Mindfulness Meditation Reduces Stress and Hospital Stay in Gastrointestinal Tumor Patients During Perioperative Period

Abstract

Background

The study aims to explored the impact of short-term mindfulness meditation training on physiological and psychological stress levels in patients with gastrointestinal tumors during the perioperative period.

Material/Methods

We randomly allocated 78 participants to either the experimental group (n=39) or the control group (n=39). The control group received perioperative nursing, while the experimental group engaged in a daily mindfulness meditation practice from the second day of admission until the fifth day after surgery, excluding the day of surgery. The pre- and post-intervention physiological stress levels of serum cortisol, blood pressure, and heart rate were assessed. The State Anxiety Inventory Scale (SAI), Visual Analog Scale (VAS), and Five Facet Mindfulness Questionnaire (FFMQ) were utilized to measure psychological stress. The rehabilitation and additional indices were also observed.

Results

The serum cortisol and SAI in both groups showed an increasing trend on the 3^rd day after surgery, followed by a decreasing trend. On the 5^th day after surgery, significant reductions were observed in cortisol (t=−2.054, P=0.043) and VAS (t=−2.29, P=0.025). The experimental group exhibited lower levels of cortisol and SAI compared to the control group, while the FFMQ score gradually increased with intervention. Additionally, the experimental group demonstrated significantly shortened hospital stays (t=−3.157, P=0.002) and reduced requirements for postoperative analgesics.

Conclusions

Perioperative short-term mindfulness meditation can improve the mindfulness ability of patients with gastrointestinal tumors, relieve anxiety and tension, reduce serum cortisol, regulate blood pressure and heart rate, generally reduce perioperative psychological and physiological stress responses, and control hospital time and cost.

Introduction

Gastrointestinal cancers represent over a quarter of global cancer incidence and one-third of cancer deaths, markedly impacting China’s health burden [1,2]. These malignancies trigger significant psychological distress, including depression and anxiety, compounded by surgical stressors like fasting, anesthesia, pain, and reconstructive procedures [3–5]. Such conditions amplify perioperative stress, leading to neuroendocrine disturbances such as excessive cortisol, hypertension, and arrhythmias [6–8]. These disruptions can impair immune function and worsen physiological and psychological outcomes, underscoring the need for effective management of perioperative stress to enhance patient recovery and overall treatment success [9–11].

Introduced by Professor Kabat-Zinn in the 1980s, mindfulness involves non-judgmental awareness of the present, improving psychological outcomes and mental resilience [12–14]. It has been effectively used in managing chronic conditions like depression, hypertension, and cancer, showing benefits in reducing anxiety, depression, and pain, while possibly boosting immune function [15–17].

Recent studies [18,19] in gastrointestinal tumor patients showed that mindfulness during the perioperative period can mitigate physiological stress markers such as cortisol levels and blood pressure, supporting better surgical recovery and emotional stability [20–22]. The present study aimed to investigate the effectiveness of short-term mindfulness meditation in alleviating psychological and physiological stress levels among perioperative patients with gastrointestinal tumors. Addressing a critical gap in current research, this study focused on a patient group for whom prolonged mindfulness interventions are not feasible due to the rapid scheduling needs of tumor surgeries in China. We assessed whether a condensed mindfulness approach can significantly reduce stress markers such as cortisol and mitigate negative emotional states during the perioperative period, thus potentially enhancing patient recovery and affecting disease outcomes.

Material and Methods

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of Tongren Hospital, Shanghai (2022-099-02). All research involving human participants was conducted in compliance with the ethical guidelines of both the institutional and national research committees, adhering to the 1964 Helsinki Declaration and its subsequent updates. Informed consent was secured from all participants or their legal guardians prior to their inclusion in the study.

Consent for Publication

Written informed consent for publication was obtained from all patients and their families included in this analysis.

Sample Size Calculation

To define the minimum sample size, we selected 10 adult patients undergoing gastrointestinal tumor resection in our hospital, for a preliminary study based on serum cortisol difference, which is the primary endpoint of this RCT. Subsequently, we collected feedback to optimize the study plan. The mean difference in pre- and post-intervention serum cortisol levels in the experimental group was 15 μg/L (pre: 150.08±24.56 μg/L, post: 134.98±22.28 μg/L, n=10). For our sample size calculation, we used the average standard deviation of 23.42 μg/L. The sample size was calculated using PASS 15 software, with a group ratio n₁/n₂=1, α=0.05 (bilateral), and power (1-β) =0.8. Considering a 15% sample loss rate, we determined that at least 42 samples were needed in each group, totaling 84 adult patients.

Before any treatment was administered, patients or their family members provided informed consent and underwent screening based on the study’s inclusion criteria. The research design, objectives, and protocols were rigorously reviewed and approved by the ethics committee of our hospital, ensuring compliance with established guidelines and regulations. This study was conducted in strict accordance with the ethical standards of the Declaration of Helsinki for medical research involving human subjects. To safeguard participant privacy, all data were handled confidentially, and personal identifiers were removed from the dataset prior to analysis.

Participants

For this study, 84 patients undergoing gastrointestinal tumor resection in our hospital were recruited from December 2022 to July 2023. They were randomly assigned to the control and experimental group in a 1: 1 ratio. Randomized sequences were generated and determined by external individuals using SPSS software prior to participant recruitment.

Eligibility criteria

1. Age ≥18 years: Ensures participants are adults capable of giving informed consent.

2. Diagnosed with gastrointestinal tumors: Patients must have a confirmed diagnosis through CT, MRI scans, or histopathological examinations with surgical indications for tumor resection, ensuring the study focuses on the intended patient population.

