Effect of Chewing Gum on Gastrointestinal Function Recovery After Surgery of Gynecological Cancer Patients at Rajavithi Hospital: A Randomized Controlled Trial

An outline of the management and prevention of postoperative ileus: A review

Postoperative ileus (POI) is a prevalent surgical complication, which results in prolonged hospitalization, patient distress, and substantial economic burden. The literature aims to present a brief outline of interventions for preventing and treating POI post-surgery. Data from 2014 to 2023 were gathered from reputable sources like PubMed, PubMed Central, Google Scholar, Research Gate, and Science Direct. Inclusion criteria focused on studies exploring innovative treatments and prevention strategies for POI, using keywords such as novel POI treatments, non-pharmacological prevention, POI incidence rates, POI management, and risk factors. The findings revealed that integration of preventive measures such as coffee consumption, chewing gum, probiotics, and use of dikenchuto within enhanced recovery programs has significantly reduced both the frequency and duration of POI, without any adverse effects, with minimally invasive surgical approaches showing promise as an additional preventive strategy. While treatment options such as alvimopan, NSAIDs, and acupuncture have demonstrated efficacy, the use of lidocaine has raised concerns due to associated adverse effects. The ongoing exploration of novel therapeutic strategies such as targeting the mast cells, vagal nerve stimulation and tight junction protein, and prokinetic-mediated instigation of the cholinergic anti-inflammatory trail not only holds promise for enhanced treatment but also deepens the understanding of intricate cellular and molecular pathways underlying POI. POI presents a complex challenge in various surgical specialties, necessitating a multifaceted management approach. The integration of preventive and treatment measures within enhanced recovery programs has significantly reduced POI frequency and duration.

Machine learning-based prediction models affecting the recovery of postoperative bowel function for patients undergoing colorectal surgeries

PURPOSE

The debate surrounding factors influencing postoperative flatus and defecation in patients undergoing colorectal resection prompted this study. Our objective was to identify independent risk factors and develop prediction models for postoperative bowel function in patients undergoing colorectal surgeries.

METHODS

A retrospective analysis of medical records was conducted for patients who undergoing colorectal surgeries at Peking University People's Hospital from January 2015 to October 2021. Machine learning algorithms were employed to identify risk factors and construct prediction models for the time of the first postoperative flatus and defecation. The prediction models were evaluated using sensitivity, specificity, the Youden index, and the area under the receiver operating characteristic curve (AUC) through logistic regression, random forest, Naïve Bayes, and extreme gradient boosting algorithms.

RESULTS

The study included 1358 patients for postoperative flatus timing analysis and 1430 patients for postoperative defecation timing analysis between January 2015 and December 2020 as part of the training phase. Additionally, a validation set comprised 200 patients who undergoing colorectal surgeries from January to October 2021. The logistic regression prediction model exhibited the highest AUC (0.78) for predicting the timing of the first postoperative flatus. Identified independent risk factors influencing the time of first postoperative flatus were Age (p < 0.01), oral laxatives for bowel preparation (p = 0.01), probiotics (p = 0.02), oral antibiotics for bowel preparation (p = 0.02), duration of operation (p = 0.02), postoperative fortified antibiotics (p = 0.02), and time of first postoperative feeding (p < 0.01). Furthermore, logistic regression achieved an AUC of 0.72 for predicting the time of first postoperative defecation, with age (p < 0.01), oral antibiotics for bowel preparation (p = 0.01), probiotics (p = 0.01), and time of first postoperative feeding (p < 0.01) identified as independent risk factors.

CONCLUSIONS

The study suggests that he use of probiotics and early recovery of diet may enhance the recovery of bowel function in patients undergoing colorectal surgeries. Among the various analytical methods used, logistic regression emerged as the most effective approach for predicting the timing of the first postoperative flatus and defecation in this patient population.

Efficacy analysis of enhanced recovery after surgery in laparoscopic-assisted radical resection of type I choledochal cyst

Objective

The objective of this study was to investigate the feasibility and effectiveness of laparoscopic-assisted radical resection of type I choledochal cyst (CC) guided by the principles of enhanced recovery after surgery (ERAS).

