Effect of enhanced recovery after surgery-based anesthesia resuscitation on awakening quality in da Vinci robotic rectal cancer surgery

Abstract

BACKGROUND

Rectal cancer is a common digestive tract malignancy influenced by genetic, dietary, and environmental factors. While traditional open surgery is effective, it often leads to significant recovery challenges and complications. The da Vinci robotic system provides a minimally invasive option, enhancing precision and reducing recovery time. However, the anesthesia recovery phase is critical for effective patient outcomes, particularly in older individuals. This study explores the impact of enhanced recovery after surgery (ERAS)-based anesthesia resuscitation on awakening quality in patients undergoing da Vinci robotic rectal cancer surgery, aiming to improve recovery protocols.

AIM

To analyze the impact of anesthesia resuscitation interventions grounded in the principles of ERAS on the awakening quality of patients undergoing da Vinci robotic rectal cancer surgery.

METHODS

A total of 84 rectal cancer patients admitted from February 2021 to December 2022 were selected and randomized into two groups: The control group (n = 42) received conventional anesthesia recovery nursing care, while the study group (n = 42) underwent anesthesia resuscitation interventions based on the ERAS framework. The quality of awakening, pain levels, vital signs, and complications were compared between the two groups.

RESULTS

The study group showed significantly shorter times for eye opening, extubation, orientation recovery, spontaneous respiration, and anesthesia recovery room stay than the control group (P < 0.05). Visual analog scale scores at 1 hours, 2 hours, 4 hours, and 6 hours post-nursing were lower in the study group (P < 0.05). In the control group, systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate at 10 minutes post-anesthesia were higher than preoperative values (P < 0.05), while no significant differences were found in the study group. These parameters were also lower in the study group at 10 minutes (P < 0.05). The complication rate was significantly lower in the study group (4.76%) than in the control group (28.56%) (P < 0.05).

CONCLUSION

The implementation of ERAS-based anesthesia resuscitation interventions in patients undergoing da Vinci robotic rectal cancer surgery enhances awakening quality, reduces complication rates, and helps stabilize vital signs.

Key Words: Rapid recovery surgery; Da Vinci robot; Rectal cancer; Quality of awakening; Anesthesia resuscitation period

Core Tip: This study investigates the impact of enhanced recovery after surgery (ERAS)-based anesthesia resuscitation on the awakening quality of patients undergoing da Vinci robotic rectal cancer surgery. By comparing 84 patients, the research demonstrates that ERAS interventions significantly shorten recovery times, reduce postoperative pain, and lower complication rates. The findings highlight the effectiveness of ERAS principles in stabilizing vital signs and enhancing overall recovery quality, suggesting a valuable approach for improving patient outcomes in robotic surgical procedures.

INTRODUCTION

Rectal cancer is one of the most prevalent malignant tumors of the digestive tract, characterized by a complex pathogenesis that is generally believed to be closely associated with genetic, dietary, and environmental factors. High-risk factors for this disease include rectal polyps, inadequate dietary fiber intake, and excessive consumption of animal fats[1,2]. In the early stages, most rectal cancer patients are asymptomatic. However, as the disease progresses, they may experience symptoms such as changes in bowel habits, constipation, bloody stools, and diarrhea. Tumor invasion into surrounding organs, such as the vagina and bladder, can lead to complications like sacral pain, urinary tract irritation, and lower limb edema[3].

Surgery remains the primary treatment for rectal cancer. Historically, open surgery was the standard approach; however, it is associated with significant drawbacks, including extensive trauma, high blood loss, and prolonged recovery times[4,5]. In contrast, the da Vinci robotic system offers numerous advantages over traditional open surgery, including enhanced operational flexibility, greater precision, reduced trauma, and faster recovery. As a result, it is increasingly utilized in the treatment of rectal cancer.

Despite these benefits, da Vinci robotic rectal cancer surgery typically requires general anesthesia, and the anesthesia recovery period is a critical phase of the surgical process. Prolonged recovery times can lead to various complications, making effective and scientific nursing care during this period essential for improving patient outcomes[6]. The enhanced recovery after surgery (ERAS) concept, which is rooted in evidence-based medicine, integrates advanced techniques in pain management, surgical methods, and anesthesiology into nursing care, thereby facilitating rapid recovery for patients during the perioperative period[7]. This study aims to investigate the impact of anesthesia resuscitation interventions based on the ERAS concept on the awakening quality of patients undergoing da Vinci robotic rectal cancer surgery.