3. Normal cognitive function and no hearing impairment: Essential to ensure participants can understand and comply with mindfulness meditation instructions. Cognitive function is assessed using the Mini-Mental State Examination (MMSE) with a cutoff score ≥ 24. Hearing was checked via basic audiological tests to ensure participants can hear instructions clearly.

4. No exposure to caffeine, nicotine, exercise, alcohol, and certain drugs before admission: These substances can affect physiological stress markers like cortisol and blood pressure, which are crucial for the study’s measurements.

Exclusion criteria

1. Mental and immune disorders: Includes psychosis, mania, PTSD, substance dependence, anxiety disorders, depression, HIV, rheumatoid arthritis, systemic lupus erythematosus, Addison’s, and Cushing’s diseases.

2. Serious infectious diseases or blood disorders: To avoid confounding effects on physiological stress measurements.

3. Tumor recurrence or previous other cancers: Patients with a history of other cancers or those with recurrent disease were excluded to maintain a homogeneous participant group regarding cancer stages and conditions.

4. Distant metastasis: Patients with confirmed distant metastases were excluded to ensure the homogeneity of the participant group in terms of cancer progression. However, patients with localized Stage IV tumors, eligible for surgical resection and without systemic metastasis, are included.

5. Recent preoperative treatment with certain drugs: Patients treated with chemoradiotherapy, antibiotics, or immunomodulatory drugs were excluded to avoid interference with the study’s primary endpoints.

6. Major stress events within the last 3 months: Such as death of a relative or divorce, excluded to minimize external psychological impacts on baseline stress levels.

7. Emergency surgery or severe postoperative complications: life-threatening events; organ failure; reoperations; ICU admission; deep surgical site infections and major thromboembolic events.

8. Participation in other studies or incomplete clinical data: Ensures that data collected are exclusively relevant to this study and its parameters.

9. Preoperative preparation time less than 3 days: Ensures sufficient time for participants to acclimate and prepare for pre-surgical assessments and interventions.

The study was reviewed and approved by the ethics committee of our hospital. All participants signed the written informed consent form.

Research Process

Composition of the Research Team

A research group was formed by a general surgeon (J. S.), a specialized head nurse in the field of general surgery (C. G), 2 nurses (X. W and Y. Y.), a psychological counselor proficient in mindfulness meditation techniques (Y. L.), and a graduate student with qualifications in psychological counseling (J. Z.). Task assignments and training were conducted before the start of the entire study.

Baseline assessment

After enrolling in this study, the baseline data of patients were collected on the day of admission, including detailed information on gender, age, height, body weight (calculated BMI), education degree, disease type, underlying disease, marriage, medical insurance, tumor stage, and surgical method (obtained from postoperative surgical records). Moreover, the patients were required to complete SAI, VAS, and FFMQ scale questionnaires, and we recorded their heart rate and basal blood pressure. At 8: 00 on the day following admission, a nurse collected a blood sample for the purpose of analyzing cortisol levels.

Mindfulness Intervention Group

After the basic information was collected, researchers provided participants in the experimental group with comprehensive instruction on mindfulness concepts, and precautions during mindfulness practice. They facilitated patients’ use of noise-canceling headphones to initiate participants’ mindfulness meditation experience, thereby fostering a deep understanding and mastery of its technical essentials.

The mindfulness sessions were structured around 2 main practices: 1) Participants were guided through a 10-minute session focusing on breath awareness. They were instructed to sit in a comfortable position, close their eyes, and pay attention to the sensation of their breath entering and exiting their nostrils, aiming to maintain this focus throughout the session; 2) Following the breathing exercise, a 20-minute body scan was conducted. Participants were guided to mentally scan their body from head to toe, observing any sensations, discomfort, or tension without trying to change these sensations. This practice encourages increased bodily awareness and relaxation.

The 2 patient groups engaged in question-and-answer discussions regarding the collaborative tasks and clarified what was unclear during hospitalization: 1) Adjustment of Meditation Scheduling: Initially, the mindfulness meditation sessions were planned without a fixed time, which participants found confusing and somewhat disruptive to their daily routine in the hospital setting. Based on feedback collected through structured interviews conducted immediately following the initial meditation sessions, we established a consistent daily schedule for the mindfulness sessions (from 12: 00 to 13: 00). This adjustment helped in minimizing interference with medical treatments and nursing operations, thereby enhancing participant compliance and reducing potential biases; 2) Introduction of Comfort Aids: Feedback from participants, gathered via short, anonymous satisfaction surveys after sessions, indicated that the hospital environment could be distracting during mindfulness practices. In response, we introduced noise-canceling headphones and blackout eye masks for use during sessions, which were not originally part of the intervention. These aids significantly improved the participants’ ability to concentrate and engage fully in the meditation process, as reported in subsequent feedback; 3) Feedback on Intervention Duration: Participant feedback suggested that the duration of the mindfulness intervention, initially planned for only the postoperative period, could be extended to include preoperative days. Reflecting on this feedback, which was analyzed from daily log entries by participants, we adjusted our protocol to include mindfulness practice starting 3 days before surgery. This modification aimed to provide more comprehensive support and potentially enhance the effectiveness of the intervention. Participants reported increased relaxation and preparedness for surgery, which we hypothesize can contribute to improved clinical outcomes (Table 1).

Table 1.

Planning process and measurement of meditation activities during hospitalization.

