Does Gum Chewing Ameliorate Postoperative Ileus? Results of a Prospective, Randomized, Placebo-Controlled Trial

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.

Incidence of and risk factors for postoperative ileus between right and left laparoscopic colectomy using propensity-score-matched analysis: A retrospective multicenter study

INSTRUCTION

In colon cancer, the incidence of postoperative ileus is reportedly higher for the right-side than for the left-side colon, but those studies included small numbers of subjects and contained several biases. Furthermore, risk factors for postoperative ileus remain unclear.

METHODS

This multicenter study reviewed 1986 patients who underwent laparoscopic colectomy between 2016 and 2021 for right-side (n = 907) and left-side (n = 1079) colon cancer. After propensity score matching, 803 patients in each group were matched.

RESULTS

Postoperative ileus occurred in 97 patients. Before matching, the proportion of female patients and median age were higher and frequency of preoperative stent insertion was lower with right colectomy (P < .001 each). After matching, the number of retrieved lymph nodes (17 vs 15, P < .001) and greater rates of undifferentiated adenocarcinoma (10.6% vs 5.1%, P < .001) and postoperative ileus (6.4% vs 3.2%, P = .004) were higher in right colectomy. Multivariate analysis revealed male gender (hazard ratio, 1.798; 95% confidence interval, 1.049-3.082; P = .32) and history of abdominal surgery (hazard ratio, 1.909; 95% confidence interval, 1.073-3.395; P = .027) as independent predictors of postoperative ileus in right-side colon cancer.

CONCLUSION

This study revealed a higher risk of postoperative ileus after right colectomy with laparoscopic surgery. Male gender and history of abdominal surgery were risk factors for postoperative ileus after right colectomy.

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.

An innovative oral management procedure to reduce postoperative complications

Background

Numerous studies have shown that improving oral hygiene contributes to a reduction in the risk of postoperative complications in patients with head and neck cancer, cardiac disease, and esophageal cancer. However, the beneficial standard for oral management procedures during the perioperative period has not yet been established. Therefore, our aim was to determine whether or not their innovative oral management intervention contributed to a reduction in postoperative complications in lung cancer.

Methods

We performed a retrospective analysis of medical records of patients who underwent lung cancer surgery with lobectomy and pneumonectomy at Kyorin University Hospital. Patients were divided into 2 groups: a perioperative oral management intervention group that underwent lung cancer surgery from April 2016 to March 2018 (n = 164), and a control group without oral management that underwent surgery from April 2014 to March 2016 (n = 199). In particular, our oral management procedure emphasized oral mucosa stimulation to induce saliva discharge as in gum chewing, rather than simply using teeth brushing to reduce oral microbiome. Therefore, our oral management procedure is different from traditional oral care.

Results

This study demonstrated that our oral management practice was associated with a decline in the occurrence of postoperative pneumonia (odds ratio, 0.184; 95% CI, 0.042-0.571; P = .009), postoperative hospital stay duration (β coefficient, -4.272; 95% CI, -6.390 to -2.155; P < .001) and Clavian-Dindo classification grade II or above (odds ratio, 0.503; 95% CI, 0.298-0.835; P = .009).

Conclusions

We propose an innovative new strategy using their unique oral management procedure to reduce postoperative complications resulting from pulmonary resection.

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.

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

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 impact of chewing gum on postoperative bowel activity and postoperative pain after total laparoscopic hysterectomy

We aimed to investigate the effects of chewing gum on bowel activity and postoperative pain in patients undergoing laparoscopic hysterectomy. Patients were randomised into two groups (n = 58, study; n = 51, control). In the study group, patients started chewing sugarless gum every 2 h for 15 min, beginning at the second postoperative hour. The control group did not chew gum, and they received standard postoperative care. Both groups were compared primarily in terms of the amount of time until the first bowel movement, the time of the first passage of flatus and the time of first defaecation. The amount of time until the first bowel movement, the time of the first passage of flatus and the time of the first defaecation were found to be significantly shorter in the chewing gum group (p < .001). The amount of postoperative analgesics that were needed and VAS scores at 6-hours and 24-hours postoperatively, were found to be lower in the study group than in the control group (p < .001). Chewing gum was found to have beneficial effects on bowel motility and postoperative pain in patients undergoing laparoscopic hysterectomy. This affordable and simple method could be recommended to patients after total laparoscopic hysterectomy.Impact statementWhat is already known on this subject? Postoperative gastrointestinal dysfunction remains a source of morbidity and the major determinant of length of stay after abdominal operation. The mechanism of enhanced recovery from postoperative gastrointestinal dysfunction with the help of chewing gum is believed to be the cephalic-vagal stimulation of digestion which increases the promotability of neural and humoral factors that act on different parts of the gastrointestinal tract.What do the results of this study add? The findings of previous randomised controlled studies have been inconsistent regarding the effect of chewing gum on postoperative bowel function following abdominal gynecological surgery. In this randomised prospective study, we found that chewing gum early in the postoperative period after total laparoscopic hysterectomy hastened time to bowel motility and flatus. To our knowledge this is the first study of the impact of chewing gum on bowel motility after total laparoscopic hysterectomy.What are the implications of these findings for clinical practice and/or further research? Chewing gum early in the postoperative period following laparoscopic hysterectomy hastens time to bowel motility and flatus. The use of chewing gum is a simple and cheap strategy for promoting the recovery of gastrointestinal functions.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Efficacy of chewing gum for improving bowel function after cesarean sections: a randomized controlled trial

