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

Effect of chewing gum in reducing postoperative ileus after gastroduodenal perforation peritonitis surgery: A prospective randomised controlled trial

Chewing gum reduces the duration of postoperative ileus and early recovery of bowel function following elective abdominal surgery. However, its role has not been studied in cases of gastroduodenal perforation peritonitis, prompting us to conduct this study. Patients were randomised into two groups, 39 patients received chewing gum (study group) and 43 patients were in the control group. Sensation of hunger, appearance of first bowel sound, and passages of flatus and faeces were significantly early in the study group; their hospital stay was also shorter. Chewing gum reduces the duration of postoperative ileus in cases of gastroduodenal perforation peritonitis.Registration number: IEC/2020-23/3359 dated 13 December 2020, Institutional Ethics Committee, Netaji Subhash Chandra Bose Medical College, Jabalpur, India.

The implementation of an inflammatory bowel disease-specific enhanced recovery after surgery protocol: an observational cohort study

BACKGROUND

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has resulted in improved postoperative outcomes in colorectal cancer surgery. The evidence regarding feasibility and impact on outcomes in surgery for inflammatory bowel disease (IBD) is limited.

METHODS

We performed a retrospective observational cohort study, comparing patient trajectories before and after implementing an IBD-specific ERAS protocol at Zealand University Hospital. We assessed the occurrence of serious postoperative complications of Clavien-Dindo grade 3 or higher as our primary outcome, with postoperative length of stay in days and rate of readmissions as secondary outcomes, using χ2, Mann-Whitney test, and odds ratios adjusted for sex and age.

RESULTS

From 2017 to 2023, 394 patients were operated on for IBD and included in our study. In the ERAS cohort, 39/250 patients experienced a postoperative complication of Clavien-Dindo grade 3 or higher compared to 27/144 patients in the non-ERAS cohort (15.6% vs. 18.8%, p = 0.420) with an adjusted odds ratio of 0.73 (95% CI 0.42-1.28). There was a significantly shorter postoperative length of stay (median 4 vs. 6 days, p < 0.001) in the ERAS cohort compared to the non-ERAS cohort. Readmission rates remained similar (22.4% vs. 16.0%, p = 0.125).

CONCLUSIONS

ERAS in IBD surgery was associated with faster patient recovery, but without an impact on the occurrence of serious postoperative complications and rate of readmissions.

The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Postoperative ileus is a frequent condition, leading to complications and a longer hospital stay. Few studies have demonstrated the benefit of early oral feeding in preventing ileus after gastrointestinal surgery. This study aims to evaluate the efficacy of early versus delayed oral feeding on the recovery of intestinal motility, length of hospital stay, and complications.

Methods

We conducted a systematic review and meta-analysis of randomized control trials, searching PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and the ClincalTrials.gov until 31 December 2022. We evaluated the first passage of the stool, the first flatus, complications, length of postoperative stay, and vomiting. We assessed the risk of bias using the Cochrane risk of bias tool (version 2) for randomized trials and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

Results

We included 34 studies with a median sample size of 102 participants. With a moderate certainty of the evidence, the early oral feeding may reduce the time taken for the first passage of the stool (MD -0.99 days; CI 95% -1.25, -0.72), the first flatus (MD -0.70 days; CI 95% -0.87, -0.53), and the risk of complications (RR 0.69; CI 95% 0.59-0.80), while with a low certainty of evidence, it may reduce the length of stay (MD -1.31 days; CI 95% -1.59, -1.03). However, early feeding likely does not affect the risk of vomiting (RR 0.90; CI 95% 0.68, 1.18).

Conclusion

This review suggests that early oral feeding after gastrointestinal surgery may lead to a faster intestinal recovery, shorter postoperative stays, and fewer complications. However, careful interpretation is needed due to high heterogeneity and the moderate-to-low quality of evidence. Future studies should focus on the type and starting time of early oral feeding.

