Mindfulness Meditation Reduces Stress and Hospital Stay in Gastrointestinal Tumor Patients During Perioperative Period

Introduction

Gastrointestinal cancers represent over a quarter of global cancer incidence and one-third of cancer deaths, markedly impacting China’s health burden [1,2]. These malignancies trigger significant psychological distress, including depression and anxiety, compounded by surgical stressors like fasting, anesthesia, pain, and reconstructive procedures [3–5]. Such conditions amplify perioperative stress, leading to neuroendocrine disturbances such as excessive cortisol, hypertension, and arrhythmias [6–8]. These disruptions can impair immune function and worsen physiological and psychological outcomes, underscoring the need for effective management of perioperative stress to enhance patient recovery and overall treatment success [9–11].

Introduced by Professor Kabat-Zinn in the 1980s, mindfulness involves non-judgmental awareness of the present, improving psychological outcomes and mental resilience [12–14]. It has been effectively used in managing chronic conditions like depression, hypertension, and cancer, showing benefits in reducing anxiety, depression, and pain, while possibly boosting immune function [15–17].

Recent studies [18,19] in gastrointestinal tumor patients showed that mindfulness during the perioperative period can mitigate physiological stress markers such as cortisol levels and blood pressure, supporting better surgical recovery and emotional stability [20–22]. The present study aimed to investigate the effectiveness of short-term mindfulness meditation in alleviating psychological and physiological stress levels among perioperative patients with gastrointestinal tumors. Addressing a critical gap in current research, this study focused on a patient group for whom prolonged mindfulness interventions are not feasible due to the rapid scheduling needs of tumor surgeries in China. We assessed whether a condensed mindfulness approach can significantly reduce stress markers such as cortisol and mitigate negative emotional states during the perioperative period, thus potentially enhancing patient recovery and affecting disease outcomes.

Material and Methods

ETHICS APPROVAL AND CONSENT TO PARTICIPATE:

This study was approved by the Ethics Committee of Tongren Hospital, Shanghai (2022-099-02). All research involving human participants was conducted in compliance with the ethical guidelines of both the institutional and national research committees, adhering to the 1964 Helsinki Declaration and its subsequent updates. Informed consent was secured from all participants or their legal guardians prior to their inclusion in the study.

CONSENT FOR PUBLICATION:

Written informed consent for publication was obtained from all patients and their families included in this analysis.

SAMPLE SIZE CALCULATION:

To define the minimum sample size, we selected 10 adult patients undergoing gastrointestinal tumor resection in our hospital, for a preliminary study based on serum cortisol difference, which is the primary endpoint of this RCT. Subsequently, we collected feedback to optimize the study plan. The mean difference in pre- and post-intervention serum cortisol levels in the experimental group was 15 μg/L (pre: 150.08±24.56 μg/L, post: 134.98±22.28 μg/L, n=10). For our sample size calculation, we used the average standard deviation of 23.42 μg/L. The sample size was calculated using PASS 15 software, with a group ratio n₁/n₂=1, α=0.05 (bilateral), and power (1-β) =0.8. Considering a 15% sample loss rate, we determined that at least 42 samples were needed in each group, totaling 84 adult patients.

Before any treatment was administered, patients or their family members provided informed consent and underwent screening based on the study’s inclusion criteria. The research design, objectives, and protocols were rigorously reviewed and approved by the ethics committee of our hospital, ensuring compliance with established guidelines and regulations. This study was conducted in strict accordance with the ethical standards of the Declaration of Helsinki for medical research involving human subjects. To safeguard participant privacy, all data were handled confidentially, and personal identifiers were removed from the dataset prior to analysis.

PARTICIPANTS:

For this study, 84 patients undergoing gastrointestinal tumor resection in our hospital were recruited from December 2022 to July 2023. They were randomly assigned to the control and experimental group in a 1: 1 ratio. Randomized sequences were generated and determined by external individuals using SPSS software prior to participant recruitment.

