Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial

Does Chewing Gum Lead to Earlier Postoperative Gastrointestinal Recovery in Children? A Systematic Review and Meta-analysis

INTRODUCTION

Postoperative ileus is a common occurrence among children undergoing major operations, including gastrointestinal and spinal surgeries. Preliminary evidence in adults suggests that chewing gum plays a role in accelerating the return of postoperative gastrointestinal function. However, evidence is scarce in the paediatric population. The aim of this study was to investigate whether chewing gum has benefits for children.

METHODS

We searched PubMed, Medline, Embase, and Cochrane Trials databases for randomised controlled trials that compare gum chewing with standard care after elective surgery in children from 1st Jan 2005 to 31st July 2021. We assessed the identified trials for quality and performed a systematic review and meta-analysis in accordance with PRISMA and registered in PROSPERO (CRD42022358801). The main outcome measures examined were time to flatus and stool postoperatively, time to tolerate oral intake, and length of hospital stay, which were analysed using fixed effects models. We also examined clinical complication rates and postoperative pain control.

RESULTS

We included six eligible trials, with a total of 357 enrolled patients. The intervention was well tolerated without complications. There was no significant difference in time to flatus (-2.86 h; 95 % CI: -6.2 to 0.47 h, p = 0.09), time to stool (-6.39 h; 95 % CI: -13.9 to 1.2 h, p = 0.1), time to tolerate oral intake (-0.03 days; 95 % CI: -0.15 to 0.1 days, p = 0.68), and length of hospital stay (0.08 days; 95 % CI: -0.07 to 0.22 days, p = 0.29). Postoperative pain control (opioid consumption, pain score, nausea score) was similar in both groups (p > 0.05).

CONCLUSION

Current evidence demonstrates that gum chewing is not associated with earlier postoperative gastrointestinal recovery in children. Future adequately powered and well-designed trials are necessary to evaluate any clinical benefit of chewing gum for children and whether it could result differences in healthcare satisfaction.

LEVEL OF EVIDENCE

I.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role of Chewing Gum in Reducing Postoperative Ileus after Reversal of Ileostomy: A Randomized Controlled Trial

BACKGROUND

Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay.

PATIENTS AND METHODS

This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test.

RESULTS

Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000).

CONCLUSION

It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

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.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Usage of Chewing Gum in Posterior Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

The present study investigated the effectiveness of chewing gum on promoting faster bowel function and its ability to hasten recovery for patients with adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

Sham feeding with chewing gum had been reported to reduce the incidence of postoperative ileus by accelerating recovery of bowel function.

METHODS

We prospectively recruited and randomized 60 patients with AIS scheduled for PSF surgery into treatment (chewing gum) and control group. The patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth were assessed and recorded at 12, 24, 36, 48, and 60 hours postoperatively. The timing for the first fluid intake, first oral intake, sitting up, walking, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay were also assessed and recorded.

RESULTS

We found that there were no significant differences (P > 0.05) in patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth between treatment (chewing gum) and control groups. We also found that there were no significant difference (P > 0.05) in postoperative recovery parameters, which were the first fluid intake, first oral intake, sitting up after surgery, walking after surgery, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay between both groups. The wound pain was the worst at 12 hours postoperatively, which progressively improved in both groups. The abdominal pain progressively worsened to the highest score at 48 hours in the treatment group and 36 hours in the control group before improving after that. The pattern of severity and recovery of wound pain and abdominal pain was different.

CONCLUSION

We found that chewing gum did not significantly reduce the abdominal pain, promote faster bowel function, or hasten patient recovery.

LEVEL OF EVIDENCE

1.

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.

Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection

Background

Chewing gum may stimulate gastrointestinal motility, with beneficial effects on postoperative ileus suggested in small studies. The primary aim of this trial was to determine whether chewing gum reduces length of hospital stay (LOS) after colorectal resection. Secondary aims included examining bowel habit symptoms, complications and healthcare costs.

Methods

This clinical trial allocated patients randomly to standard postoperative care with or without chewing gum (sugar‐free gum for at least 10 min, four times per day on days 1–5) in five UK hospitals. The primary outcome was LOS. Cox regression was used to calculate hazard ratios for LOS.