Date	Time	Intervention activity
Admission day		Patient education and baseline assessment were conducted by the investigator. Teach the patient the basics of mindfulness meditation and assist the patient in wearing noise-canceling headphones for a preliminary mindfulness meditation experience.
		Measure SAI, VAS, FFMQ
		Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
The second day of admission	8: 00	Blood sample collection
	12: 00	Measure heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure
The third day of admission	12: 00	Measure heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure; SAI, VAS, FFMQ
One day before surgery/ Day 4 of admission	8: 00	Blood sample collection
	12: 00	Measure heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure
Day 1 after surgery	8: 00	Blood sample collection
	12: 00	Measure SAI, VAS, FFMQ, heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure
2–4 days after surgery	12: 00	Measure heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure
Five days after surgery	8: 00	Blood sample collection
	12: 00	Measure heart rate and blood pressure
	12: 30	Practice mindfulness with 30 minutes of standardized guidance while wearing noise-canceling headphones
	13: 00	Measure heart rate and blood pressure; SAI, VAS, FFMQ

30 minutes of audio recorded by an experienced mindfulness meditation instructor. SAI – State Anxiety Inventory Scale; VAS – Visual Analog Scale; FFMQ – Five Facet Mindfulness Questionnaire.

Control group

The participants in the control group received standard care and routine treatment, followed by a prescribed period of extended rest synchronized with the experimental group. Variations in pre- and post-rest heart rate and blood pressure were assessed, relevant questionnaires were administered to participants, and blood samples were collected.

Observation Indicators

Physiological Evaluation Indexes

Blood specimen collection

Blood samples were collected from participants using a standard venipuncture technique. A trained phlebotomist drew a standardized volume of 2 ml peripheral venous blood from each participant at 8: 00 every alternate day. To minimize variability and ensure consistency, all blood draws were performed after participants had fasted overnight and avoided caffeine, nicotine, alcohol, and exercise for 12 hours prior to sampling.

Blood Pressure and Heart Rate Measurement

The blood pressure and heart rate of patients in the experimental group were measured and recorded daily both before and after the intervention. In the control group, measurements were taken at the same time each day after an equal period of rest. The measurements were conducted in a serene environment, and the patients rested for a minimum of 30 minutes to mitigate potential confounding factors, such as physical exertion and emotional agitation, that can hinder accurate blood pressure assessment.

Biological Assay

After collection, blood samples were immediately processed. They were centrifuged at 3000 r/min for 10 minutes at 4°C to separate the plasma. The supernatant was then carefully transferred into cryovials and stored at −80°C until analysis. This rapid processing and stringent storage condition were maintained to prevent degradation of biomarkers such as cortisol. Cortisol levels were measured using a solid-phase competitive enzyme-linked immunosorbent assay (ELISA) kit from Hangzhou Lianke Biotechnology Co., Ltd, Hangzhou, China, following the manufacturer’s instructions. All samples were analyzed in duplicates to ensure accuracy, and mean values were calculated for each data point.

Psychological Evaluation Indexes

Psychological evaluation indices were primarily assessed using 3 relevant scales: the Self-Assessment of Anxiety (SAI) scale, the Visual Analog Scale (VAS), and the Five Facet Mindfulness Questionnaire (FFMQ). These scales were employed to measure participants’ levels of anxiety, pain intensity, and mindfulness abilities at 4 different time periods: at admission, 1 day before surgery, the first day after surgery, and fifth day after surgery.

The State Anxiety Inventory Scale

The State Anxiety Inventory Scale (SAI) [23], proposed by Charles (1961–1966) and Spielberger (1966–1979) encompasses 4 dimensions: physiological, emotional, cognitive, and behavioral responses. It is primarily employed for the assessment of state anxiety in challenging circumstances. The current scale is widely employed in scientific research and clinical assessment, establishing itself as the criterion standard [23] for quantifying anxiety on a global scale, both domestically and internationally. The SAI is administered in a quiet setting and requires participants to respond to each item based on their current feelings. The scale consists of 20 items, with 10 items of positive emotions and 10 of negative emotions. Each item ranges from 1 (no) to 4 (very obvious). Scoring involves reversing 10 items, and the total score ranges from 20 to 80 points, where higher scores indicate more severe anxiety.

Visual Analog Scale

The Visual Analog Scale (VAS) [24] is a widely used single-dimensional tool for assessing pain intensity in patients. The VAS is administered by having the participant mark a point along a 10-cm line that represents their pain intensity, from ‘no pain’ to ‘extreme pain.’ The VAS scores are accurate, simple, and sensitive, with continuous value changes that can better reflect subtle shifts in pain levels and facilitate statistical analysis. Therefore, the VAS is the preferred method for measuring pain in both clinical settings [24] and scientific research.

Chinese version of the Five Facet Mindfulness Questionnaire

The Chinese version of the Five Facet Mindfulness Questionnaire (FFMQ) [25] is designed to assess individual mindfulness. The FFMQ is administered in a standardized manner where participants are required to rate each item from 1 (not at all) to 5 (completely), based on their usual way of experiencing and responding to feelings and thoughts. The scale covers 5 areas related to mindfulness: (1) Observation, noticing or paying attention to external and internal experiences; (2) Description, using words to describe the internal experience; (3) Acting consciously, focusing on current activities rather than mechanically; (4) Non-judgment of inner experience, taking a non-evaluative stance towards feelings and thoughts; (5) Non-response to inner experience, allowing feelings and thoughts to flow freely without being disturbed. The scale has 39 items, each rated on a scale of 1 (not at all) to 5 (completely), with a higher score indicating a higher level of mindfulness. FFMQ is widely utilized in mindfulness research.