STATISTICAL ANALYSIS:

SPSS 26.0 software was utilized for all statistical analyses. We compared mean values of continuous variables such as cortisol levels, blood pressure, and heart rate between the control and experimental groups at baseline and specific time points after the intervention. This test was chosen due to its effectiveness in comparing means between 2 independent groups when the data is normally distributed. We analyzed changes in psychological scales (SAI, VAS, FFMQ) and physiological markers (serum cortisol, blood pressure, heart rate) over multiple time points within the same subjects. This test helps in assessing the time effect, group effect, and the interaction between time and group, which is crucial for studies with longitudinal measurements. Count data and non-normally distributed continuous variables provided a robust analysis method that does not assume normal distribution of the data. It is applied when the assumption of sphericity in repeated measures ANOVA was violated. This test is a multivariate criterion for testing the hypothesis about the effect of the independent variables on the multivariate dependent variables, offering a more general approach to handling violations of ANOVA assumptions. It is used to compare the before and after measurements within the same group, and is particularly useful for assessing the impact of our intervention on continuous variables within the experimental or control groups. Each statistical test was selected based on the data type, distribution, and the specific objectives of our analysis, ensuring that our results are robust and reliable. A significance level of P<0.05 was considered statistically significant for all tests.

Results

PARTICIPANTS’ ENTRY INTO THE GROUP:

For this study, 84 adult patients undergoing gastrointestinal tumor resection were included. However, 6 participants were excluded due to specific reasons: 3 participants voluntarily withdrew from the study, citing personal reasons, and 3 were excluded due to serious postoperative surgical complications. Thus, 78 patients (92.8%) were randomly assigned to the experimental group (n=39) and control groups (n=39). The flow chart of participant progression is shown in Figure 1.

BASELINE DATA:

The baseline characteristics of each sample group are presented in Table 2. No statistically significant differences were observed between the 2 groups to concerning gender, age, education level, BMI, disease type, underlying disease, tumor stage, and surgical method (P>0.05).

ANOVA FOR REPEATED MEASUREMENT:

In our analysis, repeated measures ANOVA was utilized to assess the effects of time (within-subjects factor) and group (between-subjects factor) on perioperative serum cortisol concentration, blood pressure, heart rate, and psychological stress indices (SAI, VAS, and FFMQ). The specific factors included:

TIME:

Measured at 5 levels corresponding to different time points in the perioperative period (upon admission, one day before surgery, the first day after surgery, the third day after surgery, and the fifth day after surgery).

GROUP:

Two levels, experimental and control.

The interaction effects between time and group were also explored to determine if changes over time differed significantly between the 2 groups. This detailed breakdown aims to provide a thorough understanding of how and why these variables fluctuate over time and between groups. The results showed that there was no significant interaction among the indices, except FFMQ (P<0.05).

CORTISOL: Cortisol levels were monitored at 5 time points around the surgery. As depicted in Figure 2, both groups initially showed an increase in cortisol, peaking on the third day after surgery, then decreasing. The experimental group’s decrease on the fifth day after surgery was significantly greater than that of the control group (P=0.043), highlighting the effectiveness of the intervention in reducing stress. No overall significant group difference was observed across the time points (F=1.503, P=0.224) (Table 3).

CHANGES OF BLOOD PRESSURE AND HEART RATE: Significant reductions were observed in heart rate (F=121.467, P=0.001) (Table 4) and systolic blood pressure (F=23.376, P=0.001) in the experimental group after the intervention, as shown in Figures 3 and 4. Conversely, diastolic blood pressure remained stable across both groups (Figure 5). In contrast, the control group exhibited no significant changes in heart rate or blood pressure, confirming the differential impact of the intervention.

