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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 85-88

Postoperative ileus: A study on the role of chewing gum to reduce its duration


Department of General Surgery, RUHS College of Medical Sciences, Jaipur, Rajasthan, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Manish Jakhar
Department of General Surgery, RUHS College of Medical Sciences, Sector 11, Kumbha Marg, Pratap Nagar, Jaipur - 302 033, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_84_17

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  Abstract 

Background: Post operative ileus (POI) is the transient absence of gut motility without any mechanical obstruction, commonly occuring after abdominal surgery. It is reported to occur in 25% patients. Although it may resolve spontaneously with two-three days there have been many studies which have evaluated the role of early feeding in recovery from postoperative ileus. The study was conducted to evaluate the role of chewing gum for early recovery of postoperative ileus.
Materials and Methods: This prospective comparative study was conducted from March, 2017 to September, 2017 on patients who underwent exploratory laparotomy and any kind of intestinal anastomosis either during emergency or elective surgeries. The patients were divided into 2 groups each group having 25 patients. Patients in study group (n=25) were asked to chew one stick of chewing gum for 30 min four times a day until passing flatus while the control group (n=25) patients were kept nil per orally until the passage of flatus. A probability value of less than 5% (P < 0.05) was considered significant. The Chi-square test was used to check for differences between proportions.
Results: Total male patients were 33 and 17 were female. There was no significant difference in the appearance of bowel sounds, mean time of passage of flatus, stool passage and feeling of hunger between study and control group. In all these variables the mean time was shorter in study group. The patients were discharged early in study group with a statistically significant difference.
Conclusion: Based on the results it can be concluded that the chewing gum does not seem to be significant to reduce the duration of post operative ileus. Although it was seen that the duration of overall recovery of bowel movements in form of appearance of bowel sound, passing flatus and motion and feeling of hunger, occurred early in patients chewing gum but was not significant statistically.

Keywords: Chewing gum, ileus, postoperative


How to cite this article:
Kalyanwat AS, Jakhar M, Jain S. Postoperative ileus: A study on the role of chewing gum to reduce its duration. Saudi Surg J 2018;6:85-8

How to cite this URL:
Kalyanwat AS, Jakhar M, Jain S. Postoperative ileus: A study on the role of chewing gum to reduce its duration. Saudi Surg J [serial online] 2018 [cited 2018 Nov 18];6:85-8. Available from: http://www.saudisurgj.org/text.asp?2018/6/3/85/240916


  Introduction Top


Postoperative ileus (POI) is the transient absence of gut motility without any mechanical obstruction, commonly occurring after abdominal surgery. It is reported to occur in 25% patients.[1] POI spontaneously resolves within 2–3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus.[2] The pathophysiology behind this is the complex interaction between autonomic and central nervous system function, as well as local and regional substances such as inflammatory mediators, released during surgery as a part of stress response, may cause disorganized electrical activity and result into paralysis of intestine. Early feeding is associated with early recovery of gut motility,[3] but many times, patients complain of nausea and vomiting and are reluctant to take feed during postoperative period. It is reported that sham feeding stimulates bowel motility;[4],[5] it raises the recent interest in chewing gum as sham feed for early recovery of POI. The proposed mechanism of action of chewing gum in enhancing bowel motility by stimulating cephalic- vagal reflex and triggering the release of saliva, digestive juice and gastrointestinal hormones.

In some recent randomized study, gum chewing was found to improve gut motility and led to an early recovery of POI,[6] whereas in meta-analysis, it was found insignificant.[7] We conducted this study to evaluate the role of chewing gum for early recovery of POI.


  Materials and Methods Top


This prospective comparative study was conducted at RUHS College of Medical Sciences and attached RDBP Jaipuria Hospital Jaipur, Rajasthan, from March 2017 to September 2017, with the permission of the Research Review Board and Ethical Committee of the college. Informed written consent was obtained from all the patients enrolled in the study. In this study, the patients included were those who underwent laparotomy and underwent any kind of intestinal anastomosis either during emergency or elective surgeries. It included all anastomosis done by hand sewing as well as by GI stapler and also included all types of anastomosis, whether end to end, end to side, or side to side. In the study, we included all the patients who underwent clean contaminated laparotomy, that is elective laparotomy with prior bowel preparation and contaminated laparotomy where prior bowel preparation was not done but gut was opened in controlled manner so the contamination of the peritoneal cavity was very minimal, followed by resection anastomosis of intestine whether it was between small intestines, between small and large intestines, or between large intestines. We also included the patients with ileostomy closure in which ileoileal end-to-end anastomosis was done. We excluded the dirty laparotomy in which feculent peritonitis and purulent peritonitis were present. Furthermore, patients with anastomotic leak, patients with septicemia, and the patients who were in shock were excluded from the study. The patients were divided into two groups by drawing a slip with each group having 25 patients.

