons (2019) Oct;62(10):e436 ;. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum. 2019 Jan;62(1):3–8. doi: 10.1097/DCR.0000000000001238. Erratum in: Dis Colon Rectum. PMID: 30531263 Cao LX, Chen ZQ, Jiang Z, Chen QC, Fan XH, Xia SJ, Lin JX, Gan HC, Wang T, Huang YX (2020) Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery. World J Gastroenterol. Jun 21;26(23):3271–3282. doi: 10.3748/wjg.v26.i23.3271 . PMID: 32684741; PMCID: PMC7336322 Ertas IE, Gungorduk K, Ozdemir A, Solmaz U, Dogan A, Yildirim Y (2013) Oct;131(1):118 – 22 Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial. Gynecol Oncol. doi: 10.1016/j.ygyno.2013.07.098. Epub 2013 Jul 29. PMID: 23906657 Ljungqvist O, Scott M, Fearon KC (2017) Enhanced Recovery After Surgery: A Review. JAMA Surg. Mar 1;152(3):292–298. doi: 10.1001/jamasurg.2016.4952 . PMID: 28097305 Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC (2019 May) Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 29(4):651–668. doi: 10.1136/ijgc-2019-000356. Epub 2019 Mar 15. PMID: 30877144 Bogani G, Sarpietro G, Ferrandina G, Gallotta V, DI Donato V, Ditto A, Pinelli C, Casarin J, Ghezzi F, Scambia G, Raspagliesi F (2021 May) Enhanced recovery after surgery (ERAS) in gynecology oncology. Eur J Surg Oncol 47(5):952–959 Epub 2020 Oct 28. PMID: 33139130 Güenaga KF, Matos D, Wille-Jørgensen P (2011) Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. Sep 7;2011(9):CD001544. doi: 10.1002/14651858.CD001544.pub4 . PMID: 21901677; PMCID: PMC7066937 Kathopoulis N, Chatzipapas I, Valsamidis D, Samartzis K, Kipriotis K, Loutradis D, Protopapas A Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?J Obstet Gynaecol Res. 2021Apr; 47(4):1487–1496. doi: 10.1111/jog.14674 . Epub 2021 Feb 8. PMID: 33559272. Ju YU, Min BW, A Review of Bowel Preparation Before Colorectal Surgery (2021 Apr) Ann Coloproctol 37(2):75–84. doi: 10.3393/ac.2020.04.01. Epub 2020 May 15. PMID: 32674551; PMCID: PMC8134921 Ryan NA, Ng VS, Sangi-Haghpeykar H, Guan X (2015) Jul-Sep;19(3):e2015.00035 Evaluating Mechanical Bowel Preparation Prior to Total Laparoscopic Hysterectomy. JSLS. doi: 10.4293/JSLS.2015.00035 . PMID: 26175552; PMCID: PMC4487956 Diakosavvas M, Thomakos N, Psarris A, Fasoulakis Z, Theodora M, Haidopoulos D, Rodolakis A (2020) Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery. ScientificWorldJournal. 142020:8546037. 10.1155/2020/8546037 . PMID: 32110164; PMCID: PMC7042550 Liu WT, Hsiao CW, Jao SW, Yu MH, Wu GJ, Liu JY, Liu CC, Chan JH, Hu JM, Hu SI, Chang PK Is preoperative bowel preparation necessary for gynecological oncology surgery? Taiwan J Obstet Gynecol. 2016 Apr;55(2):198–201. doi: 10.1016/j.tjog.2016.02.009 . PMID: 27125402 Kalogera E, Van Houten HK, Sangaralingham LR, Borah BJ, Dowdy SC (2020) Aug;223(2):231.e1-231.e12 Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2020.02.035. Epub 2020 Feb 26. PMID: 32112733 LAWRANCE IC, WILLERT P R MURRAY,K.. A validated bowel-preparation tolerability questionnaire and assessment of three commonly used bowel-cleansing agents[J].Digestive Diseases and Sciences,2013, 58(4):926–935. PMID: 23095990 Kovoor JG, Stretton B, Jacobsen JHW, Gupta AK, Ovenden CD, Hewitt JN, Glynatsis JM, Edwards S, Campbell K, Asokan GP, Tivey DR, Babidge WJ, Rayner CK, Anthony AA, Trochsler MI, Horowitz M, Hewett PJ, Jones KL, Maddern GJ Gastrointestinal recovery after surgery: protocol for a systematic review. BMJ Open. 2021 Oct 13;11(10):e054704. doi: 10.1136/bmjopen-2021-054704 . PMID: 34645666; PMCID: PMC8515468 Kaslow SR, Gani F, Alshaikh HN, Canner JK Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery. BJS Open. 2018 May 10;2(4):238–245. doi: 10.1002/bjs5.66. PMID: 30079393; PMCID: PMC6069354 Chapman SJ, Thorpe G, Vallance AE, Harji DP, Lee MJ, Fearnhead NS, Association of Coloproctology of Great Britain and Ireland Gastrointestinal Recovery Group ;. Systematic review of definitions and outcome measures for return of bowel function after gastrointestinal surgery. BJS Open. 2018 Oct 1;3(1):1–10. doi: 10.1002/bjs5.102. PMID: 30734010; PMCID: PMC6354191 Schoultz I, Keita ÃV (2020) The Intestinal Barrier and Current Techniques for the Assessment of Gut Permeability. Cells. Aug 17;9(8):1909. doi: 10.3390/cells9081909 . PMID: 32824536; PMCID: PMC7463717 Grootjans J, Thuijls G, Verdam F, Derikx JP, Lenaerts K, Buurman WA Non-invasive assessment of barrier integrity and function of the human gut. World J Gastrointest Surg. 2010 Mar 27;2(3):61 – 9. doi: 10.4240/wjgs.v2.i3.61 . PMID: 21160852; PMCID: PMC2999221 Reijntjes B, van Suijlichem M, Woolderink JM, Bongers MY, Reesink-Peters N, Paulsen L, van der Hurk PJ, Kraayenbrink AA, Apperloo MJA, Slangen B, Schukken T, Tummers FHMP, van Kesteren PJM, Huirne JAF, Boskamp D, Lunter G, de Bock GH, Mourits MJE (2022 Feb) Recurrence and survival after laparoscopy versus laparotomy without lymphadenectomy in early-stage endometrial cancer: Long-term outcomes of a randomised trial. Gynecol Oncol 164(2):265–270 Epub 2021 Dec 23. PMID: 34955237 Melamed A, Margul DJ, Chen L, Keating NL, Del Carmen MG, Yang J, Seagle BL, Alexander A, Barber EL, Rice LW, Wright JD, Kocherginsky M, Shahabi S, Rauh-Hain JA (2018 Nov) Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer. N Engl J Med 15(20):1905–1914. doi: 10.1056/NEJMoa1804923. Epub 2018 Oct 31. PMID: 30379613; PMCID: PMC6464372 Won H, Maley P, Salim S, Rao A, Campbell NT, Abbott JA (2013) Mar;121(3):538–546 Surgical and patient outcomes using mechanical bowel preparation before laparoscopic gynecologic surgery: a randomized controlled trial. Obstet Gynecol. doi: 10.1097/AOG.0b013e318282ed92 . PMID: 23635616 Muzii L, Bellati F, Zullo MA, Manci N, Angioli R, Panici PB (2006) Mar;85(3):689 – 93 Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril. doi: 10.1016/j.fertnstert.2005.08.049. PMID: 16500339 Battersby CLF, Battersby NJ, Slade DAJ, Soop M, Walsh CJ (2019 Mar) Preoperative mechanical and oral antibiotic bowel preparation to reduce infectious complications of colorectal surgery - the need for updated guidelines. J Hosp Infect 101(3):295–299 Epub 2018 Dec 21. PMID: 30579970 Shockley ME, Beran B, Nutting H, Arnolds K, Sprague ML, Zimberg S (2017 Sep-Oct) Sterility of Selected Operative Sites During Total Laparoscopic Hysterectomy. 24:990–997. 10.1016/j.jmig.2017.06.004 . Epub 2017 Jun 10. PMID: 28611000 J Minim Invasive Gynecol6 Cite Share Download PDF Status: Posted Version 1 posted 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1939829","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":131007440,"identity":"a88bdcd2-cf60-4b25-abb7-a411e49275f5","order_by":0,"name":"ShanShan Wang","email":"","orcid":"https://orcid.org/0000-0002-9453-2993","institution":"Zhejiang University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"ShanShan","middleName":"","lastName":"Wang","suffix":""},{"id":131007441,"identity":"5328b3c2-f0de-43c8-880a-e75466b65ddd","order_by":1,"name":"Hongyan Xu","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongyan","middleName":"","lastName":"Xu","suffix":""},{"id":131007442,"identity":"7581fa3c-6cd1-4d51-9c64-01d0006b07e0","order_by":2,"name":"XingXia Li","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"XingXia","middleName":"","lastName":"Li","suffix":""},{"id":131007443,"identity":"acafca02-21ad-4223-a091-3be0142d10d6","order_by":3,"name":"Suwen