Objective: To investigate the effects of chewing xylitol-free gum at different intervals after cesarean sections.Study design: One hundred fifty patients undergoing cesarean sections were randomized into a gum chewing group (n = 75) and a control group (n = 75). Patients in the gum group chewed one sugarless gum for 30 min at 3, 5, and 7 h postoperatively. The two groups were compared in terms of time to first bowel movement, first feeling of hunger, first passage of flatus, and defecation time. Postoperative satisfaction with bowel movements was rated on a scale of 1-5.Results: First bowel movement time (4.93 ± 1.05 versus 7.97 ± 2.33 h postoperatively, p = .0001), first feeling of hunger (5.51 ± 1.68 versus 6.30 ± 1.58 h postoperatively, p = .004), first passage of flatus (11.73 ± 4.61 versus 14.10 ± 2.71 h postoperatively, p = .001), and mean length of hospital stay (2.30 ± 0.49 versus 2.50 ± 0.50 d, p = .015) were significantly reduced in the gum group compared with the control group. Postoperative satisfaction scores for overall bowel function were better in the patients who chewed gum.Conclusion: Gum chewing at frequent intervals in the early postoperative period promotes the early return of bowel movements, shortens hospitalization, and increases patient satisfaction regarding bowel function.

Management of postoperative ileus after robot-assisted laparoscopic prostatectomy

To compare different postoperative management methods on the recovery of bowel function after robot-assisted laparoscopic prostatectomy (RALP).This is a prospective study of 716 patients who underwent RALP at Severance Hospital in Seoul, South Korea, between March 2017 and February 2018. Instructions for the different postoperative management methods (mobilization, abdominal massage, hot pack therapy, and gum chewing) were presented to patients, who subsequently reported when these activities were performed as well as the time to first flatus on a designated form.There were no significant differences in age, height, weight, body mass index, body surface area, prevalence of hypertension and diabetes mellitus, and in American Society of Anesthesiologists (ASA) scores with respect to early bowel recovery. Prolonged times of surgery and anesthesia significantly caused delays in bowel recovery. The total number and time of mobilization, total time of hot pack therapy, and number of gum chewing were significantly and positively associated with bowel recovery. A Kaplan-Meier analysis showed that all of the postoperative management methods were positively associated with the mean time to first flatus.Methods of postoperative management (mobilization, abdominal massage, hot pack therapy, and gum chewing) have positive effect on bowel motility after RALP. Furthermore, reductions in the times of surgery and anesthesia could significantly decrease prolonged delays in bowel recovery.

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.

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.

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.

Influence of gum-chewing on postoperative bowel activity after laparoscopic surgery for gastric cancer: A randomized controlled trial

BACKGROUND

In some studies, gum-chewing was demonstrated to have a beneficial effect on resumption of bowel function; however, other contradictory findings in other studies refute the effects of gum-chewing on peristaltic movements and digestive system stimulation. In addition, most previous studies were after colorectal or gynecology surgery, whereas few reports focused on the effect of gum-chewing after gastrectomy. The aim of this randomized controlled trial was to assess the effectiveness of gum-chewing on postoperative bowel function in patients who had undergone laparoscopic gastrectomy.

METHODS

From March 2014 to March 2016, 75 patients with gastric cancer received elective laparoscopic surgery in Shanghai Tongji hospital and were postoperatively randomly divided into 2 groups: 38 in a gum-chewing (Gum) group and 37 in a control (No gum) group. The patients in the Gum group chewed sugarless gum 3 times daily, each time for at least 15 minutes, until the day of postoperative exhaust defecation.

