Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial. Gynecol Oncol. 2013;131:118-122. [PMID: 23906657 DOI: 10.1016/j.ygyno.2013.07.098]

Effects of patient-based self-assessed fatigue intervention on early postoperative ambulation following gynaecological oncology surgery: a randomised controlled non-inferiority trial

OBJECTIVES

To assess the impact of a patient-based self-assessed fatigue intervention aimed at promoting early postoperative ambulation.

DESIGN

Prospective randomised controlled trial.

SETTING

Single-centre, conducted at the Obstetrics and Gynaecology Department of the Xiangyang Central Hospital, China.

PARTICIPANTS

Eligible were adult patients undergoing elective gynaecologic oncologic surgery.

INTERVENTIONS

The intervention group utilised a modified Borg Rating of Perceived Experience (RPE) scale for self-assessment of fatigue levels. The control group followed fixed-activity distance guidelines postoperatively.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the self-reported the time to first flatus postoperatively. Secondary outcomes encompassed the time to first defecation, incidence of moderate-to-severe abdominal distention, ileus, postambulation adverse events (nausea, vomiting and dizziness), patient satisfaction with early ambulation instructions, compliance with early ambulation and average hospital costs and length of stay.

RESULTS

Between June 2021 and October 2022, 552 patients were enrolled. The self-assessed fatigue intervention group demonstrated non-inferior the time to first flatus compared with the fixed-activity distance assessment group (25.59±14.59 hours vs 26.10±14.19 hours, pnon-inferiority<0.001). Compliance with activity was higher in the intervention group (49.40% vs 36.02%, p<0.001), although it did not reach 50%. The intervention group also exhibited significantly higher mean hospital costs, length of stay and incidence of moderate-to-severe abdominal distention (p<0.001).

CONCLUSIONS

The self-assessed fatigue intervention for early postoperative ambulation in gynaecologic oncology patients shows promise as an effective strategy; however, compliance is suboptimal. An intervention based on mandatory, yet reasonable, fixed-activity distance may represent the most viable current approach. Further research is warranted to confirm these findings.

TRIAL REGISTRATION NUMBER

CTR2100046035.

Effect of abdominal hot pack application on gastrointestinal motility recovery after comprehensive gynecologic staging surgery

OBJECTIVE

To evaluate whether abdominal hot water pack application improves gastrointestinal motility following gynecological oncology surgery.

METHODS

The study was registered at ClinicalTrials.gov (NCT04833699). (https://clinicaltrials.gov/ct2/show/NCT04833699?cond=NCT04833699&draw=2&rank=1). In this randomized controlled trial, participants were randomly assigned (1:1) to the hot water pack group (standardized enhanced recovery protocols plus rubber water bag with a fluffy cover filled with boiled tap water [80°C] and placed on the abdomen at 3, 6, 9, and 12 h postoperatively for 30 min each time) or the control group (standardized enhanced recovery protocols). A subumbilical or supraumbilical vertical midline incision was made to perform staging surgery procedures, including hysterectomy, salpingo-oophorectomy with retroperitoneal lymphadenectomy. The primary outcome was the time to first passage of flatus from the end of the staging procedure.

RESULTS

In total, 121 women were randomized to the control (n = 62) or hot water pack (n = 59) group. The use of an abdominal hot water pack significantly reduced the mean time to passing first flatus (25.2 ± 3.6 vs. 30.6 ± 3.9 h; hazard ratio [HR] = 4.4; 95% confidence interval [CI]: 2.8-7.1; P < 0.0001), mean time to first bowel movements (28.4 ± 4.0 vs. 34.4 ± 4.5 h; HR = 4.9; 95% CI: 3.0-7.9; P < 0.0001), mean time to first defecation (33.4 ± 4.9 vs. 41.0 ± 7.6 h; HR = 4.3; 95% CI: 2.1-6.8; P < 0.0001), and mean time to tolerating solid diet (2.1 ± 0.6 vs. 2.8 ± 1.0 days; HR = 4.4; 95% CI: 2.2-8.7; P < 0.0001) compared to the control group. The postoperative ileus incidence was significantly lower in the hot water pack group (3.4%) than the control group (16.1%) (P = 0.01).