Feng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBAC9gYwZcPACGLwEKOF5wCYSiNdy2Eojygt7L2HX/5sO2/PPCOB8cHbNgZ5c4JaeM6lWfO23WZmnJHAbDi3jcFwZwMBLfYSOWbGjNtuswG1sEnztjEkGBwgZIv8GzPDn9vO8QC1sP8mTosEj/ED3m0HJEC2MBOnhSfHjJn3X7IBY8/DZsk55yQMNxDUwn7G+OOPM3b2hu3JBz+8KbORJ2gLELBJgEjDBnBkShBWDwTMH0CkPFFqR8EoGAWjYEQCAD1uOwN/G7fmAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-0883-0418","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Suwen","middleName":"","lastName":"Feng","suffix":""}],"badges":[],"createdAt":"2022-08-08 06:14:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1939829/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1939829/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":25721583,"identity":"f711c613-cd71-44ab-9d04-dbec469f8da9","added_by":"auto","created_at":"2022-08-26 17:19:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60591,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/5b507293d932e4a3a582e1c1.png"},{"id":25722713,"identity":"d1944d89-cd2f-4057-b4b3-9136ed1e2485","added_by":"auto","created_at":"2022-08-26 17:29:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":75566,"visible":true,"origin":"","legend":"\u003cp\u003eTime to gastrointestinal function recovery after surgery\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/b3c9b806478e6fbb9ef74144.jpg"},{"id":25721586,"identity":"894400a6-569c-40a5-9f22-e49561ba2978","added_by":"auto","created_at":"2022-08-26 17:19:48","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88914,"visible":true,"origin":"","legend":"\u003cp\u003eGastrointestinal symptoms after surgery\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/10cf36382946193c33ec910f.jpg"},{"id":25721584,"identity":"72dddba8-6232-492d-b6d1-9a064361e603","added_by":"auto","created_at":"2022-08-26 17:19:48","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":43775,"visible":true,"origin":"","legend":"\u003cp\u003ePlasma D-lactate and diamine oxidase levels before and after bowel preparation\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/a48b0b1dc6021da6601c271c.jpg"},{"id":25722176,"identity":"27b5c563-405a-4d51-bde9-700b9ed5dc7a","added_by":"auto","created_at":"2022-08-26 17:24:48","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":60300,"visible":true,"origin":"","legend":"\u003cp\u003e\tOrally administered intestinal cleanser-related symptoms in the control group\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/bf5b2fbf90daa55304d6a757.jpg"},{"id":27344555,"identity":"cf386a45-840a-4bab-93e6-c74cfa9d2318","added_by":"auto","created_at":"2022-10-04 21:33:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585628,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1939829/v1/e11f084a-1507-4388-9ed3-52a30acef810.pdf"}],"financialInterests":"","formattedTitle":"Effect of non-mechanical bowel preparation on postoperative gastrointestinal recovery after surgery of gynaecological malignant tumours: A randomised controlled trial","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGynaecological malignant tumours mainly include cervical cancer, endometrial carcinoma, and ovarian cancer, all of which seriously threaten women's health. For early stage gynaecological malignancies, surgery remains the primary treatment approach,it assists in tumour staging and debulking. Moreover, radical or total hysterectomy, with or without pelvic lymph node dissection, is generally recommended for gynaecological malignancies [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Mechanical bowel preparation was originally adopted from colorectal surgery for many years, this approach has been the main preoperative preparation method for gynaecological pelvic surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Mechanical bowel preparation is presumed to reduce faecal bulk and bacterial colonisation, thereby facilitating intraoperative bowel management and surgical field visualisation; it also reduces the risks of postoperative complications (e.g. anastomotic leakage and surgical site infection) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. After abdominal and pelvic surgery, recovery of gastrointestinal function is often delayed, which can affect postoperative rehabilitation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Delayed gastrointestinal function recovery may cause abdominal distention, abdominal pain, nausea, vomiting, and intestinal paralysis-related bowel ileus; it can also lead to a prolonged hospital stay [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For these reasons, various procedures have been investigated in terms of their ability to promote rapid recovery in the perioperative period.\u003c/p\u003e \u003cp\u003eThere is increasing interest in the use of enhanced recovery protocols after surgery, i.e. combinations of best practices aimed at standardising perioperative care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This approach focuses on evidence-based postoperative care and adjustments to presurgical methods, such as the omission of mechanical bowel preparation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There is evidence that mechanical bowel preparation does not provide significant benefits with respect to infection after colon and rectal surgery; moreover, it leads to preoperative discomfort and complications (e.g. nausea, bloating, dehydration, electrolyte imbalances, and perforation risk), especially in older patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, non-mechanical bowel preparation protocols are increasingly being used, in accordance with the enhanced recovery after surgery approach implemented in colorectal surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Some researchers have also investigated the application of non-mechanical bowel preparation in abdominal and pelvic surgeries for the treatment of gynaecological diseases. Among patients who underwent benign gynaecological laparoscopic procedures, mechanical bowel preparation was not superior to non-mechanical bowel preparation in terms of intraoperative visualisation of the surgical field, ease of bowel management, or overall ease of surgery [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In patients with gynaecological malignant tumours, non-mechanical bowel preparation may be acceptable, considering the low risk of intraluminal entry during surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A previous retrospective analysis suggested that mechanical bowel preparation provides no significant benefit during gynaecological oncology surgery with simultaneous colon or rectal resection [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, mechanical bowel preparation was not associated with a lower incidence of postoperative ileus compared to non-mechanical bowel preparation, indicating no specific advantage for postoperative restoration of gastrointestinal function [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These findings suggest that the non-mechanical bowel preparation strategy, based on enhanced recovery after surgery, may improve the outcomes of patients undergoing gynaecological oncology surgeries. However, there remains limited supporting evidence from prospective and randomised clinical trials, especially in China.