Randomized clinical trial of the effect of gum chewing on postoperative ileus and inflammation in colorectal surgery

Effect evaluation of different preventive measures for ileus after abdominal operation: A systematic review and network meta-analysis

Background

Different approaches to the prevention of postoperative ileus have been evaluated in numerous randomized controlled trials. This network meta-analysis aimed to investigate the relative effectiveness of different interventions in preventing postoperative ileus.

Methods

Randomized controlled trials (RCTS) on the prevention of postoperative ileus were screened from Chinese and foreign medical databases and compared. STATA software was used for network meta-analysis using the frequency method. Random-effects network meta-analysis was also used to compare all schemes directly and indirectly.

Results

A total of 105 randomized controlled trials with 18,840 participants were included in this report. The results of the network meta-analysis showed that intravenous analgesia was most effective in preventing the incidence of postoperative ileus, the surface under the cumulative ranking curve (SUCRA) is 90.5. The most effective intervention for reducing the first postoperative exhaust time was postoperative abdominal mechanical massage (SUCRA: 97.3), and the most effective intervention for reducing the first postoperative defecation time was high-dose opioid antagonists (SUCRA: 84.3). Additionally, the most effective intervention for reducing the time to initiate a normal diet after surgery was accelerated rehabilitation (SUCRA: 85.4). A comprehensive analysis demonstrated the effectiveness and prominence of oral opioid antagonists and electroacupuncture (EA) combined with gum.

Conclusion

This network meta-analysis determined that oral opioid antagonists and EA combined with chewing gum are the most effective treatments and optimal interventions for reducing the incidence of postoperative ileus. However, methods such as abdominal mechanical massage and coffee require further high-quality research.

The effect of dimethicone on preventing ileus in patients with pelvic and femoral fractures: A clinical trial

Ileus and pseudo-obstruction are clinical syndromes that are among the most common postoperative complications. Identifying an effective treatment approach for these conditions is essential. Therefore, the aim of this study is to investigate the effect of Dimethicone on preventing ileus in patients with pelvic and femoral fractures. This study was conducted on 120 patients, with 60 individuals in the Dimethicone group and 60 individuals in the control group. After recording demographic information and clinical notes, bowel movements and defecation after surgery were also recorded. The statistical tests of Chi-square, Fisher's exact-test, Mann-Whitney, and independent t-test were utilized to compare the data. The primary outcome of the study determined the incidence of ileus in the intervention and control groups (intervention group = 1.7 % and control group = 3.3 %) (P = 0.99). The secondary outcome involved comparing the time of gas expulsion between the two groups, intervention, and control (intervention group = 21.05 h and control group = 22.03 h) (P = 0.065). Although the time of gas and feces expulsion, as well as the initiation of bowel movements and the occurrence of ileus, were lower in the intervention group, there was no statistically significant difference in the postoperative results, particularly regarding the occurrence of ileus and the reduction in the duration of feces and gas expulsion and the initiation of bowel movements in patients receiving Dimethicone compared to the control group. Considering the lack of statistical significance in the obtained results and the absence of similar studies using Dimethicone, further research and larger sample size studies with Dimethicone or other pharmacological methods are needed to find the most effective treatment approach in reducing the occurrence of ileus after surgery.

Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis

BACKGROUND

This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer.

METHODS

This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer.

RESULTS

The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD],  -  1.12; 95% confidence interval [CI], (-  1.25 to -  1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, -  1.31; 95% CI, -  1.67 to -   0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, -  2.87; 95% CI, -  3.84 to -  1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15).

CONCLUSION

Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.

Mismatch of populations between randomised controlled trials of perioperative interventions in major abdominal surgery and current clinical practice

BACKGROUND

Demographics of patients undergoing major abdominal surgery are changing. External validity of relevant RCTs may be limited by participants not resembling patients encountered in clinical practice. We aimed to characterise differences in age, weight, BMI, and ASA grade between participants in perioperative trials in major abdominal surgery and patients in a reference real-world clinical practice sample. The secondary aim was to investigate whether time since trial publication was associated with increasing mismatch between these groups.

METHODS

MEDLINE and Embase were searched for multicentre RCTs from inception to September 2022. Studies of perioperative interventions in adults were included. Studies that limited enrolment based on age, weight, BMI, or ASA status were excluded. We compared trial cohort age, weight, BMI, and ASA distribution to those of patients undergoing major abdominal surgery at our tertiary referral hospital during September 2021 to September 2022. We used a local, single-institution reference sample to reflect the reality of clinical practice (i.e. patients treated by a clinician in their own hospital, rather than averaged nationally). Mismatch was defined using comparison of summary characteristics and ad hoc criteria based on differences relevant to predicted mortality risk after surgery.

RESULTS

One-hundred and six trials (44,499 participants) were compared to a reference cohort of 2792 clinical practice patients. Trials were published a median (IQR [range]) 13.4 (5-20 [0-35]) years ago. A total of 94.3% of trials were mismatched on at least one characteristic (age, weight, BMI, ASA). Recruitment of ASA 3 + participants in trials increased over time, and recruitment of ASA 1 participants decreased over time (Spearman's Rho 0.58 and - 0.44, respectively).

CONCLUSIONS

Patients encountered in our current local clinical practice are significantly different from those in our defined set of perioperative RCTs. Older trials recruit more low-risk than high-risk participants-trials may thus 'expire' over time. These trials may not be generalisable to current patients undergoing major abdominal surgery, and meta-analyses or guidelines incorporating these trials may therefore be similarly non-applicable. Comparison to local, rather than national cohorts, is important for meaningful on-the-ground evidence-based decision-making.

Efficacy and safety of preoperative chewing gum for undergoing elective surgery: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

This meta-analysis aimed to investigate the safety and feasibility of preoperative chewing gum in adult patients undergoing elective surgery.

BACKGROUND

Postoperative chewing gum has been shown to be safe and effective for most surgeries, while the safety and efficacy of preoperative chewing gum are still controversial.

DESIGN

A meta-analysis of randomised controlled trials was performed.

NO PATIENT OR PUBLIC CONTRIBUTION

This was a meta-analysis involving no people or animals.

METHODS

The literature search was performed in 9 databases from inception to July 2022. Randomised controlled trials that compared the safety and efficacy of preoperative chewing gum and preoperative chewing no gum in adult patients undergoing elective surgery were included. The study was reported in compliance with PRISMA statement.

TRIAL REGISTRATION

PROSPERO CRD42022330223.

RESULTS

Fourteen trials involving 1433 adult patients who undergo elective surgery were pooled in this meta-analysis. The results showed that preoperative chewing gum group resulted in no significant difference in gastric pH (p = .13) and gastric fluid volume (p = .25) compared with non-gum-chewing group. In comparison with the non-gum-chewing group, the gum-chewing group was associated with shorter preoperative thirst score (p = .02), lower incidence of postoperative nausea (p = .0004), lower incidence of postoperative sore throat, lower incidence of postoperative hoarseness, lower postoperative pain score, shorter first postoperative anal exhaust time (p < .00001), shorter first postoperative defecation time (p < .00001) and shorter hospital days (p = .02).

CONCLUSIONS

Preoperative chewing gum was associated with lower discomforts and complication rates, without increasing gastric pH and gastric fluid volume. This strategy may be an innovative, feasible and safe choice for elective surgery in adults.