CONCLUSION

Abdominal hot water pack application improved gastrointestinal function recovery in women following surgical staging procedures for gynecological malignancy.

Effect evaluation of different preventive measures for ileus after abdominal operation: A systematic review and network meta-analysis

Background

Different approaches to the prevention of postoperative ileus have been evaluated in numerous randomized controlled trials. This network meta-analysis aimed to investigate the relative effectiveness of different interventions in preventing postoperative ileus.

Methods

Randomized controlled trials (RCTS) on the prevention of postoperative ileus were screened from Chinese and foreign medical databases and compared. STATA software was used for network meta-analysis using the frequency method. Random-effects network meta-analysis was also used to compare all schemes directly and indirectly.

Results

A total of 105 randomized controlled trials with 18,840 participants were included in this report. The results of the network meta-analysis showed that intravenous analgesia was most effective in preventing the incidence of postoperative ileus, the surface under the cumulative ranking curve (SUCRA) is 90.5. The most effective intervention for reducing the first postoperative exhaust time was postoperative abdominal mechanical massage (SUCRA: 97.3), and the most effective intervention for reducing the first postoperative defecation time was high-dose opioid antagonists (SUCRA: 84.3). Additionally, the most effective intervention for reducing the time to initiate a normal diet after surgery was accelerated rehabilitation (SUCRA: 85.4). A comprehensive analysis demonstrated the effectiveness and prominence of oral opioid antagonists and electroacupuncture (EA) combined with gum.

Conclusion

This network meta-analysis determined that oral opioid antagonists and EA combined with chewing gum are the most effective treatments and optimal interventions for reducing the incidence of postoperative ileus. However, methods such as abdominal mechanical massage and coffee require further high-quality research.

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.

Short-Term Effects of Connective Tissue Massage After Hysterectomy: A Randomized Controlled Study

OBJECTIVE

The aim of this study was to investigate the effects of connective tissue massage (CTM) on postoperative pain severity, first passage of flatus and the first defecation, and functionality in patients after total laparoscopic hysterectomy (TLH) or total abdominal hysterectomy (TAH).

METHODS

A total of 60 patients who underwent TLH or TAH were included in the study. Patients who underwent TLH were randomly grouped as TLH-CTM (n = 15) and TLH control (n = 16), and those who underwent TAH were randomly grouped as TAH-CTM (n = 14) and TAH control (n = 15). CTM was applied twice postoperatively at the third hour and after 24 hours. The pain severity scores and functional activity limitation levels of the patients were evaluated with the visual analog scale. The number of analgesics use and first passage of flatus and the first defecation were recorded.

RESULTS

The first passage of flatus and the first defecation after surgery were shorter in the TLH-CTM and TAH-CTM groups compared with the TLH and TAH control groups (P < 0.001). The first passage of flatus and the first defecation, pain intensity, and analgesics use of the TLH-CTM group were the lowest among all groups (P < 0.05). The improvement in functionality level in the TLH-CTM group was higher than those in the other groups (P < 0.05).

CONCLUSION

This study showed that CTM reduced postoperative pain severity, use of analgesics, first passage of flatus, and first defecation after TAH or TLH.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Enhanced Recovery after Surgery Protocol Accelerates Recovery of Lumbar Disc Herniation among Elderly Patients Undergoing Discectomy via Promoting Gastrointestinal Function

This study aimed to analyze the effect of the enhanced recovery after surgery (ERAS) protocol on the recovery of gastrointestinal function in patients with lumbar disc herniation after discectomy. A total of 179 patients with lumbar disc herniation were randomly divided into the ERAS and non-ERAS groups. The non-ERAS group received routine nursing, and the ERAS group received ERAS strategy. The two groups were compared for general recovery indicators such as postoperative hemoglobin and prealbumin, satisfaction, and length of hospital stay. Gastrointestinal function was also evaluated, such as postoperative feeding time, intestinal chirping recovery time, intestinal exhaust gas recovery time, and complications such as ileus, nausea, and vomiting. The satisfaction of patients in the ERAS group (86.15 ± 2.43) was significantly higher than that in the non-ERAS group (77.19 ± 3.32), and the difference was statistically significant (P < 0.05). The average time of eating in the ERAS group was 2.27 h after surgery. In addition, the amount of eating in the ERAS group was significantly better than that in the non-ERAS group, and the difference was statistically significant. In the ERAS group, intestinal chirping recovery time recovered to normal time, and exhaust recovery time and average defecation time were significantly shorter than those in the non-ERAS group. In the ERAS group, the average amount of hemoglobin and prealbumin decreased 3 days after operation, which was significantly lower than that in the non-ERAS group. To sum up, ERAS has an evident effect on the recovery of gastrointestinal function after discectomy of disc herniation, which can promote the recovery of patients.