MATERIALS AND METHODS

General information

A total of 84 patients with rectal cancer who were admitted to Affiliated Hospital of North Sichuan Medical College from February 2021 to December 2022 were selected for this study. The inclusion criteria were as follows: (1) Meeting the diagnostic criteria for rectal cancer; (2) Undergoing da Vinci robotic surgery with appropriate surgical indications; and (3) Having complete medical records. Exclusion criteria included: (1) Patients with a prior history of abdominal surgery; (2) Those who received neoadjuvant chemotherapy prior to surgery; and (3) Patients with coagulation dysfunction.

Using a random number table method, the participants were divided into two groups: The control group, which consisted of 42 patients, and the study group, also encompassing 42 patients. In the control group, there were 24 males and 18 females, with ages ranging from 46 to 76 years, yielding an average age of (55.26 ± 3.14) years. The study group comprised 21 males and 21 females, aged between 42 and 75 years, with an average age of (55.09 ± 3.16) years. Statistical analysis showed no significant differences in demographic data between the two groups (P > 0.05).

Methods

The control group underwent standard anesthesia recovery nursing, which involved several key aspects: Guiding patients on dietary choices, advising medication in accordance with the doctor’s recommendations, providing information about the surgery upon the patients’ awakening, dynamically monitoring vital signs, and offering psychological counseling. The study group received anesthesia recovery period intervention based on ERAS concept: (1) Team formation: The intervention group was established by anesthesiologists and nurses in anesthesia recovery room, and the head nurse was responsible for the management and nursing work. Based on the nursing process and responsibilities of the anesthesia recovery room, the responsibilities of each team member were clarified. The team members were trained regularly and examined strictly. After passing the examination, they took part in nursing work; (2) Clear evidence basis: “rectal cancer”, “recovery quality”, “general anesthesia” and other keywords were used to find literature in the search website, and the content of the literature was integrated and analyzed, combined with previous nursing experience, and individualized intervention plan was formulated; and (3) Nursing implementation: Preparation for resuscitation: The temperature of anesthesia recovery room was controlled at 22-25 °C, the humidity was adjusted at 50%-60%, the operation of medical equipment such as monitors in the recovery room was checked, various instruments and drugs were classified, and sputum suction tubes and other items were prepared. Strengthen monitoring: Dynamic monitoring of the vital signs of patients, observe whether the occurrence of restlessness, once found abnormal immediately deal with; If the patient’s respiratory rate (RR) is at a low level, the nurse immediately calls the patient and instructs the patient to do simple limb movements such as blinking to determine whether the patient is awake. Position nursing: Put a soft pad under the shoulder and neck of the patient, raise the head of the bed by 5-10°, turn over and massage the patient at regular intervals. Body temperature care: Regularly check the patient’s body temperature, once the body temperature is less than 36 °C, cover the limbs with the warming blanket, and remove the warming blanket when the body temperature recovers. Pain nursing: Observe the patient’s expression, give analgesic drugs according to the doctor’s advice, observe the patient’s condition during medication, and adjust the drug dose appropriately. Braking nursing: Observe the recovery of patients, if the reaction is severe, use restraint band, evaluate the indications of extubation regularly, and extubate immediately once it is confirmed that the indications are met. Control of infusion: Control of infusion speed, infusion volume, maintain infusion number of 20 drops/minutes approximately 40 drops/minutes. Post-recovery care: After the patient was awake, the patient was guided to introduce himself by question and answer method, the surgical results were informed to the patient, and the postoperative precautions were emphasized.

Observation indicators

(1) Quality of awakening: Document the patient’s eye opening, extubation, recovery of orientation, restoration of autonomous respiration, and duration of stay in the anesthesia recovery room; (2) Pain level: Pain levels were assessed using the visual analog scale (VAS) at multiple time points: Preoperative, after 1 hour of care, after 2 hours, after 4 hours, and after 6 hours. The scale, which ranges from 0 to 10, reflects the intensity of pain experienced, with higher scores indicating greater pain; (3) Vital signs: Systolic blood pressure (SBP), heart rate (HR), diastolic blood pressure (DBP), and RR were measured using a cardiac monitor (PM-7000D type, Wuhan, China) both before surgery and 10 minutes after admission to the anesthesia recovery room; and (4) Complications: The incidence of complications, including hypothermia, agitation, respiratory depression, and abnormal HR, was calculated.