RELEVANCE TO CLINICAL PRACTICE

This study's results could be used as an evidence for the implementation of preoperative chewing gum in perioperative care for adult patients undergoing elective surgery.

Global cost of postoperative ileus following abdominal surgery: meta-analysis

BACKGROUND

Following abdominal surgery, postoperative ileus is a common complication significantly increasing patient morbidity and cost of hospital admission. This is the first systematic review aimed at determining the average global hospital cost per patient associated with postoperative ileus.

METHODS

A systematic search of electronic databases was performed from January 2000 to March 2023. Studies included compared patients undergoing abdominal surgery who developed postoperative ileus to those who did not, focusing on costing data. The primary outcome was the total cost of inpatient stay. Risk of bias was assessed using the Newcastle-Ottawa assessment tool. Summary meta-analysis was performed.

RESULTS

Of the 2071 studies identified, 88 papers were assessed for full eligibility. The systematic review included nine studies (2005-2022), investigating 1 860 889 patients undergoing general, colorectal, gynaecological and urological surgery. These studies showed significant variations in the definition of postoperative ileus. Six studies were eligible for meta-analysis showing an increase of €8233 (95 per cent c.i. (5176 to 11 290), P < 0.0001, I2 = 95.5 per cent) per patient with postoperative ileus resulting in a 66.3 per cent increase in total hospital costs (95 per cent c.i. (34.8 to 97.9), P < 0.0001, I2 = 98.4 per cent). However, there was significant bias between studies. Five colorectal-surgery-specific studies showed an increase of €7242 (95 per cent c.i. (4502 to 9983), P < 0.0001, I2 = 86.0 per cent) per patient with postoperative ileus resulting in a 57.3 per cent increase in total hospital costs (95 per cent c.i. (36.3 to 78.3), P < 0.0001, I2 = 85.7 per cent).

CONCLUSION

The global financial burden of postoperative ileus following abdominal surgery is significant. While further multicentre data using a uniform postoperative ileus definition would be useful, reducing the incidence and impact of postoperative ileus are a priority to mitigate healthcare-related costs, and improve patient outcomes.

The impact of gum-chewing on postoperative ileus following gynecological cancer surgery: A systematic review and meta-analysis of randomized controlled trials

Objective

To assess the effect and safety of gum-chewing on the prevention of postoperative ileus after gynecological cancer surgery.

Methods

We conducted a systematic review of randomized controlled trials (RCTs) published between 2000 and 2022 in English and Chinese, using the EBSCO, Web of Science, Scopus, Cochrane Central Register of Controlled Trials (Cochrane database), PubMed, Medline (via Ovid), Chinese National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, and Wan Fang databases. A total of 837 studies were screened using Endnote software, and those that met the inclusion criteria were selected for analysis. The main outcome of interest was the incidence of postoperative ileus, and secondary outcomes included time to first flatus, time to first bowel movement, and length of hospital stay.

Results

Two authors extracted data and performed quality assessment independently. The review included six RCTs with a total of 669 patients. Compared with routine care, gum-chewing could significantly reduce the incidence of postoperative ileus (RR 0.46, 95% CI: 0.30, 0.72, P=0.0006), shorten the time to first flatus (WMD -9.58, 95% CI: -15.04, -4.12, P=0.0006), first bowel movement (WMD -11.31, 95% CI: -21.05, -1.56, P=0.02), and the length of hospital stay (WMD -1.53, 95% CI: -2.08, -0.98, P<0.00001).

Conclusions

Gum-chewing is associated with early recovery of gastrointestinal function after gynecological cancer surgery and may be an effective and harmless intervention to prevent postoperative ileus.

Systemaic review registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, identifier CRD42022384346.

Effects of Gum Chewing on Recovery From Postoperative Ileus: A Randomized Clinical Trail

BACKGROUND

Sham feeding with products such as chewing gum has been theorized to decrease the incidence and time to resolution of postoperative ileus. The conflicting findings in the literature on this subject are because in part of the use of mixed study populations, which has led to difficulties in assessing the value of sham feeding in ameliorating this condition.

PURPOSE

The aim of this study was to evaluate the efficacy of postsurgical gum chewing in restoring normal bowel movement in patients with colorectal cancer who had undergone abdominal surgery for colon resection.

METHODS

A randomized controlled trial was used to examine the time to first postoperative flatus and defecation. The intervention group ( n = 30) received xylitol chewing gum on the first day after colon resection, one piece of gum for 15 minutes, 3 times daily, until the time to first flatus and defecation. Both the intervention and control groups ( n = 30) received standard postoperative care and were encouraged to walk as soon as possible after surgery. The time to first flatus was reported by patients.

RESULTS

The time to first flatus and defecation in the intervention group was significantly shorter than that in the control group (39.13 ± 15.66 vs. 52.92 ± 21.97 hours and 54.55 ± 18.90 vs. 77.98 ± 34.59 hours, respectively). However, after controlling for age and surgical duration, only time to first flatus was significantly shorter in the intervention group. Significantly positive correlations were found between time to first flatus and time to first defecation in both groups.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

In this study, gum chewing was shown to have a positive effect on the time to first postoperative flatus and defecation. This inexpensive and noninvasive intervention may be recommended to decrease the time to resolution of postsurgical ileus in middle-aged and older patients who have undergone open abdominal surgery for colorectal resection.

Effects of chewing gum on gastrointestinal function in patients following spinal surgery: a meta-analysis and systematic review

PURPOSE

There are conflicting opinions regarding the efficacy of chewing gum for the recovery of gastrointestinal function in patients following spinal surgery. Thus, we aimed to conduct a systematic review and meta-analysis of existing articles to evaluate the effect of gum-chewing on patients following spinal surgery.

METHODS

A computer search was used to identify randomised controlled trials (RCTs) involving gum-chewing from eight databases: Cochrane Library, PubMed, Embase, MEDLINE, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database, and WanFang Data. After evaluating the risk of bias for the included studies, we used the Revman 5.3 software to conduct a meta-analysis of the data.

RESULTS

The study included seven RCTs, with a total of 706 patients. The meta-analysis reported that gum-chewing could shorten the interval between surgery and first bowel movement (mean deviation [MD] = - 23.02; 95% confidence interval [CI]: - 24.67, - 21.38; P < 0.00001), first flatus (MD = - 1.54; 95% CI - 2.48, - 0.60; P = 0.001), and first bowel sounds (MD = - 5.08; 95% CI - 6.02, - 4.15; P < 0.00001). Moreover, there was a significant reduction in postoperative analgesic dosage within 12 h (standardised mean difference [SMD] = - 0.28; 95% CI - 0.52, - 0.05; P = 0.02). However, there were no significant differences between the chewing gum and control groups (P > 0.05) regarding the postoperative nausea score, abdominal pain score, 24- and 48-h analgesic drug dosage, and length of hospital stay.

CONCLUSION

To a certain extent, masticating gum can promote the recovery of gastrointestinal function and reduce the need for postoperative analgesics in patients following spinal surgery. However, this conclusion is affected by the quantity and quality of the included articles. Therefore, additional high-quality studies are needed to verify these results.

The potential for autonomic neuromodulation to reduce perioperative complications and pain: a systematic review and meta-analysis

BACKGROUND

Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain.

METHODS

Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I² index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes.