Results

Data from 402 of 412 patients, of whom 199 (49·5 per cent) were allocated to chewing gum, were available for analysis. Some 40 per cent of patients in both groups had laparoscopic surgery, and all study sites used enhanced recovery programmes. Median (i.q.r.) LOS was 7 (5–11) days in both groups (P = 0·962); the hazard ratio for use of gum was 0·94 (95 per cent c.i. 0·77 to 1·15; P = 0·557). Participants allocated to gum had worse quality of life, measured using the EuroQoL 5D‐3L, than controls at 6 and 12 weeks after operation (but not on day 4). They also had more complications graded III or above according to the Dindo–Demartines–Clavien classification (16 versus 6 in the group that received standard care) and deaths (11 versus 0), but none was classed as related to gum. No other differences were observed.

Conclusion

Chewing gum did not alter the return of bowel function or LOS after colorectal resection. Registration number: ISRCTN55784442 (http://www.controlled-trials.com).

No advantage observed

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.

Independent risk factors for prolonged postoperative ileus development

BACKGROUND

Postoperative ileus (POI) has a significant impact on patient wellbeing, and with a 15% incidence in colectomy patients costs US hospitals >$1.3 billion per year. Although some causative mechanisms have been identified, little is known about what places patients at risk for ileus. We aimed to identify factors that independently influence the development of POI.

MATERIALS AND METHODS

Patients who underwent elective surgery between 2011 and 2012 were identified from the colectomy-specific American College of Surgeons National Surgical Quality Improvement Program database. Descriptive statistics were calculated, and demographics, comorbidities, preoperative treatments, and operative characteristics were evaluated as risk factors using multivariate analyses.

RESULTS

A total of 9734 patients were included in this analysis; 1364 (14%) were found to have POI. Patients who developed an ileus were more likely to develop any postoperative complication, to be readmitted, and require reoperation compared with patients without POI. In addition, we identified 13 independent risk factors for POI.

CONCLUSIONS

Five modifiable risk factors for development of POI were identified as follows: smoking, weight loss, preoperative oral antibiotics, mechanical bowel preparation, and surgical approach. These identifications provide insight into possible targets for preoperative modification, which may lead to improvements in patients' quality of life and influence outcomes such as postoperative complications, readmission, and reoperation.

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.

Effect of Coffee on the Length of Postoperative Ileus After Elective Laparoscopic Left-Sided Colectomy: A Randomized, Prospective Single-Center Study

BACKGROUND

Postoperative ileus is common problem after colorectal surgery. A positive effect of coffee to bowel movement has been described. It is still unclear whether coffee decreases the risk of postoperative ileus.

OBJECTIVE

The purpose of this study was to determine whether consuming a 100-mL cup of coffee is effective in preventing or reducing postoperative ileus.

DESIGN

This was a prospective, single-center, randomized controlled study.

SETTINGS

The study was conducted at a university teaching hospital.

PATIENTS

All of the patients who were scheduled for elective laparoscopic left-sided colectomy at our hospital after the detection of malignant disease in a preoperative biopsy between January 2013 and December 2014 entered the study. The patients were assigned randomly before surgery to receive coffee with caffeine (first group), coffee without caffeine (second group), or water (third group) after the procedure (100 mL 3 times daily).

MAIN OUTCOME MEASURES

The primary end point was time to first bowel movement; secondary end points were time to first flatus and time to tolerance of solid food.

RESULTS

A total of 105 patients were randomly assigned, 35 to each group. Fifteen patients were excluded. Patient demographic characteristics were similar in the groups. The time until the first bowel movement (measured in days) was significantly (p < 0.05) shorter in the decaffeinated coffee group (3.00 ± 1.50) versus the coffee with caffeine (3.75 ± 1.53) and water groups (4.14 ± 1.14). The time until tolerance of solid food was significantly shorter in decaffeinated group versus coffee with caffeine and water groups (1.85 versus 2.60 and 2.80; p < 0.05). Time until the first flatus (1.47 versus 1.57 and 1.77 for decaffeinated coffee versus coffee with caffeine and water; p > 0.05) did not show statistical significance. Postoperative hospital stay was similar in all 3 of the groups.

LIMITATIONS

This is a single-center study with a relatively small sample size.

CONCLUSIONS

Coffee consumption after colectomy was safe and in the decaffeinated group associated with a reduced time to first bowel action. Caffeine is not a main ingredient affecting the length of postoperative ileus.