All patients in the study group (n = 25) were asked to chew one stick of chewing gum for 30 min four times a day in morning, afternoon, evening, and before bed time, from 6 h after surgery (after recovery from anesthesia) until passing flatus. In the control group (n = 25), patients were kept nil per orally in the postoperative period until the passage of flatus. Commercially available chewing gum was used in this study. Every patient was asked to report immediately the time of feeling an intestinal movement, passing flatus or stool, first time of feeling hunger, first time of eat, and document the time of hospital discharge.

Routine blood investigation and serum electrolyte levels were done in all cases. Serum electrolyte was monitored daily for 3 days and was corrected if imbalanced. For analgesia injection, diclofenac was given every 8 h in intravenous form for 3 days. Early mobilization was encouraged. Oral intake was started after passing flatus, and the patient was discharged when they passed stool.

The statistical package for social sciences (SPSS) software version 20.0 manufactured by IBM Corporation was used for the statistical analysis. A probability value of <5% (P < 0.05) was considered statistically significant. The Chi-square test was used to check for differences between proportions.


  Results Top


In this study, total number of fifty patients were included and prospectively randomized into two groups, 25 patients in the study group and 25 in the control group. The groups were equivalent by demographics and surgical characteristics. During the study period, a total number of 53 patients were enrolled. Two patients required postoperative Intensive Care Unit care with inotropic agent support; these were excluded from the study. One patient developed wound dehiscence was also excluded from the study.

Total male patients were 33 and 17 were females. The mean age of study group was 38.12 ± 14.41 years, and in the control group, it was 38.08 ± 14.07 years.

Among the various procedures performed, ileoileal anastomosis was done in 36 patients, ileotransverse anastomosis done in nine patients, jejunojejunal side to side anastomosis done in 3 patients, and colorectal anastomosis done in two patients.

Abdominal drain was placed in pelvis in all the patients and was removed when drain output was <50 ml/day and serous. Five (2.5%) patients, 3 in the study group and 2 in the control group, developed wound discharge and was managed conservatively. No patients had anastomotic leak in both the groups.

The mean time for appearance of bowel sound in the study group was 51.54 ± 6.33 h and 61.20 ± 8.42 h in the control group [Table 1]. Although bowel sounds appeared early in the study group, statistically, it was not significant (P = 0.13). The mean time for passage of flatus in study group was 67.36 ± 5.12 h and 74.64 ± 9.05 h in control group. The patients in the study group passed flatus earlier than the control group but not significant statistically (P = 0.14). The passing of stool in the study group (89.44 ± 7.64) was also early as compared to the control group (103.76 ± 16.29), but again, this was not significant statistically (P = 0.21). The mean time of feeling of hunger was 70.72 ± 5.53 h in the study group and 80.96 ± 11.83 h in the control group; again, it was statistically not significant (P = 0.06). The duration of surgery was 120.6 ± 24.76 min in the study group and 113.06 ± 29.56 min in the control group; the P value was 0.81 which was not statistically significant. The patient was discharged early in the study group 104.96 ± 10.45 h than in the control group 121.44 ± 20.62 h and it was statistically significant (P = 0.03).
Table 1: Evaluation of various variables in the study and control group

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  Discussion Top


In various meta-analysis, it was empathized that more research is needed to establish the role of chewing gum in early recovery of POI.[7],[8] The present study was conducted to evaluate the effect of gum chewing on POI in patients undergoing intestinal resection anastomosis. This study included a total of fifty patients, out of which 25 were in the study group in which chewing gum was given and 25 were in the control group in which chewing gum was not given. The duration of surgery is known to affect POI. The duration of surgery between the groups was not significant statistically (P = 0.81). There was no requirement of blood transfusion intraoperatively and postoperatively in any patient in either group.

The mean time for appearance of bowel sound was shorter in the study group, but it was not statistically significant. Marwah et al. reported that appearance of bowel sound was significantly earlier in the study group.[6] Matros et al. in their clinical trial suggested that gum chewing does not reduce the duration of POI.[9]

In the study group, the time for the passage of first flatus and the first defecation were short, but it was not statistically significant. Matros et al. reported in their randomized trial that there were no significant difference in time to passage of first bowel movement.[9] Marwah et al. reported that the mean time for the passage of first flatus as well as the first stool was significantly shorter in the study group.[6] Andersson et al. reported that the mean time to first flatus and defecation was shorter in the intervention group although the difference was not significant.[10] Quah et al.[11] and Cavuşoğlu et al.[12] also reported that the time for the passage of first flatus and the first defecation were short in the study group, but it was not statistically significant.