ANALYSIS OF SAI, VAS, AND FFMQ: Repeated measures ANOVA showed that SAI, VAS, and FFMQ were significantly different between the 2 groups at different times (F=16.675, P=0.001; F=486.076, P=0.001; F=32.709, P=0.001 for SAI, VAS, and FFMQ, respectively) (Table 5). We observed that the SAI scores increased and then decreased with the intervention in both groups (Figure 6), and the SAI scores of the experimental group at each time point were lower than those of the control group. With the increasing number of interventions, the mindfulness ability tended to improve in the experimental group, and the FFMQ scores of the experimental group at each time point were higher than those of the control group (p=0.001,). In contrast, FFMQ did not change significantly with time in the control group. In addition, the VAS showed significant differences between the groups only on the 5th day after the operation (Figure 7).

COMPARATIVE ANALYSIS OF REHABILITATION AND OTHER INDICES: The results demonstrate a significant reduction in length of hospital stay (t=−3.157, P=0.002) and postoperative supplementary analgesic requirements (t=−2.039, P=0.045) in the experimental group compared to the control group (Table 6). Although no statistically significant differences were found, the experimental group still exhibited better results for time to first postoperative flatus, postoperative complications, postoperative fever, and hospitalization costs compared to the control group.

Discussion

Mindfulness meditation, extensively studied in neuroscience and psychology, holds promise for surgical applications, particularly in managing perioperative stress in gastrointestinal tumor patients. Studies like those by Emanuel et al and Hanley support mindfulness as a feasible adjunctive tool for surgical settings, anticipating significant benefits in stress management and patient recovery. Our study specifically addresses the gap in applying short-term mindfulness interventions in such high-stakes environments. We found that even brief mindfulness training could significantly alleviate physiological and psychological stress, thus reducing hospital stay durations and associated costs. This finding underscores the importance of adapting mindfulness techniques to fit the surgical timeline, potentially enhancing patient outcomes by mitigating the harmful effects of prolonged stress responses like increased blood pressure, suppressed immune function, and exacerbated organ strain during the perioperative period.

This study introduces significant novelties in the application of short-term mindfulness interventions to manage perioperative stress in patients undergoing gastrointestinal tumor resection. By demonstrating that brief mindfulness practices can significantly reduce serum cortisol levels and improve psychological stress markers (SAI, VAS, and FFMQ scores), our research highlights the clinical viability of incorporating mindfulness into the perioperative care regimen. The innovative aspect of condensing mindfulness training to suit the surgical schedule addresses a critical gap in perioperative patient care. Clinically, this approach offers a non-pharmacological method to enhance patient outcomes, potentially reducing postoperative complications and shortening hospital stays. These findings suggest that even limited-duration mindfulness interventions could substantially benefit patients facing high-stress surgical environments, providing a scalable and cost-effective adjunct therapy in surgical settings.

This study highlights the significant benefits of short-term mindfulness meditation in reducing hospital stay durations and associated costs for patients undergoing gastrointestinal tumor surgery. The experimental group, which underwent mindfulness training, had a notable decrease in total hospitalization time compared to the control group (9.21±3.11 vs 11.62±3.62 days, P=0.002), with no significant difference in preoperative stays but a substantial reduction postoperatively (5.33±1.63 vs 6.87±3.00 days, P<0.010). This reduction underscores the intervention’s cost-effectiveness, aligning with systematic reviews indicating mindfulness as a financially viable clinical strategy. Statistically, mindfulness intervention significantly lowered serum cortisol levels (120.38±35.78 vs 139.95±47.54, P<0.043) and improved mindfulness scores (143.46±12.11 vs 116.95±11.57), demonstrating its efficacy in managing physiological and psychological stress during the perioperative period. These results are consistent with earlier findings that show short-term mindfulness interventions can swiftly affect stress indicators postoperatively, contributing to shorter hospital stays. The experimental group also had lower demands for supplementary analgesics compared to controls (5±12.82% vs 11±28.2%, P=0.045), suggesting an additional benefit in managing postoperative pain. This finding is particularly relevant as it indicates that even brief mindfulness interventions can mitigate acute perioperative pain, potentially reducing the need for additional pain management. These findings show the possible benefit of integrating mindfulness practices into perioperative care, emphasizing their role in enhancing patient recovery and reducing healthcare resource utilization. Future studies should explore optimizing the frequency and duration of mindfulness interventions to maximize clinical benefits.

