Abstract
Background and Aims:
As gynaecological laparoscopic minimally invasive surgery continues to advance, it becomes essential to explore how inhalation anaesthesia and intravenous anaesthesia affect the recovery of gastrointestinal function after surgery. The objective was to compare the effects of total intravenous anaesthesia (TIVA) and inhalation anaesthesia on the time of the first defecation and the time of consuming solid food for patients following laparoscopic total hysterectomy.
Methods:
This research involved 134 female participants aged 18–65 years, classified as American Society of Anesthesiologists physical status I–II, who were scheduled to undergo elective laparoscopic hysterectomy procedures. Participants were randomly allocated into two cohorts: one receiving TIVA (Group P) (underwent TIVA induction with propofol, remifentanil, and rocuronium administration, supplemented by ongoing administration of propofol-remifentanil infusions), and the other group was administered inhalational anaesthesia (Group S) (using sevoflurane delivered through precise tidal volume ventilation alongside rocuronium, with maintenance achieved through combined sevoflurane inhalation and remifentanil infusion). The primary outcome was the time to initial defecation and tolerance of solid food (SF + D), while the final outcome was determined by the longer duration required to achieve these two outcomes. The I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) score, the numeric rating scale score for pain, and the numeric rating scale score for postoperative nausea and vomiting, the time to first flatus, gastric antral motility index, and intestinal peristalsis rate within 1 minute determined by bedside ultrasound were also recorded.
Results:
The mean to first defecation + hard food tolerance (SF + D) was 51 [standard deviation (SD: 8.47)] in Group S and 47 (SD: 9.45) in Group P (P = 0.02), and the mean difference between the groups was − 4.46 (95% CI: 0.20, 7.00). None of the I-FEED scores were statistically significant (P = 0.074, Z = −1.79). Patients in Group P experienced superior analgesic effects and more stable haemodynamics.
Conclusion:
The postoperative recovery of gastrointestinal function can be enhanced by employing total intravenous anaesthesia instead of inhalation anaesthesia.
Keywords: Anaesthesia, defecation, food tolerance, gastrointestinal motility, hysterectomy, I-FEED, inhalation, intravenous, laparoscopy, sevoflurane, volatile agent
INTRODUCTION
Most hysterectomy procedures are performed using laparoscopic techniques, which effectively minimise intraoperative blood loss, alleviate postoperative discomfort, and reduce hospitalisation duration.[1] However, changes in patient position during surgery and the introduction of artificial pneumoperitoneum can impact inhibitory neuronal reflexes involving adrenergic and noradrenergic pathways, leading to intestinal oedema caused by excessive intravascular fluid volume.[2,3,4] A recent study showed that the rate of postoperative gastrointestinal dysfunction (POGD) after laparoscopic gynaecological surgery was 7.8%, and anaesthesia was an independent risk factor.[5] POGD encompasses manifestations such as queasiness and retching, swelling of the belly, aversion to oral intake, and suboptimal gastrointestinal motility and elimination that arise due to surgical and anaesthetic factors.[6,7] Two prominent techniques for general anaesthesia include total intravenous anaesthesia (TIVA) and inhalation anaesthesia. Propofol and sevoflurane have been the dominant anaesthetics in clinical use for the past two decades, and they are representative drugs for intravenous anaesthesia and inhalation anaesthesia, respectively.[8]
We investigated the effects of two different anaesthetic methods on POGD following laparoscopic total hysterectomy. We designed this randomised controlled trial (RCT) to compare the effects of TIVA versus inhaled anaesthesia on gastrointestinal recovery after laparoscopic total hysterectomy. The primary objective was to evaluate postoperative first defecation + hard food tolerance (SF + D) values. Secondary objectives included assessment of I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) values, time to first flatus, and gastrointestinal motility index measured by ultrasound. We hypothesised that patients who received TIVA would have faster recovery of gastrointestinal function after surgery than those who received inhaled anaesthesia.
METHODS
This single-blind RCT was executed from September to December 2023. This study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2300075491; dated 6 September 2023) (https://www.chictr.org.cn/showproj.html?proj=200867). This study obtained ethical clearance (approval code: XYFY2023-KL089-01) from the Institutional Review Board at Xuzhou Medical University’s Affiliated Hospital, dated 18 May 2023. Following receipt of signed consent forms from all subjects who permitted their clinical information to be used for academic analysis, the trial’s execution adhered to CONSORT protocol requirements for reporting RCTs. The study was carried out in compliance with the principles outlined in the Declaration of Helsinki (2013) and adhered to Good Clinical Practice guidelines.