Methods

A retrospective cohort study of type I CC admitted to our hospital between May 2020 and December 2021 were analyzed, a total of 41 patients with choledochal cyst underwent surgery during this period and 30 cases were selected based on inclusion and exclusion criteria. Patients (n = 15) who received the traditional treatment from May 2020 to March 2021 were included in the traditional group. Patients (n = 15) who received ERAS from April 2021 to December 2021 were included in the ERAS group. Both groups underwent surgery performed by the same surgical team. Preoperative data of the two groups were recorded, and relevant data were statistically analyzed and compared.

Results

There was a statistically significant difference in the dose of opioids. Significant differences were observed between the ERAS and traditional groups in the results of the FLACC pain assessment scale on the 1st and 2nd day after surgery, time of gastric tube, urinary catheter and abdominal drainage tube removal, time of first defecation after operation, time of first eating after operation, time to reach full food intake, results of CRP, ALB, and ALT on the 3rd and 7th postoperative day, postoperative hospital stay, and total treatment cost. No significant differences were observed between the two groups in terms of gender, age, body weight, cyst size, preoperative CRP, ALB, ALT, intraoperative blood loss, operation time, and the number of cases converted to laparotomy. Neither the FLACC pain assessment scale on the 3rd day after surgery, the incidence of postoperative complications, nor the rate of readmission within 30 days showed significant differences.

Conclusions

Laparoscopic-assisted radical resection of type I CC guided by the principles of ERAS is safe and effective for children. The ERAS concept demonstrated advantages over traditional laparoscopic surgery, including reduced opioid use, shorter time to first postoperative defecation, earlier resumption of postoperative feeding, shorter time to reach full feeding, shorter postoperative hospital stay, and lower total treatment cost.

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.

Quality Improvement Project to Reduce Opioid Use in Patients Undergoing Cesarean Birth

After observing the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols for gynecological surgery patients, an interdisciplinary team initiated a quality improvement project with an ERAS protocol to minimize opioid use of patients undergoing elective cesarean birth. Secondary outcomes during the three-month project included decreasing the patient's length of stay and inpatient care costs. We used the Lean Six Sigma methodology and measured aggregated patient outcomes of opioid use, length of hospital stay, and total cost. In addition, we incorporated the ERAS protocol into the electronic health record. Results showed a reduction use of morphine milligram equivalents of opioids, a slight decrease in length of hospital stay, and no change in the inpatient costs. The team recognized that implementation of an ERAS protocol is a best practice to reduce opioid use in patients undergoing a cesarean birth and decided to permanently include it in patient care processes.

Electroacupuncture for Gastrointestinal Function Recovery after Gynecological Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Evidence for the efficacy and safety of electroacupuncture (EA) on gastrointestinal function recovery after gynecological surgery is unclear.

OBJECTIVE

This meta-analysis aimed to evaluate the effects of EA on recovery of postoperative gastrointestinal function for patients receiving gynecological surgery. Data sources: PubMed, Cochrane Central Register of Controlled Trials (CINAHL), Embase, China National Knowledge Infrastructure (CNKI), Weipu (CQVIP), and Wanfang databases were systematically searched from the inception dates to May 30, 2020, for relevant randomized controlled trials (RCTs). Study selection: RCTs that evaluated EA for postoperative gastrointestinal function directly related to gynecological surgery in adults aged 18 years or over. Data extraction and synthesis: paired reviewer independently extracted the data and assessed study quality. Standardized mean differences (SMD) were calculated as the effect measure from a random effects model. Main outcomes and measures: time to first flatus (TFF), time to bowel sounds recovery (TBS), and time to first defecation (TFD) were recorded as primary outcomes; postoperative nausea and vomiting (PONV), motilin (MTL), gastrin (GAS), pH value of gastric mucosa (pHi), gastric mucosal partial pressure of carbon dioxide (PgCO2), vasoactive intestinal peptide (VIP), and adverse event were reported as secondary outcomes.