Rehabilitation and Other Indicators

Rehabilitation outcomes and additional observational indices were carefully measured using standardized protocols to ensure accuracy and reproducibility. Specific measures included: 1) Time to First Postoperative Flatus: This was recorded as the duration from the completion of surgery until the patient first passed intestinal gas, indicating initial recovery of gastrointestinal function. Nurses monitored and documented this event using patient self-reports and clinical observations; 2) Length of Hospital Stay: The duration of each patient’s hospital stay was calculated from the date of admission to the date of discharge, using hospital administrative records; 3) Occurrence of Complications and Fever: Postoperative complications were documented by the attending surgeons and classified according to predefined clinical criteria. Fever was defined as a body temperature exceeding 37.3°C, measured with a digital thermometer twice daily during the hospital stay; 4) Postoperative Supplementary Analgesia Requirements: The use of additional analgesics, specifically the administration of tramadol (0.1 g IM), was recorded whenever a patient requested pain relief beyond the routine postoperative pain management protocol, which included 50mg of flurbiprofen axetil administered intravenously twice daily; 5) Hospitalization Costs: Total costs incurred during each patient’s stay were calculated by the hospital’s billing department, including costs associated with surgery, medication, room charges, and any additional treatments or procedures.

The duration from the completion of surgery until the patient awakens and passes intestinal gas for the first time was defined as the time of first postoperative flatus passage. Non-steroidal anti-inflammatory drugs (intravenous infusion of 50 mg flurbiprofen axetil twice daily for 3 days) were routinely employed for postoperative analgesia. In cases where analgesic efficacy is insufficient, patients require supplementary analgesics (0.1g tramadol IM.). The postoperative supplementary analgesic requirement in this study refers to the number of patients using tramadol. Postoperative fever was defined as a temperature exceeding 37.3°C.

Statistical Analysis

SPSS 26.0 software was utilized for all statistical analyses. We compared mean values of continuous variables such as cortisol levels, blood pressure, and heart rate between the control and experimental groups at baseline and specific time points after the intervention. This test was chosen due to its effectiveness in comparing means between 2 independent groups when the data is normally distributed. We analyzed changes in psychological scales (SAI, VAS, FFMQ) and physiological markers (serum cortisol, blood pressure, heart rate) over multiple time points within the same subjects. This test helps in assessing the time effect, group effect, and the interaction between time and group, which is crucial for studies with longitudinal measurements. Count data and non-normally distributed continuous variables provided a robust analysis method that does not assume normal distribution of the data. It is applied when the assumption of sphericity in repeated measures ANOVA was violated. This test is a multivariate criterion for testing the hypothesis about the effect of the independent variables on the multivariate dependent variables, offering a more general approach to handling violations of ANOVA assumptions. It is used to compare the before and after measurements within the same group, and is particularly useful for assessing the impact of our intervention on continuous variables within the experimental or control groups. Each statistical test was selected based on the data type, distribution, and the specific objectives of our analysis, ensuring that our results are robust and reliable. A significance level of P<0.05 was considered statistically significant for all tests.

Results

Participants’ Entry Into the Group

For this study, 84 adult patients undergoing gastrointestinal tumor resection were included. However, 6 participants were excluded due to specific reasons: 3 participants voluntarily withdrew from the study, citing personal reasons, and 3 were excluded due to serious postoperative surgical complications. Thus, 78 patients (92.8%) were randomly assigned to the experimental group (n=39) and control groups (n=39). The flow chart of participant progression is shown in Figure 1.

Figure 1.

Flow chart of patient recruitment. Diagram created using Microsoft Word, Office 365 (Microsoft Corporation, Redmond, WA, USA).

Baseline Data

The baseline characteristics of each sample group are presented in Table 2. No statistically significant differences were observed between the 2 groups to concerning gender, age, education level, BMI, disease type, underlying disease, tumor stage, and surgical method (P>0.05).

Table 2.

Baseline characteristics of the strategy by group (mindfulness and control).

Headcount (n=78)		Mindfulness (n=39)	Control (n=39)	P-value
Gender (%)	Male	18 (48.7)	22 (53.8)	0.375
	Female	21 (51.3)	17 (46.3)
Age (%)	<60 years old	10 (25.6)	8 (20.5)	0.502
	≥60 years old	29 (74.4)	31 (79.2)
BMI (%)	BMI <18.5 kg/m2	3 (7.7)	4 (10.2)	0.717
	18.5 kg/m2 ≤BMI <24 kg/m2	26 (66.7)	26 (66.7)
	24 kg/m2 ≤BMI <28 kg/m2	9 (23.0)	8 (20.5)
	BMI ≥28kg/m2	1 (2.6)	1 (2.6)
Degree of education (%)	Primary school education	8 (20.5)	6 (15.4)	0.230
	Junior high school degree	21 (53.8)	19 (48.7)
	High school or secondary school degree	10 (25.7)	13 (33.3)
	College degree or above	0 (0)	1 (2.6)
Background disease (%)	None	20 (51.3)	20 (51.3)
	Hypertension	11 (28.2)	7 (18.0)	0.224
	Diabetes	4 (10.2)	2 (5.1)
	Coronary heart disease	2 (5.1)	5 (12.8)
	Cerebral infarction	1 (2.6)	2 (5.1)
	Else	1 (2.6)	3 (7.7)
Type of operation (%)	Laparoscopic surgery	6 (19.5)	5 (6.3)	0.749
	Laparotomy	33 (80.5)	34 (92.7)
Type of disease (%)	Gastric cancer	8 (17.1)	10 (29.3)	0.76
	Colon cancer	20 (51.2)	15 (41.5)
	Carcinoma of the rectum	11 (31.7)	14 (29.3)
Staging and grading cancer (%)	Stage I	6 (21.9)	9 (14.7)	0.898
	Stage II	12 (29.3)	6 (17.1)
	Stage III	19 (43.9)	21 (60.9)
	Stage IV	2 (4.9)	3 (7.3)
Marital status (%)	Married	39 (100)	39 (100)	1
Medical insurance type (%)	Possess	28 (71.8)	28 (71.8)	1
	None	11 (28.2)	11 (28.2)

