Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials

Efficacy and safety of therapeutic means for postoperative ileus: an umbrella review of meta-analyses

BACKGROUND & AIMS

Postoperative ileus is treated using a large number of methods with variable efficacy. This study further clarifies the advantages and disadvantages of existing treatments through umbrella evaluation.

METHOD

This study conducted a systematic search of databases to select and include meta-analyses discussing the treatment of postoperative ileus. We recalculated the estimated values, 95% confidence intervals, heterogeneity estimates, small study effects, excessive significance tests, and publication biases for each included study using both random and fixed effect models.

RESULTS

A total of 24 meta-analyses, including 27 treatment protocols, were reviewed in this study. Among them, chewing gum, coffee, ERAS(Enhanced Recovery After Surgery) protocols, acupuncture, opioid receptor antagonists, Da-Cheng-Qi-Tang, early enteral nutrition, and Zusanli point injection therapy have been shown to significantly improve postoperative ileus (Class II). Opioid receptor antagonists, early enteral nutrition, ERAS, and chewing gum have also been found to significantly reduce the postoperative hospital stay (Class II).

CONCLUSION

Eight treatment options can effectively reduce postoperative ileus, while the effectiveness and safety of other treatment options for postoperative ileus require further confirmation through high-quality research.

Effect of chewing gum on clinical outcomes and postoperative recovery in adult patients after gastrointestinal surgery: an umbrella review

BACKGROUND

Gastrointestinal surgery is crucial for many medical conditions but can lead to difficult recoveries. Chewing gum is proposed as a remedy, yet existing reviews offer conflicting results. This umbrella review aims to synthesize the effectiveness of chewing gum on time to first flatus, time to first bowel movement, length of stay and complication rates in adult patients.

METHODS

We conducted an umbrella review, searching seven databases up to 17 November 2023, with an updated search extending to 1 January 2025. The focus was on post-surgery chewing gum interventions. The quality and certainty of evidence were assessed using the AMSTAR-2 tool and umbrella review criteria.

RESULTS

Seventeen reviews, encompassing 26 672 participants from 264 primary studies, were included. Meta-analyses indicated reductions in time to first flatus by -0.36 days (95% CI = -0.61, -0.1) or -12.26 hours (95% CI = -14.73, -9.78), time to first bowel movement by -0.59 days (95% CI = -0.94, -0.23) or -19.29 hours (95% CI = -23.79, -14.79), and length of stay by -0.85 days (95% CI = -1.22, -0.48) or -20.08 hours (95% CI = -28.62, -11.54). Additionally, chewing gum was associated with fewer postoperative complications.

CONCLUSION

Chewing gum may significantly aid postoperative care by reducing time to first flatus, time to first bowel movement, and length of stay. However, many included reviews were of low quality with weak evidence, highlighting the need for more rigorous studies to confirm these benefits. Integrating chewing gum into clinical practice could enhance recovery and optimize hospital bed turnover, making it a valuable addition to postoperative care protocols.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

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

PURPOSE

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATION

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

The Efficacy of Probiotics, Prebiotics, and Synbiotics in Patients Who Have Undergone Abdominal Operation, in Terms of Bowel Function Post-Operatively: A Network Meta-Analysis

BACKGROUND

Abdominal operations may lead to post-operative bowel dysfunction, while administration of probiotics, prebiotics and synbiotics may limit its manifestation. Τhe study aimed to assess the efficacy of probiotics, prebiotics and synbiotics in patients who undergone abdominal operation, in terms of bowel function post-operatively.

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials (Central), Embase, US Registry of clinical trials, and sources of grey literature were searched. The relative effect sizes were estimated, and we obtained the relative ranking of the interventions using cumulative ranking curves.

RESULTS

In total, 30 studies were included in the analysis. For the outcome of post-operative ileus, probiotics was superior to placebo/no intervention (relative risk, RR: 0.38; 95%CI: 0.14-0.98) with the highest SUCRA (surface under the cumulative ranking) value (92.1%). For time to first flatus, probiotics (MD: -0.47; 95%CI: -0.78 to -0.17) and synbiotics (MD: -0.53; 95%CI: -0.96 to -0.09) were superior to placebo/no intervention. For time to first defecation and for post-operative abdominal distension probiotics were superior to placebo/no intervention. For post-operative hospitalization days, synbiotics were superior to placebo/no intervention (MD: -3.07; 95%CI: -4.80 to -1.34).

CONCLUSIONS

Administration of probiotics in patients who had undergone abdominal surgery reduced the prevalence of post-operative ileus, time to first flatus, time to first defecation, and prevalence of post-operative abdominal distension. Synbiotics reduce time to first flatus and post-operative hospitalization days.