RESULTS

From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n=721) or volunteers (n=679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n=23] or cervical transcutaneous [n=5]) were most common. Vagal neuromodulation reduced pain (n=10 studies; SMD=2.29 [95% CI, 1.08-3.50]; P=0.0002; I²=97%) and inflammation (n=6 studies; SMD=1.31 [0.45-2.18]; P=0.003; I²=91%), and improved cognition (n=11 studies; SMD=1.74 [0.96-2.52]; P<0.0001; I²=94%) and cardiovascular function (n=6 studies; SMD=3.28 [1.96-4.59]; P<0.00001; I²=96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both.

CONCLUSIONS

Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.

Transcutaneous electrical acupoint stimulation applied in lower limbs decreases the incidence of paralytic ileus after colorectal surgery: A multicenter randomized controlled trial

BACKGROUND

Postoperative paralytic ileus prolongs hospitalization duration, increases medical expenses, and is even associated with postoperative mortality; however, effective prevention of postoperative paralytic ileus is not yet available. This trial aimed to assess the preventative effectiveness of transcutaneous electrical acupoint stimulation applied in the lower limbs on postoperative paralytic ileus incidence after colorectal surgery.

METHODS

After ethics approval and written informed consent, 610 patients from 10 hospitals who were scheduled for colorectal surgery between May 2018 and September 2019 were enrolled. Patients were randomly allocated into the transcutaneous electrical acupoint stimulation (stimulated on bilateral Zusanli, Shangjuxu, and Sanyinjiao acupoints in lower limbs for 30 minutes each time, total 4 times) or sham (without currents delivered) group with 1:1 ratio. The primary outcome was postoperative paralytic ileus incidence, defined as no flatus for >72 hours after surgery.

RESULTS

Compared to the sham treatment, transcutaneous electrical acupoint stimulation lowered the postoperative paralytic ileus incidence by 8.7% (32.3% vs 41.0%, P = .026) and decreased the risk of postoperative paralytic ileus by 32% (OR, 0.68; P = .029). Transcutaneous electrical acupoint stimulation also shortened the recovery time to flatus, defecation, normal diet, and bowel sounds. Transcutaneous electrical acupoint stimulation treatment significantly increased median serum acetylcholine by 55% (P = .007) and interleukin-10 by 88% (P < .001), but decreased interleukin-6 by 47% (P < .001) and inducible nitric oxide synthase by 42% (P = .002) at 72 hours postoperatively.

CONCLUSION

Transcutaneous electrical acupoint stimulation attenuated the postoperative paralytic ileus incidence and enhanced gastrointestinal functional recovery, which may be associated with increasing parasympathetic nerve tone and its anti-inflammatory actions.

Gum Chewing, Added to Conventional Feeding, Reduces Risk of Post-Operative Ileus after Elective Hip and Knee Arthroplasty Procedures in Elderly Population: A Protocol for a Parallel Design, Open-Label, Randomized Controlled Trial

Introduction:

Postoperative ileus (poi) is defined as a temporary cessation of bowel movement after a surgical procedure. Cessation of bowel movement not only leads to disturbing constipation but also may lead to nausea, loss of appetite, and food intolerance. Literature reports “sham feeding” (gum-chewing) effect as an increase in chewing and saliva which enhances the gastric emptying and overall motility of gut as a cephalic phase of digestion. Therefore, we aim to assess the effect of adding gum-chewing to the conventional postoperative feeding regimen on restoring postoperative bowel function and length of stay in hospital of patients undergoing elective hip arthroplasty.

Methods and analysis:

This is a single-center, open-label, parallel design, superiority randomized-controlled trial with 2 treatment arms. The primary and secondary outcomes will be the time interval in hours from the end of surgery until the passage of flatus and the time interval in hours from the end of surgery until the passage of stool. Statistical analysis will be done using STATA software. Length of stay will be calculated by Kaplan–Meier analysis, with unadjusted comparison of groups by Mantel–Cox log rank test. Risk ratios for the time-to-become ileus free and time-to-discharge from hospital will be calculated by Cox regression modeling. P value as 0.05 or less will be taken as significant.

Ethics And Dissemination:

This protocol is exempted from Ethical review at this stage however all the required approvals will be taken from the ethical review committee before starting the study. Informed consent will be taken form the patient to enroll him/her in the study. Results of the study will be disseminated to the study participants, public health, and clinical professionals. The results would also be published in a reputable international journal.

Trial Registration:

This trial is registered on clinicaltrials.gov with ID: NCT04489875.

Highlights

Non-pharmacological interventions for the prevention of postoperative ileus after gynecologic cancer surgery

Postoperative ileus (POI) is characterized by impaired gastrointestinal motility after surgery. POI is a major concern for surgeons because it increases hospital stay, the cost of care, and postoperative morbidity in patients who have undergone extensive gynecological oncological surgery. Although several interventions have been proposed and investigated, no effective treatment for the prevention and management of POI has been established. The present review summarizes the current evidence on non-pharmacological interventions, including coffee consumption and chewing gum, used to prevent and treat POI. We obtained studies from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions

BACKGROUND

Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures.

METHODS

A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.

CONCLUSION

This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

Safety and Suitability of the SmartPill® after Abdominal Surgery: Results of the Prospective, Two-Armed, Open-Label PIDuSA Trial

INTRODUCTION

Postoperative ileus (POI) is a common complication after abdominal surgery. Until today, an evidence-based treatment of prolonged POI is still lacking, which can be attributed to the poor quality of clinical trials. Various different surrogate markers used to define POI severity are considered to be the cause of low-quality trials making it impossible to derive treatment recommendation. The SmartPill®, which is able to record pH values, temperature and pressure after ingestion, could be an ideal tool to measure transit times and peristalsis and therefore analyze POI severity. Unfortunately, the device has no approval for postoperative use due to safety concerns. The primary objective of the study is to determine safety of the SmartPill® in patients undergoing surgery. Secondary objectives were the quality of the recorded data and the suitability of the SmartPill® for analyzing intestinal motility after different surgical procedures.

METHODS

The PIDuSA Study is a prospective, 2-arm, open-label trial. At the end of surgery, the SmartPill® was applied to 49 patients undergoing abdominal surgery having a high risk for impaired intestinal motility and 15 patients undergoing extra-abdominal surgery. Patients were visited daily to access safety data of the SmartPill® on the basis of adverse and serious adverse events (AEs/SAEs). Suitability and data quality were investigated by analyzing data completeness and feasibility to determine transit times and peristalsis for all sections of the gastrointestinal tract.

RESULTS

In total, 179 AEs and 8 SAEs were recorded throughout the study affecting 42 patients in the abdominal (158 AEs) and 9 patients in the extra-abdominal surgery group (21 AEs, p = 0.061); none of them were device related. Primary capsule failure was observed in 5 patients, ultimately resulting in an impossibility of data analysis in only 3 patients (4.4%). 9% of the recorded data were incomplete due to the patient's incompliance in keeping the receiver close to the body. In 3 patients (4.4%), isolated small bowel transit could not be determined due to pH alterations as a result of prolonged POI.

DISCUSSION

Our study demonstrates that the use of the SmartPill® is safe after surgery but requires a reasonable patient compliance to deliver meaningful data. An objective analysis of transit times and peristalsis was possible irrespective of type and site of surgery in over 95% indicating that the SmartPill® has the potential to deliver objective parameters for POI severity in future clinical trials. However, in some patients with prolonged POI, analysis of small bowel transit could be challenging.