P-value for the between-group comparison at baseline. BMI – body mass index.

ANOVA for Repeated Measurement

In our analysis, repeated measures ANOVA was utilized to assess the effects of time (within-subjects factor) and group (between-subjects factor) on perioperative serum cortisol concentration, blood pressure, heart rate, and psychological stress indices (SAI, VAS, and FFMQ). The specific factors included:

Time

Measured at 5 levels corresponding to different time points in the perioperative period (upon admission, one day before surgery, the first day after surgery, the third day after surgery, and the fifth day after surgery).

Group

Two levels, experimental and control.

The interaction effects between time and group were also explored to determine if changes over time differed significantly between the 2 groups. This detailed breakdown aims to provide a thorough understanding of how and why these variables fluctuate over time and between groups. The results showed that there was no significant interaction among the indices, except FFMQ (P<0.05).

Cortisol

Cortisol levels were monitored at 5 time points around the surgery. As depicted in Figure 2, both groups initially showed an increase in cortisol, peaking on the third day after surgery, then decreasing. The experimental group’s decrease on the fifth day after surgery was significantly greater than that of the control group (P=0.043), highlighting the effectiveness of the intervention in reducing stress. No overall significant group difference was observed across the time points (F=1.503, P=0.224) (Table 3).

Figure 2.

Changes of perioperative cortisol level. T0 – the second day in the hospital; T1 – 1 day before surgery, T2 – the first day after surgery, T3 – the third day after surgery, T4 – the 5^th day after surgery. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Table 3.

Comparison of cortisol levels at different time points in the perioperative period between the 2 groups (Mean±SD) (μg/L).

Time	Mindfulness (n=39)	Control (n=39)	t-value	P-value
the second day of admission	107.93±40.94	106.46±46.28	−0.149	0.882
One day before surgery	113.69±35.32	116.07±45.14	−0.264	0.792
The first day after surgery	127.72±51.67	136.43±63.40	−0.666	0.508
The third day after surgery	144.58±36.31	151.55±60.01	−0.621	0.537
The fifth day after surgery	120.38±35.78	139.95±47.54	−2.054	0.043
Ftime	7.013			0.001
Fgroup	1.503			0.224
Ftime*group	0.686			0.604

1. Repeated measurement ANOVA was used at different time points between the groups, and the covariance of the measured values at different time points met the H-type hypothesis without correction. The results of multivariate analysis of variants of Pillai’s Trace were not satisfied with the H-type hypothesis. 2. Comparison of differences at the same time point between groups was performed by independent sample t test, represented by (Mean±SD).

Changes of blood pressure and heart rate

Significant reductions were observed in heart rate (F=121.467, P=0.001) (Table 4) and systolic blood pressure (F=23.376, P=0.001) in the experimental group after the intervention, as shown in Figures 3 and 4. Conversely, diastolic blood pressure remained stable across both groups (Figure 5). In contrast, the control group exhibited no significant changes in heart rate or blood pressure, confirming the differential impact of the intervention.

Table 4.

Comparison of perioperative blood pressure and heart rate between the 2 groups before and after each intervention.