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 implementation of enhanced recovery after surgery protocols in ovarian malignancy surgery

The enhanced recovery after surgery (ERAS) refers to multimodal interventions to reduce the length of hospital stay and complications at various steps of perioperative care. It was first developed in colorectal surgery and later embraced by other surgical disciplines including gynecologic oncology. The ERAS Society recently published guidelines for gynecologic cancer surgeries to enhance patient recovery. However, limitations exist in the implementation of the guidelines in ovarian cancer patients due to the distinct characteristics of the disease. In the present review, we discuss the results that have been published in the literature to date regarding the ERAS protocols in ovarian cancer patients, and explain why more evidence needs to be specifically assessed in this type of malignancy among other gynecologic cancers.

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.

Coffee consumption for recovery of intestinal function after laparoscopic gynecological surgery: A randomized controlled trial

BACKROUND

To investigate the effect of postoperative coffee consumption on bowel motility after laparoscopic gynecological surgery.

MATERIALS AND METHODS

In this randomized controlled trial, patients were allocated postoperatively to 3 cups of either coffee or warm water at 6, 12, or 18 h after the operation. Total hysterectomy and bilateral salpingectomy were performed on all patients. In addition, a salpingo-oophorectomy and systematic pelvic with/without para-aortic lymphadenectomy were performed according to clinical indications. The primary endpoint was time to the first passage of flatus after surgery.

RESULTS

A total of 96 patients were enrolled; 49 patients were assigned to the coffee group, and 47 were enrolled in the control group (warm water). The median time to flatus (19 [13-35] vs. 25 [15-42] h; hazard ratio [HR] 1.9, 95% confidence interval [CI], 1.2-2.9; P = 0.0009), median time to defecation (30 [22-54] vs. 38 [26-65] h, HR 2.4, 95% CI, 1.5-3.8; P < 0.0001), and mean time to tolerate food (2 [2-5] vs. 3 [2-8] days, HR 1.5, 95% CI, 1.02-2.3; P = 0.002) were decreased significantly in patients who consumed coffee compared with the control subjects. Postoperative ileus was observed in seven patients (14.9%) in the control group and one patient (2.0%) in the coffee group (P = 0.02). No adverse events were attributed to coffee consumption.

CONCLUSION

Postoperative coffee intake after laparoscopic gynecological surgery hastened the recovery of gastrointestinal function by reducing the time to the first passage of flatus, time to the first defecation, and time to tolerate a solid diet. This simple, cheap, and well-tolerated treatment merits routine use alongside other existing enhanced recovery pathways in the postoperative setting.

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

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

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

Objective:

To evaluate the efficacy of postoperative gum-chewing compare with routine postoperative care on the recovery of gastrointestinal function after comprehensive surgical staging for gynecological cancer.

Materials and Methods:

A total of 82 patients who underwent comprehensive surgical staging for gynecological cancer at Rajavithi Hospital between October 1st, 2018 and June 30th, 2019 were randomly allocated into two groups: Gum-chewing group (n=40) and control group (n=42). In the gum-chewing group, patients were assigned to chew sugar-free gum for 30 minutes starting from the first postoperative morning then every 8 hours until the first passage of flatus. In the control group, patients have received routine postoperative care. The primary endpoint was time to first flatus after surgery. The secondary endpoints were time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, ileus symptoms, length of a hospital stay, and potential adverse events of gum-chewing, including dry mount, choking, and aspiration.