Comparison of treatment to improve gastrointestinal functions after colorectal surgery within enhanced recovery programmes: a systematic review and meta-analysis

Despite a significant improvement with enhanced recovery programmes (ERP), gastro-intestinal (GI) functions that are impaired after colorectal resection and postoperative ileus (POI) remain a significant issue. In the literature, there is little evidence of the distinction between the treatment assessed within or outside ERP. The purpose was to evaluate the efficiency of treatments to reduce POI and improve GI function recovery within ERP. A search was performed in PubMed and Scopus on 20 September 2019. The studies were included if they compared the effect of the administration of a treatment aiming to treat or prevent POI or improve the early functional outcomes of colorectal surgery within an ERP. The main outcome measures were the occurrence of postoperative ileus, time to first flatus and time to first bowel movement. Treatments that were assessed at least three times were included in a meta-analysis. Among the analysed studies, 28 met the eligibility criteria. Six of them focused on chewing-gum and were only randomized controlled trials (RCT) and 8 of them focused on Alvimopan but none of them were RCT. The other measures were assessed in less than 3 studies over RCTs (n = 11) or retrospective studies (n = 2). In the meta-analysis, chewing gum had no significant effect on the endpoints and Alvimopan allowed a significant reduction of the occurrence of POI. Chewing-gum was not effective on GI function recovery in ERP but Alvimopan and the other measures were not sufficiently studies to draw conclusion. Randomised controlled trials are needed.Systematic review registration number CRD42020167339.

Chewing gum prophylaxis for postoperative nausea and vomiting in the intensive care unit: a pilot randomised controlled trial

Objective: To test the effectiveness of chewing gum in the prophylaxis of postoperative nausea and vomiting (PONV) in patients admitted to the intensive care unit (ICU) after surgery. Design: Prospective, open label, pilot randomised controlled trial. Setting: Two metropolitan ICUs. Participants: Ninety postoperative adult patients admitted to the ICU. Intervention: Patients administered chewing gum, who chewed for at least 15 minutes every 4 hours, were compared with a control group, who were administered a 20 mL sip of water orally every 4 hours. Main outcome measures: The primary outcome was the number of patient-reported episodes of nausea in the first 24 hours after the operation. Secondary outcomes included vomiting or dry retching episodes, and duration and severity of nausea. Results: Forty-six patients were randomly allocated to chewing gum and 44 patients to water. There was no difference between groups in the number of patients with nausea (10 [22%] chewing gum v 12 [27%] control patients; P = 0.72), nausea episodes (22 episodes; [median, 0; IQR, 0-0] v 21 episodes [median, 0; IQR, 0-1] per patient in each group respectively), vomiting/retching (2 [4%] chewing gum v 6 [14%] control patients; P = 0.24), or duration/severity of nausea. Conclusion: Regular postoperative administration of chewing gum in a surgical ICU patient cohort did not reduce nausea, vomiting or retching. The prevalence of PONV is less than previously reported. Our findings can inform future studies of PONV prophylaxis in post-surgical ICU patients. Trial registration: Australian New Zealand Clinical Trial Registry No. ACTRN12617001185358.

Effect of stellate ganglion block on postoperative recovery of gastrointestinal function in patients undergoing surgery with general anaesthesia: a meta-analysis

Background

The return of gastrointestinal function is an important sign of postoperative recovery in patients undergoing surgery with general anaesthesia. We aimed to summarize the effects of stellate ganglion block on the recovery of gastrointestinal function as a means of exploring methods through which anaesthesiologists can contribute to postoperative patient recovery.

Methods

We performed a quantitative systematic review of randomized controlled trials published between January 1, 1988, and November 11, 2019, in PubMed, the Cochrane Library, China National Knowledge Infrastructure, Chinese VIP Information, and the Wanfang and SinoMed databases. Study quality was assessed by using the GRADE criteria and bias of included studies were assessed using the revised Cochrane risk-of-bias tool for randomized trials. The time to peristaltic sound resumption, flatus, postoperative eating and the incidence of abdominal bloating in the stellate ganglion block and control groups were compared. The control group consisted of either a stellate ganglion block with normal saline or no treatment. Meta-analysis was performed using Review Manager software.

Results

After searching for relevant articles, 281 studies were identified, and five articles with data on 274 patients were eligible. Regarding postoperative flatus time, stellate ganglion block resulted in a mean reduction of 15 h (P = 0.02); then a sensitivity analysis was performed, and the standard mean difference decreased to 6 h (P = 0.007). For gastrointestinal surgery, the mean reduction was 23.92 h (P = 0.0002). As for the evaluation of the recovery of peristaltic sounds, stellate ganglion block promoted the recovery of regular peristaltic bowel sounds an average of 14.67 h earlier than in the control (P = 0.0008). When it comes to nutrients, stellate ganglion block shortened the total parenteral nutrition time by more than 50 h in patients who had undergone gastrointestinal surgery (P<0.00001). Finally, stellate ganglion block prevented the occurrence of postoperative abdominal bloating (P = 0.001).) No complications related to stellate ganglion block were reported.

Conclusion

Stellate ganglion block may promote postoperative gastrointestinal recovery in patients undergoing various surgeries under general anaesthesia. However, additional trials investigating the use of stellate ganglion block are necessary to confirm our finding.

Trial registration

This meta-analysis has been registered at the International Prospective Register of Systematic Reviews (registration number CRD42020157602).

The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking.

METHODOLOGY

A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality.

RESULTS

Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD - 0.31, 95% CI - 0.36, - 0.26, p < 0.00001) and time to defecation (WMD - 0.47, 95% CI - 0.60, - 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality.

CONCLUSION

The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting.

The clinical and economical impact of postoperative ileus in patients undergoing colorectal surgery

BACKGROUND

Colorectal surgery is associated with postoperative ileus (POI). Despite its widespread manifestation, the influence of POI on recovery, quality of life (QoL), and costs is largely unknown. The aim of this study was to assess whether the inflammatory processes found in experimental studies are also evident in patients undergoing colorectal surgery. In addition, the impact of POI on short and long-term QoL and costs was investigated.

METHODS

We analyzed the outcomes of the SANICS-II trial, including prospective evaluation of inflammatory parameters in blood samples, costs from a societal perspective and QoL, using validated questionnaires. Outcomes were compared between patients with and without POI, and in particular patients with POI as unique complication.

KEY RESULTS

A total of 265 patients (POI, n = 66 vs non-POI, n = 199) were included and 38/66 had POI as only complication. CRP levels were significantly increased on postoperative day (POD) 1, 2, 3, and 4 in patients with POI. Furthermore, plasma levels of cytokines IL-6, Il-8 and IL-10 were significantly increased the first 2 days after resection. Patients with POI had a higher overall complication rate and a reduced QoL 3 months postoperatively, even in the only POI group. Moreover, mean societal cost per patient with POI was 38%-47% higher at 3 months postoperatively.

CONCLUSIONS & INFERENCES

Supporting findings from experimental studies, inflammatory parameters were increased in patients with only POI and comparable with all patients with POI. These results demonstrate the impact and large contribution of POI in postoperative inflammation, costs and QoL in patients undergoing colorectal surgery.