Strategies to reduce ileus after colorectal surgery: A qualitative umbrella review of the collective evidence

BACKGROUND

Various strategies were proposed to reduce postoperative ileus after colorectal surgery. This umbrella review aimed to provide a comprehensive overview of current evidence on measures to reduce the incidence and severity of postoperative ileus after colorectal surgery.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic search was conducted in PubMed and Scopus to identify systematic reviews that assessed the efficacy of interventions used to prevent postoperative ileus after colorectal surgery. Data on study characteristics, interventions, and outcomes were summarized in a narrative manner.

RESULTS

A total of 26 systematic reviews incorporating various strategies like early oral feeding, gum chewing, coffee consumption, medications, and acupuncture were included. Early oral feeding reduced postoperative ileus and accelerated bowel function return. The most assessed intervention was chewing gum, which was associated with a median reduction of postoperative ileus by 45% (range, 11%-59%) and shortening of the time to first flatus and time to defecation by a median of 11.9 and 17.7 hours, respectively. Coffee intake showed inconsistent results, with a median shortening of time to flatus and time to defecation by 1.32 and 14.45 hours, respectively.

CONCLUSION

Early oral feeding, chewing gum, and alvimopan were the most commonly assessed and effective strategies for reducing postoperative ileus after colorectal surgery. Medications used to reduce postoperative ileus included alvimopan, intravenous lidocaine, dexamethasone, probiotics, and oral antibiotics. Intravenous dexamethasone and lidocaine and oral probiotics helped hasten bowel function return. Acupuncture positively impacted the recovery of bowel function.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Background and Objective

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods

All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key Content and Findings

Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions

Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Chewing Gum Cannot Reduce Postoperative Abdominal Pain and Nausea After Posterior Spinal Fusions in Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

STUDY DESIGN

A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE

The aim of this study was to determine the effect of chewing gum on postoperative abdominal pain, nausea, and hospital stays after posterior spinal fusions (PSFs) in patients with adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Chewing gum had been extensively reported to improve bowel motility and is recommended to hasten bowel recovery following gastrointestinal surgery. However, there is no conclusive evidence regarding the effect of chewing gum on postoperative abdominal pain, nausea, and hospital stays after PSFs in AIS patients.

METHODS

A comprehensive literature search was performed for relevant randomized controlled trials using PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Embase. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative abdominal pain and nausea in AIS patients undergoing PSFs. Hospital stays were also investigated. The study was conducted using the checklist for PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

RESULTS

Three randomized controlled trials were included in the systematic review and the meta-analysis. No significant effect of chewing gum was highlighted concerning the postoperative abdominal pain scores at 24 and 48 hours [24 h: mean difference (MD)=0.45, 95% CI=-0.97 to 0.07, P =0.09; 48 h: MD=-0.24, 95% CI=-0.79 to 0.32, P =0.41]. No significant difference regarding the postoperative nausea scores was found at 24 and 48 hours (24 h: MD=0.26, 95% CI=-0.27 to 0.79, P =0.34; 48 h: MD=0.06, 95% CI=-0.36 to 0.48, P =0.77). No significant difference regarding hospital stays was found (MD=0.13, 95% CI=-0.02 to 0.28, P =0.09).

CONCLUSIONS

Based on the current studies, chewing gum does not have a significant effect on postoperative abdominal pain, nausea, or hospital stays after PSFs in AIS patients. As the effect of chewing gum in reducing postoperative abdominal pain exhibits a tendency towards statistical significance ( P =0.09), the effect of chewing gum in spinal surgery merits further studies with larger sample size.

Chewing gum base: A comprehensive review of composition, production, and assessment methods: Advances and approaches in biodegradability

The gum base mass is a colloidal system and the main component of chewing gum; which is an inert, non-nutritious, indigestible, and insoluble part of chewing gum, therefore this substance does not dissolve in the mouth when chewed. The gum base plays the most crucial role in determining the mechanical properties, flexibility, and overall quality of chewing gum. Moreover, it acts as a delivery system to transport sweeteners, flavorings, and other ingredients in chewing gum. Despite the massive market for chewing gum and the provision of a list of the main ingredients in gum base by the Code of Federal Regulations and some international organizations, there is a lack of information about chewing gum base and its compositions in the literature. Therefore, the purpose of this review is to present an overview of the characteristics, ingredients and applications, production process, assessment, and modification methods of the gum base along with the advances and approaches in biodegradability. Biodegradability concerns play a promoting role in the research and development of chewing gum and its applications in the food industry, medical and dental sectors. Reviewing previous studies can surely help for faster development of this path.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

The Effect of Postoperative Gum Chewing on Gastrointestinal Function Following Laparoscopic Gynecological Surgery. A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To assess the effect of postoperative gum chewing on gastrointestinal function in women following laparoscopic gynecological surgery for benign indications.