RESULTS

The mean time to first flatus (83.4 ± 35.6 vs. 79.2 ± 24.2 hours; P = 0.554) and the mean time to first defecation (125.7 ± 41.2 vs. 115.4 ± 34.2 hours; P = 0.192) were no different between the no gum and Gum groups. There was also no significant difference in the incidence of postoperative ileus (P = 0.896) and postoperative hospital stay (P = 0.109) between the 2 groups. The postoperative pain score at 48 hours (P = 0.032) in the Gum group was significantly higher than in the no gum group. There was no significant difference between the 2 groups in regards to patient demographics, comorbidities, duration of surgery, complications, and nausea/vomiting score.

CONCLUSION

Gum-chewing after laparoscopic gastrectomy did not hasten the return of gastrointestinal function. In addition, gum-chewing may increase patient pain on the second postoperative day.

Gum chewing for promoting intestinal function recovery after colorectal cancer surgery: A meta-analysis

AIM

To evaluate the effect of gum chewing on intestinal function recovery after colorectal cancer surgery.

METHODS

we searched databases such as PubMed and EMBASE for randomized controlled trials that evaluated the effect of gum chewing on the intestinal function recovery after colorectal cancer surgery published till June 2016. RevMan5.3 analysis software was used for data consolidation.

RESULTS

A total of 22 studies involving 2285 patients were included in this study. Meta-analysis results showed that gum chewing after operation produced a significant difference in times to first flatus [-0.57, 95% confidence interval (CI): -0.74-(-0.41)], defecation [-0.62, 95%CI: -1.06-(-0.18)], bowel movement [-0.44, 95%CI: -0.72-(-0.16)], gastrin level (29.92, 95%CI: 15.65-44.19), feeding [-1.33, 95%CI: -2.19-(-0.48)], hospital stay [-1.33, 95%CI: -2.19-(-0.48)], and ileus (0.33, 95%CI: 0.14-0.78), although no significant difference was found in postoperative nausea (0.90, 95%CI: 0.59-1.39), vomiting (0.91, 95%CI: 0.59-1.39), abdominal distention (0.62, 95%CI: 0.36-1.06), or mortality (2.25, 95%CI: 0.63-8.09).

CONCLUSION

Gum chewing after colorectal cancer surgery may accelerate intestinal function recovery, but does not reduce postoperative complications. Larger rigorous studies are needed for better understanding of the role of gum chewing.

Effect of gum chewing on reducing postoperative ileus and recovery after colorectal surgery: A randomised controlled trial

AIM

This study aimed to determine the effect of gum chewing on the reduction of postoperative ileus and recovery after surgery.

METHODS

This study was conducted a randomized controlled trial in 60 patients who underwent colorectal surgery between November 2011 and December 2012. Patients in the experimental group chewed gum three times a day. The time of flatus and defecation, the time to start feeding, pain levels and time of discharge were monitored.

RESULTS

Post-surgery results for gum-chewing were first flatus and defecation times and the time to start feeding was shorter; pain levels were lower on the 3rd - 5th days; patients were discharged in a shorter time post-surgery.

CONCLUSIONS

Chewing gum is a simple intervention for reducing postoperative ileus after colorectal surgery. Further studies that examine the effectiveness of gum chewing on other surgical interventions in which the development risk of postoperative ileus should be performed.

The Effect of Gum Chewing, Early Oral Hydration, and Early Mobilization on Intestinal Motility After Cesarean Birth

AIM

The aim of the study was to investigate the effect of gum chewing, early oral hydration, and early mobilization after cesarean birth on intestinal sounds, passing gas, and intestinal evacuation.

DESIGN

Randomized controlled study.

SETTING

This study was conducted at the Obstetrics Service of the one Obstetrics and Child Diseases Hospital.

PARTICIPANTS

A total of 240 females divided into 8 groups of 30 subjects each were included within the scope of the sample.

METHODS

The women who underwent cesarean birth were divided into eight groups by using 2(3) factorial test levels, depending on the use of three different methods of gum chewing, early oral hydration, and early mobilization. No intervention was applied to the women in the control group. For the other seven groups, the intestinal sounds were checked every 30 minutes with a stethoscope over the abdomen and the first time of passing gas and the first evacuation time were recorded by asking the mother. The data were evaluated with numbers, mean, and percentage calculations, Student's t test, one-way variance analysis, correlation, and Tukey HSD test.

RESULTS

The intestinal sounds were heard earlier, gas was passed earlier, and bowel movements were earlier in the first group that received all interventions compared to the other groups (p < .05). The patient could not be discharged before 48 hours had passed after the cesarean birth according to the hospital protocol and the time of discharge was therefore not affected by interventions.