Acute Colonic Pseudo-Obstruction After Posterior Spinal Fusion: A Case Report and Literature Review

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome occurs in 0.22%-7% of patients undergoing surgery, with a mortality of up to 46%. ACPO increased median hospital days versus control in spinal surgery (14 vs. 6 days; P < 0.001). If defined as postoperative ileus, the incidence was 7%-13.4%. Postoperative ileus is associated with 2.9 additional hospital days and an $80,000 increase in cost per patient. We present a case of ACPO in an adult patient undergoing spinal fusion for correction of scoliosis and review the available literature to outline clinical characteristics and surgical outcomes.

CASE DESCRIPTION

The patient was a 31-year-old woman with untreated advanced scoliosis with no history of neurologic issues. T2-L3 spinal instrumentation and fusion was completed. Plain abdominal radiography showed of dilated cecum 11 cm and the department of general surgery was consulted. Neostigmine administration was planned after conservative treatment failure after transfer to the intensive care unit. The patient was discharged home with no recurrence >60 days. Thirty cases were found in our literature review using PubMed and Embase databases and summarized.

CONCLUSIONS

Of 30 cases reviewed, only 3 cases of ACPO were specific to patients undergoing spinal fusion for scoliosis. According to the literature, 20% of patients had resolution with conservative treatment, 40% with neostigmine, and 30% with surgical intervention. Other noninvasive treatments may have similar efficacy in preventing complications leading to surgical invention. Sixty clinical trials and 9 systematic reviews were summarized with an updated management algorithm.

Transcutaneous electrical acupuncture stimulation (TEAS) for gastrointestinal dysfunction in adults undergoing abdominal surgery: study protocol for a prospective randomized controlled trial

BACKGROUND

Postoperative gastrointestinal (GI) dysfunction (PGD) is a common problem after abdominal surgery. PGD can increase the length of hospital stay and may lead to serious complications. Acupuncture and moxibustion are alternative therapies for PGD that have been used in some settings. However, the effect of preventive application of acupuncture or transcutaneous electrical acupuncture stimulation (TEAS) is still uncertain. The purpose of this study is to investigate the efficacy of the continuous application of TEAS on GI function recovery in adults undergoing abdominal surgery. At the same time, we will try to confirm the mechanism of TEAS through the brain-gut axis.

METHODS/DESIGN

This study is a prospective, single-center, two-arm, randomized controlled trial that will be performed in a general hospital. In total, 280 patients undergoing abdominal surgery were stratified by type of surgery (i.e. gastric or colorectal procedure) and randomized into two treatment groups. The experimental group will receive TEAS stimulation at L14 and PC6, ST36 and ST37. The sham group will receive pseudo-TEAS at sham acupoints. The primary outcome will be the time to the first bowel motion by auscultation. The recovery time of flatus, defecation, the changes in perioperative brain-intestinal peptides, postoperative pain, perioperative complications, and hospitalization duration will be the secondary outcomes.

DISCUSSION

The results of this study will demonstrate that continuous preventive application of TEAS can improve the GI function recovery in patients undergoing abdominal surgery and that this effect may act through brain-gut peptides.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900023263 . Registered on 11 May 2019.

Effect of Postoperative Oral Intake on Prognosis for Esophageal Cancer

Background: Patients undergoing surgery for esophageal cancer are at risk of prolonged hospital stay for postoperative malnutrition. Postoperative early oral feeing is a part of the “enhanced recovery after surgery protocol” for coping with this risk. However, the usefulness of early oral intake during perioperatively is questionable. Methods: In total, 117 patients treated surgically for esophageal cancer were analyzed in the study. We assessed the oral energy sufficiency rate per nutritional requirement (oral-E/NR) at the fourth week postoperatively and classified the patients into two groups: Poor oral intake group (POI group; <25% oral-E/NR) and the control group (≥25% oral-E/NR). We analyzed the relationship among postoperative oral intake and prognoses. Results: The POI group had worse postoperative nutritional status and a lower survival rate than the control group. In a multivariate analysis, <25% oral-E/NR was one of the independent factors contributing to negative outcomes postoperatively (adjusted hazard ratio: 2.70, 95% confidence interval: 1.30–5.61). Conclusions: In patients undergoing surgery for esophageal cancer, poor postoperative oral intake negatively affected not only on their postoperative nutritional status but also their overall prognosis. It is necessary to improve the adequacy of oral intake postoperatively for patients with esophageal cancer.

An economic evaluation of perioperative enteral nutrition in patients undergoing colorectal surgery (SANICS II study)

AIMS

The objective of this (trial based) economic evaluation was to assess, from a societal perspective, the cost-effectiveness of perioperative enteral nutrition compared with standard care in patients undergoing colorectal surgery.

MATERIALS AND METHODS

Alongside the SANICS II randomized controlled trial, global quality-of-life, utilities (measured by EQ-5D-5L), healthcare costs, production losses, and patient and family costs were assessed at baseline, 3 months, and 6 months. Incremental cost-effectiveness ratios (ICERs) (i.e. cost per increased global quality-of-life score or quality-adjusted life year [QALY] gained) and cost effectiveness acceptability curves were visualized.

RESULTS

In total, 265 patients were included in the original trial (n = 132 in the perioperative enteral nutrition group and n = 133 in the standard care group). At 6 months, global quality-of-life (83 vs 83, p = .357) did not differ significantly between the groups. The mean total societal costs for the intervention and standard care groups were €14,673 and €11,974, respectively, but did not reach statistical significance (p = .109). The intervention resulted in an ICER of -€6,276 per point increase in the global quality of life score. The gain in QALY was marginal (0.003), with an additional cost of €2,941, and the ICUR (Incremental cost utility ratio) was estimated at €980,333.

LIMITATIONS

The cost elements for all the participating centers reflect the reference prices from the Netherlands. Patient-reported questionnaires may have resulted in recall bias. Sample size was limited by exclusion of patients who did not complete questionnaires for at least at two time points. A power analysis based on costs and health-related quality-of-life (HRQoL) was not performed. The economic impact could not be analyzed at 1 month post-operatively where the effects could potentially be higher.

CONCLUSIONS

This study suggests that perioperative nutrition is not beneficial for the patients in terms of quality-of-life and is not cost-effective.

Placebo Economics: A Systematic Review About the Economic Potential of Utilizing the Placebo Effect

Background: Recent research shows that placebo mechanisms can be utilized in ethical and legal ways such as in open-label conditions, when patients know that they receive placebos, and through psychological interventions aiming to optimize patients' expectations. Showing that placebo interventions are also cost-efficient could improve their acceptability. Objective: To review studies that performed health economic evaluations (HEEs) of intentional placebo interventions and to review studies that intentionally applied placebo interventions and reported outcomes eligible for HEEs. Methods: Two systematic reviews of the literature were performed. For the first review, we searched MEDLINE using "placebo" and Medical Subject Headings (MeSH) terms associated with HEEs such as "costs," "cost-benefit analyses," and "economics." Studies were eligible if they employed patients, applied placebo interventions, included an appropriate control group, and reported results of cost analyses. For the second review, we searched the Journal of Interdisciplinary Placebo Studies (JIPS) database and MEDLINE using search terms for outcomes eligible for cost-utility analyses, such as "quality of life" or "quality-adjusted life years" ("QALYs"). Risk of bias of all studies found was assessed according to the Cochrane Handbook, and a narrative synthesis of the results is provided. Results: The first search resulted in 1,853 articles, which were screened for eligibility. Two studies were found only in which costs or cost-effectiveness analysis were reported, but with medium to high risks of biases. The second search yielded 164 articles particularly from the JIPS database of which 11 studies met our search criteria: in six studies, patients received placebo pills in open-label conditions; three studies investigated effects of patient-physician relationships; and two studies used psychological interventions to optimize treatment expectations, in patients with various diseases and disorders. These studies report outcomes potentially eligible for HEEs when costs of interventions were known. Risks of biases were low to medium, but patients were not blinded to the conditions in most studies. Conclusions: The state of knowledge about HEEs of placebo interventions is scarce. To gain more visibility and acceptability for placebo interventions, future studies should measure outcomes usable for HEEs and costs of interventions, and HEEs should be performed for existing studies if data are available.