DATA SOURCES

We screened 5 major databases (Medline, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov) from inception till February 2023.

METHODS OF STUDY SELECTION

No language restrictions were applied. We included randomized controlled trials comparing the postoperative bowel function between patients who chewed and patients who did not chew gum postoperatively after laparoscopic gynecological procedures for benign indications.

TABULATION, INTEGRATION, AND RESULTS

Data from 5 studies on 670 patients were extracted and analyzed by 3 independent reviewers. Meta-analysis was performed with RevMan 5.4 software (Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2020), with mean differences (MDs), pooled risk ratios, and random-effects model. Postoperative gum chewing significantly reduced the time to first bowel sounds and the time to first passage of flatus (MD -2.58 hours 95% confidence interval (CI) -4.12 to -1.04 p = .001 and MD -3.97 hours 95% CI -6.26 to -1.68 p <.001, respectively). The time to first defecation, the time to first postoperative patients' mobilization, the length of hospital stay, and the risk of postoperative bowel obstruction showed no statistically significant difference between the 2 groups. When subgroup analysis was performed according to the type of the laparoscopic procedure, it failed to reveal a positive impact of postoperative gum chewing in both the times to first passage of flatus and first defecation following laparoscopic hysterectomies (MD -5.35 hours 95% CI -10.93 to 0.23 p = .06 and MD -15.93 hours 95% CI -40.13 to 8.28 p = .20, respectively).

CONCLUSION

The results of the present meta-analysis support that postoperative gum chewing following laparoscopic gynecological procedures seems to have a positive effect on the early mobilization of the gastrointestinal tract. However, these results should be interpreted with caution due to the small number of the included randomized controlled clinical trials.

Effects of menthol gum chewing on postoperative nausea, vomiting, and length of hospital stay in children undergoing appendectomy: A randomized controlled trıal

PURPOSE

This study aimed to determine the effects of menthol gum chewing on nausea, vomiting, and length of hospital stay after appendectomy in children.

BACKGROUND

Postoperative nausea and vomiting (PONV) can be induced by general anesthesia. Several drugs are available to reduce the risk of PONV; however, their cost and side effects limit their clinical use.

METHOD

This was a randomized controlled clinical trial that included 60 children aged 7-18 years who underwent an appendectomy at the Pediatric Surgery Clinic of a tertiary hospital between April and June 2022. Data for this study were collected via the developed information form, which included participants' descriptive characteristics and bowel function parameters, and the Baxter Retching Faces (BARF) nausea scale. Children in the study group who underwent an appendectomy were given chewing gum and asked to chew it for an average of 15 min, whereas those in the control group received no intervention.

RESULTS

The BARF nausea score measured during the menthol gum chewing period was lower in the study group, and the difference score value calculated after pretest time was higher in the study group, as expected (p < 0.001). Moreover, menthol gum chewing was found to shorten hospital stay by 1 day (p < 0.05).

CONCLUSION

Menthol gum chewing reduced the severity of postoperative nausea and length of hospital stay.

PRACTICE IMPLICATION

Chewing gum can be used as a nonpharmacological method by pediatric nurses in clinical practice to reduce the severity of postoperative nausea and length of hospital stay.

Effect of acupuncture inclusion in the enhanced recovery after surgery protocol on tumor patient gastrointestinal function: a systematic review and meta-analysis of randomized controlled studies

Introduction

Acupuncture has been shown to be effective in restoring gastrointestinal function in tumor patients receiving the enhanced recovery after surgery (ERAS) protocol. The present systematic review and meta-analysis aimed to evaluate the rationality and efficacy of integrating acupuncture in the ERAS strategy to recuperate gastrointestinal function.