The inclusion criteria included female patients aged 19–65 years, with a body mass index (BMI) of 18–27 kg/m2 and American Society of Anesthesiologists (ASA) physical status I–II. Exclusion criteria were allergies to narcotic medications, alcohol abuse or neuropsychiatric disorder, chronic use of hypnotics and sedatives, opioid misuse, haemoglobin level < 9.0 mg/dL, cardiopulmonary dysfunction, known gastrointestinal dysfunction, and liver and kidney impairment. The study also excluded patients in cases with a change in the surgical approach, transfer to the intensive care unit (ICU), or if the patient remained intubated after surgery.
Each participant was assigned to either Group P or Group S in a 1:1 ratio using an online randomisation tool at www.randomization.com. The allocation process followed a block size of 6. At the time of anaesthesia induction, the primary anaesthesiologist, unaware of the group assignments, opened the sealed opaque envelopes and prepared the necessary medication. The outcome assessors, data collectors, and statisticians were unaware of the group allocations, did not participate in any anaesthesia or surgical procedures, and did not discuss treatment specifics with the participants.
All surgical procedures commenced at 8:00 AM, with participants having to abstain from food for 8 hours and drink for 4 hours. Continuous monitoring was conducted in the operating room, including heart rate (HR), electrocardiogram (ECG) parameters, pulse oxygen saturation (SpO2), upper-limb blood pressure (MBP), and anaesthesia index (Ai, Pearl care Anaesthesia Depth Monitor, Con-view YY-105, Zhejiang Yiyang Medical Technology Co., Ltd.). After establishing intravenous (IV) access, IV dexmedetomidine was administered at 1 μg/kg/min, while 100% oxygen was delivered via mask at an oxygen flow rate of 6–7 L/min. After 10 minutes, the dexmedetomidine infusion was stopped, and anaesthesia induction began. In Group P, anaesthesia was induced with IV fentanyl (4 μg/kg), propofol (2 mg/kg), and rocuronium (0.6 mg/kg). Anaesthesia was maintained with IV remifentanil infusion (0.1–0.3 μg/kg/min) and propofol (3–6 mg/kg/h). In Group S, anaesthesia was induced with sevoflurane (6%–8%) and IV rocuronium (0.6 mg/kg). Anaesthesia was maintained with sevoflurane within the range of 1.5%–2.5% dial concentration and IV infusion of remifentanil at a rate of 0.1–0.3 μg/kg/min. Assisted ventilation was provided to both groups after loss of consciousness and eyelash reflexes; tracheal intubation occurred when the Ai value dropped below 60. The ventilator was operated in the volume control ventilation mode with an inspiratory oxygen flow rate of 2 L/min, respiratory rate of 10–15 breaths/min, tidal volume of 8–10 mL/kg, and partial pressure of carbon dioxide in end-expiratory gas (PETCO2) of 35–45 mmHg. The pneumoperitoneum pressure ranged from 9 to 14 mmHg. Temperature protection and monitoring were maintained throughout the procedure. The Anaesthesia Index (Ai) was maintained within a range of 40–60, and the blood pressure within a range of 100%±20% of its initial value. IV ephedrine (3 mg) or phenylephrine (40 μg) was administered if blood pressure dropped below 30% of baseline, based on heart rate. IV urapidil (5 mg) was administered if blood pressure exceeded 30% of the baseline value. IV atropine (0.5 mg) was administered if the heart rate fell below 50 beats per minute; IV esmolol (1 mg/kg) was administered when the heart rate was 30% above baseline, as needed. IV flurbiprofen axetil (50 mg) was administered 15 minutes before surgery concluded. The administration of medications through IV and inhalation routes stopped 5 minutes before the end of the surgical procedure. The flow rate of oxygen for inspiration was set to 6 L/min at the end of surgery. Patients were then transferred to the post-anaesthesia care unit (PACU) for recovery and extubation following routine administration of IV neostigmine and atropine antagonists unless contraindicated. Extubation after a clear judgment of the patient’s ability to protect and maintain airway patency. Recovery from anaesthesia was evaluated using the Stewart sedation score 3 minutes after extubation.
Postoperatively, patients received patient-controlled intravenous analgesia (PCIA), with a continuous infusion of dexmedetomidine at a rate of 0.1 µg/kg/h and flurbiprofen axetil a dose of 6 mg/kg/h in a total volume of 100 mL. Initially, no loading dose was administered, with a continuous infusion rate of 2 mL/h. Each patient-controlled dosage comprised 0.5 mL and had a lockout interval of 15 minutes. Patients were recommended to activate the patient-controlled button when their numeric rating scale score for pain (NRS) score reached ≥4. If pain persisted after three consecutive effective activations, rescue analgesic methods involved intravenous administration of flurbiprofen or tramadol.