Chewing gum for declining ileus and accelerating gastrointestinal recovery after appendectomy

Objective

Ileus usually occurs after abdominal surgery and is allied with complication and delays recovery. It is hypothesized that chewing gum reduces postoperative ileus by improving early recovery of gastrointestinal function. This study aimed to explore whether chewing gum after appendectomy accelerates the recovery of gastrointestinal function.

Methods

Randomized control trial was used in this study. This study was conducted in the General Surgery Department at Zagazig University Hospital. A total of 240 patients undergoing appendectomy were involved in this study; they were divided into the chewing sugar-free gum group (120) and the control group (120). Two tools were utilized in this study. Tool I: Structured Interviewing Schedule: part 1: assessment of personnel characteristics. Part 2: assessment of anthropometric measurements of the studied subjects as well as pre- and intraoperative indicators of them. Tool II: postoperative assessment sheet: assessed postoperative parameters of the intestinal function, occurrence of postoperative ileus, and related symptoms were assessed among studied participants.

Results

There were highly significant statistical differences in the time of resumption of gastrointestinal functions and postoperative ileus symptoms between the two groups (P <0.001), which was significantly shorter in the chewing gum group compared to the control group.

Conclusions

The use of chewing gum is a useful and cheap method that can be employed to cut down the time to recover and accelerate normalization of gastrointestinal function. Chewing sugar-free gum after abdominal surgery is recommended to be added to the protocol of nursing care in the surgery units as well as its involvement in the nursing curriculum.

Health-related quality of life and cost-effectiveness analysis of gum chewing in patients undergoing colorectal surgery: results of a randomized controlled trial

BACKGROUND

Postoperative ileus (POI) and anastomotic leakage (AL) following colorectal surgery severely increase healthcare costs and decrease quality of life. This study evaluates the effects of reducing POI and AL via perioperative gum chewing compared to placebo (control) on in-hospital costs, health-related quality of life (HRQoL), and assesses cost-effectiveness.

METHODS

In patients undergoing elective, open colorectal surgery, changes in HRQoL were assessed using EORTC-QLQ-C30 questionnaires and costs were estimated from a hospital perspective. Incremental cost-effectiveness ratios were estimated.

RESULTS

In 112 patients, mean costs for ward stay were significantly lower in the gum chewing group when compared to control (€3522 (95% CI €3034-€4010) versus €4893 (95% CI €3843-€5942), respectively, p = .020). No differences were observed in mean overall in-hospital costs, or in mean change in any of the HRQoL scores or utilities. Gum chewing was dominant (less costly and more effective) compared to the control in more than 50% of the simulations for both POI and AL.

CONCLUSION

Reducing POI and AL via gum chewing reduced costs for ward stay, but did not affect overall in-hospital costs, HRQoL, or mapped utilities. More studies with adequate sample sizes using validated questionnaires at standardized time points are needed.

Nutritional interventions to improve recovery from postoperative ileus

PURPOSE OF REVIEW

Postoperative ileus (POI) is an important contributor to postoperative morbidity. However, postoperative outcomes have improved by enhanced recovery after surgery (ERAS) programs. Enteral nutrition is an essential part of ERAS and many studies suggest a therapeutic effect of nutrition on POI.

RECENT FINDINGS

Early postoperative enteral nutrition has been shown to reduce various complications, including POI, although studies are heterogeneous. Experimental studies suggest that composition and timing of the enteral feed is important for the potential beneficial effects: lipid-enriched nutrition given just before, during, and directly after surgery was most effective in reducing POI in an experimental setting. In a clinical study in patients undergoing advanced rectal cancer surgery, direct start of enteral tube feeding reduced POI. Conversely, perioperative lipid-enriched enteral nutrition did not reduce POI in patients undergoing colorectal surgery with an ERAS protocol.

SUMMARY

POI is common and remains an important determinant of postoperative recovery following colorectal surgery. Nutrition is a potential therapeutic means to reduce POI. Timing and composition of the enteral feed have been shown to be essential for the beneficial effects of enteral nutrition in an experimental setup. However perioperative lipid-enriched nutrition does not reduce POI in patients undergoing colorectal surgery with an ERAS protocol.

Anti-inflammatory Effects of Enhanced Recovery Programs on Early-Stage Colorectal Cancer Surgery

BACKGROUND

Postoperative ileus (POI) is observed in 20-30% of patients undergoing colorectal cancer surgery, despite enhanced recovery programs (ERPs). Cyclooxygenase (COX)-2 is identified as a key enzyme in POI, but other arachidonic acid pathway enzymes have received little attention despite their potential as selective targets to prevent POI. The objectives were to compare the expression of arachidonic acid metabolism (AAM) enzymes (1) between patients who underwent colorectal cancer surgery and followed an ERP or not (NERP), (2) and between ERP patients who experimented POI or not and (3) to determine the ability of antagonists of these pathways to modulate contractile activity of colonic muscle.

METHODS

This was a translational study. Main outcome measures were gastrointestinal motility recovery data, mRNA expressions of key enzymes involved in AAM (RT-qPCR) and ex vivo motility values of the circular colon muscle. Twenty-eight prospectively included ERP patients were compared to eleven retrospectively included NERP patients that underwent colorectal cancer surgery.

RESULTS

ERP reduced colonic mucosal COX-2, microsomal prostaglandin E synthase (mPGES1) and hematopoietic prostaglandin D synthase (HPGDS) mRNA expression. mPGES1 and HPGDS mRNA expression were significantly associated with ERP compliance (respectively, r2 = 0.25, p = 0.002 and r2 = 0.6, p < 0.001). In muscularis propria, HPGDS mRNA expression was correlated with GI motility recovery (p = 0.002). The pharmacological inhibition of mPGES1 increased spontaneous ex vivo contractile activity in circular muscle (p = 0.03).

CONCLUSION

The effects of ERP on GI recovery are correlated with the compliance of ERP and could be mediated at least in part by mPGES1, HPGDS and COX-2. Furthermore, mPGES1 shows promise as a therapeutic target to further reduce POI duration among ERP patients.

Gum chewing aids bowel function return and analgesic requirements after bowel surgery: a randomized controlled trial

AIM

The aim was to compare the effectiveness of chewing sugar-free gum after bowel resection on bowel function and length of stay.

METHOD

This was a randomized controlled trial of patients undergoing elective open or laparoscopic bowel surgery, who were allocated into two groups: a chewing gum group (CG); or a nonchewing gum group (NG). Primary outcomes were time to discharge (length of hospital stay [LOS]), time to first flatus (TFF) and time to first bowel motion (TBM). Secondary outcomes were complication rates, pain and total morphine equivalent (TMEq) medication for 7 days after the procedure.