Index	Group	Time	Pre-intervention (Mean ± SD)	Post-intervention (Mean ± SD)	Difference value (Mean ± SD)	t-value	P-value	Ftime	Fgroup	Ftime*group
			mmHg	mmHg	mmHg
SP	Mindfulness	The second day of admission	137.85±15.9	125.74±15.33	−12.11±8.35	9.501	0.001	F=2.085 P=0.057	F=121.467 P=0.001	F=0.150 P=0.114
		The third day of admission	129.31±13.23	119.92±13.03	−9.39±6.54	8.956	0.001
		One day before surgery	131.08±23.05	122.67±21.45	−8.41±9.52	5.517	0.001
		The first day after surgery	131.92±15.80	121.77±19.52	−10.15±17.09	3.711	0.001
		The second day after surgery	132.08±15.41	123.26±13.96	−8.82±8.60	6.401	0.001
		The third day after surgery	131.69±14.64	126.28±17.79	−5.41±8.89	3.799	0.001
		Four days after surgery	130.72±12.64	123.21±13.71	−7.51±5.87	7.998	0.001
		The fifth day after surgery	131.69±14.64	125.67±13.63	−6.02±13.91	2.706	0.001
	Control	The second day of admission	128.33±17.83	129.74±17.48	1.41±12.17	−0.724	0.474
		The third day of admission	125.31±16.18	124.77±16.07	−0.54±5.56	0.605	0.549
		One day before surgery	125.00±18.19	122.69±15.92	−2.31±16.26	1.004	0.322
		The first day after surgery	128.13±18.83	130.18±19.37	2.05±9.15	−1.4	0.17
		The second day after surgery	126.27±13.61	124.77±16.06	−1.47±18.02	0.515	0.609
		The third day after surgery	127.69±14.15	128.53±15.70	0.84±9.69	0.549	0.589
		Four days after surgery	124.82±14.90	128.97±15.05	4.15±10.81	−2.399	0.021
		The fifth day after surgery	128.60±13.21	128.72±13.24	0.12±10.78	−0.594	0.556
DP	Mindfulness	The second day of admission	82.03±12.13	80.64±12.12	−1.38±8.19	3.309	0.298	F=0.970 P=0.460	F=1.120 P=0.293	F=1.751 P=0.111
		The third day of admission	77.43±9.19	76.74±8.77	−0.69±6.38	5.001	0.502
		One day before surgery	75.97±9.51	75.05±8.61	−0.92±5.39	3.382	0.292
		The first day after surgery	77.00±10.38	76.62±10.61	−0.38±5.95	3.555	0.688
		The second day after surgery	76.59±9.81	74.41±10.16	−2.18±6.82	1.996	0.053
		The third day after surgery	78.89±9.14	78.08±9.71	−0.82±4.09	4.3	0.219
		Four days after surgery	78.08±10.63	77.56±10.69	−0.51±4.63	3.391	0.493
		The fifth day after surgery	78.07±10.63	75.62±9.39	−2.46±5.69	2.902	0.01
	Control	The second day of admission	74.85±10.07	76.54±10.54	1.69±1.42	−1.189	0.242
		The third day of admission	74.38±9.26	75.10±8.78	0.718±1.05	0.684	0.498
		One day before surgery	72.28±9.13	75.46±10.79	1.51±0.83	1.829	0.075
		The first day after surgery	75.46±10.79	75.56±9.31	0.10±1.08	−0.095	0.952
		The second day after surgery	73.56±9.72	73.18±8.50	−0.385±1.26	0.305	0.762
		The third day after surgery	74.54±8.32	74.69±8.57	0.15±1.23	−0.125	0.901
		Four days after surgery	72.59±8.44	73.28±8.22	0.690±1.06	−0.653	0.518
		The fifth day after surgery	72.59±8.45	72.00±7.19	−0.59±1.06	0.553	0.584
HR	Mindfulness	The second day of admission	71.33±16.98	67.18±10.86	−4.15±13.85	1.873	0.069	F=0.699 P=0.673	F=23.376 P=0.001	F=0.515 P=0.820
		The third day of admission	73.41±13.98	66.92±13.06	−6.49±9.08	4.464	0.001
		One day before surgery	73.03±11.45	70.28±11.11	−2.74±4.62	3.712	0.001
		The first day after surgery	79.26±12.65	74.82±13.88	−4.44±7.20	3.848	0.001
		The second day after surgery	82.41±14.50	75.37±14.98	−6.46±7.85	5.138	0.001
		The third day after surgery	80.33±14.32	75.05±13.69	−5.18±8.10	3.994	0.001
		Four days after surgery	78.85±12.37	73.69±11.81	−5.15±11.06	2.91	0.006
	Control	The fifth day after surgery	78.79±9.46	73.33±9.59	−5.46±7.45	4.575	0.001
		The second day of admission	77.64±1.63	76.69±1.42	−0.95±12.91	0.459	0.649
		The third day of admission	74.95±2.12	74.13±1.92	−0.82±7.98	0.642	0.524
		One day before surgery	73.44±1.58	74.51±1.75	1.08±9.21	−0.73	0.47
		The first day after surgery	76.69±1.42	76.59±1.51	−0.10±5.73	0.112	0.912
		The second day after surgery	75.74±1.44	75.49±1.51	−0.26±4.46	0.359	0.721
		The third day after surgery	77.62±1.83	78.31±1.73	0.69±6.59	−0.656	0.515
		Four days after surgery	75.18±1.26	76.69±1.35	1.51±5.12	−1.844	0.073
		The fifth day after surgery	76.21±1.40	75.10±1.32	−1.10±5.43	1.269	0.212

1. SP – systolic blood pressure; DP – diastolic blood pressure; HR – heart rate. 2. Blood pressure and heart rate before and after intervention were expressed by (Mean±SD). 3. Systolic blood pressure difference = (systolic blood pressure after intervention - systolic blood pressure before intervention); Diastolic pressure difference = (diastolic pressure after intervention - diastolic pressure before intervention); Heart rate difference = (heart rate after intervention - heart rate before intervention). 4. If the difference is positive, the corresponding index increases after intervention; if the difference is negative, the corresponding index decreases after intervention. 5. The difference between groups was tested by paired sample t test.

Figure 3.

Systolic blood pressure of the 2 groups changes before and after intervention. Pre – before intervention; Post – post-intervention. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Figure 4.

The heart rate of the 2 groups changes before and after intervention. Pre – before intervention; Post – post-intervention. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Figure 5.

Diastolic blood pressure of the 2 groups changes before and after intervention. Pre – before intervention; Post – post-intervention. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Analysis of SAI, VAS, and FFMQ

Repeated measures ANOVA showed that SAI, VAS, and FFMQ were significantly different between the 2 groups at different times (F=16.675, P=0.001; F=486.076, P=0.001; F=32.709, P=0.001 for SAI, VAS, and FFMQ, respectively) (Table 5). We observed that the SAI scores increased and then decreased with the intervention in both groups (Figure 6), and the SAI scores of the experimental group at each time point were lower than those of the control group. With the increasing number of interventions, the mindfulness ability tended to improve in the experimental group, and the FFMQ scores of the experimental group at each time point were higher than those of the control group (p=0.001,). In contrast, FFMQ did not change significantly with time in the control group. In addition, the VAS showed significant differences between the groups only on the 5^th day after the operation (Figure 7).