The primary outcome was the time to initial defecation and tolerance towards solid food (SF+D). In contrast, the outcome was determined by the longer duration required to achieve these two outcomes. For example, if the first defecation time is a hour and the first solid food intake time is b hours (a > b), the final result is a hours, and vice versa. The definition of solid foods and non-solid foods was referred to the consensus of nutrition experts.[8] Secondary outcome measures included the I-FEED score (intake, feeling nauseated, emesis, physical examination, and duration of symptom manifestation) scoring system. The numeric rating scale score for postoperative nausea and vomiting score (PONV) (0 = no symptoms, 10 = worst imaginable nausea and vomiting), the NRS (0 = no pain, 10 = worst imaginable pain) were calculated at 8, 24, 48, and 72 hours, and at 7 and 30 days. Frequency of intestinal peristalsis in one minute and gastric antral motility index) (MI) (MI = Amplitude of antral contraction*Frequency of contraction) was measured at 24 and 48 hours by bedside ultrasound [Figure 1]. MI > 0.8 indicates normal gastrointestinal motility, 0.4 < MI <=0.8 suggests decreased gastrointestinal motility, and MI <=0.4 indicates impaired gastrointestinal motility. The time to first flatus passage was also recorded.
Figure 1.
Antral motility index calculated under ultrasound. Figure ① shows the surface localisation of the gastric antrum area calculated. Figure ② illustrates the surface localisation of the colonic peristalsis rate, sliding downward after positioning the left costal margin. Figure ③ shows the ultrasound image of the gastric antrum area measurement; L represents the left liver, A represents the abdominal aorta, and S represents the gastric antrum. Figure ④ shows the ultrasound method used to measure the size of the gastric antrum. Finally, Figure ⑤ shows the colonic pocket; H = left hemicolon
The patient’s demographic characteristics (age, height, weight, and education), nutritional status, and surgical history (including abdominal surgery and caesarean sections) were recorded before surgery. Vital signs (heart rate, blood pressure, pulse oxygen) were recorded at various time points: before induction (T0), 3 minutes after intubation (T1), 5 minutes after postural change (T2), 10 minutes after postural change (T3), 30 minutes after postural change (T4), at the end of operation (T5), and the exit point from PACU (T6). Furthermore, various parameters were recorded, including surgery and anaesthesia duration, extubation time, length of stay in the PACU, consumption of remifentanil, propofol, and sevoflurane, volume of vasoactive drugs used, blood loss, and Steward sedation score post-extubation. All data were collected in the operating room, PACU, and ward.
The study sample size was determined using PASS 15.0 (NCSS, LLC, Kaysville, USA). Drawing from the findings of the preliminary experiment, the average duration of solid food and defecation (SF + D) after intravenous propofol administration was calculated to be 48.01 hours, with a standard deviation (SD) of 5.10. The mean duration of SF + D in the sevoflurane inhalation group was 50.81 hours. Considering an alpha level of 0.05 and a power (1− β) of 0.8, it was determined that each group would require 60 patients, maintaining a ratio of 1:1 between groups. However, accounting for a potential dropout rate of 10%, approximately 67 patients per group would be needed, resulting in an overall requirement of approximately 134 patients.
The statistical analysis was performed using the SPSS® 27.0 software (IBM Corp, Armonk, NY, USA). The Kolmogorov-Smirnov normality test and Levene’s variance homogeneity evaluation were implemented sequentially. Normally distributed quantitative variables were presented as mean (SD). Statistical comparisons between the two groups (SF+D) were conducted using an independent-samples t-test. A two-factor repeated measures analysis of variance was employed to compare differences between the two groups at various time points. In contrast, a one-factor repeated measures analysis of variance was utilised to assess changes within the same group across different time points (MBP). Quantitative data not following a normal distribution were presented as median (M) with the interquartile range (IQR). Differences between the two groups were analysed using the Mann-Whitney U test [initial emission time, baseline data (age and BMI), anaesthesia time, draw-tube time, and PACU-stay time)], data of the operation (amount of remifentanil, liquid infusion, blood loss, urine, number of PCIA activation, and remedial pain relief). Generalised estimating equation (GEE) were used for comparing the two groups at different time points (NRS, PONV score, MI, intestinal peristalsis rate). Enumeration data were expressed as percentages (%) and analysed through the Chi-square test or Fisher’s exact test [baseline data (history of abdominal surgery, history of caesarean section, abdominal adhesion, and history of dysmenorrhea) and intraoperative data (use of vasoactive agents)]. P value < 0.05 indicated statistically significant results. Multiple linear regression analyses were applied for SF+D. Age, BMI, history of abdominal surgery, history of caesarean section, dysmenorrhea, history of abdominal adhesion, intraoperative fluid volume, urine volume, blood loss, anaesthesia time, and remifentanil dosage were considered as independent factors in univariate linear regression analysis. A variance inflation factor (VIF) greater than 10 suggested the presence of multicollinearity among the variables. Univariate linear regression analysis was performed at a significance level of 0.1, and multiple linear regression models were constructed.