RESULTS

We included eighteen RCTs (1117 participants). Our findings suggested that compared to the control group (CG), electroacupuncture group (EG) showed significant effects on TFF (SMD = -0.98, 95% CI: [-1.28, -0.68], P < 0.00001, I 2 = 69%), TBS (SMD = -0.98, 95% CI: [-1.84, -0.12], P=0.03, I 2 = 92%), and TFD (SMD = -1.23, 95% CI: [-1.59, -0.88], P < 0.0001, I 2 = 0%). Moreover, the incidence of PONV at postoperative 6 h (OR = 0.42, 95% CI: [0.27, 0.64], P < 0.0001, I 2 = 0%) and 24 h (OR = 0.46, 95% CI: [0.32, 0.68], P < 0.0001, I 2 = 0%) was lower in the EG than that in the CG, whereas no significant difference in ratio of PONV at postoperative 48 h (OR = 0.55, 95% CI: [0.20, 1.51], P=0.25, I 2 = 0%) was detected between the two groups. Meanwhile, there was a significant effect in favor of EA on the level of MTL at postoperative 6 h (SMD = -0.93, 95% CI: [-1.36, -0.61], P < 0.0001, I 2 = 21%), while no significant effect was observed at postoperative 24 h (SMD = -0.43, 95% CI: [-0.89, 0.02], P=0.06, I 2 = 69%) in the EG when compared to the CG. Additionally, a large significant effect on decreasing PgCO2 was found in the EG in comparison to the CG, but no significant effect in favor of EA on GAS, VIP, or pHi was observed. It was reported that there was one participant with pain at the needling sites and bruising, and three participants withdrew because they were not intolerant to EA.

CONCLUSIONS

EA could be a promising strategy for the prevention and treatment of gastrointestinal dysfunction after gynecological surgery, including shortening TFF and TFD, TBS, regulating MTL, and decreasing the ratio of PONV within postoperative 24h. The effects on MTL and PONV varied with different intervention points, and EA used at 30 min prior to surgery might be recommended. However, the evidence quality ranged from low to very low, and large-scale and high-quality RCTs were warranted.

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

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

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

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

The effect of chewing gum on bowel function postoperatively in patients with total laparoscopic hysterectomy: a randomised controlled trial

We aimed to investigate the efficacy of chewing gum on bowel movements after minimally invasive gynaecologic surgery, total laparoscopic hysterectomy (TLH). The study was designed as a prospective randomised controlled study. We divided the patients into two groups regarding postoperative chewing gum after elective TLH operation. The demographic status and characteristics of the patients as well as, anaesthesia and operation records were obtained. The study group was asked to chew gum for 15 min in an hour starting from post-operative 4th hour until the patient passed flatus. In each patient, first auscultation of bowel sounds, first flatus and first defaecation time, as well as first mobilisation time and discharge time, were recorded. We compared the difference in abdominal distension, nausea and vomiting and post-operative ileus (POI) rates. Eight patients were excluded from the study due to matching with exclusion criteria. The remaining 126 patients were divided into two groups. First bowel sounds, first bowel movements, the timing of first gas discharge and the timing of the first defaecation was found significantly earlier in the given-chewing gum group (p < .001). The timing of patient discharge and POI were found to be similar in each group (p > .05). Mild symptoms of ileus were observed in two patients (3.2%) in the not given-chewing gum group and three patients (5.5%) in the given-chewing gum group. The symptoms were better tolerated by the patients who chew gums and no side effects regarding the treatment were observed. In post-operative patient care after minimally invasive surgery, chewing gum has a beneficial effect on bowel movements. This inexpensive and well-tolerated procedure ameliorates gastrointestinal (GI) functions, whereas it has little benefit on early mobilisation and timing of the patient discharge after patients undergoing TLH.Impact StatementWhat is already known on this subject? There are many studies in the literature on the effect of gum on postoperative bowel movements, early mobilisation and short-term hospitalisation. However, there are still doubts about its use after minimally invasive surgery, especially in gynaecology practice.What do the results of this study add? Chewing gum after surgery is a well-tolerated, effective, safe, easy and convenient method and is easily accepted by patients. Its use by gynaecologists after TLH is still not clear. Our aim is to show the relationship between chewing gum and TLH with this study; We believe that early mobilisation after laparoscopic hysterectomy will not be of significant benefit after minimally invasive gynaecological surgeries as it is not significantly effective in early nutrition and early patient discharge.What are the implications of these findings for clinical practice and/or further research? Our statistically not significant results obtained in this study may change after conducting randomised prospective studies involving more patients. However, we believe that giving chewing-gum after laparoscopic hysterectomy will not have a significant benefit.