Gastrointestinal dysfunction after laparoscopic hysterectomy: Re-assessing anaesthetic modality in light of confounding factors

Dear Editor, We read the article ‘Effects of total intravenous anaesthesia (TIVA) versus inhalation anaesthesia on gastrointestinal function recovery after laparoscopic hysterectomy’[1] and would like to offer a few constructive critiques. The definition of gastrointestinal dysfunction following general anaesthesia remains ambiguous. In clinical practice, tolerance to oral feed and passage of flatus are two commonly used independent indicators of gastrointestinal recovery and not the combined metric of two (tolerance of solid food plus defecation) as described in this study. Moreover, when these parameters were assessed separately, the authors did not find any significant difference between the two studied groups, yet they considered the combined effect as a significant outcome. Current evidence suggests that the impact of anaesthesia type (TIVA versus inhalational anaesthesia) on gastrointestinal motility is more pronounced in prolonged surgeries, where anaesthetic exposure and surgical stress are substantial and not in short-duration procedures like laparoscopic hysterectomy.[2] This is because when TIVA with propofol is used, it mainly gets distributed in vessel-rich organs over vessel-poor tissues like bowel, and its short context-sensitive decrement time when used for a shorter duration has a limited residual effect on the gastrointestinal tract.[3] Similarly, inhalational agents also reach equilibrium concentrations with similar pharmacokinetic profiles, further minimising differential impact. Several confounding factors which could result in bias were not adequately addressed in this study. Patient factors like advanced age, high body mass index, diabetes, and chronic kidney disease, which could delay gastric emptying, were not addressed.[4] Secondly, atropine, which is known to inhibit bowel motility, was administered to six patients in the inhalational group. Thirdly, propofol’s well-established antiemetic properties may have contributed to the reduced incidence of nausea and vomiting in TIVA groups. Finally, the factors which affect gastrointestinal recovery, like pre-operative bowel habits, timing of mobilisation, and dietary resumption patterns, were not assessed by the authors.[5] In conclusion, while we commend the authors for exploring an important clinical question, we believe limitations in methodology and potential confounders limit generalising this study’s clinical findings. Presentation at conferences/CMEs and abstract publication No. Study data availability No data available with the article. 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. Declaration of use of permitted tools No Scales/figures/scores/tables were used. Supplementary material No Supplementary material is available with the article. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.