\u003c/p\u003e \u003cp\u003eHere, we conducted a randomised controlled trial to assess the outcomes of mechanical bowel preparation in patients undergoing gynaecological oncology surgeries. We compared the effects of non-mechanical bowel preparation on patient recovery after gynaecological oncology surgeries to conventional mechanical bowel preparation. Our results provide useful insights for optimisation of preoperative bowel preparation methods in clinical practice\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e This randomized trial was performed from from October 2019 to August 2020. after obtaining approval of the the Ethics Committee of Women\u0026lsquo;s Hospital School of Medicine Zhejiang university (approval No. 2019003). Written informedconsent was obtained from all enrolled patients. The study was registered with Chictr.org.cn.( ChiCTR2200059101).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eParticipants\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThis study enrolled patients at a University Hospital in Hangzhou who were diagnosed with gynaecological malignancies from October 2019 to August 2020. All enrolled patients were scheduled for a total hysterectomy plus pelvic or para-aortic lymph node dissection under general anaesthesia with tracheal intubation. The inclusion criteria were as follows: age 18\u0026ndash;75 years; no history of abdominal surgery; no history of mental illness; and provision of written informed consent. The exclusion criteria were as follows: suspicion of gastrointestinal metastasis based on the preoperative findings; inability to tolerate orally administered intestinal cleansers; inability to tolerate mechanical enema; pregnancy; presence of severe cardiovascular and cerebrovascular diseases, endocrine diseases, mental illness, or chronic intestinal diseases (e.g. intestinal tuberculosis, Crohn\u0026rsquo;s disease, or chronic non-specific ulcerative colitis); presence of an emergency abdominal condition (e.g. gastrointestinal perforation, gastrointestinal bleeding, intestinal obstruction, or volvulus); and poor compliance with instructions concerning rapid recovery.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eRandomisation and blinding\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe research coordinator used a computer to generate 110 random numbers, and then sealed the numbers in an opaque airtight envelope. Each enrolled patient obtained a number from the envelope. The control group (numbers 1\u0026ndash;55) comprised patients who underwent mechanical bowel preparation. The experimental group (numbers 56\u0026ndash;110) comprised patients who did not undergo mechanical bowel preparation. Data collectors, research coordinators, surgeons, and data analysts were all blinded to the patients\u0026rsquo; group assignments.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eInterventions\u003c/span\u003e \u003c/p\u003e \u003cp\u003eAll surgeries were performed by the same group of surgeons. Patients in the control group were instructed to eat a low fibre diet provided by the hospital, along with oral intake of intestinal cleansing agents (four bags of polyethylene glycol electrolyte powder dissolved in water) 1 day before surgery; subsequently, they fasted for 8 h and did not drink any liquid for 4 h before the induction of anaesthesia. The cleansing agent (polyethylene glycol electrolyte powder) was prepared as follows: each bag was mixed with 1,000 ml of warm water and then stirred to completely dissolve the powder. Patients were instructed to rapidly drink 600 ml, followed by 250 ml at intervals of 15 min, such that all cleansing agent preparations were consumed within 3 h. If a patient experienced severe abdominal bloating, intake could be slowed or stopped until symptoms resolved. On the day of surgery, each patient\u0026rsquo;s intestinal cleanliness was assessed by the charge nurse at 6:00 am. If the patient exhibited residual or turbid stool, a mechanical enema procedure was conducted through the anus to ensure that no stool remained in the bowel.\u003c/p\u003e \u003cp\u003ePatients in the experimental group were required to adhere to a preoperative dietary and fasting protocol identical to that for the control group, but mechanical bowel preparation was not performed on the day of surgery.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eMeasurements\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe following patient information was collected through a questionnaire upon study enrolment: age, education level, body mass index, and diagnosis. Clinical data (e.g. wound healing progress, incidence of surgical site infection, and length of hospital stay) were obtained from medical records.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ePrimary outcomes\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe primary outcomes were postoperative gastrointestinal function parameters\u003c/p\u003e \u003cp\u003eTo evaluate postoperative gastrointestinal recovery, a datasheet was used including the times to first bowel movement, first passage of flatus, first passage of stool after surgery, and incidence of bowel obstruction. Two well-trained nurses collected the data through discussions with the patients, as well as auscultation; they recorded all information within 6 h after surgery.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eSecondary outcomes\u003c/span\u003e \u003c/p\u003e \u003cp\u003ePostoperative gastrointestinal symptoms, and plasma concentrations of D-lactate and diamine oxidase. Postoperative gastrointestinal symptoms were evaluated by the Common Adverse Events Evaluation Criteria 4.0 (Chinese version), as recommended by the US Health and Public Service (2009); these symptoms included postoperative nausea, vomiting, bloating, abdominal pain, and related gastrointestinal symptoms. All symptoms and types of discomfort were recorded by two well-trained nurses within 48 h after surgery.\u003c/p\u003e \u003cp\u003e To evaluate intestinal barrier function and integrity, plasma D-lactate and diamine oxidase concentrations were measured using the Human D-lactate Assay Kit (ab83429; Abcam, Cambridge, UK) and Human Diamine Oxidase ELISA Kit (E-EL-H1241c; Elabscience, Houston, TX, USA), in accordance with the manufacturers\u0026rsquo; instructions. Briefly, 3\u0026ndash;5 mL of peripheral venous blood was collected from each patient into plastic whole blood tubes coated with K\u003csub\u003e2\u003c/sub\u003eEDTA at 6:30 am, 1 day before surgery, and after the patient entered the operating room on the day of surgery; each sample was centrifuged at 1,600 \u0026times; g for 15 min. The plasma was then aliquoted and frozen at -80℃ for subsequent use. Plasma was pre-treated with the 10 kD Spin Column (ab93349; Abcam) for deproteinisation, and then mixed with D-Lactate Enzyme Mix and Substrate Mix in 50-\u0026micro;L reaction wells. Next, 50 \u0026micro;L of Reaction Mix was added to each well and incubated for 30 min; the optical density was assessed at 450 nm using a microplate reader. For plasma diamine oxidase enzyme-linked immunosorbent assay analysis, 100 \u0026micro;L of plasma was added to each well of a pre-coated microplate and incubated at room temperature for 90 min. Then, sequential incubations of 1\u0026times; biotinylated detection antibody, 1\u0026times; horseradish peroxidase conjugate, and tetramethylbenzidine substrate solution were performed; a wash step was conducted after incubation with each solution. The optical density was also assessed at 450 nm using a microplate reader. The final plasma D-lactate and diamine oxidase concentrations were calculated based on the standard curve generated during each assay.