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.

Prophylactic effects of probiotics or synbiotics on postoperative ileus after gastrointestinal cancer surgery: A meta-analysis of randomized controlled trials

Background

Postoperative ileus is a major problem following gastrointestinal cancers surgery, several randomized controlled trials have been conducted investigating the use of probiotics or synbiotics to reduce postoperative ileus, but their findings are controversial.

Objective

We conducted a meta-analysis to determine the effect of probiotics or synbiotics on early postoperative recovery of gastrointestinal function in patients with gastrointestinal cancer.

Methods

The Embase, Cochrane Library, PubMed, and Web of Science databases were comprehensively searched for randomized controlled trials (RCTs) that evaluated the effects of probiotics or synbiotics on postoperative recovery of gastrointestinal function as of April 27, 2021. Outcomes included the time to first flatus, time to first defecation, days to first solid diet, days to first fluid diet, length of postoperative hospital stay, incidence of abdominal distension and incidence of postoperative ileus. The results were reported as the mean difference (MD) and relative risk (RR) with 95% confidence intervals (CI).

Results

A total of 21 RCTs, involving 1776 participants, were included. Compared with the control group, probiotic and synbiotic supplementation resulted in a shorter first flatus (MD, -0.53 days), first defecation (MD, -0.78 days), first solid diet (MD, -0.25 days), first fluid diet (MD, -0.29 days) and postoperative hospital stay (MD, -1.43 days). Furthermore, Probiotic and synbiotic supplementation reduced the incidence of abdominal distension (RR, 0.62) and incidence of postoperative ileus (RR, 0.47).

Conclusion

Perioperative supplementation of probiotics or synbiotics can effectively promote the recovery of gastrointestinal function after gastrointestinal cancer surgery.

How Can Nutrition Help with Gastrointestinal Tract-Based Issues?

Many horses are fed differently than their wild ancestors. They often have limited access to pasture and are fed conserved forage and concentrates rich in starch and sugars, in only 2 meals per day. Feeding practices in contrast to natural feeding behavior can lead to gastrointestinal issues. Standard nutritional evaluation is warranted because of its important role in prevention and in treatment and management of diseases. When medical and nutritional treatments are combined, success rates are higher. New techniques to characterize equine microbiota have been used, allowing for microbiota manipulation to prevent and treat intestinal diseases.

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.

Effect of Gum Chewing on Recovery After Surgery for Colorectal Surgery Patients: A Randomized Controlled Trial

The aim of this study was to determine the role of chewing gum in bowel functions after left colon and/or rectal surgery. In this randomized controlled study, the sample consisted of adult patients who had undergone elective open left colon and/or rectal surgical interventions under general anesthesia. The sample comprised 17 patients in the experimental group and control group. The patients in the experimental group chewed a sugar-free gum after removal of their nasogastric tubes, 3 times a day for 45 minutes, from the first postoperative morning until they had first flatus. Routine care was maintained for the patients in the control group until their first flatus. The effects of chewing gum on the length of time until first flatus, the first defecation in the postoperative period, and the discharge of patients were investigated. The patients in the experimental group had flatus and defecation earlier, and the duration of their hospital stay was shorter than those of patients in the control group. It was found that gum chewing as a physiological method promotes the early initiation of bowel functions and, consequently, shortens the hospital stay after elective left colon and/or rectal surgery.

The Effect of Gum Chewing on Abdominal Pain and Nausea Caused by Polyethylene Glycol Solution Used for Intestinal Cleansing Before Colonoscopy: An Endoscopist-Blinded, Randomized Controlled Trial

Gum chewing is known to have a positive effect on intestinal motility. Most studies have examined its effect on ileus, but there has been no discussion of the effects of polyethylene glycol used in preparation for colonoscopy. The purpose of this study was to determine the effect of gum chewing on abdominal pain and nausea caused by polyethylene glycol solution used for intestinal cleansing before colonoscopy. The study was planned as a single-center, randomized, controlled experimental study. The research sample was determined using power analysis (n = 60). Consecutive patients undergoing colonoscopy were randomized into the experimental and control groups. Patients in the gum group chewed mint-flavored sugar-free gum for 20 minutes every 2 hours until the start of colonoscopy after consuming 2 L of polyethylene glycol solution. Patients in the control group drank only polyethylene glycol solution. Examination of precolonoscopy pain and nausea revealed a statistically significant difference in the gum chewing group (p < .05). Patients using sugar-free gum experienced statistically significant fewer problems after colonoscopy. Gum chewing had a positive effect on abdominal pain and nausea. There are no drawbacks to presolution chewing, and it may be recommended for patients.