Statistical analysis

SPSS23.0 software was used to process the data, mean ± SD for measurement data (t-test), and % for count data (χ² test). P < 0.05 means there is a statistical difference.

RESULTS

Comparison of the quality of resuscitation between the two groups

The study group exhibited shorter times for eye opening, extubation, recovery of orientation, recovery of spontaneous respiration, and duration of stay in the anesthesia recovery room compared to the control group (P < 0.05) (Table 1).

Table 1 Comparison of resuscitation quality between the two groups (minutes, mean ± SD).

Group	Cases	Eye opening time	Extubation time	Directional force recovery time	Recovery time for spontaneous breathing	Duration of stay in anesthesia recovery room
Control group	42	12.19 ± 1.88	17.98 ± 2.04	45.65 ± 4.82	22.98 ± 2.15	55.49 ± 5.42
Research group	42	10.12 ± 1.63	14.29 ± 1.89	38.62 ± 2.47	17.58 ± 2.01	43.25 ± 2.41
t		5.391	8.599	8.412	11.890	13.373
P value		< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

Comparison of pain degree between the two groups

The VAS scores in the study group were significantly lower than those in the control group at 1 hour, 2 hours, 4 hours, and 6 hours post-nursing (P < 0.05) (Table 2).

Table 2 Comparison of pain degree between the two groups (score, mean ± SD).

Group	Cases	Before operation	After 1 hour nursing	After 2 hours of nursing	After 4 hours of nursing	After 6 hours of nursing
Control group	42	4.63 ± 1.28	3.78 ± 1.26	3.27 ± 1.15	2.45 ± 0.15	1.96 ± 0.12
Research group	42	4.49 ± 1.35	3.25 ± 1.01	2.83 ± 0.32	2.11 ± 0.18	1.21 ± 0.11
t		0.487	2.127	2.388	9.404	29.858
P value		0.627	0.036	0.019	< 0.001	< 0.001

Comparison of vital signs between the two groups

The levels of SBP, DBP, HR, and RR were significantly higher in the control group 10 minutes after admission to the anesthesia recovery room compared to their preoperative values (P < 0.05). In contrast, there was no statistically significant difference in these indicators between the preoperative measurements and those taken 10 minutes after admission in the study group (P > 0.05). Moreover, the levels of SBP, DBP, HR, and RR in the study group 10 minutes post-admission were lower than those of the control group (P < 0.05) (Table 3).

Table 3 Comparison of vital signs between the two groups (mean ± SD).

Group	Cases	Time	SBP, mmHg	DBP, mmHg	HR, times/minutes	RR, times/minutes
Control group	42	Preoperative	120.87 ± 15.59	83.46 ± 8.26	76.57 ± 15.61	17.15 ± 2.59
		Admission to anaesthesia recovery room 10 minutes	139.45 ± 10.52	98.45 ± 8.61	95.36 ± 8.45	22.24 ± 2.06
t			6.402	8.142	6.860	9.967
P value			< 0.001	< 0.001	< 0.001	< 0.001
Research group	42	Preoperative	120.63 ± 15.47	84.19 ± 7.96	77.51 ± 16.12	16.98 ± 2.63
		Admission to anaesthesia recovery room 10 minutes	123.54 ± 10.78a	86.15 ± 6.82a	81.08 ± 8.15a	18.15 ± 3.21a
t			1.000	1.211	1.280	1.827
P value			0.320	0.229	0.203	0.071

^aP < 0.05 vs control group.

SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HR: Heart rate; RR: Respiratory rate.

Comparison of complications between the two groups

The complication rate of 4.76% in the study group was lower than that of 28.56% in the control group (P < 0.05) (Table 4).

Table 4 Comparison of complications between the two groups, n (%).