\u003c/p\u003e \u003cp\u003eSurgery-related assessment criteria included visualisation of the surgical field (good, fair, or poor), injuries to anatomical structures, involuntary defecation during surgery, total operation time, and length of hospital stay. These criteria were measured using a self-administered questionnaire completed immediately after the procedure by the chief surgeon. Although the participants could not be blinded to their allocation, they were asked not to reveal it to the chief surgeon.\u003c/p\u003e \u003cp\u003eA previously published questionnaire [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] was used to measure patient tolerance of bowel preparation. It included nine items: unpleasant smell and taste, polydipsia, nausea, vomiting, bloating, abdominal pain, headache, dizziness, and sleep disturbance. Each item was assigned one of five grades (none, very mild, mild, moderate, or severe). Patients completed the questionnaire immediately before surgery with assistance from a well-trained research nurse.\u003c/p\u003e \u003cp\u003e Wound healing and surgical site infection were assessed by surgeons in accordance with diagnostic criteria established by the China Hospital Infection Professional Committee. These assessments were recorded by a specialist nurse.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eStatistical analysis\u003c/span\u003e \u003c/p\u003e \u003cp\u003eAnalyzed by PASS2021, we estimated that a sample size of 100 (each group sample size of 50), which could achieve 90% power to reject the null hypothesis of equal means when the population mean difference of time to first passage of flatus was \u0026micro;1 - \u0026micro;2\u0026thinsp;=\u0026thinsp;55\u0026thinsp;\u0026minus;\u0026thinsp;50\u0026thinsp;=\u0026thinsp;5 with a standard deviation for both groups of 7.6 and with a significance level (alpha) of 0.05 using a two-sided two-sample equal-variance t-test. Assuming a loss to follow-up rate of 10%, the final overall sample size was set at 110.\u003c/p\u003e \u003cp\u003eFor continuous data that exhibited a normal distribution and homogeneity of variance, differences were assessed using independent samples t-tests; other data were compared using non-parametric tests. Categorical data were compared by chi-squared, adjusted chi-squared, or Fisher's exact tests. Statistical analysis was performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA) and p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cem\u003ePatient baseline characteristics\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBetween October 2019 and August 2020, 110 patients were randomly allocated to the experimental group (n\u0026thinsp;=\u0026thinsp;55) or control group (n\u0026thinsp;=\u0026thinsp;55); most patients were diagnosed with cervical or endometrial cancer. Of the 110 patients, five dropped out or were excluded during the study (n\u0026thinsp;=\u0026thinsp;1 per group cancelled surgery for personal reasons; n\u0026thinsp;=\u0026thinsp;1 per group had missing data; and n\u0026thinsp;=\u0026thinsp;1 could not tolerate mechanical bowel preparation). The remaining 105 patients were included in the final analysis (n\u0026thinsp;=\u0026thinsp;53 in the experimental group and n\u0026thinsp;=\u0026thinsp;52 in the control group). The study flow chart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The two groups were comparable in terms of age, education level, body mass index, diagnosis, and surgical approach \u003cem\u003e(P\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05); these data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All surgeries were performed for the treatment of gynaecological malignancies. Cervical cancer was the most common diagnosis (68 cases, 64.76%), followed by endometrial cancer (34 cases, 32.28%).\u003c/p\u003e \u003cp\u003eThe most common treatment was laparoscopic surgery (91 cases, 86.67%); open surgery was performed in the remaining 14 cases (13.33%). The most common surgical approach was sub-radical hysterectomy and pelvic lymph node dissection (54 cases, 51.42%), followed by radical hysterectomy and pelvic lymph node dissection (43 cases, 40.95%). No cases involved bowel resection.\u003c/p\u003e \u003cp\u003e \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\u003ePatient demographic and clinical characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e501.25\u0026thinsp;\u0026plusmn;\u0026thinsp;10.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.90\u0026thinsp;\u0026plusmn;\u0026thinsp;10.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.60\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et = -0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.723\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\u003e24.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ\u0026thinsp;=\u0026thinsp;0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.783\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\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 \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u0026sup2;= 1.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.907\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(29.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (28.84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56(53.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (55.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27(51.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(16.19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (13.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (19.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of disease\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 \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u0026sup2;= 2.743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68(64.76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (67.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (62.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(32.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (33.96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational Trophoblastic tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\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 \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u0026sup2;= 0.720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic total hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy sub-radical hysterectomy and pelvic lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(7.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy radical hysterectomy and pelvic lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(5.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic sub-radical hysterectomy and pelvic lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54(51.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (53.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (49.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic radical hysterectomy and pelvic lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35(33.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (35.