Methods

We searched eleven databases for relevant randomized clinical trials (RCTs) of acupuncture for the treatment of gastrointestinal dysfunction in tumor patients treated with the ERAS protocol. The quality of each article was assessed using the Cochrane Collaboration risk of bias criteria and the modified Jadad Scale. As individual symptoms, the primary outcomes were time to postoperative oral food intake, time to first flatus, time to first distension and peristaltic sound recovery time (PSRT). Pain control, adverse events, and acupoint names reported in the included studies were also investigated.

Results

Of the 211 reviewed abstracts, 9 studies (702 patients) met eligibility criteria and were included in the present systematic review and meta‑analysis. Compared to control groups, acupuncture groups showed a significant reduction in time to postoperative oral food intake [standardized mean difference (SMD) = -0.77, 95% confidence interval (CI) -1.18 to -0.35], time to first flatus (SMD=-0.81, 95% CI -1.13 to -0.48), time to first defecation (SMD=-0.91, 95% CI -1.41 to -0.41, PSRT (SMD=-0.92, 95% CI -1.93 to 0.08), and pain intensity (SMD=-0.60, 95% CI -0.83 to -0.37).The Zusanli (ST36) and Shangjuxu (ST37) acupoints were used in eight of the nine included studies. Adverse events related to acupuncture were observed in two studies, and only one case of bruising was reported.

Discussion

The present systematic review and meta‑analysis suggested that acupuncture significantly improves recovery of gastrointestinal function and pain control in tumor patients receiving the ERAS protocol compared to the control group. Moreover, ST36 and ST37 were the most frequently used acupoints. Although the safety of acupuncture was poorly described in the included studies, the available data suggested that acupuncture is a safe treatment with only mild side effects. These findings provide evidence-based recommendations for the inclusion of acupuncture in the ERAS protocol for tumor patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/ PROSPERO, identifier CRD42023430211.

Nurse-delivered acupressure on early postoperative gastrointestinal function among patients undergoing colorectal cancer surgery

Objective

Postoperative gastrointestinal dysfunction occurred up to 25% of patients who undergo colorectal cancer surgery, which could cause severe complications and increase economic burden. This study aims to evaluate the effectiveness of nurse-delivered acupressure on early postoperative gastrointestinal function among patients undergoing colorectal cancer surgery.

Methods

A total of 112 adult patients (≥ 18 years) scheduled to receive colorectal cancer surgery were randomized into two groups. Acupressure was practiced at ST36 for five days after operation, while the control group used gently rubbing skin. Primary outcomes were the time to first passage of flatus and defecation, while the secondary outcomes were the degree of abdominal distention and bowel motility. The Student's t-test and Mann-Whitney U test or Chi-square test and regression analyses were used, while for repeated measures of outcomes, area under the curve (AUC) was compared between groups and subgroups.

Results

After adjusting for potential confounding variables, acupressure significantly shortened the time to have first flatus passage by 11.08 ​h (95%CI: -19.36 to -2.81; P ​< ​0.01). The first passage time of defecation (mean, 77.00 ​± ​36.27 ​h vs. 80.08 ​± ​28.88 ​h), abdominal distention (AUC, 5.68 ​± ​5.24 vs. 5.92 ​± ​4.03), and bowel motility (AUC, 12.09 ​± ​4.70 vs. 11.51 ​± ​3.00) in the intervention group had some improvement although the differences were not statistically significant (P ​> ​0.05).

Conclusions

This study indicated that acupressure done by trained nurses could be an effective and feasible solution to promote early gastrointestinal function recovery among patients undergoing colorectal cancer surgery.

Trial registration

Chinese Clinical Trial Registry (ChiCTR-IOR-17012460).

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.

The Effect of Chewing Sugar-Free Gum to Improve Bowel Movement After Colorectal Surgeries in Patients With Colorectal Cancer

Introduction

Colorectal cancer is classified as the second most prevalent type of cancer among males and females in Jordan; approximately 1260 (10.9%) out of 11559 cases were diagnosed with colorectal cancer in 2020. According to American statistics, colorectal cancer is the third leading cause of cancer-related deaths among both males and females, as well as the second leading cause when combining both numbers .

