Obstetrics & Gynecology · Medical Literature
Milk of magnesia in enhanced recovery after surgery for preventing postoperative ileus after hysterectomy: randomized controlled trial.
Abstract
To evaluate whether adding milk of magnesia (MOM) to an enhanced recovery after surgery (ERAS) pathway prevents postoperative ileus (POI) and improves postoperative bowel function. This randomized controlled trial at the Gynecology Unit, Siriraj Hospital (Bangkok, Thailand) enrolled patients undergoing hysterectomy for benign or malignant indications during September 2023 through February 2024. Participants were randomly assigned to ERAS alone (n = 80) or ERAS plus MOM (n = 80). The MOM group received 15 mL on postoperative day 0 and then 30 mL twice daily until first flatus or bowel movement. The primary outcome was the time from surgery to resumption of a well-tolerated solid diet. Secondary outcomes included POI incidence, time to first flatus, patient-reported outcomes, and MOM-related complications. Among 160 patients, 60 (37.5%) had gynecologic malignancies: endometrial cancer (n = 34), ovarian cancer (n = 16), cervical cancer (n = 8), and leiomyosarcoma (n = 2). Time to well-tolerated solid diet was significantly shorter in the MOM group compared with the control group (20.6 ± 10.9 vs 28.8 ± 16.3 h; P < 0.001). The incidence of POI was also significantly lower (3.8% vs 27.5%; P < 0.001), and time to first flatus was shorter (17.1 ± 7.9 vs 22.3 ± 10.8 h; P < 0.001). Patient-reported outcomes favored the MOM group, with higher eating and daily activity satisfaction scores. No severe adverse events occurred in the MOM group. Adding MOM to ERAS was associated with reduced POI incidence and faster recovery of bowel function in patients undergoing abdominal hysterectomy for benign or malignant conditions. Thai Clinical Trials Registry (TCTR: TCTR20230816005), registered on 16 August 2023.
Clinical relevance
Postoperative ileus (POI) remains a significant source of morbidity, prolonged hospitalization, and patient dissatisfaction following hysterectomy, even within optimized ERAS pathways. This RCT addresses the gap of whether an inexpensive, widely available osmotic laxative — milk of magnesia (MOM) — can augment standard ERAS protocols to further reduce POI incidence in a gynecologic surgical population that includes both benign and malignant indications. Given the high prevalence of hysterectomy globally and the persistent burden of POI despite ERAS implementation, these findings are immediately clinically actionable.
Key findings
1. Time to resumption of a well-tolerated solid diet was significantly shorter in the MOM group versus ERAS-alone controls (20.6 ± 10.9 h vs. 28.8 ± 16.3 h; P < 0.001), representing a mean reduction of approximately 8.2 hours. 2. The incidence of POI was markedly lower in the MOM group compared to controls (3.8% vs. 27.5%; P < 0.001), yielding a number needed to treat (NNT) of approximately 4.2 to prevent one case of POI. 3. Time to first flatus was significantly shorter in the MOM group (17.1 ± 7.9 h vs. 22.3 ± 10.8 h; P < 0.001), reflecting a mean reduction of approximately 5.2 hours. 4. Patient-reported outcomes, including eating satisfaction and daily activity satisfaction scores, were superior in the MOM group, indicating meaningful patient-centered benefit beyond objective bowel function metrics. 5. The study population included a high-risk subgroup: 60 of 160 patients (37.5%) had gynecologic malignancies (endometrial cancer n=34, ovarian cancer n=16, cervical cancer n=8, leiomyosarcoma n=2), suggesting benefit extends to oncologic surgical cases. 6. No severe adverse events were attributable to MOM, supporting a favorable safety profile at the dosing regimen used (15 mL on POD 0, then 30 mL twice daily until first flatus or bowel movement).
Practice implications
Clinicians managing patients undergoing abdominal hysterectomy — for both benign and malignant indications — should consider incorporating oral milk of magnesia into existing ERAS protocols, initiating 15 mL on postoperative day 0 and continuing 30 mL twice daily until first flatus or bowel movement, as this regimen was associated with a >7-fold reduction in POI incidence without serious adverse events. Patient selection can be broad, encompassing both benign gynecologic and gynecologic oncology populations, though extrapolation to minimally invasive or non-gynecologic abdominal surgery requires further study. Given its low cost, wide availability, and favorable safety profile, MOM represents a pragmatic and evidence-supported adjunct to standard ERAS care that may reduce length of stay and improve patient-reported recovery experience.