RESULTS

Between 2010 and 2013, 162 patients were randomized; four were excluded, leaving 158 in the study (82 in the CG and 76 in the NG). There was no difference in LOS between the CG (5.8 days) and the NG (6.1 days) (P = 0.403) or in the median TFF between the CG (42.0 h) and the NG (58.0 h) (P = 0.076). The median TBM was lower in the CG (40.0 h) than in the NG (90.0 h) (P = 0.002). There was no difference in intra-operative complications between the CG (9%) and the NG (9%) (P = 0.901) or in early postoperative complications (44% for CG and 55% for NG) (P = 0.131). There was no difference in TMEq at 24 h postprocedure, but the CG had reduced TMEq from days 2 to 7 post procedure and for the 7-day total. Pain was higher among patients in the NG on day 3.

CONCLUSION

Chewing sugar-free gum resulted in an earlier return to bowel function and decreased analgesic requirements. There was no decrease in overall LOS or postoperative complications.

The Effect of Myopenia on the Inflammatory Response Early after Colorectal Surgery

BACKGROUND

Myopenia (low skeletal muscle mass) is associated with an increased risk of complications following colorectal surgery, however, the underlying mechanism is poorly understood. This study investigates the effect of myopenia on the early postoperative systemic inflammatory response.

MATERIALS AND METHODS

In 78 patients undergoing colorectal surgery, the presence of myopenia was preoperatively assessed using computed tomography images of the third lumbar vertebra. Interleukin-8 (IL-8) and soluble tumor necrosis factor receptor-1 (TNFRSF1A) were measured in plasma before and 4 h after start of surgery as part of a randomized controlled trial investigating the effect of perioperative gum chewing on the inflammatory response. Multivariable linear regression analysis was performed to assess the effect of myopenia on inflammatory markers while correcting for possible confounders.

RESULTS

Four hours after start of surgery, IL-8 was higher in patients with myopenia than in patients without myopenia (352 ± 268 vs. 239 ± 211 pg/ml, P = 0.048), while TNFRSF1A was similar between groups. After adjusting for sex and the intervention with perioperative gum chewing, myopenia remained associated with higher postoperative IL-8 concentrations (P = 0.047).

CONCLUSION

Myopenia may affect IL-8 early after colorectal surgery. However, more studies are needed to validate these findings.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery

Background

Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care.

Methods

A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications.

Results

Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either.

Conclusion

The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).

Meta-analysis comparing chewing gum versus standard postoperative care after colorectal resection

Background

Previous incomplete studies investigating the potential of chewing gum (CG) in patients undergoing colorectal resection did not obtain definitive conclusions. This updated meta-analysis was therefore conducted to evaluate the effect and safety of CG versus standard postoperative care protocols (SPCPs) after colorectal surgery.

Results

Total 26 RCTs enrolling 2214 patients were included in this study. The CG can be well-tolerated by all patients. Compared with SPCPs, CG was associated with shorter time to first flatus (weighted mean difference (WMD) −12.14 (95 per cent c.i. −15.71 to −8.56) hours; P < 0.001), bowl movement (WMD −17.32 (−23.41 to −11.22) hours; P < 0.001), bowel sounds (WMD −6.02 (−7.42 to −4.63) hours; P < 0.001), and length of hospital stay (WMD −0.95 (−1.55 to −0.35) days; P < 0.001), a lower risk of postoperative ileus (risk ratio (RR) 0.61 (0.44 to 0.83); P = 0.002), net beneficial and quality of life. There were no significant differences between the two groups in overall complications, nausea, vomiting, bloating, wound infection, bleeding, dehiscence, readmission, reoperation, mortality.

Materials and Methods

The potentially eligible randomized controlled trials (RCTs) that compared CG with SPCPs for colorectal resection were searched in PubMed, Embase, Cochrane library, China National Knowledge Infrastructure (CNKI), and Chinese Wanfang databases through May 2016. The trial sequential analysis was adopted to examine whether a firm conclusion for specific outcome can be drawn.

Conclusions

CG is benefit for enhancing return of gastrointestinal function after colorectal resection, and may be associated with lower risk of postoperative ileus.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial

BACKGROUND

Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes.

METHODS

We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670.

FINDINGS

Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05).

INTERPRETATION

Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications.

FUNDING

Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Progress in research of early postoperative inflammatory small bowel obstruction

Early postoperative inflammatory small bowel obstruction (EPISBO) is a mechanical and dynamic obstruction resulting from a variety of postoperative factors that occur early after abdominal surgery. EPISBO is a special phenomenon after abdominal surgery and has unique clinical features. Current research shows that many risk factors are associated with the occurrence of EPISBO. Conservative treatment is the first choice of treatment because this kind of bowel obstruction is not suitable for surgical treatment. Conventional rehydration and parenteral nutrition support treatment are the cornerstone of EPISBO treatment. The therapeutic value of various drugs such as somatostatin has been demonstrated and TCM treatment also plays an important role. This review aims to present the progress in the research of EPISBO.

Effect of Early vs Late Start of Oral Intake on Anastomotic Leakage Following Elective Lower Intestinal Surgery: A Systematic Review

BACKGROUND

Experimental and clinical studies have demonstrated a beneficial effect of early enteral nutrition (EN) on anastomotic leakage following colorectal surgery. Early oral intake is a common form of early EN with various clinical benefits, but the effect on anastomotic leakage is unclear. This systematic review investigates the effect of early vs late start of oral intake on anastomotic leakage following lower intestinal surgery.

METHODS

A systematic literature search was performed using the PubMed, Embase, Medline, and Cochrane databases. Randomized controlled trials were included that compared early (within 24 hours) vs late start of oral intake following elective surgery of the small bowel, colon, or rectum. Meta-analysis was performed for anastomotic leakage, overall complications, length of stay, and mortality. Sensitivity analysis was performed in which studies of inferior methodological quality were excluded.

RESULTS

Nine studies including 879 patients met eligibility criteria. Early start of oral intake significantly reduced overall complications (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.46-0.93; P = .02), length of stay (mean difference, -0.89; 95% CI, -1.22 to -0.57; P < .001), and anastomotic leakage (OR, 0.40; 95% CI, 0.17-0.95; P = .04) compared with late start of oral intake. However, in the sensitivity analysis only the overall reduction of length of stay remained significant.

CONCLUSION

The effect of early oral intake on anastomotic leakage is unclear as existing studies are heterogeneous and at risk of bias. High-quality studies are needed to study the potential benefit of EN on anastomotic healing.

Chewing Gum for Intestinal Function Recovery after Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis

Background

This meta-analysis was performed to assess the efficacy and safety of chewing gum in intestinal function recovery after colorectal cancer surgery.

Methods

A systematic search was conducted in PubMed, Embase, Science Direct, and Cochrane library for relevant randomized controlled trials (RCTs) published until April 2017. Summary risk ratios or weighted mean differences with 95% confidence intervals were used for continuous and dichotomous outcomes, respectively.

Results

17 RCTs with a total number of 1845 patients were included. Gum chewing following colorectal cancer surgery significantly reduced the time to first passage of flatus (WMD −0.55; 95% CI −0.94 to −0.16; P = 0.006), first bowel movement (WMD −0.60; 95% CI −0.87 to −0.33; P < 0.0001), start feeding (WMD −1.32; 95% CI −2.18 to −0.46; P = 0.003), and the length of postoperative hospital stay (WMD −0.88; 95% CI −1.59 to −0.17; P = 0.01), but no obvious differences were found in postoperative nausea, vomiting, abdominal distention, pneumonia, and mortality, which were consistent with the findings of intention to treat analysis.