LINKING EVIDENCE TO ACTION

All of the three different interventions, such as gum chewing, early oral hydration, and early mobilization after cesarean birth, increase intestinal motility. The interventions are recommended during postoperative routine care to shorten hospital stay and prevent postoperative ileus.

Efficacy of Gum Chewing on Bowel Movement After Open Colectomy for Left-Sided Colorectal Cancer: A Randomized Clinical Trial

BACKGROUND

Prolonged intestinal paralysis can be a problem after gastrointestinal surgery. Several systematic reviews and meta-analyses have suggested the efficacy of gum chewing for the prevention of postoperative ileus.

OBJECTIVE

The purpose of this study was to examine the efficacy of gum chewing for the recovery of bowel function after surgery for left-sided colorectal cancer and to determine the physiological mechanism underlying the effect of gum chewing on bowel function.

DESIGN

This was a single-center, placebo-controlled, parallel-group, prospective randomized trial.

SETTINGS

The study was conducted at a general hospital in Japan.

PATIENTS

Forty-eight patients with left-sided colorectal cancer were included.

INTERVENTIONS

The patients were randomly assigned to a gum group (N = 25) and a control group (N = 23). Four patients in the gum group and 1 in the control group were subsequently excluded because of difficulties in continuing the trial, resulting in the analysis of 21 and 22 patients in the respective groups. Patients in the gum group chewed commercial gum 3 times a day for ≥5 minutes each time from postoperative day 1 to the first day of food intake.

MAIN OUTCOME MEASURES

The time to first flatus and first bowel movement after the operation were recorded, and the colonic transit time was measured. Gut hormones (gastrin, des-acyl ghrelin, motilin, and serotonin) were measured preoperatively, perioperatively, and on postoperative days 1, 3, 5, 7, and 10.

RESULTS

Gum chewing did not significantly shorten the time to the first flatus (53 ± 2 vs. 49 ± 26 hours; p = 0.481; gum vs. control group), time to first bowel movement (94 ± 44 vs. 109 ± 34 hours; p = 0.234), or the colonic transit time (88 ± 28 vs. 88 ± 21 hours; p = 0.968). However, gum chewing significantly increased the serum levels of des-acyl ghrelin and gastrin.

LIMITATIONS

The main limitation was a greater rate of complications than anticipated, which limited the significance of the findings.

CONCLUSIONS

Gum chewing changed the serum levels of des-acyl ghrelin and gastrin, but we were unable to demonstrate an effect on the recovery of bowel function.

Chew on this: reducing postoperative ileus with chewing gum

BACKGROUND

Postoperative ileus (POI), a common postoperative complication, increases length of stay and costs. Although bowel rest and delayed oral intake were once thought to help prevent POI, newer evidence shows that chewing gum can be beneficial. METHODS--LITERATURE SEARCH: The literature was searched for the terms ileus, gum, chewing, and gum chewing for 2006 to 2013.

STUDY SELECTION

All prospective randomized controlled trials comparing gum chewing in adults with a control treatment after abdominal surgery (except cesarean section) were included; an outcome measure was required as a dependent variable.

FINDINGS

Seven primary research studies from around the world were gathered.

RESULTS

Across all studies, patients in the gum-chewing experimental group both passed flatus and defecated before those in the non-gum-chewing control group. Where length of stay was studied, patients in all but one experimental group were in the hospital for less time.

LIMITATIONS

These included small sample sizes, lack of blinding in all but one study, differences in standards of care among hospitals and countries represented, unspecified types of gum, and variable timing and frequency of gum chewing among studies.

DISCUSSION

Patients who chewed gum postoperatively had less POI, passed flatus sooner, had an earlier bowel movement and a shorter length of stay, and were more satisfied. Gum chewing is recommended as adjunctive therapy to reduce postoperative POI.

Chewing gum for postoperative recovery of gastrointestinal function

BACKGROUND

Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo-vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery.

OBJECTIVES

To examine whether chewing gum after surgery hastens the return of gastrointestinal function.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand-searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and metaRegister of Controlled Trials.

SELECTION CRITERIA

We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta-analyses using a random-effects model. We investigated the influence of study quality, reviewers' methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta-regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost.