The Use of Coffee to Decrease the Incidence of Postoperative Ileus: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the efficacy of providing coffee to elective abdominal surgery patients, immediately postoperatively, to lessen postoperative ileus.

DESIGN

A systematic review with meta-analysis of six randomized controlled trials published since 2012.

METHODS

Methodological quality was evaluated using the Cochrane guidelines. The Grading of Recommendations, Assessment, Development, and Evaluations assessment tool evaluated the quality of the evidence. Subgroup analyses were completed if the I² statistic demonstrated heterogeneity (greater than 50%).

FINDINGS

Coffee was statistically significant in shortening the time between surgery and the first passage of stool (mean difference, -9.38; 95% confidence interval, -17.60 to -1.16; P = .03). Although not statistically significant (P = .20), the overall effect favored shorter hospital stays for those patients receiving coffee.

CONCLUSIONS

The current systematic review and meta-analysis suggests that coffee given as early as 2 hours postoperatively decreases time to first bowel movement. In addition, patients tolerated solid food faster and were discharged sooner when given coffee immediately postoperatively.

Does Coffee Intake Reduce Postoperative Ileus After Laparoscopic Elective Colorectal Surgery? A Prospective, Randomized Controlled Study: The Coffee Study

BACKGROUND

Postoperative ileus after colorectal surgery is a frequent problem that significantly prolongs hospital stay and increases perioperative costs.

OBJECTIVE

The aim was to evaluate the effect of standardized coffee intake on postoperative bowel movement after elective laparoscopic colorectal resection.

DESIGN

This is a prospective randomized controlled trial that was conducted between September 2014 and December 2016.

SETTINGS

This study was performed in a public cantonal hospital in Switzerland with accreditation for colon and rectum cancer surgery.

PATIENTS

Patients who underwent elective colorectal surgery were included.

INTERVENTIONS

Patients were randomly assigned either to the intervention group receiving coffee or the control group receiving tea. A total of 150 mL of the respective beverage was drunk 3 times per day every postoperative day until discharge.

MAIN OUTCOME MEASURES

The primary end point was time to first bowel movement. Secondary end points included the use of laxative, insertion of a nasogastric tube, length of hospital stay, and postoperative complications.

RESULTS

A total of 115 patients were randomly assigned: 56 were allocated to the coffee group and 59 to the tea group. After coffee intake, the first bowel movement occurred after a median of 65.2 hours versus 74.1 hours in the control group (intention-to-treat analysis; p = 0.008). The HR for earlier first bowel movement after coffee intake was 1.67 (p = 0.009). In the per-protocol analysis, hospital stay was shorter in the coffee group (6 d in the coffee group vs 7 d in the tea group; p = 0.043).

LIMITATIONS

The rate of protocol violation, mostly coffee consumption in the tea arm, was relatively high, even if patients were clearly instructed not to consume coffee if they were in the tea arm.

CONCLUSIONS

Coffee intake after elective laparoscopic colorectal resection leads to faster recovery of bowel function. Therefore, coffee intake represents a simple and effective strategy to prevent postoperative ileus. See Video Abstract at http://links.lww.com/DCR/A955.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02469441.

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.

Chewing gum for declining ileus and accelerating gastrointestinal recovery after appendectomy

Objective

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

Methods

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

Results

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

Conclusions

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

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.

Effect of chewing gum on gastrointestinal function after gynecological surgery: A systematic literature review and meta-analysis

AIM

Recently, several randomized controlled trials (RCT) reported the effect of chewing gum on gastrointestinal function after gynecological surgery; however, these results are inconsistent. The aim of this study was to systematically analyze the effect of chewing gum on postoperative gastrointestinal function and complications in women undergoing gynecological surgery.

METHODS

Pumbed, Embase, Cochrane Library, Web of Science, Chinese Wanfang databases, China National Knowledge Infrastructure and http://clinicaltrials.gov were searched from inceptions to April 30, 2017. Studies including chewing gum's impact on postoperative gastrointestinal function or complications were evaluated. Two authors individually performed data extraction from 10 RCT. Weighted mean difference (WMD) and odds ratio (OR) were used.

RESULTS

Contrasting the group of standard postoperative care, the gum chewing group had a lower duration from the end of operation to first aerofluxus (WMD -7.55, 95%CI: -10.99 to -4.12); first intestinal sounds (WMD -6.20, 95%CI: -8.14 to -4.27); first defecation (WMD -12.24, 95%CI: -18.47 to -6.01); hospitalization duration (WMD -0.72. 95%CI -1.19 to -0.25); and lower incidence of nausea (OR 0.45, 95%CI: 0.29 to 0.69), vomiting (OR 0.38, 95%CI: 0.22 to 0.68) and postoperative ileus (OR 0.25, 95%CI: 0.14 to 0.44).