RESULTS
In this study, 134 patients were recruited, all scheduled to undergo laparoscopic hysterectomy under general anaesthesia between September and December 2023. Of these, four cases were where surgery was temporarily cancelled, and two had intraoperative changes in surgical methods. Ultimately, the research was concluded with a total of 128 participants [Figure 2].
Figure 2.
Consolidated Standards of Reporting Trials (CONSORT) flow diagram. Group P = propofol group; Group S = sevoflurane group
Statistical analysis revealed comparable baseline characteristics between both cohorts regarding age, BMI, history of prior surgeries, ASA classification, duration of surgery, and anaesthesia time (P >0.05) [Table 1]. The mean to first defecation + hard food tolerance (SF + D) was 51 (SD: 8.47) in Group S and 47 (SD: 9.45) in Group P (P = 0.02) [Table 2], and the mean difference between the groups was − 4.46 (95% CI: 0.20, 7.00). The analysis of multiple regression indicated a positive association between anaesthesia time (P = 0.05) with SF+D. Group S exhibited substantial enhancement compared to Group P at T3, T5, and T6 in HR, and was faster at T6 in MBP. There was no significant difference in HR and MAP at other time points (P > 0.05) [Figure 3]. Compared with Group P, the use of atropine (P = 0.04) and esmolol loss in Group S were significantly increased (P = 0.02) [Table 3]. There were no significant differences in the total amount of infusion, bleeding volume, urine volume, extubation time, PACU stay time, Steward score after extubation, effective PCIA pressing times, or the number of rescue analgesia between the two groups (P > 0.05) [Table 3].
Table 1.
Comparison of general data between the two groups
| Group S (n=65) | Group P (n=63) | Effect size (95%CI) | |
|---|---|---|---|
| Age (years) | 50 (45, 54) | 51 (47, 57) | 0.28 (−0.63, 0.07) |
| BMI (kg/m2) | 23.4 (21.72, 23.85) | 23.05 (22.03, 23.67) | 0.047 (−0.3, 0.39) |
| ASA physical status (I/II) | 6/59 | 10/53 | 0.100 |
| History of abdominal surgery | 25 (38.5) | 19 (30.2) | 0.087 |
| History of caesarean section | 19 (29.2) | 7 (11.1) | 0.225 |
| Dysmenorrhea | 16 (24.6) | 12 (19.0) | 0.067 |
| Abdominal adhesions | 2 (3.1) | 0 (0) | 0.124 |
| Duration of anaesthesia (h) | 1.87 (1.42, 2.17) | 2.08 (1.78, 2.25) | 0.41 (−0.76, 0.06) |
| Extubation time (h) | 0.17 (0.12, 0.25) | 0.18 (0.12, 0.25) | 0.229 (−0.12, 0.58) |
| PACU stay time (h) | 0.50 (0.37, 0.59) | 0.48 (0.35, 0.58) | 0.254 (−0.09, 0.60) |
Data are presented as mean (standard deviation), median (interquartile range) or number of patients (percentages). Effect sizes were calculated using Cohen’s D (continuous data) and Phi (2×2 table). Group P=propofol group; Group S=sevoflurane group; BMI=body mass index; ASA=American Society of Anesthesiologists; PACU=post-anaesthesia care unit; CI=confidence interval
Table 2.