Objective

The current study aimed to assess the effectiveness of chewing gum in reducing postoperative ileus in patients with cancer after colorectal surgeries and evaluate the length of hospital stay (LOS) after colorectal resection, complications, and costs.

Methods

One-hundred twenty-nine patients who underwent colorectal surgeries at a specialized cancer center in Jordan from April 2019 to May 2020 were recruited. After colorectal surgeries, patients were randomized into two groups. The control group (69 patients) received conventional postoperative care; the experimental group (60 patients) was asked to chew free sugar gum over one hour in the morning, noon, and evening until the first flatus.

Result

The passage of the first flatus was significantly shorter in the experimental group (mean 48.02 h) than in the control group (116.45); p = .001. Also, there was a significant difference between both groups according to gender and age.

Conclusion

Chewing free sugar gum after colorectal surgeries can significantly improve the recovery of bowel motion by accelerating the time to first auscultation to bowel sounds, the first passage of flatus, and reduction in the LOS, which went in agreement with many studies. However, chewing gum is considered a safe, cheap, and practical method to reduce ileus.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Risk factors for postoperative urinary retention in patients undergoing colorectal surgery: a systematic review and meta-analysis

PURPOSE

Postoperative urinary retention (POUR) is a common complication following colorectal surgery. The incidence of POUR among colorectal surgery patients varies widely, and the risk factors and outcomes of POUR are also debatable. This meta-analysis aims to systematically evaluate the risk factors for POUR in patients after colorectal surgery.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, Medline, and Chinese databases (CBM, CNKI, and WanFang Databases) were searched to identify relevant cohort studies (from inception to August 2022). Two researchers independently conducted literature quality evaluation and data extraction. All data were analyzed by using the Review Manager 5.4 software.

RESULTS

Nineteen studies with 101,025 patients were included in this meta-analysis. The risk factors for POUR in colorectal surgery patients were male sex, older age, diabetes mellitus, urological diseases, tumor location in the lower rectum, APR, laparoscopic surgery, operation time ≥ 4 h, postoperative date of urinary catheter removal, excessive intraoperative intravenous fluid volume, and postoperative ileus. The postoperative anastomotic leak, on the other hand, was not a risk factor for POUR.

CONCLUSIONS

Multiple risk factors influence the incidence of POUR in patients undergoing colorectal surgery. To reduce the incidence of POUR in colorectal surgery patients, medical staff should identify risk factors early and enforce interventions to prevent them.

Caffeine for intestinal transit after laparoscopic colectomy: randomized clinical trial (CaCo trial)

BACKGROUND

Coffee has been suggested to help postoperative gastrointestinal motility but the mechanism is not known. This trial assessed whether caffeine shortened time to bowel activity after laparoscopic colectomy.

METHODS

This was a single-centre, randomized, double-blinded, placebo-controlled superiority trial (October 2015 to August 2020). Patients aged at least 18 years undergoing elective laparoscopic colectomy were assigned randomly to receive 100 mg or 200 mg caffeine, or a placebo (250 mg corn starch) three times a day orally. The primary endpoint was the time to first bowel movement. Secondary endpoints included colonic transit time, time to tolerance of solid food, duration of hospital stay, and perioperative morbidity.

RESULTS

Sixty patients were assigned randomly to either the 200-mg caffeine group (20 patients), the 100-mg caffeine group (20) or the placebo group (20). In the intention-to-treat analysis, the mean(s.d.) time to first bowel movement was 67.9(19.2) h in the 200-mg caffeine group, 68.2(32.2) h in the 100-mg caffeine group, and 67.3(22.7) h in the placebo group (P = 0.887). The per-protocol analysis and measurement of colonic transit time confirmed no measurable difference with caffeine.

CONCLUSION

Caffeine was not associated with reduced time to first bowel movement.

REGISTRATION NUMBER

NCT02510911 (http://www.clinicaltrials.gov).