The mean time taken for the feeling of hunger was short in the study group, but it was not significant. Schuster et al. reported that the mean time for appearance of feeling of hunger was short in patients' chewing gum, but the difference was not statistically significant.[13] Marwah et al. found that the mean time taken to experience the feeling of hunger was significantly shorter in the study group in comparison to the control group.[6]

The patients in the study group were discharged early than the control group, and it was the only finding in this study which was statistically significantly (P = 0.03). The postoperative hospital stay was shorter in study group (mean 104.96 ± 10.45 h) as compared to the control group (mean 121.44 ± 20.62 h). Marwah, et al.,[6] Chan MK,[14] and Noble EJ, et al.[15] also reported a statistically significant shorter hospital stay in the study group whereas Fitzgerald JE et al.[16] and de Castro SM, et al.[17] found that it was not statistically significant.


  Conclusion Top


The chewing gum does not seem to be significant to reduce the duration of post operative ileus. Although it was seen that the duration of overall recovery of bowel movements in form of appearance of bowel sound, passing flatus and motion and feeling of hunger, occured early in patients chewing gum but was not significant statistically. Nonetheless the patients in gum chewing group significantly discharged early. The chewing gum does not cause any complications and adverse reactions. It require more studies and research to establish the role of chewing gum in post operative ileus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vather R, Bissett I. Management of prolonged post-operative ileus: Evidence-based recommendations. ANZ J Surg 2013;83:319-24.  Back to cited text no. 1
    
2.
Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci 1990;35:121-32.  Back to cited text no. 2
    
3.
Schwenk W, Böhm B, Haase O, Junghans T, Müller JM. Laparoscopic versus conventional colorectal resection: A prospective randomised study of postoperative ileus and early postoperative feeding. Langenbecks Arch Surg 1998;383:49-55.  Back to cited text no. 3
    
4.
Jepsen JM, Skoubo-Kristensen E, Elsborg L. Rectosigmoid motility response to sham feeding in irritable bowel syndrome. Evidence of a cephalic phase. Scand J Gastroenterol 1989;24:53-6.  Back to cited text no. 4
    
5.
Stern RM, Crawford HE, Stewart WR, Vasey MW, Koch KL. Sham feeding. Cephalic-vagal influences on gastric myoelectric activity. Dig Dis Sci 1989;34:521-7.  Back to cited text no. 5
    
6.
Marwah S, Singla S, Tinna P. Role of gum chewing on the duration of postoperative ileus following ileostomy closure done for typhoid ileal perforation: A prospective randomized trial. Saudi J Gastroenterol 2012;18:111-7.  Back to cited text no. 6
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7.
Atkinson C, Penfold CM, Ness AR, Longman RJ, Thomas SJ, Hollingworth W, et al. Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection. Br J Surg 2016;103:962-70.  Back to cited text no. 7
    
8.
Su'a BU, Pollock TT, Lemanu DP, MacCormick AD, Connolly AB, Hill AG, et al. Chewing gum and postoperative ileus in adults: A systematic literature review and meta-analysis. Int J Surg 2015;14:49-55.  Back to cited text no. 8
    
9.
Matros E, Rocha F, Zinner M, Wang J, Ashley S, Breen E, et al. Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg 2006;202:773-8.  Back to cited text no. 9
    
10.
Andersson T, Bjerså K, Falk K, Olsén MF. Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy – Arandomized controlled trial. BMC Res Notes 2015;8:37.  Back to cited text no. 10
    
11.
Quah HM, Samad A, Neathey AJ, Hay DJ, Maw A. Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Dis 2006;8:64-70.  Back to cited text no. 11
    
12.
Cavuşoğlu YH, Azili MN, Karaman A, Aslan MK, Karaman I, Erdoğan D, et al. Does gum chewing reduce postoperative ileus after intestinal resection in children? A prospective randomized controlled trial. Eur J Pediatr Surg 2009;19:171-3.  Back to cited text no. 12
    
13.
Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg 2006;141:174-6.  Back to cited text no. 13
    
14.
Chan MK, Law WL. Use of chewing gum in reducing postoperative ileus after elective colorectal resection: A systematic review. Dis Colon Rectum 2007;50:2149-57.  Back to cited text no. 14
    
15.
Noble EJ, Harris R, Hosie KB, Thomas S, Lewis SJ. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg 2009;7:100-5.  Back to cited text no. 15
    
16.
Fitzgerald JE, Ahmed I. Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery. World J Surg 2009;33:2557-66.  Back to cited text no. 16
    
17.
de Castro SM, van den Esschert JW, van Heek NT, Dalhuisen S, Koelemay MJ, Busch OR, et al. A systematic review of the efficacy of gum chewing for the amelioration of postoperative ileus. Dig Surg 2008;25:39-45.  Back to cited text no. 17
    



 
 
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