CONCLUSION

Chewing gum is an effective measure to ameliorate gastrointestinal function and decrease complications after gynecological surgery.

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.

Preoperative risk factors for prolonged postoperative ileus after colorectal resection

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Randomized clinical trial of chewing gum after laparoscopic colorectal resection

BACKGROUND

Chewing gum may enhance intestinal motility after surgery. This trial studied whether chewing gum could lead to a further reduction in ileus in patients who had a laparoscopic colorectal resection and followed an enhanced recovery programme.

METHODS

Patients undergoing laparoscopic colorectal resection were randomized to a control or intervention group. Patients in the control group received a standardized recovery programme. Patients in the intervention group were, in addition, given chewing gum three times daily from day 1 until discharge. Primary outcome measures were time to first flatus and first bowel motion. Time to feeling hungry and hospital stay were secondary outcome measures.

RESULTS

Forty-one patients were randomized into each group. Thirty-seven patients underwent rectal resection and 45 had a colonic resection. Time to passage of flatus was shorter (18 versus 34 h; P = 0·007), first bowel motion occurred earlier (19 versus 44 h; P = 0·001) and time to feeling hungry was earlier (16 versus 25 h; P = 0·001) in the intervention group. There was no difference in the duration of hospital stay (5 days in the intervention group versus 5·5 days in the control group). Subgroup analyses revealed that the benefits of chewing gum were clearer in patients who had a colonic resection, with a shorter time to first flatus (20 versus 35 h; P = 0·043), first bowel motion (19 versus 53 h; P = 0·014) and feeling hungry (14 versus 40 h; P = 0·001). No adverse events were attributed to chewing gum.

CONCLUSION

Chewing gum is a simple intervention that speeds intestinal transit in patients managed with a recovery programme after laparoscopic colorectal resection.

REGISTRATION NUMBER

NCT02419586 (https://clinicaltrials.gov/).

Nicotine chewing gum for the prevention of postoperative ileus after colorectal surgery: a multicenter, double-blind, randomised, controlled pilot study

PURPOSE

When postoperative ileus is not resolved after 5 days or recurs after resolution, prolonged POI (PPOI) is diagnosed. PPOI increases discomfort, morbidity and hospitalisation length, and is mainly caused by an inflammatory response following intestinal manipulation. This response can be weakened by targeting the cholinergic anti-inflammatory pathway, with nicotine as essential regulator. Chewing gum, already known to stimulate gastrointestinal motility itself, combined with nicotine is hypothesised to improve gastrointestinal recovery and prevent PPOI. This pilot study is the first to assess efficacy and safety of nicotine gum in colorectal surgery.

METHODS

Patients undergoing elective oncological colorectal surgery were enrolled in this double-blind, parallel-group, controlled trial and randomly assigned to a treatment protocol with normal or nicotine gum (2 mg). Patient reported outcomes (PROMS), clinical characteristics and blood samples were collected. Primary endpoint was defined as time to first passage of faeces and toleration of solid food for at least 24 h.

RESULTS

In total, 40 patients were enrolled (20 vs. 20). In both groups, six patients developed PPOI. Time to primary endpoint (4.50 [3.00-7.25] vs. 3.50 days [3.00-4.25], p = 0.398) and length of stay (5.50 [4.00-8.50] vs. 4.50 days [4.00-6.00], p = 0.738) did not differ significantly between normal and nicotine gum. There were no differences in PROMS, inflammatory parameters and postoperative complications.

CONCLUSIONS

We proved nicotine gum to be safe but ineffective in improving gastrointestinal recovery and prevention of PPOI after colorectal surgery. Other dosages and administration routes of nicotine should be tested in future research.

Chewing gum for enhancing early recovery of bowel function after caesarean section

BACKGROUND

Caesarean sections (CS) are the most frequent major surgery in the world. A transient impairment of bowel motility is expected after CS. Although this usually resolves spontaneously within a few days, it can cause considerable discomfort, require symptomatic medication and delay hospital discharge, thus increasing costs. Chewing gum in the immediate postoperative period is a simple intervention that may be effective in enhancing recovery of bowel function in other types of abdominal surgeries.

OBJECTIVES

To assess the effects of chewing gum to reduce the duration of postoperative ileus and to enhance postoperative recovery after a CS.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 June 2016), LILACs (20 June 2016), ClinicalTrials.gov (20 June 2016), WHO International Clinical Trials Registry Platform (ICTRP) (20 June 2016) and the reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled trials comparing chewing gum versus usual care, for women in the first 24 hours after a CS. We included studies published in abstract form only.Quasi-randomised, cross-over or cluster-randomised trials were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies for inclusion, extracted data and assessed the risk of bias following standard Cochrane methods. We present dichotomous outcome results as risk ratio (RR) with 95% confidence intervals (CI) and continuous outcome results as mean differences (MD) and 95% CI. We pooled the results of similar studies using a random-effects model in case of important heterogeneity. We used the GRADE approach to assess the overall quality of evidence.