MAIN RESULTS

We identified 81 studies that recruited 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: -11.9, -8.9): 12.5 hours (95% CI: -17.2, -7.8) in CRS, 7.9 hours (95% CI: -10.0, -5.8) in CS, 10.6 hours (95% CI: -12.7, -8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: -14.5, -10.9): 18.1 hours (95% CI: -25.3, -10.9) in CRS, 9.1 hours (95% CI: -11.4, -6.7) in CS, 12.3 hours (95% CI: -14.9, -9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: -0.8, -0.5): 1.0 days in CRS (95% CI: -1.6, -0.4), 0.2 days (95% CI: -0.3, -0.1) in CS, 0.8 days (95% CI: -1.1, -0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: -6.4, -3.7): 3.21 hours (95% CI: -7.0, 0.6) in CRS, 4.4 hours (95% CI: -5.9, -2.8) in CS, 6.3 hours (95% CI: -8.7, -3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS.There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well-tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome.Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS.Meta-regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies.

AUTHORS' CONCLUSIONS

This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery.

Chewing gum and postoperative ileus in adults: a systematic literature review and meta-analysis

INTRODUCTION

Post-operative ileus (POI) is a major problem following elective abdominal surgery. Several studies have been published investigating the use of chewing gum to reduce POI. These studies however, have produced variable results. Thus, there is currently no consensus on whether chewing gum should be widely instituted as a means to help reduce POI.

METHODS

We performed a systematic literature review to evaluate whether the use of chewing gum post-operatively improves POI in abdominal surgery. A comprehensive review of the literature was conducted according to the guidelines in the PRISMA statement. The following databases were searched: MEDLINE, PUBMED, EMBASE, SCOPUS, Science Direct, CINAHL and the Cochrane Central Register of Controlled Trials. Clinical outcomes were extracted and meta-analysis was performed.

RESULTS

There were 1019 patients from 12 randomised controlled studies included in this review. Only one study was conducted in an Enhanced Recovery after Surgery (ERAS) environment. Seven of the twelve studies concluded that chewing gum reduced post-operative ileus. The remaining five studies found no clinical improvement. Overall, there was a small benefit in reducing time to flatus, and time to bowel motion, but no difference in the length of stay or complications.

CONCLUSION

Chewing gum offers only a small benefit in reducing time to flatus and time to passage of bowel motion following abdominal surgery. This benefit is of limited clinical significance. Further studies should be conducted in a modern peri-operative care environment.

Facilitating return of bowel function after colorectal surgery: alvimopan and gum chewing

Postoperative ileus is common after colorectal surgery, and has a huge impact on hospital LOS. With the impeding cost crisis in the United States, safely reducing length of stay is essential. Chewing gum and pharmacological treatment with alvimopan are safe, simple tools to reduce postoperative ileus and its associated costs. Future research will determine if integrating these tools with laparoscopic procedures and enhanced recovery pathways is a best practice in colorectal surgery.

A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery protocols?

BACKGROUND

Sham feeding has been shown to hasten the return of GI function following colorectal surgery, before the advent of enhanced recovery after surgery protocols. Few data exist regarding the efficacy of sham feeding in the modern era, with rapid postoperative feeding.

OBJECTIVE

We sought to perform a meta-analysis on the effect of sham feeding in colorectal surgery, with a separate analysis on trials that used rapid postoperative feeding.

DATA SOURCES

Cochrane, MEDLINE, EMBASE, Scopus, and PubMed were searched by using the terms gum OR sham feeding OR chew AND (colorect OR resect).

STUDY SELECTION

All studies were randomized controlled trials (in any language) performed on adults, comparing standard care with gum chewing following colorectal resection. From 439 citations, 10 articles were included.

INTERVENTION

The intervention was sham feeding by means of gum chewing.

MAIN OUTCOME MEASURES

The outcome measures were time to return of flatus, time to first bowel movement, complication rates, length of hospital stay, readmission rates, and reoperation rates.

RESULTS

Ten randomized controlled trials (n = 612) were included. Sham feeding resulted in a reduction in time to flatus of 31 minutes (p = 0.003) and time to first bowel movement of 30 minutes (p = 0.05). Sham feeding also resulted in a reduction in length of stay by 0.5 days (p = 0.007), and a reduction in complication rates (relative risk = 0.687, p = 0.017), although this appeared to be associated with publication bias. Analysis of trials that used rapid postoperative feeding (n = 282) revealed no difference in postoperative GI function.

LIMITATIONS

This review was limited by the heterogeneity of postoperative feeding regimes, in addition to limited reporting by trials of postoperative morbidity.

CONCLUSIONS

Sham feeding following colorectal surgery is safe, results in small improvements in GI recovery, and is associated with a reduction in the length of hospital stay. It confers no advantage if patients are placed on a rapid postoperative feeding regime.

Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial

OBJECTIVE

To determine whether sham feeding with chewing gum improved gastrointestinal recovery after colorectal resection surgery, in the presence of routine postoperative feeding.