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

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.

Alvimopan for the reduction of postoperative ileus after long posterior spinal fusion: placebo-controlled double-blind randomized trial

OBJECTIVE

The aim of this study was to evaluate the efficacy of alvimopan administration after posterior spinal fusion (PSF) in adult spine surgery patients who are taking opioid agents.

METHODS

In this placebo-controlled, double-blind randomized trial, PSF patients were randomized in blocks to placebo or study drug. Primary and secondary outcome measures were return to normal bowel function, including time to passage of flatus and stool, time to tolerance of oral nutrition, and time to hospital discharge. Patients were included regardless of chronic opioid consumption status.

RESULTS

Thirty-one patients provided consent for participation, and 26 patients (13 per group) completed the study. There were no differences between groups with respect to time to flatus, time to bowel movement, time to oral nutrition tolerance, and time to discharge. Calculated effect sizes favored placebo for all interventions.

CONCLUSIONS

Alvimopan did not hasten return to bowel function for any primary or secondary outcome measures when compared with placebo for patients undergoing PSF. There were no adverse events related to alvimopan, including for patients with chronic opioid consumption. While underpowered to determine a statistical difference, it is unlikely that a clinically relevant effect exists.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

The effect of coffee/caffeine on postoperative ileus following elective colorectal surgery: a meta-analysis of randomized controlled trials

PURPOSE

Postoperative ileus (POI) is the most common complication of elective colon resection. Coffee or caffeine has been reported to be useful in improving gastrointestinal function after abdominal surgery. This study aimed to investigate the effect of coffee/caffeine on POI in patients undergoing elective colorectal surgery.

METHODS

We searched Cochrane library, Embase, PubMed, and ClinicalTrials.gov (until July 2021) to identify randomized controlled trials (RCTs) evaluating the effect of coffee or caffeine on bowel movements and POI in patients undergoing elective colorectal surgery. The mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes were calculated and are presented with 95% confidence intervals (CIs). A random effects model was used in all meta-analyses.

RESULTS

A total of four RCTs including 312 subjects met the inclusion criteria and were included in the meta-analysis. Postoperative coffee or caffeine consumption decreased the time to first bowel movement (MD, - 10.36 h; 95% CI, - 14.61 to - 6.11), shortened the length of hospital stay (MD, - 0.95 days; 95% CI, - 1.57 to - 0.34), and was associated with a decreased risk of the use of any laxatives after the procedure (RR, 0.64; 95% CI, 0.44 to 0.92). The time to first flatus, time to tolerance of solid food, risk of any postoperative complication, postoperative reinsertion of a nasogastric (NG) tube, and anastomotic leakage showed no statistical differences between groups.

CONCLUSION

Postoperative coffee or caffeine consumption improved bowel movement and decreased the duration of hospital stay in patients undergoing elective colorectal surgery. This method is safe and can prevent or treat POI.

Dissecting the Perioperative Care Bundle

Enhanced recovery after surgery (ERAS) protocols are comprehensive perioperative care pathways designed to mitigate the physiologic stressors associated with surgery and, in turn, improve clinical outcomes and lead to health care cost savings. Although individual components may differ, ERAS protocols are typically organized as multimodal care "bundles" that, when followed closely and in their entirety, are meant to generate amplified cumulative benefits. This manuscript examines some of the critical components, describes some areas where the science is weak (but dogma may be strong), and provides some of the evidence or lack thereof behind components of a standard ERAS protocol.

The effects of bit chewing on borborygmi, duodenal motility, and gastrointestinal transit time in clinically normal horses

OBJECTIVE

To determine the influence of bit chewing on gastrointestinal transit in clinically normal horses.

STUDY DESIGN

Prospective crossover designed study.

ANIMALS

Six healthy adult horses.