Radical Cystectomy Perioperative Care Redesign

OBJECTIVE

To present an evidence-based review of the perioperative management of the radical cystectomy (RC) patient in the context of a care redesign initiative.

METHODS

A comprehensive review of the key factors associated with perioperative management of the RC patient was completed. PubMed, Medline, and the Cochrane databases were queried via a computerized search. Specific topics were reviewed within the scope of the three major phases of perioperative management: preoperative, intraoperative, and postoperative. Preference was given to evidence from prospective randomized trials, meta-analyses, and systematic reviews.

RESULTS

Preoperative considerations to improve care in the RC patient should include multi-disciplinary medical optimization, patient education, and formal coordination of care. Efforts to mitigate the risk of malnutrition and reduce postoperative gastrointestinal complications may include carbohydrate loading, protein nutrition supplementation, and avoiding bowel preparation. Intraoperatively, a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus. Finally, enhanced recovery protocols including novel medications, early feeding, and multi-modal analgesia approaches are associated with earlier postoperative convalescence.

CONCLUSION

RC is a complex and morbid procedure that may benefit from care redesign. Evidence based quality improvement is integral to this process. We hope that this review will help guide further improvement initiatives for RC.

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.

Chewing gums has stimulatory effects on bowel function in patients undergoing cesarean section: a randomized controlled trial

The aim of study was to investigate the effect of postoperative gum chewing on the recovery of bowel function after cesarean section. Total 100 women delivered by lower uterine segment section cesarean under local anesthesia (spinal). Eligible patients were randomly allocated into two groups: a gum-chewing group (n=50) or a control group (n= 50). The gum-chewing group participants who received one stick of sugarless gum for one hours, three times daily immediately after recovery from anesthesia and the control group had the usual postoperative care until being discharged. All women were followed up regularly until discharge from hospital, and recorded the times to the first bowel sounds of normal intestinal sounds, the time to the first passage of flatus, the time to the first feeling of hunger, and the time to the first defecation. The operative data, postoperative tolerance of gum chewing, and postoperative complications were documented. There was no statistically significant difference between the two groups in terms of demographic characteristics such as age, body mass index, parity, duration of surgery, number of miscarriages and curettages, time to the first feeding, the amount of serum intake, and type of cesarean section. The mean average postoperative interval of the first bowel sounds (21.9 versus 26.1 hours, p= 0.016), the first feeling of hunger (11.8 versus 14.5 hours, p= 0.050), the first passage of flatus (24.8 versus 30.0 hours, P=0.002), the first defecation (30.6 versus 38.4 hours, P= 0.0001) was significantly shorter compared to the control group.

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).

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.

Chewing sugar-free gum reduces ileus after cesarean section in nulliparous women: a randomized clinical trial

Background

Gum chewing after cesarean section may stimulate bowel motility and decrease duration of postoperative ileus.

Objectives

The current study assessed the effect of chewing sugar-free gum on the return of bowel function, where cesarean section had been performed in nulliparous women.

Materials and Methods

In a randomized clinical trial, 60 patients, scheduled for cesarean section were randomly divided in to 2 groups gum-chewing group (n = 30) and control group (n = 30) postoperatively. The patients in the gum-chewing group postoperatively chewed sugar free gum 3 times daily each time for 1 hour until discharge. The patients' demographic characteristics, duration of surgery, mean hunger time, flatus and bowel motility were compared in the two groups.

Results

There was no significant difference between the 2 groups regarding patient demographics, intraoperative, and postoperative care. In the gum-chewing and the control group there was a significant difference in the mean postoperative interval of the first bowel movement (20.89 ± 8.8 versus 27.93 ± 9.3 hours, P = 0.004), the first feeling of hunger (10.37 ± 6.0 versus 16.33 ± 9.3 hours, P = 0.005), the first passage of flatus (25.02 ± 5.8 versus 31.08 ± 9.7 hours, P = 0.003), and the first defecation (31.17 ± 5.3versus 40.08 ± 8.8 hours, P = 0.000) respectively, which were significantly shorter in the gum-chewing group compared to those of the control group. There were no major complications in either group. All patients in the gum-chewing group tolerated it without any major complications and side effects.

Conclusions

The study results demonstrated that bowel motility after cesarean section in nulliparous women can be accelerated by gum chewing which is a useful, inexpensive and well-tolerated method for mothers in post-cesarean section.