Table 5.

Comparison of psychological stress response at different time points in the perioperative period between 2 groups (Mean±SD).

Scale type	Group	Admission day	One day before surgery	The first day after surgery	The fifth day after surgery	Ftime	Fgroup	Ftime*group
SAI score	Mindfulness	31.70±7.75	36.69±7.04	37.13±12.02	31.69±8.82	16.675	2.780	2.555
	Control	34.54±8.56	45.03±9.12	42.10±8.29	34.08±8.58
	t-value	−1.539	−4.516	−2.128	−1.120
	P-value	0.128	0.001	0.037	0.230	0.001	0.073	0.062
VAS score	Mindfulness	0.85±1.50	0.74±1.35	5.77±1.35	1.13±0.92	486.076	0.555	1.743
	Control	0.92±1.31	0.82±1.52	5.87±1.24	1.72±1.32
	t-value	−0.242	−0.236	−0.350	−2.290
	P-value	0.809	0.814	0.727	0.025	0.001	0.458	0.159
FFMQ score	Mindfulness	116.95±11.57	121.51±11.58	121.67±12.12	143.46±12.11	32.709	34.94	33.084
	Control	116.00±10.11	114.18±11.11	117.53±8.91	115.85±9.52
	t-value	0.386	2.853	1.710	11.193
	P-value	0.701	0.006	0.097	0.001	0.001	0.001	0.001

Repeated measurement ANOVA was used at different time points between the groups, and the covariance of the measured values at different time points met the H-type hypothesis without correction. The results of multivariate analysis of variants of Pillai’s Trace were not satisfied with the H-type hypothesis. SAI –State Anxiety Inventory Scale; VAS – Visual Analog Scale; FFMQ – Five Facet Mindfulness Questionnaire.

Figure 6.

Changes of perioperative anxiety level. T0 – the second day in the hospital; T1 – 1 day before surgery, T2 – the first day after surgery, T3 – the 5^th day after surgery. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Figure 7.

Changes in perioperative pain level. T0 – the second day in the hospital; T1 – 1 day before surgery, T2 – the first day after surgery, T3 – the 5^th day after surgery. Statistical analysis performed and figure created using SPSS 26.0 software (IBM Corp., Armonk, NY, USA).

Comparative Analysis of Rehabilitation and other Indices

The results demonstrate a significant reduction in length of hospital stay (t=−3.157, P=0.002) and postoperative supplementary analgesic requirements (t=−2.039, P=0.045) in the experimental group compared to the control group (Table 6). Although no statistically significant differences were found, the experimental group still exhibited better results for time to first postoperative flatus, postoperative complications, postoperative fever, and hospitalization costs compared to the control group.

Table 6.

Comparison of rehabilitation indexes and other additional measures between the 2 groups.

	indexes	Mindfulness (n=39)	Control (n=39)	t/χ2-value	P-value
Rehabilitation index	First exhaust time (h)1	34.54±15.80	37.64±19.69	−0.748	0.457
	Length of hospital stay (d)1	9.21±3.11	11.62±3.62	−3.157	0.002
	Postoperative fever(%)3	3 (7.6)	7 (17.9)		0.310
	Total febrile duration(h)1	1.67±4.64	2.67±9.46	−0.593	0.555
	Pre-operation	3.48±1.57	3.66±1.63	−0.496	0.622
	Post-operation	5.33±1.63	6.87±3.00	−2.814	0.006
Additional observations	Complication (%)3	1 (2.5)	2 (5.1)		1.000
	Postoperative analgesia requirements(%)2	5 (12.82)	11 (28.2)	2.831	0.160
	Hospitalization costs (yuan)1	67139.02±20964.3	88793.63±107031.19	−1.24	0.219

1. “1” means using the independent sample t test; “2” means using the chi-square test; “3” means using Fisher exact test. 2. “h” means hour; “d” means number of days.

Discussion

Mindfulness meditation, extensively studied in neuroscience and psychology, holds promise for surgical applications, particularly in managing perioperative stress in gastrointestinal tumor patients. Studies like those by Emanuel et al and Hanley support mindfulness as a feasible adjunctive tool for surgical settings, anticipating significant benefits in stress management and patient recovery. Our study specifically addresses the gap in applying short-term mindfulness interventions in such high-stakes environments. We found that even brief mindfulness training could significantly alleviate physiological and psychological stress, thus reducing hospital stay durations and associated costs. This finding underscores the importance of adapting mindfulness techniques to fit the surgical timeline, potentially enhancing patient outcomes by mitigating the harmful effects of prolonged stress responses like increased blood pressure, suppressed immune function, and exacerbated organ strain during the perioperative period.

This study introduces significant novelties in the application of short-term mindfulness interventions to manage perioperative stress in patients undergoing gastrointestinal tumor resection. By demonstrating that brief mindfulness practices can significantly reduce serum cortisol levels and improve psychological stress markers (SAI, VAS, and FFMQ scores), our research highlights the clinical viability of incorporating mindfulness into the perioperative care regimen. The innovative aspect of condensing mindfulness training to suit the surgical schedule addresses a critical gap in perioperative patient care. Clinically, this approach offers a non-pharmacological method to enhance patient outcomes, potentially reducing postoperative complications and shortening hospital stays. These findings suggest that even limited-duration mindfulness interventions could substantially benefit patients facing high-stress surgical environments, providing a scalable and cost-effective adjunct therapy in surgical settings.