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ePrimary outcomes\u003c/span\u003e \u003c/p\u003e \u003cp\u003eTime to gastrointestinal function recovery after surgery\u003c/p\u003e \u003cp\u003eGastrointestinal function recovery after surgery is reflected in the time to first bowel movement, time to first passage of flatus, and time to first passage of stool. Patients in the experimental group achieved first bowel movement, first passage of flatus, and first passage of stool within mean intervals of 27.87, 50.96, and 75.94 h; these intervals in the control group were 29.48 h (Z = -0.660, P\u0026thinsp;=\u0026thinsp;0.509), 55.08 h (Z = -1.331, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.183), and 98.50 h (Z = -4.264, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA\u0026ndash;C). There was no case of bowel obstruction occurred in either group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eSecondary outcomes\u003c/span\u003e \u003c/p\u003e \u003cp\u003eGastrointestinal symptoms after surgery\u003c/p\u003e \u003cp\u003eCompared with the control group, patients in the experimental group experienced significantly fewer postoperative gastrointestinal symptoms, including postoperative nausea (18.9% vs. 38.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026), vomiting (26.4% vs. 51.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007), and abdominal pain (34.0% vs. 78.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u0026ndash;C). No participants reported moderate or severe bloating in either group after surgery. However, the incidence of mild bloating was significantly lower in the experimental than control group (3.8% vs. 26.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eConcentrations of plasma D-lactate and diamine oxidase before and after bowel preparation\u003c/p\u003e \u003cp\u003eThe concentrations of plasma D-lactate and diamine oxidase were assessed to determine intestinal barrier function and integrity. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the concentrations of plasma D-lactate (3.87 vs. 4.07 nmol/mL) and diamine oxidase (20.56 vs. 21.72 ng/mL) in the experimental group did not significantly differ before and after bowel preparation. Conversely, the concentrations of plasma D-lactate (2.93 vs. 5.68 nmol/mL, Z = -5.428, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and diamine oxidase (20.46 vs. 54.49 ng/mL, Z = -6.193, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) significantly increased after bowel preparation in the control group, implying that the intestinal barrier had been compromised.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOperation-related assessment criteria\u003c/p\u003e \u003cp\u003eIntraoperative visualisation of the surgical field was more frequently rated as \u0026ldquo;satisfactory \u0026rdquo; or \u0026ldquo;fair\u0026rdquo; in the experimental than control group (92.45% vs. 78.85%, χ\u0026sup2; = 3.969, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046). No injuries to anatomical structures occurred during surgery in either group. Moreover, no involuntary defecation occurred in the experimental group, while it occurred in three cases in the control group; however, the incidence did not significantly differ between the groups. The mean total operation time was 173.58\u0026thinsp;\u0026plusmn;\u0026thinsp;37.40 min in the experimental group and 203.88\u0026thinsp;\u0026plusmn;\u0026thinsp;35.40 min in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Two cases of surgical site infection were observed in the control group, but there were none in the experimental group. The rate of wound healing after surgery did not significantly differ between the two groups (χ\u0026sup2; = 2.078, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.243). Additionally, the length of hospital stay did not significantly differ between the groups (12.69 vs. 12.30 days, Z = -0.755, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.450).\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\u003eComparison of operation-related assessment criteria between the groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation-related assessment criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIntraoperative visualisation of the surgical field\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;=3.969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGood.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e41 (78.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49(92.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10(19.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(7.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1(1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInvoluntary bowel movements during surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;= 1.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOperation time(min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e203.88\u0026thinsp;\u0026plusmn;\u0026thinsp;35.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e173.58\u0026thinsp;\u0026plusmn;\u0026thinsp;37.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;4.262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWound healing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;= 2.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGrade A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50(96.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGrade B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1(1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGrade C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1(1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2;= 2.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50(96.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSuperfical infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1(1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDeep infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1(1.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCleanser-related symptoms in the control group\u003c/p\u003e \u003cp\u003eAfter mechanical bowel preparation, patients in the control group complained of bloating (82.35%), unpleasant taste (78.43%), sleep disturbance (70.59%), nausea (68.63%), abdominal pain (64.71%), vomiting (45.10%), polydipsia (33.33%), dizziness (25.49%), and headache (7.84%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eGastrointestinal dysfunction is a common form of postoperative morbidity after abdominal and pelvic gynaecological cancer surgery, and represents a multifaceted complication that frequently delays hospital discharge after surgery [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The effects of mechanical bowel preparation on the recovery of bowel function remain controversial. In patients undergoing colorectal surgery, a combined mechanical and oral antibiotic bowel preparation strategy was associated with favourable clinical outcomes, including reduced postoperative ileus and shorter hospital stay [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A large-scale retrospective study revealed that the use of a bowel preparation strategy did not reduce the rates of postoperative complications, such as postoperative ileus, after benign or malignant hysterectomy, irrespective of surgical method (minimally invasive approach or laparotomy) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Generally, the times to first passage of flatus, first passage of stool, and first bowel movement are the measures most frequently used to define gastrointestinal function recovery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, the mechanical bowel preparation group exhibited delayed gastrointestinal function recovery with prolonged times to first passage of flatus, first passage of stool, and first bowel movement. Postoperative complaints (e.g. nausea, vomiting, abdominal pain, and mild abdominal distension) were also more frequent among patients in the mechanical bowel preparation group. These findings implied that the recovery of bowel function was directly affected by mechanical bowel preparation.