Results:

Chewing gum was statistically significant in reducing time to first flatus compared with routine postoperative care (median 24.7 (range 2.2-86.5) vs 35.4 (range 7.2-80.9) hours, p=0.025). The length of a hospital stay was also significantly shorter in the gum-chewing group (median 3.0 (range 1.0-8.8) vs 3.5 (range 1.8-50.0) days, p=0.023). There were no significant differences in time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, and ileus symptoms between both two groups. No adverse events related to postoperative gum-chewing were observed.

Conclusion:

Gum-chewing was associated with early recovery of gastrointestinal function in patients undergoing surgery for gynecological cancer. It is an inexpensive and physiologic intervention that appears to be reasonably safe and should be recommended as an adjunct in postoperative care of gynecological cancer surgery.

Impact of pre-operative walking on post-operative bowel function in patients with gynecologic cancer

BACKGROUND

There is a paucity of data on whether pre-operative walking and functional capacity has a direct association with post-operative gastrointestinal function in patients who have undergone surgery to treat gynecologic cancers.

OBJECTIVE

To explore the relationship between pre-operative walking and post-operative recovery of bowel function.

METHODS

This randomized trial was performed from January 1, 2018 to August 31, 2018. All patients had a diagnosis of endometrial or ovarian cancer and were scheduled for comprehensive staging. Group A served as the control group who did not walk regularly on the last night before surgery. Patients in group B walked for 30 min at an average speed of 3 km/h from 20.00 to 20.30 and 21.30. to 22.00 on the last night before surgery under the supervision of a nurse or doctor. The study was registered with clinicaltrials.gov (no: NCT03553121).

RESULTS

A total of 85 patients were enrolled: 43 patients were assigned to the walking group and 42 to the control group. There were no significant differences in demographics between the groups. Median age was 57.3±8.5 in the control and 59.9±9.1 in the walking group. In addition, 28 patients had endometrial cancer and 14 had ovarian cancer in the control group. 33 patients and 10 patients in the walking group had endometrial and ovarian cancer, respectively. The mean time to first flatus was shorter in the walking group than in the control group (32.5±10.4 vs 40.6±16.9 hours, respectively; p=0.010). In addition, the time to first defecation was significantly shorter in the walking group (62.8±26.7 vs 91.4±51.8 hours; p=0.002). Patients who walked before surgery were less likely to have post-operative paralytic ileus (25.0% vs 60.7%; p=0.003). Walking before the operative period and laparoscopic surgery independently protected against the development of post-operative paralytic ileus.

CONCLUSION

Walking before surgery expedited time to bowel motility and ability to tolerate food. In addition, this method significantly decreased the risk of post-operative paralytic ileus.We consider that walking before surgery may be integrated into the pre-operative management of patients under going surgery for gynecologic cancers.

CLINICAL TRIAL REGISTRATION

clinicaltrial.org record number: NCT03553121.

Influence of preoperative enema application on the return of gastrointestinal function in elective Cesarean sections: a randomized controlled trial

AIM

There is an extensive literature on the mechanical bowel preparation by an enema in colorectal, abdominal, and gynecologic surgeries that provide evidence against the use of enema. There are, however, few studies investigating the effect of enema prior to elective Cesarean sections. The aim of this study is to investigate whether preoperative enema facilitates the return of gastrointestinal activity in pregnant women undergoing elective Cesarean section.

MATERIALS AND METHODS

The surgeon-blinded prospective randomized controlled study included 225 elective Cesarean patients between the ages of 18 and 44. The patients were randomized into two groups: those who had enema preoperatively (n = 114) and those who did not (n = 111). The outcome measures were first bowel sound time and first flatus time, the length of hospital stay, the rate of mid ileus symptoms, and additional analgesic and antiemetic need.

RESULTS

In the non-enema group, the time of the first bowel sound, flatus time, length of hospital stay, the rates of additional analgesic need, additional antiemetic need, and mild ileus symptoms were respectively 10.5 ± 5.8 hours, 16.0 ± 7.6 hours, 1.9 ± 0.3 days, 8.1%, 7.2%, and 2.7%. For the enema group, the same parameters were respectively 11.6 ± 4.7 hours, 17.5 ± 6.5 hours, 1.8 ± 0.3 days, 7%, 6.1% ,and 1.8%. For all parameters, the difference between the groups was not statistically significant (p values were respectively .09, .12, .8, .79, .68, and .26).