This study highlights the significant benefits of short-term mindfulness meditation in reducing hospital stay durations and associated costs for patients undergoing gastrointestinal tumor surgery. The experimental group, which underwent mindfulness training, had a notable decrease in total hospitalization time compared to the control group (9.21±3.11 vs 11.62±3.62 days, P=0.002), with no significant difference in preoperative stays but a substantial reduction postoperatively (5.33±1.63 vs 6.87±3.00 days, P<0.010). This reduction underscores the intervention’s cost-effectiveness, aligning with systematic reviews indicating mindfulness as a financially viable clinical strategy. Statistically, mindfulness intervention significantly lowered serum cortisol levels (120.38±35.78 vs 139.95±47.54, P<0.043) and improved mindfulness scores (143.46±12.11 vs 116.95±11.57), demonstrating its efficacy in managing physiological and psychological stress during the perioperative period. These results are consistent with earlier findings that show short-term mindfulness interventions can swiftly affect stress indicators postoperatively, contributing to shorter hospital stays. The experimental group also had lower demands for supplementary analgesics compared to controls (5±12.82% vs 11±28.2%, P=0.045), suggesting an additional benefit in managing postoperative pain. This finding is particularly relevant as it indicates that even brief mindfulness interventions can mitigate acute perioperative pain, potentially reducing the need for additional pain management. These findings show the possible benefit of integrating mindfulness practices into perioperative care, emphasizing their role in enhancing patient recovery and reducing healthcare resource utilization. Future studies should explore optimizing the frequency and duration of mindfulness interventions to maximize clinical benefits.

Recent related articles have inspired and shaped our research. Dave et al [26] discussed the benefits of mindfulness in gastroenterology, underscoring its efficacy in enhancing well-being and patient care, akin to our findings on its impact during the perioperative phase. Our research extends these insights by quantitatively demonstrating how short-term mindfulness interventions reduce stress markers and enhance postoperative recovery in gastrointestinal surgery patients. Hymowitz et al [27] review the broader applications of mindfulness-based interventions (MBIs) to improve postoperative outcomes, corroborating our results and emphasizing the potential of MBIs to optimize patient recovery and satisfaction. Benchimol-Elkaim et al [28] explored an innovative VR-based approach to reduce pediatric perioperative anxiety. Although targeting a different demographic with technology-enhanced mindfulness, their work highlights the adaptability of MBIs across various surgical contexts. Our study contributes by focusing on adult patients with gastrointestinal tumors, showing that even traditional, short-term mindfulness practices can significantly mitigate stress and improve clinical outcomes without advanced technological interventions.

Riegner et al [29] applied thermal stimulation (49°C) to the lower extremities of 40 participants to induce a sensation of burning. After 4 separate 20-minute sessions of mindfulness training, the group practicing mindfulness reported a significant reduction of 32% in pain intensity and a corresponding decrease of 33% in the unpleasantness of pain. Reiner et al [30] conducted a similar experiment to that of Riegner et al, while Garland et al [31] demonstrated that administering a single 15-minute mindfulness exercise in a hospital setting immediately reduced acute pain intensity by 30%. Although there are slight variations in the types and intensity of pain induced above, these findings support our study’s conclusions by providing evidence that mindfulness can alleviate acute pain [32,33]. This effect may be attributed to activating cortical regions like the orbitofrontal cortex and right anterior insula that regulate pain perception, evaluation, cognition, and emotional response, thus enhancing patients’ ability to coexist harmoniously with their pain [34]. Alternatively, mindfulness intervention might stimulate parasympathetic nerve activity within the autonomic nervous system, which helps mitigate unpleasant sensations associated with pain, leading to its ultimate relief. Although we still lack a clear understanding of the precise biological mechanism behind the analgesic effects of mindfulness training, conducting more comprehensive clinical studies will provide compelling evidence for optimizing strategies and provide patients with enhanced care and improved treatment outcomes [35].

This study is limited by its small, single-center sample, potentially introducing selection bias and reducing the generalizability of our findings. The lack of blinding and the absence of long-term follow-up further limit the conclusiveness of our results. We did not examine the effects of mindfulness on perioperative complications or long-term disease outcomes. Additionally, intraoperative adverse events and mild postoperative complications, such as superficial surgical site infections, could affect postoperative cortisol levels. These factors, which were not controlled for in our analysis, could have influenced the study results and introduce additional biases. There is a need for multi-center trials with refined exclusion criteria, including controls for hypertension and medication effects on heart rate. Implementing a blinded design, considering intraoperative factors like bleeding and surgery duration, and incorporating long-term follow-ups will enhance our understanding of mindfulness’s impact on perioperative stress and patient outcomes.

Conclusions

Our hypothesis that short-term mindfulness meditation alleviates perioperative stress reaction in patients with gastrointestinal cancer is supported by the results of the study. It can not only enhance mental health by lessening perioperative anxiety, but also by reducing cortisol concentration, a sensitive indicator of stress, and reducing systolic blood pressure and heart rate to achieve the effect of alleviating stress levels and improving the mindfulness ability of the patient. Additionally, it alleviates postoperative pain, reduces the need for analgesic drugs, promotes patient rehabilitation after surgery, and shortens hospital stay.