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.

Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy

Background

Postoperative ileus is a common problem after abdominal surgery. It was postulated that coffee intake would decrease postoperative ileus after colectomy.

Methods

This was a multicentre parallel open-label randomized trial. Patients with malignant or benign disease undergoing elective open or laparoscopic colectomy were assigned randomly before surgery to receive either coffee or water after the procedure (100 ml three times daily). The primary endpoint was time to first bowel movement; secondary endpoints were time to first flatus, time to tolerance of solid food, length of hospital stay and perioperative morbidity.

Results

A total of 80 patients were randomized, 40 to each group. One patient in the water arm was excluded owing to a change in surgical procedure. Patient characteristics were similar in both groups. In intention-to-treat analysis, the time to the first bowel movement was significantly shorter in the coffee arm than in the water arm (mean(s.d.) 60·4(21·3) versus 74·0(21·6) h; P = 0·006). The time to tolerance of solid food (49·2(21·3) versus 55·8(30·0) h; P = 0·276) and time to first flatus (40·6(16·1) versus 46·4(20·1) h; P = 0·214) showed a similar trend, but the differences were not significant. Length of hospital stay (10·8(4·4) versus 11·3(4·5) days; P = 0·497) and morbidity (8 of 40 versus 10 of 39 patients; P = 0·550) were comparable in the two groups.

Conclusion

Coffee consumption after colectomy was safe and was associated with a reduced time to first bowel action. Registration number: NCT01079442 (http://www.clinicaltrials.gov).

First flatus time and xerostomia associated with gum-chewing after liver resection

AIMS AND OBJECTIVES

The aim of this study was to compare the return of bowel function and xerostomia in patients who were and were not instructed to chew gum after elective open liver resection.

BACKGROUND

Patients who undergo liver resection have limited early ambulation, because they require bed rest after surgery to prevent internal bleeding. They normally also require narcotic analgesics or patient-controlled analgesia for pain control. For these reasons, they often have symptoms of intestinal gas accumulation, abdominal distension and/or abdominal pain.

DESIGN

Prospective case-control study.

METHODS

Forty-two patients with hepatocellular carcinoma who were treated at Samsung Medical Center from September 2010 to February 2011 were included in this study. Patients who were scheduled for elective liver resection for hepatocellular carcinoma and were over 30 years of age were eligible. Patients were assigned to a gum-chewing group or a non-gum-chewing (control) group before surgery.

RESULTS

The mean age of the gum-chewing group was 54·9 (±9·7) years, and the mean age of the control group was 55·1 (±8·4) years. The mean values of first flatus time and xerostomia were higher in the control group than in the gum-chewing group. First flatus time and xerostomia grade were significantly decreased in gum-chewing group compared with the control group after adjustment for hospitalisation days, duration of surgery and amount of analgesics administered.

CONCLUSION

Patients who were instructed to chew gum after surgery demonstrated faster bowel function recovery and lower xerostomia grade after elective open liver resection than patients who did not chew gum.

RELEVANCE TO CLINICAL PRACTICE

Gum-chewing is an inexpensive, helpful adjunct to standard postoperative care after liver resection.

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.

Improvement of an Enhanced Recovery Protocol for Radical Cystectomy

Introduction:

Enhanced recovery protocols (ERPs) aim to improve outcome following major abdominal surgery. Our ERP for radical cystectomy focuses on reduced bowel preparation and standardised feeding and analgesic regimens. Although the ERP safely decreased hospital stay, time to return of bowel function has not been affected. The current study aims to assess the addition of chewing gum on return of bowel function as part of an ERP.

Patients and methods:

We examined the addition of chewing gum to our ERP. Data was obtained retrospectively from 112 consecutive patients, 56 before and 56 after implementing chewing gum in to the EPR. The primary outcome measured was return of bowel function signified by first defecation after surgery.

Results:

The demographics of the two groups showed no significant difference in age, gender distribution, American Society of Anesthesiologists grade, or type of urinary diversion. A significant reduction in the time to return of bowel function was observed in patients using chewing gum post-operatively (4 versus 6 days, p < 0.0001). The median inpatient stay was 13 days in both groups; however there was a trend to an earlier discharge in those patients receiving chewing gum.

Conclusion:

The introduction of chewing gum to our ERP is associated with a faster return of bowel function and may lead to a reduced inpatient stay.