CONCLUSIONS

The study suggests that preoperative enema in elective cesarean sections does not prevent postoperative gastrointestinal complications and does not shorten the recovery of bowel movements or length of hospital stay.

Nutritional Interventions to Improve Clinical Outcomes in Ovarian Cancer: A Systematic Review of Randomized Controlled Trials

Among all gynaecological neoplasms, ovarian cancer has the highest rate of disease-related malnutrition, representing an important risk factor of postoperative mortality and morbidity. Hence, the importance of finding effective nutritional interventions is crucial to improve ovarian cancer patient's well-being and survival. This systematic review of randomized controlled trials (RCTs) aims at assessing the effects of nutritional interventions on clinical outcomes such as overall survival, progression-free survival, length of hospital stay (LOS), complications following surgery and/or chemotherapy in ovarian cancer patients. Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until December 2018. A total of 14 studies were identified. Several early postoperative feeding interventions studies (n = 8) were retrieved mainly demonstrating a reduction in LOS and an ameliorated intestinal recovery after surgery. Moreover, innovative nutritional approaches such as chewing gum intervention (n = 1), coffee consumption (n = 1), ketogenic diet intervention (n = 2) or fruit and vegetable juice concentrate supplementation diet (n = 1) and short-term fasting (n = 1) have been shown as valid and well-tolerated nutritional strategies improving clinical outcomes. However, despite an acceptable number of prospective trials, there is still a lack of homogeneous and robust endpoints. In particular, there is an urgent need of RCTs evaluating overall survival and progression-free survival during ovarian oncology treatments. Further high-quality studies are warranted, especially prospective studies and large RCTs, with more homogeneous types of intervention and clinical outcomes, including a more specific sampling of ovarian cancer women, to identify appropriate and effective nutritional strategies for this cancer, which is at high risk of malnutrition.

Nutritional Interventions to Improve Clinical Outcomes in Ovarian Cancer: A Systematic Review of Randomized Controlled Trials

Among all gynaecological neoplasms, ovarian cancer has the highest rate of disease-related malnutrition, representing an important risk factor of postoperative mortality and morbidity. Hence, the importance of finding effective nutritional interventions is crucial to improve ovarian cancer patient's well-being and survival. This systematic review of randomized controlled trials (RCTs) aims at assessing the effects of nutritional interventions on clinical outcomes such as overall survival, progression-free survival, length of hospital stay (LOS), complications following surgery and/or chemotherapy in ovarian cancer patients. Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until December 2018. A total of 14 studies were identified. Several early postoperative feeding interventions studies (n = 8) were retrieved mainly demonstrating a reduction in LOS and an ameliorated intestinal recovery after surgery. Moreover, innovative nutritional approaches such as chewing gum intervention (n = 1), coffee consumption (n = 1), ketogenic diet intervention (n = 2) or fruit and vegetable juice concentrate supplementation diet (n = 1) and short-term fasting (n = 1) have been shown as valid and well-tolerated nutritional strategies improving clinical outcomes. However, despite an acceptable number of prospective trials, there is still a lack of homogeneous and robust endpoints. In particular, there is an urgent need of RCTs evaluating overall survival and progression-free survival during ovarian oncology treatments. Further high-quality studies are warranted, especially prospective studies and large RCTs, with more homogeneous types of intervention and clinical outcomes, including a more specific sampling of ovarian cancer women, to identify appropriate and effective nutritional strategies for this cancer, which is at high risk of malnutrition.

Optimize patient outcomes among females undergoing gynecological surgery: A randomized controlled trial

BACKGROUND

Optimizing early education in gynecological procedures utilizing an Enhanced Recovery after Surgery (ERAS) program and a bundle concept may optimize patient outcomes after surgery.

PURPOSE

Evaluate whether an ERAS bundle compared to standard education can affect length of stay, 30 day readmission, and patient satisfaction among patients undergoing gynecologic surgery.