BACKGROUND

Sham feeding with chewing gum has been shown to accelerate the return of gut function after colorectal surgery. This study sought to determine whether sham feeding with gum, after colorectal resection, accelerates return of gastrointestinal function in patients on a rapid feeding enhanced recovery program.

METHODS

A randomized "two armed" controlled clinical trial was performed. Equal groups of open and laparoscopic colorectal resection surgical patients were recruited. Patients in the intervention arm received chewing gum 4 times a day postoperatively. All patients in the trial were placed on an established, standardized Enhanced Recovery After Surgery program. The primary outcome was time to return of gut function, assessed by time to flatus and first bowel motion. Secondary outcomes were time to tolerate diet, symptoms of ileus in the form of nausea, vomiting and distension, pain as assessed by analgesic consumption and visual analogue scales, complications, and length of hospital stay.

RESULTS

A total of 161 patients were recruited. Postoperative morbidity was equivalent between groups, with no complications related to gum chewing. There was no difference between groups with respect to the primary outcomes of time to flatus and bowel motion. There was less perception of pain in the intervention group on days 2 to 5, and no difference with respect to all other secondary outcomes.

CONCLUSIONS

Sham feeding with gum, after open and laparoscopic colorectal resectional surgery is safe, but does not hasten the return of gastrointestinal function in patients who receive accelerated postoperative feeding. (ACTRN12607000538448).

Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial

OBJECTIVE

To investigate whether gum chewing affects the return of bowel function after complete staging surgery for gynecologic malignancies.

METHODS

A total of 149 patients undergoing abdominal complete surgical staging for various gynecological cancers were randomized into a gum-chewing group (n=74) or a control group (n=75). The patients chewed sugarless gum three times from the first postoperative morning until the first passage of flatus. Each chewing session lasted 30 min. Total abdominal hysterectomy with systematic pelvic and para-aortic lymphadenectomy was performed on all patients as part of complete staging surgery. Groups were compared in terms of time to first bowel movement time, first flatus and feces pass time, postoperative analgesic and antiemetic drug requirement, postoperative oral intake tolerance, mild ileus symptoms and hospital stay.

RESULTS

The mean time to flatus (34.0 ± 11.5 vs. 43.6 ± 14.0 h; p<0.001), mean time to defecation (49.6 ± 18.7 vs. 62.5 ± 21.5h; p<0.001), mean time to bowel movement (41.5 ± 15.7 vs. 50.1 ± 5.9h; p=0.001), mean time to tolerate diet (4.0 ± 0.8 vs. 5.0 ± 0.9 days; p<0.001), mean length of hospital stay (5.9 ± 1 vs. 7.0 ± 1.4 days; p<0.001) were significantly reduced in patients that chewed gum compared with controls. Mild ileus symptoms were observed in 27 (36%) patients in the control group compared to 11(14.9%) patients in the gum-chewing group [relative risk, 2.4; 95% confidence interval, 1.2-4.5; p=0.004]. Severe symptoms were observed in two patients (2.7%) in the control group.

CONCLUSIONS

Gum chewing early in the postoperative period following elective total abdominal hysterectomy and systematic retroperitoneal lymphadenectomy hastens time to bowel motility and ability to tolerate feedings. This inexpensive and well-tolerated treatment should be added as an adjunct in postoperative care of gynecologic oncology.

Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials

BACKGROUND AND AIM

Chewing gum proposal has been used in surgery to reduce postoperative ileus for more than 10 years; however, the efficacy remains imprecise. The aim of this study was to accurately assess whether the use of the chewing gum could reduce duration of postoperative ileus following the abdominal surgery.

METHODS

A systematic review was conducted in Medline, EMBASE, and the Cochrane Library through December 2012 to identify randomized controlled trials comparing with and without the use of chewing gum in patients undergoing abdominal surgery. The outcome of interest was time to flatus, time to bowel movement, and length of stay. Subgroup analyses were performed to examine the impact of different studies structural design. Cumulative meta-analyses were used to examine how the evidence has changed over time.

RESULTS

Seventeen randomized controlled trials involving 1374 participants were included. Overall time (in days) for the patients to pass flatus (weighted mean difference [WMD], -0.31; 95% confidence interval [CI], -0.43 to -0.19; P = 0.000); time to bowel movement (WMD, -0.51; 95% CI, -0.73 to -0.29; P = 0.000); and length of stay (WMD, -0.72; 95% CI, -1.02 to -0.43; P = 0.000) were significantly reduced in the treatment group. However, both of these results demonstrated significant heterogeneity. No evidence of publication bias was observed. Cumulative meta-analysis showed that chewing gum reduces duration of postoperative ileus that has been available for over 6 years.