Follow-up outcomes at postoperative between the two groups
| Group S (n=65) | Group P (n=63) | Effect size (95%CI) | |
|---|---|---|---|
| SF+D (h) | 51 (8.47) | 47 (9.45) | P=0.02 (0.20, 7.00) |
| 'MI (>0.8/0.4–0.8/<0.4) | |||
| 24 h (n) | 48/10/7 | 52/10/1 | P=0.51 |
| 48 h (n) | 65/0/0/ | 63/0/0/ | |
| Intestinal peristalsis rate (times/min) | |||
| 24 h | 1 (2.45) | 2 (1.93) | P=0.397 (−0.42, 1.07) |
| 48 h | 3 (1.58) | 4 (1.50) | P=0.124 (−0.91, 0.11) |
| The initial emission time (h) | 23 (14.5,33) | 21 (16.5,35) | P=0.681 (−5.15, 3.38) |
Data are presented as mean (standard deviation), median (interquartile range); Group P=propofol group; Group S=sevoflurane group; SF+D=initial defecation and tolerance towards solid food; MI=gastric antral motility index
Figure 3.
Intraoperative haemodynamic outcomes. Group P = propofol group; Group S = sevoflurane group; HR = heart rate; MBP = upper-limb blood pressure. The medians are depicted as solid lines within the interquartile range. A “*” denotes a comparison with another group at the same latitude (“*” for P < 0.05, “**” indicating P < 0.001)
Table 3.
Perioperative data comparison between the two groups
| Group S (n=65) | Group P (n=63) | P | |
|---|---|---|---|
| Remifentanil consumption (mg) | 2.3 (2, 2.8) | 2.5 (1.95, 3) | 0.924 |
| Utilisation of vasoactive agents | |||
| Ephedrine | 8 [12] | 10 [16] | 0.111 |
| Phenylephrine | 51 [78] | 46 [73] | 0.472 |
| Urapidil | 3 [4] | 0 [0] | 0.254 |
| Atropine | 6 [9] | 0 [0] | 0.040 |
| Esmolol | 12 [18] | 1 [1] | 0.02 |
| Intraoperative fluid infusion (mL) | 1000 (800, 1300) | 1000 (900, 1250) | 0.439 |
| Blood loss (mL) | 50 (50, 100) | 40 (30, 95) | 0.002 |
| Urine volume (mL) | 300 (150, 300) | 250 (200, 400) | 0.204 |
| Steward score (n=6/5/4/3/2/1/0) | 57/8/0/0/0/0/ | 61/2/0/0/0/0/ | 0.111 |
| The number of effective PCIA compressions | 5 (4, 6) | 5 (4, 6) | 0.741 |
| Number of rescue analgesics | 3 (3, 5) | 4 (3, 5) | 0.469 |
Data are presented as mean (standard deviation), median (interquartile range) or number of patients (%). Group P=propofol group; Group S=sevoflurane group; PCIA =Patient-Controlled Intravenous Analgesia
The subjects of individuals exhibiting I-FEED scores indicative of regular gastrointestinal function after surgery was 28 (43.1%) in Group S and 35 (55.6%) in Group P, postoperative gastrointestinal intolerance was 30 (46.2%) in Group S and 27 (42.9%) in Group P, and POGD was 7 (10.8%) in Group S and 1 (1.6%) in Group P. None of the I-FEED scores were statistically significant (P = 0.074; Z = −1.79; 95% CI: 0.069, 0.079).
Comparisons of MI values and intestinal motility frequency across all measured intervals revealed no statistically significant variations between the groups (P > 0.05) [Figure 4]. There was negligible disparity in median time to first flatus between Group S and Group P [23 (IQR: 14.5–33) vs 21 (IQR: 16.5–35) h (P > 0.05) [Table 2].
Figure 4.
MI values and intestinal peristalsis values. Group P = propofol group; Group S = sevoflurane group; MI = gastric antral motility index; The medians are depicted as solid lines within the interquartile range, while short lines represent the maximum and minimum values. A “#” symbol indicates a comparison with the baseline of the same group (“#” for P < 0.05, “##” indicating P < 0.001), whereas “*” denotes a comparison with another group at the same latitude (“*” for P < 0.05, “**” indicating P < 0.001)
Both groups’ scores for nausea and vomiting did not exhibit any significant disparity at each time point (P > 0.05). However, Group S exhibited higher pain scores compared to Group P at 8 h (95%CI: −1.40, −0.59; P < 0.001),72 h (95%CI: −0.76, −0.27; P < 0.001), and 7 days (95%CI: −0.40, −0.07; P = 0.06).
DISCUSSION
This study showed that inhaled anaesthesia resulted in a longer time to recovery of gastrointestinal function than TIVA. TIVA may provide more stable intraoperative haemodynamics and postoperative analgesia.