\u003c/p\u003e \u003cp\u003eGastrointestinal integrity is critical for bowel function; it ensures a physical barrier against potentially harmful compounds such as bacteria, toxins, and antigens [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Various methods are available for non-invasive assessment of barrier integrity and function. In this study, we assessed the plasma concentrations of D-lactate and diamine oxidase, which have been shown to be inversely associated with the permeability of the small intestine [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As mentioned above, the increased concentrations of D-lactate and diamine oxidase after mechanical bowel preparation suggested that intestinal barrier function had become impaired, leading to delayed recovery of bowel function.\u003c/p\u003e \u003cp\u003eTotal hysterectomy or radical hysterectomy, with or without pelvic and para-aortic lymph node dissection, are the main surgical procedures for patients with early stage gynaecological malignancies (e.g. endometrial, cervical, and ovarian cancer). Laparoscopic and minimally invasive surgical methods are considered alternatives to laparotomy; they are becoming more common, especially for the treatment of endometrial cancer [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], although there has been some controversy regarding their use in the treatment of cervical cancer [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. An empty bowel may facilitate management and improve visualisation, particularly when working in the deep pelvis during a laparoscopic operation in which the bowel may be difficult to retract. Therefore, mechanical bowel preparation is a standard practice before gynaecological surgery; there is some evidence that mechanical bowel preparation leads to improvements in surgical view and bowel management [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, some studies have revealed no significant advantages of a mechanical bowel preparation strategy in gynaecological and gynaecological oncology surgeries [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In contrast to these reports, we found inferior surgical field visualisation and longer surgical times in the mechanical compared to non-mechanical bowel preparation group. Notably, most (86.67%) patients in our cohort underwent laparoscopic surgery; no procedures involved resection or reconstitution of the bowel or other structures. Thus, we conclude that mechanical bowel preparation confers no benefits with respect to surgical field visualisation during gynaecological surgery not involving bowel resection.\u003c/p\u003e \u003cp\u003eAnother proposed benefit arising from the use of a bowel preparation strategy is a reduction of surgical site infections, because mechanical bowel preparation is presumed to reduce the abundance of intestinal microbiota [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. During total laparoscopic hysterectomy, some procedures (e.g. uterine manipulation and specimen delivery via colpotomy) may increase the risk of surgical site infection [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Considering the potential for intraoperative involuntary defecation, vaginal contamination is sometimes inevitable because of the anatomical proximity to the anus. In our study, three cases of involuntary defecation, and two of surgical site infection, occurred in the mechanical bowel preparation group; no such cases occurred in the non-mechanical bowel preparation group. Although these differences were not statistically significant, the findings indicated that the mechanical bowel preparation strategy did not prevent surgical site infection. The underlying mechanism might be related to a reduction of intestinal barrier integrity, as indicated by the plasma concentrations of D-lactate and diamine oxidase. After bowel preparation, these concentrations were significantly elevated in the mechanical, but not in non-mechanical, bowel preparation group. Reduced intestinal integrity has been associated with bacterial translocation and an increased risk of infection.\u003c/p\u003e \u003cp\u003eFurthermore, the mechanical bowel preparation procedure causes discomfort for patients. Our questionnaire survey showed that most patients in the control group experienced an unpleasant taste, abdominal distension, abdominal pain, nausea, vomiting, and sleep disturbance. A few patients experienced irritation, thirst, dizziness, and headache. Furthermore, the trans-anal enema undermined patient privacy, led to repeated defecation, and impacted self-esteem; these aspects enhanced preoperative anxiety among affected patients. In addition, the mechanical bowel preparation procedure was time-consuming and increased the treatment cost by 28 USD per patient.\u003c/p\u003e \u003cp\u003eImportantly, there were some limitations to our study. Firstly, there may have been selection bias because all patients were treated in a single hospital. Secondly, our patients had early stage gynaecological malignancies that did not require bowel resection. Thirdly, the patients could not be blinded to their group allocation and the evaluation of subjective symptoms may have been affected by psychological factors associated with the allocation. Thus, further multicentre studies with additional patients and late-stage gynaecological malignancies are needed to validate our findings.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eNon-mechanical bowel preparation for patients with gynaecological malignant tumours promotes the recovery of gastrointestinal function after surgery. It also reduces the potential for adverse gastrointestinal symptoms without increasing the likelihood of intraoperative damage to adjacent organs or postoperative complications (e.g. intestinal obstruction and surgical site infection), while conserving medical resources. Overall, non-mechanical bowel preparation before surgery for gynaecological malignancies is safe and feasible for clinical applications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWe would like to thankC hangkun Zhu, Songfa Zhang, Xiaofen Luo and Peiyu Feng for their help with data collection and with the operation treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The study was no funding supported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of \u0026nbsp;Women\u0026lsquo;s Hospital School of Medicine Zhejiang university (approval No. 2019003) and was performed in line with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed written consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e✓ All authors meet the criteria for authorship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e✓ All those entitled to authorship are listed as authors. The detailed contributions of each author were as follows: (1) Shanshan Wang: data collection, analysis and interpretation, paper drafting and revision; (2) Hongyan Xu: study design, data collection, paper drafting and revision; (3)Xingxia Li: data collection and paper revision; (4) Suwen Feng: study design and paper revision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCohen PA, Jhingran A, Oaknin A, Denny L, Cervical cancer (2019) Lancet. Jan 12;393(10167):169\u0026ndash;182. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(18)32470-X\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(18)32470-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30638582\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorice P, Leary A, Creutzberg C, Abu-Rustum N, Darai E (2016) Endometrial cancer. Lancet. Mar 12;387(10023):1094\u0026ndash;1108. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(15)00130-0\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(15)00130-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2015 Sep 6. PMID: 26354523\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLheureux S, Gourley C, Vergote I, Oza AM (2019) Epithelial ovarian cancer. Lancet. Mar 23;393(10177):1240\u0026ndash;1253. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(18)32552-2\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(18)32552-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30910306\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiakosavvas M, Thomakos N, Haidopoulos D, Liontos M, Rodolakis A (2020 Nov) Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature. Arch Gynecol Obstet 302(5):1049\u0026ndash;1061. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00404-020-05704-1.\u003c/span\u003e\u003cspan address=\"10.1007/s00404-020-05704-1.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Epub 2020 Aug 1. PMID: 32740871\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRollins KE, Javanmard-Emamghissi H, Lobo DN (2018 Jan) Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis. World J Gastroenterol 28(4):519\u0026ndash;536. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3748/wjg.v24.i4.519.\u003c/span\u003e\u003cspan address=\"10.3748/wjg.v24.i4.519.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e PMID: 29398873; PMCID: PMC5787787\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, Feingold DL, Steele SR, Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons (2019) Oct;62(10):e436 ;. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum. 2019 Jan;62(1):3\u0026ndash;8. doi: 10.1097/DCR.0000000000001238. Erratum in: Dis Colon Rectum. PMID: 30531263\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao LX, Chen ZQ, Jiang Z, Chen QC, Fan XH, Xia SJ, Lin JX, Gan HC, Wang T, Huang YX (2020) Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery. World J Gastroenterol. Jun 21;26(23):3271\u0026ndash;3282. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3748/wjg.v26.i23.3271\u003c/span\u003e\u003cspan address=\"10.3748/wjg.v26.i23.3271\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32684741; PMCID: PMC7336322\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErtas IE, Gungorduk K, Ozdemir A, Solmaz U, Dogan A, Yildirim Y (2013) Oct;131(1):118 \u0026ndash; 22 Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial. Gynecol Oncol. doi: 10.1016/j.ygyno.2013.07.098. Epub 2013 Jul 29. PMID: 23906657\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLjungqvist O, Scott M, Fearon KC (2017) Enhanced Recovery After Surgery: A Review. JAMA Surg. Mar 1;152(3):292\u0026ndash;298. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamasurg.2016.4952\u003c/span\u003e\u003cspan address=\"10.1001/jamasurg.2016.4952\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28097305\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC (2019 May) Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 29(4):651\u0026ndash;668. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/ijgc-2019-000356.\u003c/span\u003e\u003cspan address=\"10.1136/ijgc-2019-000356.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Epub 2019 Mar 15. PMID: 30877144\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBogani G, Sarpietro G, Ferrandina G, Gallotta V, DI Donato V, Ditto A, Pinelli C, Casarin J, Ghezzi F, Scambia G, Raspagliesi F (2021 May) Enhanced recovery after surgery (ERAS) in gynecology oncology. Eur J Surg Oncol 47(5):952\u0026ndash;959 Epub 2020 Oct 28. PMID: 33139130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;enaga KF, Matos D, Wille-J\u0026oslash;rgensen P (2011) Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. Sep 7;2011(9):CD001544. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD001544.pub4\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD001544.pub4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 21901677; PMCID: PMC7066937\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKathopoulis N, Chatzipapas I, Valsamidis D, Samartzis K, Kipriotis K, Loutradis D, Protopapas A Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?J Obstet Gynaecol Res. 2021Apr; 47(4):1487\u0026ndash;1496. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jog.14674\u003c/span\u003e\u003cspan address=\"10.1111/jog.14674\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2021 Feb 8. PMID: 33559272.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJu YU, Min BW, A Review of Bowel Preparation Before Colorectal Surgery (2021 Apr) Ann Coloproctol 37(2):75\u0026ndash;84. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3393/ac.2020.04.01.\u003c/span\u003e\u003cspan address=\"10.3393/ac.2020.04.01.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Epub 2020 May 15. PMID: 32674551; PMCID: PMC8134921\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan NA, Ng VS, Sangi-Haghpeykar H, Guan X (2015) Jul-Sep;19(3):e2015.00035 Evaluating Mechanical Bowel Preparation Prior to Total Laparoscopic Hysterectomy. JSLS. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4293/JSLS.2015.00035\u003c/span\u003e\u003cspan address=\"10.4293/JSLS.2015.00035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 26175552; PMCID: PMC4487956\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiakosavvas M, Thomakos N, Psarris A, Fasoulakis Z, Theodora M, Haidopoulos D, Rodolakis A (2020) Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery. ScientificWorldJournal. 142020:8546037. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2020/8546037\u003c/span\u003e\u003cspan address=\"10.1155/2020/8546037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32110164; PMCID: PMC7042550\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu WT, Hsiao CW, Jao SW, Yu MH, Wu GJ, Liu JY, Liu CC, Chan JH, Hu JM, Hu SI, Chang PK Is preoperative bowel preparation necessary for gynecological oncology surgery? Taiwan J Obstet Gynecol. 2016 Apr;55(2):198\u0026ndash;201. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tjog.2016.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.tjog.2016.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 27125402\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalogera E, Van Houten HK, Sangaralingham LR, Borah BJ, Dowdy SC (2020) Aug;223(2):231.e1-231.e12 Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2020.02.035. Epub 2020 Feb 26. PMID: 32112733\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLAWRANCE IC, WILLERT P R MURRAY,K.. A validated bowel-preparation tolerability questionnaire and assessment of three commonly used bowel-cleansing agents[J].Digestive Diseases and Sciences,2013, 58(4):926\u0026ndash;935. PMID: 23095990\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKovoor JG, Stretton B, Jacobsen JHW, Gupta AK, Ovenden CD, Hewitt JN, Glynatsis JM, Edwards S, Campbell K, Asokan GP, Tivey DR, Babidge WJ, Rayner CK, Anthony AA, Trochsler MI, Horowitz M, Hewett PJ, Jones KL, Maddern GJ Gastrointestinal recovery after surgery: protocol for a systematic review. BMJ Open. 2021 Oct 13;11(10):e054704. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021-054704\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-054704\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34645666; PMCID: PMC8515468\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaslow SR, Gani F, Alshaikh HN, Canner JK Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery. BJS Open. 2018 May 10;2(4):238\u0026ndash;245. doi: 10.1002/bjs5.66. PMID: 30079393; PMCID: PMC6069354\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman SJ, Thorpe G, Vallance AE, Harji DP, Lee MJ, Fearnhead NS, Association of Coloproctology of Great Britain and Ireland Gastrointestinal Recovery Group ;. Systematic review of definitions and outcome measures for return of bowel function after gastrointestinal surgery. BJS Open. 2018 Oct 1;3(1):1\u0026ndash;10. doi: 10.1002/bjs5.102. PMID: 30734010; PMCID: PMC6354191\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoultz I, Keita \u0026Atilde;V (2020) The Intestinal Barrier and Current Techniques for the Assessment of Gut Permeability. Cells. Aug 17;9(8):1909. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cells9081909\u003c/span\u003e\u003cspan address=\"10.3390/cells9081909\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32824536; PMCID: PMC7463717\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrootjans J, Thuijls G, Verdam F, Derikx JP, Lenaerts K, Buurman WA Non-invasive assessment of barrier integrity and function of the human gut. World J Gastrointest Surg. 2010 Mar 27;2(3):61 \u0026ndash; 9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4240/wjgs.v2.i3.61\u003c/span\u003e\u003cspan address=\"10.4240/wjgs.v2.i3.61\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 21160852; PMCID: PMC2999221\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReijntjes B, van Suijlichem M, Woolderink JM, Bongers MY, Reesink-Peters N, Paulsen L, van der Hurk PJ, Kraayenbrink AA, Apperloo MJA, Slangen B, Schukken T, Tummers FHMP, van Kesteren PJM, Huirne JAF, Boskamp D, Lunter G, de Bock GH, Mourits MJE (2022 Feb) Recurrence and survival after laparoscopy versus laparotomy without lymphadenectomy in early-stage endometrial cancer: Long-term outcomes of a randomised trial. Gynecol Oncol 164(2):265\u0026ndash;270 Epub 2021 Dec 23. PMID: 34955237\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelamed A, Margul DJ, Chen L, Keating NL, Del Carmen MG, Yang J, Seagle BL, Alexander A, Barber EL, Rice LW, Wright JD, Kocherginsky M, Shahabi S, Rauh-Hain JA (2018 Nov) Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer. N Engl J Med 15(20):1905\u0026ndash;1914. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa1804923.\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1804923.\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Epub 2018 Oct 31. PMID: 30379613; PMCID: PMC6464372\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWon H, Maley P, Salim S, Rao A, Campbell NT, Abbott JA (2013) Mar;121(3):538\u0026ndash;546 Surgical and patient outcomes using mechanical bowel preparation before laparoscopic gynecologic surgery: a randomized controlled trial. Obstet Gynecol. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0b013e318282ed92\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0b013e318282ed92\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 23635616\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuzii L, Bellati F, Zullo MA, Manci N, Angioli R, Panici PB (2006) Mar;85(3):689 \u0026ndash; 93 Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril. doi: 10.1016/j.fertnstert.2005.08.049. PMID: 16500339\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBattersby CLF, Battersby NJ, Slade DAJ, Soop M, Walsh CJ (2019 Mar) Preoperative mechanical and oral antibiotic bowel preparation to reduce infectious complications of colorectal surgery - the need for updated guidelines. J Hosp Infect 101(3):295\u0026ndash;299 Epub 2018 Dec 21. PMID: 30579970\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShockley ME, Beran B, Nutting H, Arnolds K, Sprague ML, Zimberg S (2017 Sep-Oct) Sterility of Selected Operative Sites During Total Laparoscopic Hysterectomy. 24:990\u0026ndash;997. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2017.06.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2017.06.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Jun 10. PMID: 28611000 J Minim Invasive Gynecol6\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mechanical bowel preparation, gynaecological malignant tumours, enhanced recovery after surgery, randomised controlled trial","lastPublishedDoi":"10.21203/rs.3.rs-1939829/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1939829/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003eTo investigate the efcacy and safety of Non-mechanical bowel preparation in patients undergoing surgery of gynaecological malignant tumour.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients (n=105) were randomized to receive mechanical bowel preparation（MBP）or Non-mechanical bowel preparation (Non-MBP). The primary outcomes were postoperative gastrointestinal function\u003cstrong\u003e.\u003c/strong\u003e Secondary outcomes included Postoperative complaints and plasma of D-lactate and diamine oxidase(DAO). Visualisation of the surgical field, involuntary defecation during surgery, operation time, wound healing, surgical site infection, length of hospital stay, andtolerance of mechanical bowel preparation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Participants in the Non-MBP group exhibited shorter times until first bowel movement (27.87 vs. 29.48 h), first passage of flatus (50.96 vs. 55.08 h), and first passage of stool (75.94 vs. 98.50 h);they also exhibited fewer postoperative gastrointestinal symptoms, including nausea (18.9% vs. 38.5%), vomiting (26.4% vs. 51.9%), abdominal pain (34.0% vs. 78.9%), and bloating (3.8% vs.26.9%). The plasma D-lactate and DAO were significantly increased (2.93 vs. 5.68 nmol/mL and 20.46 vs. 54.49 ng/mL) after bowel preparation in the MBP group; but no differences in the Non-MBP group after bowel preparation. Compared with the MBP group, surgical field visualisation was superior (92.45% vs. 78.85%), and the operation time was shorter (173.58 vs. 203.88 min) in the Non-MBP group. Patients undergoing MBP complained of bloating (82.35%), \u003c/p\u003e\u003cp\u003eunpleasant taste (78.43%), sleep disturbance (70.59%), nausea (68.63%), abdominal pain (64.71%), vomiting(45.10%), polydipsia (33.33%), dizziness (25.49%), and headache (7.84%).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eNon-MBP is more conducive to the recovery of postoperative gastrointestinal function after surgery of gynaecological malignant tumour.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration number: \u003c/strong\u003eChictr.org.cn.( ChiCTR2200059101).\u003c/p\u003e","manuscriptTitle":"Effect of non-mechanical bowel preparation on postoperative gastrointestinal recovery after surgery of gynaecological malignant tumours: A randomised controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-26 17:19:46","doi":"10.21203/rs.3.rs-1939829/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b52ed6d2-a71e-4bfc-9c9d-d5f19b021c3f","owner":[],"postedDate":"August 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-04T21:33:20+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-26 17:19:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1939829","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1939829","identity":"rs-1939829","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}