CONCLUSIONS

Results of the meta-analysis suggest that chewing gum following abdominal surgery offers benefits in reducing the time of postoperative ileus.

Defining postoperative ileus: results of a systematic review and global survey

BACKGROUND

There is a lack of an internationally accepted standardised clinical definition for postoperative ileus (POI). This has made it difficult to estimate incidence and identify risk factors and has compromised external validity of clinical trials.

AIM

To clarify terminology of POI and propose concise, clinically quantifiable definitions.

METHODS

A systematic review extracted definitions from randomised trials published between 1996 and 2011 investigating POI after abdominal surgery. This was followed by a global survey seeking opinions of those who have published in the field.

RESULTS

Definitions were extracted from 52 identified trials. Responses were received in the survey from 45 of 118 corresponding authors. Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) "interval from surgery until passage of flatus/stool AND tolerance of an oral diet"; prolonged POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after day 4 postoperatively without prior resolution of POI"; recurrent POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of POI". Concordance of the latter two definitions with survey responses were ≥75 %.

CONCLUSION

We have proposed standardised endpoints for use in future studies to facilitate objective comparison of competing interventions.

A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding

BACKGROUND

A number of small prospective studies with conflicting results have evaluated the effect of sugar-free chewing gum on postoperative GI recovery in patients initially maintained nil per os after major colorectal surgery.

OBJECTIVE

We sought to evaluate the effect of sugared chewing gum in combination with early enteral feeding on recovery of GI function after major colorectal surgery to ascertain any additive effects of this combination.

DESIGN

This was a randomized prospective study.

SETTING

This study was conducted at a single-institution tertiary referral center.

PATIENTS

Patients undergoing major colorectal surgery were included.

INTERVENTIONS

Patients were randomly assigned to sugared chewing gum (Gum) (instructed to chew 3 times daily; 45 minutes each time for 7 days postoperatively) or No Gum after major colorectal surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was time to tolerating low residue diet without emesis for 24 hours. The secondary outcomes measured were time to flatus, time to bowel movement, postoperative hospital stay, postoperative pain, nausea, and appetite.

RESULTS

One hundred fourteen patients (60 No Gum; 54 Gum) were included in our analysis after randomization. There was no significant difference in time to tolerating a low-residue diet, time to flatus, time to bowel movement, length of postoperative hospital stay, postoperative complications, postoperative pain, nausea, or appetite between patients assigned to Gum or No Gum. There was an increased incidence of bloating, indigestion, and eructation in the Gum group (13%) in comparison with the No Gum group (2%) (p = 0.03).

LIMITATIONS

Study subjects and investigators were not blinded. Multiple types of operations may cause intergroup variability.

CONCLUSIONS

There does not appear to be any benefit to sugared chewing gum in comparison with no gum in patients undergoing major colorectal surgery managed with early feeding in the postoperative period. There may be increased incidence of bloating, indigestion, and eructation, possibly related to swallowed air during gum chewing.

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Eficacia de la Goma de Mascar en el Restablecimiento del Tránsito Intestinal por íleo Paralitico Postoperatorio: Un Estudio Prospectivo y Aleatorio

Introducción

El íleo postoperatorio es una importante causa de morbilidad después de un procedimiento quirúrgico abdominal. Un factor causal del retardo de la motilidad del tracto gastrointestinal es la presencia de una hiperactividad simpática generalizada que inhibe la motilidad intestinal.

La fase cefálica de la digestión se inicia con la masticación, que activa al nervio vago (parasimpático) estimulando la actividad eléctrica del músculo gastrointestinal y control hormonal. Por tal motivo, el presente trabajo pretende conocer si la goma de mascar estimula la actividad parasimpática y si logra restablecer el tránsito intestinal lo más precoz posible.

Métodos

Estudio experimental, prospectivo, longitudinal, randomizado y aleatorio. Se seleccionaron 2 grupos de acuerdo al orden de ingreso en Servicio de Cirugía—Hospital Clínico Viedma (hospital 3er nivel), atendidos por herida penetrante de abdomen con lesión del tubo digestivo, un grupo control y otro de estudio a los que se administró goma de mascar a las 6 horas del postoperatorio.

Resultados

Pacientes que recibieron goma de mascar recuperaron más rápidamente la motilidad intestinal con expulsión de gases antes de las 12 horas en el 76% de los casos, en comparación con el grupo control que eliminó más allá de las 24 horas, pacientes del grupo estudio experimentaron movimientos intestinales y defecación por primera vez dentro de las primeras 48 horas en un 65%, dos días antes que el grupo control.