POGD after laparoscopic surgery has attracted increasing attention; however, its definition and associated clinical indicators are yet to be determined.[9,10] In clinical practice, subjective perceptions, clinical manifestations, and mobile bedside examinations are often more significant than chemical tests and imaging examinations due to considerations such as hospitalisation costs for this transient symptom.[11,12] Not only the subjective feeling scale but also the objective index SF+D, time to first flatus, and gastrointestinal motility index measured by bedside ultrasound were used in this study.
By measuring the presence of radionuclides in the gastrointestinal tract, SF+D was considered to provide a more precise prediction of postoperative recovery of gastrointestinal function compared to commonly employed methods, such as assessing the time of first bowel movement.[13,14] Several meta-analyses demonstrated that intravenous anaesthesia leads to a lower incidence of POGD than inhalation anaesthesia, enhancing postoperative recovery.[15,16] Niu et al.[17] observed greater abdominal distension in patients who received procedures under total inhalation anaesthesia than those under TIVA. Kim et al., also highlighted that TIVA with propofol/remifentanil provided protective benefits against endothelial glycocalyx damage during surgery, unlike volatile anaesthesia involving sevoflurane/remifentanil.[18] Yin et al.[19] found that compared with TIVA based on propofol, inhalation anaesthesia led to greater changes in intestinal flora after laparoscopic surgery.
However, an investigation by Meng et al.[20] assessing different anaesthetic approaches for male subjects undergoing transforaminal lumbar interbody fusion (TLIF) demonstrated comparable rates of digestive system complications across study cohorts.
There are several potential reasons for these different findings. First, the inclusion of only male participants in the sample introduces bias. Females, particularly young females, are known to have a higher risk of PONV as well as gastrointestinal dysfunction.[21] Second, compared to laparoscopic surgery, which necessitates the establishment of carbon dioxide pneumoperitoneum, transforaminal lumbar fusion involves a surgical site located further away from the abdominal cavity, resulting in a lower incidence of postoperative gastrointestinal function impairment.[22]
According to numerous studies and guidelines, the use of sevoflurane is associated with a higher incidence of PONV.[23,24] Experts recommend using the I-FEED scale to evaluate POGD in colorectal surgery patients.[8] The prevalence of POGD notably clinically differed between Group S and Group P, although the three grades of POGD were not significantly different.
Multivariate regression results indicated a notable positive association between anaesthesia duration and SF+D levels. Additionally, extubation time was found to be significantly negatively correlated with SF+D. An increase in anaesthesia time is associated with increased opioid consumption and longer operation duration, both of which are closely linked to the occurrence of POGD following laparoscopic hysterectomy.[25]
Laparoscopic pneumoperitoneum increases intra-abdominal pressure, potentially impeding venous return to the heart. During the steady-state infusion of propofol, there was a 37% reduction in the efferent impulse of the sympathetic nervous system, which stimulates the vagus nerve and inhibits the baroreflex.[26] Similarly, Group P exhibited a slower rate of change following postural change in terms of haemodynamics [Figure 3].
The first flatus time of Group S was longer than that of Group P. This could be attributed to the limited sample size, as it was determined based on the SF+D data from the pre-experiment. On the contrary, a recent study on postoperative gastrointestinal function assessment indicators found that the SF+D indicator is more efficient and accurate compared to the first postoperative flatus, first postoperative defecation, and PONV rate, which is also one of the reasons why this trial chose it as the primary outcome measure.
Possible limitations of this study include the lack of blinding of the patients to the anaesthesia method, which may have introduced bias in the postoperative results. Although sevoflurane is an inhaled anaesthetic with an aromatic odour, importantly, residual odour may still be perceived even after the patient’s consciousness and muscle strength have recovered and the tracheal tube has been removed. Furthermore, in this trial, the execution of bedside ultrasound examination within 8 hours after surgery was hindered by wound dressing coverage and pain, resulting in insufficient data at the 8-hour mark. Consequently, it is imperative to refine the assessment position further to thoroughly investigate the efficacy of bedside ultrasound in evaluating gastrointestinal motility. Additionally, the generalisability of these results needs to be examined, as the study primarily involved relatively healthy adult women.
CONCLUSION
The present study revealed that the time to recover postoperative gastrointestinal function was longer with inhalation anaesthesia than with TIVA. The latter can provide more stable intraoperative haemodynamics and postoperative analgesia.
Study data availability
De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and will be shared after approval, as per the authors’ Institution’s policy.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.
Declaration of use of permitted tools
Nil.
Presentation at conferences/CMEs and abstract publication
None.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We sincerely thank the gynaecologists and the Affiliated Hospital of Xuzhou Medical University nursing team for their invaluable assistance during this research.