Group	Cases	Hypothermia	Restlessness	Respiratory depression	Abnormal heart rate	Incidence rate
Control group	42	4 (9.52)	3 (7.14)	1 (2.38)	4 (9.52)	12 (28.56)
Research group	42	1 (2.38)	0 (0.00)	0 (0.00)	1 (2.38)	2 (4.76)
t						8.571
P value						0.003

DISCUSSION

Rectal cancer is one of the most prevalent clinical diseases, primarily caused by genetic mutations, with adenocarcinomas being the most common pathological type; squamous carcinomas are rarely encountered. In 2022, nearly 1 million new cases of rectal cancer were reported worldwide, accounting for 4% of all new cancer cases, along with over 500000 deaths, representing 3.4% of cancer-related fatalities[8,9]. The clinical treatment for rectal cancer predominantly involves surgical protocols. Historically, open surgery was frequently employed, effectively resecting lesions to alleviate patient symptoms. However, this method is associated with significant trauma, extended postoperative recovery times, and a higher incidence of complications, which can negatively impact therapeutic efficacy.

In recent years, the da Vinci robotic system has gained popularity in surgical treatments due to its high operational precision and flexibility[10-13]. This technology allows surgeons to operate without direct contact with the patient, utilizing a three-dimensional vision system to perform delicate procedures within confined surgical areas, thereby minimizing trauma. Typically, da Vinci robotic rectal cancer surgeries are performed under general anesthesia, with patients subsequently transferred to the anesthesia recovery room to await the stabilization of vital signs. Given that rectal cancer predominantly affects elderly individuals, who often have unique physiological characteristics, the anesthesia recovery period can be complicated by issues such as agitation and abnormal HRs[14].

This study implemented anesthesia recovery interventions based on the ERAS concept. Results indicated that the study group experienced shorter times for eye opening, extubation, recovery of orientation, recovery of spontaneous breathing, and overall stay in the post-anesthesia care unit compared to the control group. Additionally, the VAS scores for the study group were lower than those for the control group at 1 hours, 2 hours, 4 hours, and 6 hours post-nursing. The incidence of complications in the study group was 4.76%, significantly lower than the 28.56% observed in the control group. These findings suggest that ERAS-based anesthesia recovery interventions for patients with rectal cancer undergoing da Vinci robotic surgery are effective in reducing complications, alleviating postoperative pain, and enhancing recovery quality.

The ERAS concept emphasizes rapid recovery nursing principles, centering on the patient and addressing physical, psychological, and spiritual needs to shorten postoperative recovery times. Implementing evidence-based support before interventions ensures the scientific validity and feasibility of the nursing plan. Key interventions focus on infusion management, body temperature regulation, positioning, complication monitoring, and pain management, all aimed at promoting prompt consciousness recovery and minimizing postoperative complications. Enhanced monitoring of HR and blood oxygen saturation allows for timely detection and treatment of abnormalities, thus mitigating the impact of emergencies on patient conditions and shortening recovery times.

Additionally, appropriate body positioning and temperature management can prevent postoperative hypothermia. Pain management strategies, including the judicious use of sedative and analgesic medications, help reduce physiological stress and improve recovery quality. Psychological counseling for patients post-recovery, along with timely updates on surgical outcomes, can alleviate psychological burdens and facilitate rehabilitation[15]. Encouraging patients to adopt comfortable positions enhances comfort and respiratory function, further expediting extubation[16].

Previous studies have indicated that blood pressure and HR fluctuations are common in surgical patients entering the anesthesia recovery room due to the lingering effects of anesthetic agents and the unavoidable trauma of surgery[17,18]. In this study, the levels of SBP, DBP, HR, and RR in the study group were lower than those in the control group 10 minutes after entering the anesthesia recovery room. These results suggest that ERAS-based anesthesia recovery interventions can stabilize patients’ vital signs.

To optimize recovery, ERAS interventions should focus on preparation, adjusting the temperature and humidity of the recovery room, and ensuring that necessary items, equipment, and medications are readily available for various medical and nursing operations, thereby promoting vital sign stability. Additionally, appropriate positioning and ensuring unobstructed airways can facilitate anesthetic drug metabolism and mitigate pain stimuli’s effects on the parasympathetic nervous system, ultimately stabilizing vital signs. This study has several limitations. First, it is a single-center, retrospective analysis with a relatively small and heterogeneous patient cohort, which may introduce selection bias. Second, potential confounding factors were not fully adjusted for in the analysis. Finally, the lack of external validation may limit the generalizability of our findings. Future multicenter, prospective studies with larger sample sizes are needed to confirm these results.

CONCLUSION

In conclusion, anesthesia recovery interventions based on the ERAS concept for patients undergoing da Vinci robotic rectal cancer surgery can significantly improve recovery quality, reduce postoperative complications, and alleviate postoperative pain.