METHODS

Horses were assigned randomly to treatment (apple flavored bit) and control (no-bit) groups and studied for 2 × 1-week trial periods with a 2-week washout period between trials. Horses were fasted for 24 h and slowly refed over 3 days. The bit was placed for 20 min every 6 h. Duodenal contractions and borborygmi auscultations were evaluated every 12 h, approximately 5 min following bit placement. Gastrointestinal total transit time (GI TTT) was measured by administering 200 colored beads via stomach tube and then collected in the manure until 50% and 80% were recovered. Measured variables were compared using an ANOVA or Wilcoxon signed-rank test and the P value was noted.

RESULTS

The GI TTT was shortened in the bit chewing group (median: 106.37 h, range: 70-171 h) compared to the no-bit group (median: 170.1 h, range: 149-186 h) (P = .0156) at 80% bead passage (only 4/6 horses passed 80%). Borborygmi (P = .8193), duodenal contractions (P = .2605), and 50% bead passage (P = .0781) showed no differences.

CONCLUSION

Bit chewing was safe, inexpensive, and well tolerated. Bit chewing shortened GI TTT and might be an adjunct therapy to augment GI TTT. Further clinical studies are warranted.

CLINICAL SIGNIFICANCE

Ileus is a common complication following equine abdominal surgery with no current consistently successful treatment. Bit chewing may be a simple and inexpensive way to augment progressive GI motility.

The Role of Chewing Gum on Post-operative Bowel Recovery after Gynecological Laparoscopic Surgery: A Short Report and Updated Review

BACKGROUND: Adverse post-operative complication of gynecological laparoscopic surgery, post-operative ileus, could be reduced by mimicking early post-operative oral feeding; however, the role of chewing gum is still lack evidence. AIM: This study was conducted to assess chewing gum’s role in post-operative bowel recovery after gynecological laparoscopic surgery. METHODS: This prospective clinical trial recruited 60 participants who had undergone gynecological laparoscopic surgery under general anesthesia. The study was conducted at Arifin Achmad Hospital, Riau Province, Indonesia, from January to April 2021. The patients were equally divided into two groups: Intervention (n = 30) and control (n = 30). They were asked to chew sugar-free gum every 2 h after the surgery (i.e. 5 times within 10 h post-surgery). Time of the first flatus and the first bowel sounds were recorded (i.e. 5 times of assessment within 10 h post-surgery). In addition, a literature review was conducted to add evidence of the role of chewing gum on postoperative bowel recovery after gynecological laparoscopic surgery. RESULTS: Patients from both groups had a close age range (23–44-year-old versus 21–42-year-old). Our data suggested a significant difference in the time of the first flatus between the treatment and control group (15.95 h vs. 45.05 h), p < 0.001. The length of stay in the hospital among those from the treatment group was also significantly shorter compared to controls (15.50 h vs. 45.50 h), p < 0.001. The literature review of four updated randomized clinical trials suggests chewing gum in the early onset of first flatus and bowel movement. CONCLUSION: Chewing gum following gynecological laparoscopic surgery could accelerate gastrointestinal recovery.

State-of-the-art colorectal disease: postoperative ileus

PURPOSE

Postoperative Ileus (POI) remains an important complication for patients after abdominal surgery with an incidence of 10-27% representing an everyday issue for abdominal surgeons. It accounts for patients' discomfort, increased morbidity, prolonged hospital stays, and a high economic burden. This review outlines the current understanding of POI pathophysiology and focuses on preventive treatments that have proven to be effective or at least show promising effects.

METHODS

Pathophysiology and recommendations for POI treatment are summarized on the basis of a selective literature review.

RESULTS

While a lot of therapies have been researched over the past decades, many of them failed to prove successful in meta-analyses. To date, there is no evidence-based treatment once POI has manifested. In the era of enhanced recovery after surgery or fast track regimes, a few approaches show a beneficial effect in preventing POI: multimodal, opioid-sparing analgesia with placement of epidural catheters or transverse abdominis plane block; μ-opioid-receptor antagonists; and goal-directed fluid therapy and in general the use of minimally invasive surgery.

CONCLUSION

The results of different studies are often contradictory, as a concise definition of POI and reliable surrogate endpoints are still absent. These will be needed to advance POI research and provide clinicians with consistent data to improve the treatment strategies.

Changes to gastrointestinal function after surgery for colorectal cancer

Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.