MAIN RESULTS

We included 17 randomised trials (3149 participants) conducted in nine different countries. Seven studies (1325 women) recruited exclusively women undergoing elective CS and five studies (833 women) only included women having a primary CS. Ten studies (1731 women) used conventional feeding protocols (nil by mouth until the return of intestinal function). The gum-chewing regimen varied among studies, in relation to its initiation (immediately after CS, up to 12 hours later), duration of each session (from 15 to 60 minutes) and number of sessions per day (three to more than six). All the studies were classified as having a high risk of bias due to the nature of the intervention, women could not be blinded and most of the outcomes were self-reported.Primary outcomes of this review: for the women that chewed gum, the time to passage of first flatus was seven hours shorter than those women in the 'usual care' control group (MD -7.09 hours, 95% CI -9.27 to -4.91 hours; 2399 women; 13 studies; random-effects Tau² = 14.63, I² = 95%, very low-quality evidence). This effect was consistent in all subgroup analyses (primary and repeat CS, time spent chewing gum per day, early and conventional feeding protocols, elective and non-elective CS and time after CS when gum-chewing was initiated). The rate of ileus was on average over 60% lower in the chewing-gum group compared to the control (RR 0.39, 95% CI 0.19 to 0.80; 1139 participants; four studies; I² = 39%, low-quality evidence). Tolerance to gum-chewing appeared to be high. Three women in one study complained about the chewing gum (but no further information was provided) and none of the studies reported adverse effects (eight studies, 925 women, low-quality evidence).Secondary outcomes of this review: the time to passage of faeces occurred on average nine hours earlier in the intervention group (MD -9.22 hours, 95% CI -11.49 to -6.95 hours; 2016 participants; 11 studies; random-effects Tau² = 12.53, I² = 93%, very low-quality evidence). The average duration of hospital stay was shorter in the intervention compared to the control group (MD -0.36 days, 95% CI -0.53 to -0.18 days; 1489 participants; seven studies; random-effects Tau² = 0.04, I² = 92%). The first intestinal sounds were heard earlier in the intervention than in the control group (MD -4.56 hours, 95% CI -6.18 to -2.93 hours; 1729 participants; nine studies; random-effects Tau² = 5.41, I² = 96%). None of the studies assessed women's satisfaction in relation to having to chew gum. The need for analgesia or antiemetic agents did not differ between the intervention and control groups (average RR 0.50, 95% CI 0.12 to 2.13; 726 participants; three studies; random-effects Tau² = 0.79, I² = 69%).

AUTHORS' CONCLUSIONS

This review found 17 randomised controlled trials (involving 3149 women). We downgraded the quality of the evidence for time to first passage of flatus and of faeces and for adverse effects/intolerance to gum chewing because of the high risk of bias of the studies (due to lack of blinding and self-report). For time to first flatus and faeces, we downgraded the quality of the evidence further because of the high heterogeneity in these meta-analyses and the potential for publication bias based on the visual inspection of the funnel plots. The quality of the evidence for adverse effects/tolerance to gum chewing and for ileus was downgraded because of the small number of events. The quality of the evidence for ileus was further downgraded due to the unclear risk of bias for the assessors evaluating this outcome.The available evidence suggests that gum chewing in the immediate postoperative period after a CS is a well tolerated intervention that enhances early recovery of bowel function. However the overall quality of the evidence is very low to low.Further research is necessary to establish the optimal regimen of gum-chewing (initiation, number and duration of sessions per day) to enhance bowel function recovery and to assess potential adverse effects of and women's satisfaction with this intervention. New studies also need to assess the compliance of the participants to the recommended gum-chewing instructions. Future large, well designed and conducted studies, with better methodological and reporting quality, will help to inform future updates of this review and enhance the body of evidence for this intervention.

The use of alvimopan for postoperative ileus in small and large bowel resections

Transient ileus is a normal physiologic process after surgery. When prolonged, it is an important contributor to postoperative complications, increased length of stay and increased healthcare costs. Efforts have been made to prevent and manage postoperative ileus; alvimopan is an oral, peripheral μ-opioid receptor antagonist, and the only currently US FDA-approved medication to accelerate the return of gastrointestinal function postoperatively.