Funding Statement
Nil.
REFERENCES
- 1.Sarikaya S, Taskin MI, Bozhuyuk Sahin T, Guney G, Kececioglu M, Afsar S, et al. Comparison of perioperative outcomes between V-NOTES and total laparoscopic hysterectomy: A retrospective analysis. J Invest Surg. 2025;38:2488131. doi: 10.1080/08941939.2025.2488131. doi: 10.1080/08941939.2025.2488131. [DOI] [PubMed] [Google Scholar]
- 2.Peters EG, Pattamatta M, Smeets BJJ, Brinkman DJ, Evers SMAA, de Jonge WJ, et al. The clinical and economic impact of postoperative ileus in patients undergoing colorectal surgery. Neurogastroent Motil. 2020;32:e13862. doi: 10.1111/nmo.13862. doi: 10.1111/nmo.13862. [DOI] [PubMed] [Google Scholar]
- 3.Lavikainen LI, Guyatt GH, Luomaranta AL, Cartwright R, Kalliala IEJ, Couban RJ, et al. Risk of thrombosis and bleeding in gynecologic cancer surgery: Systematic review and meta-analysis. Am J Obstet Gynecol. 2024;230:403–16. doi: 10.1016/j.ajog.2023.10.006. [DOI] [PubMed] [Google Scholar]
- 4.Payne SC, Furness JB, Stebbing MJ. Bioelectric neuromodulation for gastrointestinal disorders: Effectiveness and mechanisms. Nat Rev Gastro Hepat. 2019;16:89–105. doi: 10.1038/s41575-018-0078-6. [DOI] [PubMed] [Google Scholar]
- 5.Madhvani K, Garcia SF, Fernandez-Felix BM, Zamora J, Carpenter T, Khan KS. Predicting major complications in patients undergoing laparoscopic and open hysterectomy for benign indications. Can Med Assoc J. 2022;194:E1306–17. doi: 10.1503/cmaj.220914. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Khawaja ZH, Gendia A, Adnan N, Ahmed J. Prevention and management of postoperative ileus: A review of current practice. Cureus J Med Science. 2022;14:e22652. doi: 10.7759/cureus.22652. doi: 10.7759/cureus.22652. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Traeger L, Koullouros M, Bedrikovetski S, Kroon HM, Moore JW, Sammour T. Global cost of postoperative ileus following abdominal surgery: Meta-analysis. BJS Open. 2023;7:zrad054. doi: 10.1093/bjsopen/zrad054. doi: 10.1093/bjsopen/zrad054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hedrick TL, McEvoy MD, Mythen MMG, Bergamaschi R, Gupta R, Holubar SD, et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgery. Anesth Analg. 2018;126:1896–907. doi: 10.1213/ANE.0000000000002742. [DOI] [PubMed] [Google Scholar]
- 9.Buscail E, Deraison C. Postoperative ileus: A pharmacological perspective. Brit J Pharmacol. 2022;179:3283–305. doi: 10.1111/bph.15800. [DOI] [PubMed] [Google Scholar]
- 10.Hou Z, Liu T, Li X, Lv H, Sun Q. Risk factors for postoperative ileus in hysterectomy: A systematic review and meta-analysis. PLoS One. 2024;19:e0308175. doi: 10.1371/journal.pone.0308175. doi: 10.1371/journal.pone. 0308175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Recker F, Kipfmueller F, Wittek A, Strizek B, Winter L. Applications of point-of-care-ultrasound in neonatology: A systematic review of the literature. Life-Basel. 2024;14:658. doi: 10.3390/life14060658. doi: 10.3390/life14060658. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Huang SS, Lin KW, Liu KL, Wu YM, Lien WC, Wang HP. Diagnostic performance of ultrasound in acute cholecystitis: A systematic review and meta-analysis. World J Emerg Surg. 2023;18:54. doi: 10.1186/s13017-023-00524-5. doi: 10.1186/s13017-023-00524-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Firut A, Margaritescu DN, Turcu-Stiolica A, Bica M, Rotaru I, Patrascu AM, et al. Preoperative immunocyte-derived ratios predict postoperative recovery of gastrointestinal motility after colorectal cancer surgery. J Clin Med. 2023;12:6338. doi: 10.3390/jcm12196338. doi: 10.3390/jcm12196338. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Jang H, An S, Lee N, Jeong E, Park Y, Kim J, et al. Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma. BMC Surg. 2023;23:61. doi: 10.1186/s12893-023-01955-2. doi: 10.1186/s12893-023-01955-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ahmed MM, Tian C, Lu J, Lee Y. Total intravenous anaesthesia versus inhalation anaesthesia on postoperative analgesia and nausea and vomiting after bariatric surgery: A systematic review and meta-analysis. Asian J Anesthesiol. 2021;59:135–51. doi: 10.6859/aja.202112_59(4).0002. [DOI] [PubMed] [Google Scholar]