Conclusions

Chewing gum could accelerate the recovery of intestinal function after colorectal cancer surgery. However, it confers no advantage in postoperative clinical complications. Further large-scale and high-quality RCTs should be conducted to confirm these results.

Abdominal vagus nerve stimulation as a new therapeutic approach to prevent postoperative ileus

BACKGROUND

Electrical stimulation of the cervical vagus nerve (VNS) prevents postoperative ileus (POI) in mice. As this approach requires an additional cervical procedure, we explored the possibility of peroperative abdominal VNS in mice and human.

METHODS

The effect of cervical and abdominal VNS was studied in a murine model of POI and lipopolysaccharide (LPS)-induced sepsis. Postoperative ileus was quantified by assessment of intestinal transit of fluorescent dextran expressed as geometric center (GC). Next, the effect of cervical and abdominal VNS on heart rate was determined in eight Landrace pigs to select the optimal electrode for VNS in human. Finally, the effect of sham or abdominal VNS on LPS-induced cytokine production of whole blood was studied in patients undergoing colorectal surgery.

KEY RESULTS

Similar to cervical VNS, abdominal VNS significantly decreased LPS-induced serum tumor necrosis factor-α (TNFα) levels (abdominal VNS: 366±33 pg/mL vs sham: 822±105 pg/mL; P<.01). In line, in a murine model of POI, abdominal VNS significantly improved intestinal transit (GC: sham 5.1±0.2 vs abdominal VNS: 7.8±0.6; P<.01) and reduced intestinal inflammation (abdominal VNS: 35±7 vs sham: 80±8 myeloperoxidase positive cells/field; P<.05). In pigs, heart rate was reduced by cervical VNS but not by abdominal VNS. In humans, abdominal VNS significantly reduced LPS-induced IL8 and IL6 production by whole blood.

CONCLUSIONS & INFERENCES

Abdominal VNS is feasible and safe in humans and has anti-inflammatory properties. As abdominal VNS improves POI similar to cervical VNS in mice, our data indicate that peroperative abdominal VNS may represent a novel approach to shorten POI in man.

Effect of gum chewing on ameliorating ileus following colorectal surgery: A meta-analysis of 18 randomized controlled trials

BACKGROUND AND OBJECTIVE

Chewing gum, as an alternative to sham feeding, had been shown to hasten the recovery of gut function following abdominal surgery. However, conclusions remained contradictory. We sought to conduct an updated meta-analysis to evaluate the efficacy of gum chewing in alleviating ileus following colorectal surgery.

METHODS

We searched PubMed, EMBASE, and Cochrane Library Databases through February 2017 to identify randomized controlled trials (RCTs) evaluating the efficacy of the additional use of chewing gum following colorectal surgery. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software. The outcomes of interest were the time to first flatus, time to first bowel movement, length of hospital stay, and some clinically relevant parameters. We also performed subgroup analyses according to the type of surgical approaches or on trials that adopted enhanced recovery after surgery (ERAS) protocol or sugared gum.

RESULTS

A total of 18 RCTs, involving 1736 patients, were included. Compared with standardized postoperative care, Chewing gum resulted in a shorter passage to first flatus [WMD = -8.81, 95%CI: (-13.45, -4.17), P = 0.0002], earlier recovery of bowel movement [WMD = -16.43, 95%CI: (-22.68, -10.19), P < 0.00001], and a reduction in length of hospital stay [WMD = -0.89, 95%CI: (-1.72, -0.07), P = 0.03]. Chewing gum was also associated with a lower risk of postoperative ileus [OR = 0.41, 95%CI: (0.23, 0.73), P = 0.003]. No evidence of significant advantages in overall postoperative complication, nausea, vomiting, bloating, readmission and reoperation towards the addition of chewing gum was observed. Subgroup analyses all favored gum chewing. However, the findings are hampered by the significant heterogeneity between trials.

CONCLUSIONS

Based on current evidence, chewing gum offers an inexpensive, well-tolerated, safe and effective method to ameliorate ileus following colorectal surgery. However, tightly controlled, randomized and considerably larger multicenter trials are warranted to further validate our findings.

Relation between postoperative ileus and anastomotic leakage after colorectal resection: a post hoc analysis of a prospective randomized controlled trial

AIM

Anastomotic leakage (AL) following abdominal surgery is a critical determinant of postoperative recovery, of which the aetiology is largely unknown. Interestingly, interventions aimed at reducing the inflammatory response and postoperative ileus (POI) have an unexpected effect on AL. The aim of this study was to investigate the relation of POI with inflammation and AL after colorectal resection.

METHOD

A post hoc analysis of a prospective randomized controlled trial in which patients underwent a colorectal resection was performed. Patients undergoing a colorectal resection were stratified into having or not having POI. The incidence of AL and other clinical parameters was registered prospectively. Intestinal fatty acid binding protein (I-FABP, a marker for tissue damage) and the inflammatory response in plasma and colon tissue were determined.

RESULTS

AL was present in nine of 43 patients in the POI group, and in one of 65 in the group without POI (P < 0.001). There was a significant association between POI and AL (OR 12.57, 95% CI: 2.73-120.65; P = 0.0005). Patients with POI had significantly higher plasma levels of soluble tumour necrosis factor receptor 1 (TNFRSF1A) at 4 h postoperatively (0.89 ng/l, interquartile range 0.56) than patients without POI (0.80 ng/l, interquartile range 0.37; P = 0.04) and higher plasma levels of C-reactive protein on the second day postoperatively (234 ± 77 vs 163 ± 86 mg/l; P = 0.001). Patients who developed AL had significantly higher plasma levels of I-FABP compared with patients without AL at 24 h after onset of surgery.

CONCLUSION

POI is associated with a higher prevalence of AL and an increased inflammatory response.

Preoperative risk factors for prolonged postoperative ileus after colorectal resection

PURPOSE

Prolonged postoperative ileus (PPOI) after colorectal resection significantly impacts patients' recovery and hospital stay. Because treatment options for PPOI are limited, it is necessary to focus on prevention strategies. The aim of this study is to investigate risk factors associated with PPOI in patients undergoing colorectal surgery.

METHODS

Data from all consecutive patients who underwent colorectal resection in our department were retrospectively analyzed from a prospective database over a 9-month period. PPOI was defined as the necessity to insert a nasogastric tube in a patient who experienced nausea and two episodes of vomiting with absence of bowel function. Multivariable analysis was performed considering a prespecified list of 16 potential preoperative risk factors.

RESULTS

A total of 523 patients (mean age 59 years; 52.2% males) were included, and 83 patients (15.9%) developed PPOI. Statistically significant independent predictors of PPOI were male sex (OR 2.07; P = 0.0034), open resection (OR 4.47; P < 0.0001), conversion to laparotomy (OR 4.83; P = 0.0015), splenic flexure mobilization (OR 1.72; P = 0.063), and rectal resection (OR 2.72; P = 0.0047). Discriminative ability of this prediction model was 0.72.

CONCLUSIONS

Therapeutic strategies aimed to prevent PPOI after colorectal resection should focus on patients with increased risk. Patients and medical staff can be informed of the higher PPOI risk, so that early treatment can be started.