Use of chewing gum in children undergoing an appendectomy: A randomized clinical controlled trial

INTRODUCTION

Post-operative ileus is a common condition among pediatric patients undergoing appendectomy. We aim to assess the feasibility, safety, and effectiveness of chewing gum to reduce ileus, and decrease time to oral tolerance.

METHODS

A randomized trial was conducted in 5-18 year old patients that underwent an appendectomy. Subjects in the intervention group received sugar-free chewing gum within the first 12 h after surgery and control group received the usual therapy. We assessed the acceptability of the intervention, time to pass first flatus, present first bowel movement, and time to tolerate oral intake.

RESULTS

A total of 41 patients were recruited, 21 in the intervention group and 20 in the control group. Mean time (SD) to first flatus in the intervention group was 17.18 h (8.18), and 24.37 h (17.53) in the control group (mean difference [MD] of -7.19 h; 95% CI, -15.7 to 1.38). Time to first bowel movement (MD, -4.6 h, 95%CI -18.5 to 9.3), time to tolerate oral intake (MD, 4.17 h; 95%CI -9.2 to 17.5), and length of hospital stay (MD, 6.9 h, 95%CI -19.1 to 33.1) appeared not to be affected by the intervention. Chewing gum was accepted, well tolerated, and without complications.

DISCUSSION

The use of chewing gum in children undergoing an appendectomy was safe and well tolerated and might lead to a faster recovery of bowel function, more studies are needed to prove if length of hospital stay and other outcomes are improved.

Xylitol Gum Chewing to Achieve Early Postoperative Restoration of Bowel Motility After Laparoscopic Surgery

Our objective was to evaluate the effects of postoperative xylitol gum chewing on gastrointestinal functional recovery after laparoscopy. Altogether, 120 patients undergoing elective gynecologic laparoscopy were randomly divided into 2 groups of 60 each (final numbers: 53 controls, 56 patients). Controls underwent a routine postoperative regimen. Starting 6 hour after surgery, study patients chewed mint-flavored, sugarless xylitol gum until flatus occurred thrice a day. Other postoperative management was routine. First bowel sounds, first flatus, first bowel movement, and discharge times were recorded. Symptoms included abdominal distension, nausea, and vomiting. First flatus and first bowel sounds occurred significantly (P<0.001) earlier in the study patients. No significant differences were found for first defecation time, hospitalization duration, or mild/severe intestinal obstruction (all P>0.05). Thus, xylitol gum chewing after laparoscopy can effectively shorten the time to first flatus and helps with postoperative gastrointestinal functional recovery. It is simple, convenient, and well tolerated.

Vagal tone: effects on sensitivity, motility, and inflammation

The vagus nerve (VN) is a key element of the autonomic nervous system. As a mixed nerve, the VN contributes to the bidirectional interactions between the brain and the gut, i.e., the brain-gut axis. In particular, after integration in the central autonomic network of peripheral sensations such as inflammation and pain via vagal and spinal afferents, an efferent response through modulation of preganglionic parasympathetic neurons of the dorsal motor nucleus of the vagus and/or preganglionic sympathetic neurons of the spinal cord is able to modulate gastrointestinal nociception, motility, and inflammation. A low vagal tone, as assessed by heart rate variability, a marker of the sympatho-vagal balance, is observed in functional digestive disorders and inflammatory bowel diseases. To restore a normal vagal tone appears as a goal in such diseases. Among the therapeutic tools, such as drugs targeting the cholinergic system and/or complementary medicine (hypnosis, meditation…), deep breathing, physical exercise, VN stimulation (VNS), either invasive or non-invasive, appears as innovative. There is new evidence in the current issue of this Journal supporting the role of VNS in the modulation of gastrointestinal functions.

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.

Prevention of Paralytic Ileus Utilizing Alvimopan Following Spine Surgery

Postoperative ileus affects a substantial proportion of patients undergoing elective spine surgery, especially in cases of spinal deformity correction and where an anterior lumbar approach is utilized. Though the first line of treatment for postoperative ileus is conservative management, recent advances in pharmacology have yielded promising options for both treatment and prevention. We report a case of a patient who underwent a two-stage posterior spinal fusion. The patient suffered with a severe, prolonged ileus after her initial surgery. To prevent ileus following her second spinal surgery, alvimopan (a µ-opioid receptor antagonist) was administered and she had a rapid return of bowel function with no signs of ileus. Alvimopan, has been shown to reduce the rate of ileus in colorectal surgery patients, and may be useful for preventing ileus in high-risk orthopedic and spine surgery patients, although prospective studies will be needed to test this hypothesis.