- 16.Smith JJ. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. J Urology. 2005;173:887. doi: 10.1097/00005392-200503000-00072. doi: 10.1097/00005392-200503000-00072. [DOI] [PubMed] [Google Scholar]
- 17.Niu Z, Gao X, Shi Z, Liu T, Wang M, Guo L, et al. Effect of total intravenous anaesthesia or inhalation anaesthesia on postoperative quality of recovery in patients undergoing total laparoscopic hysterectomy: A randomised controlled trial. J Clin Anesth. 2021;73:110374. doi: 10.1016/j.jclinane.2021.110374. doi: 10.1016/j.jclinane. 2021.110374. [DOI] [PubMed] [Google Scholar]
- 18.Kim NY, Kim KJ, Lee KY, Shin HJ, Cho J, Nam DJ, et al. Effect of volatile and total intravenous anaesthesia on syndecan-1 shedding after minimally invasive gastrectomy: A randomised trial. Sci Rep-Uk. 2021;11:1511. doi: 10.1038/s41598-021-81012-1. doi: 10.1038/s41598-021-81012-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Liu H, Qu X, Yin X, Li J, Cao Y, Wang Y, et al. Intestinal microbiome and metabolome changes induced by sevoflurane, propofol, and sevoflurane-propofol anaesthesia in patients undergoing nephrectomy. Brit J Anaesth. 2022;129:e38–40. doi: 10.1016/j.bja.2022.04.028. [DOI] [PubMed] [Google Scholar]
- 20.Meng W, Yang C, Wei X, Wang S, Kang F, Huang X, et al. Type of anaesthesia and quality of recovery in male patients undergoing lumbar surgery: A randomised trial comparing propofol-remifentanil total i.v. Anaesthesia with sevoflurane anaesthesia. BMC Anesthesiol. 2021;21:300. doi: 10.1186/s12871-021-01519-y. doi: 10.1186/s12871-021-01519-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Kienbaum P, Schaefer MS, Weibel S, Schlesinger T, Meybohm P, Eberhart LH, et al. [Update on PONV-What is new in prophylaxis and treatment of postoperative nausea and vomiting?: Summary of recent consensus recommendations and Cochrane reviews on prophylaxis and treatment of postoperative nausea and vomiting] Anaesthesist. 2022;71:123–8. doi: 10.1007/s00101-021-01045-z. [DOI] [PubMed] [Google Scholar]
- 22.Sekerak R, Mostafa E, Morris MT, Nessim A, Vira A, Sharan A. Comparative outcome analysis of spinal anaesthesia versus general anaesthesia in lumbar fusion surgery. J Clin Orthop Trauma. 2021;13:122–6. doi: 10.1016/j.jcot.2020.11.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Dubowitz JA, Cata JP, De Silva AP, Braat S, Shan D, Yee K, et al. Volatile anaesthesia and peri-operative outcomes related to cancer: A feasibility and pilot study for a large randomised control trial. Anaesthesia. 2021;76:1198–206. doi: 10.1111/anae.15354. [DOI] [PubMed] [Google Scholar]
- 24.Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020;131:411–48. doi: 10.1213/ANE.0000000000004833. [DOI] [PubMed] [Google Scholar]
- 25.Sheyn D, Bretschneider CE, Mahajan ST, Ridgeway B, Davenport A, Pollard R. Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications. Am J Obstet Gynecol. 2019;220:51. doi: 10.1016/j.ajog.2018.11.1095. doi: 10.1016/j.ajog. 2018.11.1095. [DOI] [PubMed] [Google Scholar]
- 26.Lu DH, Xu X, Zhou R, Wang C, Lan LT, Yang XY, et al. Ultrasound-guided stellate ganglion block benefits the postoperative recovery of patients undergoing laparoscopic colorectal surgery: A single-centre, double-blinded, randomised controlled clinical trial. BMC Anesthesiol. 2024;24:137. doi: 10.1186/s12871-024-02518-5. doi: 10.1186/s12871-024-02518-5. [DOI] [PMC free article] [PubMed] [Google Scholar]