Optimizing Postoperative Gastrointestinal Dysmotility Following Total Laparoscopic Hysterectomy: a Randomized Control Trial.

This study is a prospective three-arm randomized controlled trial at a single academic-affiliated institution designed to assess the effect of common bowel care regimens on return of bowel function following total laparoscopic hysterectomy. Subjects were randomized using an equal allocation ratio to one of three groups: no bowel care medication, docusate sodium, or polyethylene glycol 3350 (PEG) for the first five days postoperatively. Women aged 18-85 years old undergoing total laparoscopic hysterectomy for benign indications were included. Exclusion criteria included a known underlying gynecologic malignancy, pre-existing gastrointestinal disorders such as Crohn’s disease, ulcerative colitis, irritable bowel syndrome, history of bowel resection, insulin-dependent diabetes or gastroparesis, known gastric dysmotility, chronic use of pain medications, anticipated bowel surgery, or non-English speaking. The primary outcome of the study was to assess the time to first bowel movement after randomization to a postoperative bowel care regimen. Secondary outcomes assessed were time to first flatus postoperatively, narcotic use measured in total oral morphine equivalents in the first five days postoperatively, as well as the constipation score and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire score. There were no significant differences in time to first bowel movement postoperatively amongst those receiving no bowel care regimen, docusate sodium, or PEG (2.64 ± 1.19, 2.80 ± 1.08, 3.06 ± 1.18 days; p=0.436). Similarly, there were no significant differences in time to first flatus: 1.06 days (interquartile range 0.89-1.70) in the control group, 1.05 days (interquartile range 0.78-1.37) in the docusate sodium group, and 1.11 days (interquartile range 0.82-1.40) in the PEG group (p=0.975). Total narcotic use in the first five days postoperatively, constipation score, and the PAC-SYM score did not vary significantly amongst the groups. Body mass index (BMI) was a significant predictor of time to first bowel movement with an increased BMI associated with a shorter time to first bowel movement [HR 1.05 (1.01, 1.10); p=0.013]. In those undergoing laparoscopic hysterectomy for benign indications without any preexisting gastrointestinal disorders, the prescription of a bowel care medication does not significantly affect return of bowel function.本研究为单家附属学术医疗机构开展的前瞻性三臂随机对照试验，旨在评估常见肠道护理方案对全腹腔镜子宫切除术后肠道功能恢复的影响。研究对象按1:1:1的均等分配比例随机分为三组，于术后前5日分别接受无肠道护理药物干预、多库酯钠（docusate sodium）干预或聚乙二醇3350（polyethylene glycol 3350，PEG）干预。 纳入标准为年龄18~85岁、因良性指征接受全腹腔镜子宫切除术的女性患者。排除标准包括确诊妇科恶性肿瘤、既往胃肠道疾病（如克罗恩病、溃疡性结肠炎、肠易激综合征）、肠道手术史、胰岛素依赖型糖尿病或胃轻瘫、已知胃动力障碍、长期服用止痛药物、预期需行肠道手术，以及非英语使用者。 本研究的主要结局指标为患者随机接受术后肠道护理方案后至首次排便的时间。次要结局指标包括术后首次排气时间、术后前5日以口服吗啡当量总量计算的阿片类药物使用量，以及便秘评分与便秘症状患者评估量表（Patient Assessment of Constipation Symptoms, PAC-SYM）得分。 三组患者术后首次排便时间无显著差异：无肠道护理组为2.64±1.19天，多库酯钠组为2.80±1.08天，PEG组为3.06±1.18天（p=0.436）。同样，三组术后首次排气时间亦无显著差异：对照组为1.06天（四分位间距0.89~1.70），多库酯钠组为1.05天（四分位间距0.78~1.37），PEG组为1.11天（四分位间距0.82~1.40）（p=0.975）。术后前5日的阿片类药物总使用量、便秘评分及PAC-SYM得分在三组间均无显著差异。 体重指数（Body Mass Index, BMI）是术后首次排便时间的显著预测因素，BMI升高与首次排便时间缩短相关[风险比1.05（1.01, 1.10）；p=0.013]。对于因良性指征接受腹腔镜子宫切除术且无既往胃肠道疾病的患者，开具肠道护理药物并不会显著影响其肠道功能恢复。