Paralytic ileus in the orthopaedic patient

Paralytic ileus is marked by the cessation of bowel motility. This condition is a major clinical concern that may lead to severe patient morbidity in orthopaedic surgery and trauma patients. Ileus most commonly occurs following spinal surgery, traumatic injury, or lower extremity joint reconstruction, but it may also occur following minor orthopaedic procedures. Possible consequences of ileus include abdominal pain, malnutrition, prolonged hospital stay, hospital readmission, bowel perforation, and death. Therapies used in the treatment of ileus include minimization of opioids, early patient mobilization, pharmacologic intervention, and multidisciplinary care. Orthopaedic surgeons should be aware of the clinical signs and symptoms of paralytic ileus and should understand treatment principles of this relatively common adverse event.

The Use of Chewing Gum Postoperatively in Pediatric Scoliosis Patients Facilitates an Earlier Return to Normal Bowel Function

PURPOSE

In surgical correction of scoliosis in pediatric patients, gastrointestinal complications including postoperative ileus can result in extended hospital stays, poorer pain management, slower progression with physical therapy, and overall decreased patient satisfaction. In patients undergoing gastrointestinal, gynecological, and urological surgery, gum chewing has been shown to reduce time to flatus and passage of feces. The authors hypothesized that chewing gum could also speed return to normal bowel function in pediatric patients undergoing surgical correction of scoliosis.

METHODS

The researchers obtained institutional review board approval for a prospective, randomized, controlled trial. Eligible patients included all adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. Exclusion criteria included previous gastrointestinal surgery or preexisting gastrointestinal disease. Patients were randomized by coin flip. The treatment group chewed sugar-free bubble gum 5 times a day for 20 to 30 minutes beginning on postoperative day 1; the control group did not chew gum. Patients were asked a series of questions regarding subjective gastrointestinal symptoms each day. Time to flatus and first passage of feces were recorded as indicators of return to normal bowel function. Normality of data was assessed using normal probability plots.

RESULTS

A total of 83 patients completed the study (69 females and 14 males; mean age, 14.4 years). Of the 42 patients in the chewing gum group, 8 elected to stop chewing gum regularly before discharge for to a variety of reasons. Patients who chewed gum experienced first bowel movement on average 145.9 hours after surgery, 30.9 hours before those who did not chew gum (p = .04). Gum-chewing patients first experienced flatus an average of 55.2 hours after surgery, compared with 62.3 hours for controls. This trend did not reach statistical significance (p = .12). No difference was noted in duration of hospital stay, medications administered as required, or subjective symptoms.

CONCLUSION

Chewing gum after posterior spinal fusion for scoliosis is safe and may speed return of normal bowel function. Chewing gum after surgical correction of scoliosis facilitates an earlier return to normal bowel function, which may improve patient satisfaction in the early postoperative period.

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.

Effect of Gum Chewing on the Volume and pH of Gastric Contents: A Prospective Randomized Study

BACKGROUND

Insufficient fasting prior to endoscopic procedures performed under sedation may result in potential aspiration of gastric contents. Fasting as per ASA guidelines is recommended prior to these procedures. However, the effect of chewing gum on fasting status has been a subject of debate and often leads to procedural delays.

OBJECTIVE

Evaluation of the effect of chewing gum on the gastric volume and pH.

METHODS

In this randomized controlled prospective observer blinded trail, ASA I-III patients aged more than 18 years scheduled for esophagogastroduodenoscopy (EGD) or a combined EGD and colonoscopy under conscious sedation were studied. Patients randomized to the chewing gum group (Group-C) were allowed to chew gum until just before the start of their procedure; the remaining patients were included into Group-NC. After sedation and endoscope insertion, stomach contents were aspirated under vision of a gastroenterologist (blinded to groups).

RESULTS

Volume and pH of gastric contents aspirated from 67 patients (34 in Group-C and 33 in Group-NC) were analyzed. The demographic parameters of the groups were comparable. Gastric volume (median-interquartile range) was statistically higher in Group-C (13 ml (7.75-40.75) vs Group-NC 6 ml (1.00-14.00) (P < 0.001)]. The mean pH in both groups was comparable: 2.84 ± 2.11 in Group-C and 3.79 ± 2.53 in Group-NC (P = 0.141).

CONCLUSION

Although our results show gastric volume in patients chewing gum was statistically higher, clinical relevance of such a small difference is questionable. Thus patients who chewed gum inadvertently prior to procedure should not be denied or delayed administration of sedative and anesthetic medications.

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.

Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy--a randomized controlled trial

Background

Postoperative ileus is common after surgery. One non-pharmacological intervention that has shown promising results in reducing the duration of postoperative ileus is chewing gum after surgery. However, this has not been investigated in upper gastrointestinal surgery such as pancreatic surgery. Hence the aim of this study was to investigate the effects of chewing gum treatment on patients undergoing pancreaticoduodenectomy ad modum whipple due to pancreatic or periampullary cancer.