Es así que a los pacientes del grupo estudio se les administró alimentación vía oral al día siguiente de su cirugía en el 76% de los casos en relación al grupo control que recibieron alimentación tres a cuatro días después.

Conclusiones

La goma de mascar debería incluirse como terapia complementaria en el postoperatorio de estos pacientes, ya que favorece el temprano restablecimiento del tránsito intestinal y constituye una forma económica y fisiológica de estimular la motilidad intestinal.

Role of gum chewing on the duration of postoperative ileus following ileostomy closure done for typhoid ileal perforation: a prospective randomized trial

BACKGROUND/AIM

There is ample evidence in the recent literature that gum chewing after elective colonic anastomosis decreases postoperative ileus (POI). But there are very few studies on small bowel anastomosis done in relaparotomy cases. This study aimed to evaluate the effect of gum chewing on the duration of POI following small bowel anastomosis performed for the closure of intestinal stoma, made as temporary diversion in the selected cases of typhoid perforation peritonitis.

PATIENTS AND METHODS

Hundred patients undergoing elective small bowel anastomosis for the closure of stoma were randomly assigned to the study group (n=50) and the control group (n=50). The study group patients chewed gum thrice a day for 1 h each time starting 6 h after the surgery until the passage of first flatus. The control group patients had standard postoperative treatment.

RESULTS

Study and control group patients were comparable at inclusion. The mean time for the appearance of bowel sounds as well as the passage of first flatus was significantly shorter in the study group (P=0.040, P=0.006). The feeling of hunger was also experienced earlier in study group cases (P=0.004). The postoperative hospital stay was shorter in the study group, but the difference was not significant (P=0.059).

CONCLUSIONS

The cases of relaparotomy requiring additional adhesiolysis and small bowel anastomosis for stoma closure are benefited by postoperative gum chewing.

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus

All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.

Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery

BACKGROUND

Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.

METHODS

A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI).

RESULTS

Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI -21.49 to -3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI -34.32 to -11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI -53.29 to +5.53; P = 0.11). There were no significant differences in complication rates.

CONCLUSIONS

Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

Postoperative ileus: Impact of pharmacological treatment, laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery. POI represents the single largest factor influencing length of stay (LOS) after bowel resection, and has great implications for patients and resource utilization in health care. New methods to treat and decrease the length of POI are therefore of great importance. During the past decade, a substantial amount of research has been performed evaluating POI, and great progress has been made in our understanding and treatment of POI. Laparoscopic procedures, enhanced recovery pathways and pharmacologic treatment have been introduced. Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection. This editorial outlines resource utilization of POI, normal physiology of gut motility and pathogenesis of POI. Pharmacological treatment, fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI. The optimal integration of these treatment options continues to be assessed in prospective studies.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Pharmacologic Options to Prevent Postoperative Ileus

Objective:

To summarize the evidence on pharmacologic options in preventing postoperative ileus (POI).

Data Sources:

The Cochrane Database of Reviews and OVID databases and Food and Drug Administration (FDA) Web site were searched (1950–April 2009) using the term postoperative ileus.

Study Selection and Data Extraction:

Meta-analyses and randomized controlled trials were included for review. The FDA Web site was searched for clinical reviews and label information for drugs indicated for the prevention of POI.

Data Synthesis:

Three meta-analyses, 2 on gum-chewing and 1 on alvimopan, and 18 clinical trials were identified. Only gum chewing and alvimopan were effective in preventing POI. Gum chewing reduced the time to first flatus and bowel movement (weighted mean difference 21h, p = 0.0006 and 33h; p = 0.0002, respectively). In one meta-analysis, gum chewing significantly reduced length of stay (LOS) by 2.4 days (p < 0.00001) but this was not replicated in the second meta-analysis. Alvimopan shortened the time to reach a composite endpoint of solid food intake, plus/minus flatus, and bowel movement (93 vs 105 h; p < 0.001). A higher incidence of myocardial infarction was observed in a 12-month study of alvimopan for the treatment of opioid-induced bowel dysfunction, but not in studies in patients undergoing bowel resection. Alvimopan decreased the time to written hospital discharge order (hazard ratio 1.35; p<0.01), while the significance of a reduction in LOS (0.2–1.3 days) was not reported.

Conclusions:

Gum chewing and alvimopan are effective in preventing POI, but given safety concerns and higher cost with alvimopan, gum chewing may be preferred.