Recent related articles have inspired and shaped our research. Dave et al [26] discussed the benefits of mindfulness in gastroenterology, underscoring its efficacy in enhancing well-being and patient care, akin to our findings on its impact during the perioperative phase. Our research extends these insights by quantitatively demonstrating how short-term mindfulness interventions reduce stress markers and enhance postoperative recovery in gastrointestinal surgery patients. Hymowitz et al [27] review the broader applications of mindfulness-based interventions (MBIs) to improve postoperative outcomes, corroborating our results and emphasizing the potential of MBIs to optimize patient recovery and satisfaction. Benchimol-Elkaim et al [28] explored an innovative VR-based approach to reduce pediatric perioperative anxiety. Although targeting a different demographic with technology-enhanced mindfulness, their work highlights the adaptability of MBIs across various surgical contexts. Our study contributes by focusing on adult patients with gastrointestinal tumors, showing that even traditional, short-term mindfulness practices can significantly mitigate stress and improve clinical outcomes without advanced technological interventions.

Riegner et al [29] applied thermal stimulation (49°C) to the lower extremities of 40 participants to induce a sensation of burning. After 4 separate 20-minute sessions of mindfulness training, the group practicing mindfulness reported a significant reduction of 32% in pain intensity and a corresponding decrease of 33% in the unpleasantness of pain. Reiner et al [30] conducted a similar experiment to that of Riegner et al, while Garland et al [31] demonstrated that administering a single 15-minute mindfulness exercise in a hospital setting immediately reduced acute pain intensity by 30%. Although there are slight variations in the types and intensity of pain induced above, these findings support our study’s conclusions by providing evidence that mindfulness can alleviate acute pain [32,33]. This effect may be attributed to activating cortical regions like the orbitofrontal cortex and right anterior insula that regulate pain perception, evaluation, cognition, and emotional response, thus enhancing patients’ ability to coexist harmoniously with their pain [34]. Alternatively, mindfulness intervention might stimulate parasympathetic nerve activity within the autonomic nervous system, which helps mitigate unpleasant sensations associated with pain, leading to its ultimate relief. Although we still lack a clear understanding of the precise biological mechanism behind the analgesic effects of mindfulness training, conducting more comprehensive clinical studies will provide compelling evidence for optimizing strategies and provide patients with enhanced care and improved treatment outcomes [35].

This study is limited by its small, single-center sample, potentially introducing selection bias and reducing the generalizability of our findings. The lack of blinding and the absence of long-term follow-up further limit the conclusiveness of our results. We did not examine the effects of mindfulness on perioperative complications or long-term disease outcomes. Additionally, intraoperative adverse events and mild postoperative complications, such as superficial surgical site infections, could affect postoperative cortisol levels. These factors, which were not controlled for in our analysis, could have influenced the study results and introduce additional biases. There is a need for multi-center trials with refined exclusion criteria, including controls for hypertension and medication effects on heart rate. Implementing a blinded design, considering intraoperative factors like bleeding and surgery duration, and incorporating long-term follow-ups will enhance our understanding of mindfulness’s impact on perioperative stress and patient outcomes.

Conclusions

Our hypothesis that short-term mindfulness meditation alleviates perioperative stress reaction in patients with gastrointestinal cancer is supported by the results of the study. It can not only enhance mental health by lessening perioperative anxiety, but also by reducing cortisol concentration, a sensitive indicator of stress, and reducing systolic blood pressure and heart rate to achieve the effect of alleviating stress levels and improving the mindfulness ability of the patient. Additionally, it alleviates postoperative pain, reduces the need for analgesic drugs, promotes patient rehabilitation after surgery, and shortens hospital stay.