Methods

This study was conducted as a phase III trial that was terminated early. Patients diagnosed with pancreatic tumours scheduled for pancreaticoduodenectomy ad modum whipple were included. The treatment group received chewing gum postoperatively and standard care. Controls received glucose solution and standard care. Chewing gum and glucose were used four times a day during the whole hospital stay. Time to first flatus and stool was defined as the primary outcome. The secondary outcome was start with clear liquids, start with liquid diet and length of hospital stay.

Results

No statistically significant differences could be observed between the chewing gum intervention group and the control group. However, a numerical difference in mean time was observed in first flatus, first stool, start of clear fluids, and start of liquid diet and length of hospital stay in favour of the intervention group.

Conclusions

Although this study did not find statistically significant differences favouring the use of chewing gum for postoperative ileus, a positive trend was observed of a reduction of the impact of postoperative ileus among patients after pancreatic surgery. It also contributes valuable methodological experience that is important for future studies of chewing gum interventions during recovery after pancreatic surgery.

Trial registration

ClinicalTrials.gov identifier: NCT02319512, publication date 2014-12-17.

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

BACKGROUND

Postoperative ileus (POI) is a common complication following colorectal surgery that delays recovery and increases length of hospital stay. Gum chewing may reduce POI and therefore enhance recovery after surgery. The aim of the study was to evaluate the effect of gum chewing on POI, length of hospital stay and inflammatory parameters.

METHODS

Patients undergoing elective colorectal surgery in one of two centres were randomized to either chewing gum or a dermal patch (control). Chewing gum was started before surgery and stopped when oral intake was resumed. Primary endpoints were POI and length of stay. Secondary endpoints were systemic and local inflammation, and surgical complications. Gastric emptying was measured by ultrasonography. Soluble tumour necrosis factor receptor 1 (TNFRSF1A) and interleukin (IL) 8 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

Between May 2009 and September 2012, 120 patients were randomized to chewing gum (58) or dermal patch (control group; 62). Mean(s.d.) length of hospital stay was shorter in the chewing gum group than in controls, but this difference was not significant: 9·5(4·9) versus 14·0(14·5) days respectively. Some 14 (27 per cent) of 52 analysed patients allocated to chewing gum developed POI compared with 29 (48 per cent) of 60 patients in the control group (P = 0·020). More patients in the chewing gum group first defaecated within 4 days of surgery (85 versus 57 per cent; P = 0·006) and passed first flatus within 48 h (65 versus 50 per cent; P = 0·044). The decrease in antral area measured by ultrasonography following a standard meal was significantly greater among patients who chewed gum: median 25 (range -36 to 54) per cent compared with 10 (range -152 to 54) per cent in controls (P = 0·004). Levels of IL-8 (133 versus 288 pg/ml; P = 0·045) and TNFRSF1A (0·74 versus 0·92 ng/ml; P = 0·043) were lower among patients in the chewing gum group. Fewer patients in this group developed a grade IIIb complication (2 of 58 versus 10 of 62; P = 0·031).

CONCLUSION

Gum chewing is a safe and simple treatment to reduce POI, and is associated with a reduction in systemic inflammatory markers and complications.

REGISTRATION NUMBER

NTR2867 (http://www.trialregister.nl).

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.

Early oral feeding after emergency abdominal operations: another paradigm to be broken?

PURPOSE OF REVIEW

The scope of this article is to provide an updated review examining the role of early feeding in the postoperative period.

RECENT FINDINGS

Guidelines for postoperative care after abdominal surgery have historically outlined the dogma of 'nil by mouth' until bowel movement returns, but they are currently questioned. This change in mindset, especially after colorectal surgery, was initiated with fast-track or enhanced recovery after surgery programs, which particularly led to an opioid-sparing strategy. Many randomized trials and meta-analyses suggested an absence of benefit in keeping patients 'nil by mouth'. Conversely, in elective abdominal surgery, improvement in comfort without increased morbidity is now demonstrated with a liberal strategy, and a recent meta-analysis even demonstrated a decrease in mortality. Early caloric hydration and chewing gum are the most acceptable actions with a high level of proof. After emergency surgery, few data are available but a similar strategy should probably be chosen with no obvious benefit from maintenance of fasting.

SUMMARY

Early oral intake is possible after elective abdominal surgery and should be moderate and progressive to be well tolerated. Any sign of nausea may mean intestinal or gastric disturbance and is a caution not to pursue this policy. The strategy in emergency abdominal surgery still requires adequately powered, randomized controlled trials.