DESIGN

Prospective, comparative, randomized design SETTING: 28 bed Medical Surgical Unit SAMPLE/INTERVENTION: 50 patients undergoing hysterectomy, 25 who received post-operative evidence based bundle/standard education, and 25 who received standard education packet. Bundle components included 1) early mobilization, 2) early transition to oral pain medication, 3) early feeding, and 4) chewing gum. A follow-up phone call was made in two to three days following discharge for both groups utilizing teach-back.

RESULTS

84% (n = 21) patients in the bundle group were discharged in one day. There were no 30 day readmissions for both groups. Twenty two (88%) participants met the bundle components 100% of the time. For the indicator "walking helped with recovery" 100% (n = 25) responded "very good to excellent" for bundle group and 96% (n = 24) responded "very good to excellent" for standard group. Twenty three (92%) of the bundle group felt that that overall nursing care received was very good to excellent and 24 (96%) of the general group felt that overall nursing care received was very good to excellent.

CONCLUSION

Optimizing peri-operative education using a bundle approach to provide evidence based interventions can minimize risk and enhance early recovery for females undergoing gynecological surgery.

[Perioperative care of epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).

Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

BACKGROUND

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care.

OBJECTIVE

The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery.

STUDY DESIGN

We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature.

RESULTS

Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway.

CONCLUSION

Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

Impact of enhanced recovery after surgery (ERAS) protocol on gastrointestinal function in gynecologic oncology patients undergoing laparotomy

OBJECTIVE

To evaluate the impact of enhanced recovery after surgery (ERAS) on postoperative gastrointestinal function in gynecologic oncology patients.

METHODS

This retrospective cohort study compared gynecology oncology patients undergoing non-emergent laparotomy from 10/2016 to 6/2017 managed on an ERAS protocol to a control cohort from the year prior to ERAS implementation. Major changes to postoperative care after ERAS implementation included multimodal analgesia, early feeding, goal-directed fluid resuscitation, and early ambulation. The primary outcome was rate of postoperative ileus, defined as nausea and vomiting requiring nothing-per-mouth status or nasogastric tube (NGT) placement. Secondary outcomes included length of stay (LOS) and 30-day readmission.

RESULTS

376 patients met inclusion criteria; 197 in the control group and 179 in the ERAS group. Patient demographics were similar between groups. Ileus rate was significantly lower in the ERAS group (2.8% vs. 15.7%; p < 0.001), and fewer patients in the ERAS group required NGT placement (2.2% vs. 7.1%; p = 0.06). ERAS remained independently associated with decreased ileus rates when controlling for other patient and surgical factors (OR 0.2; p = 0.01). Epidural use was correlated with a significant increase in ileus risk (OR 2.6; p = 0.03), as was increased Charlson Comorbidity Index (OR 1.2; p < 0.01). LOS was significantly decreased in the ERAS group (2.9 vs. 4.0 days; p = 0.04), while 30-day readmission rates were similar (10.1% vs. 10.7%; p = 0.62).

CONCLUSIONS

Implementation of an ERAS protocol significantly decreases the risk of postoperative ileus in gynecologic oncology patients undergoing laparotomy. ERAS also reduced LOS compared to pre-ERAS controls.

The Optimal Time of Postoperative Feeding After Total Hip Arthroplasty: A Prospective, Randomized, Controlled Trial

Whether early postoperative feeding (EPF) after total hip arthroplasty (THA) interferes with recovery of gastrointestinal motility is unclear. This randomized controlled trial compared the feasibility and patient tolerance to either EPF (at 4 hr postoperatively) or late postoperative feeding (LPF; ⩾8 hr postoperatively). One hundred forty patients were randomized to EPF (70 hips) or LPF (70 hips). Patient characteristics, surgical technique, intraoperative characteristics, and postoperative managements were similar between two groups. No significant differences were evident between the groups for vomiting (p = .231), nausea (p = .711), regain of appetite (p = .711), amount of diet (p = .630), type of food (p = .429), abdominal pain (p = 1.000), time to passage of flatus (p = .231), time to defecations (p = .619), development of postoperative ileus (p = 1.000), and length of hospital stay (p = .643). EPF and LPF show no difference in nausea, return of bowel function, and length of hospital stay without increasing postoperative morbidity. EPF can begin about 4 hr later after elective THA.

Meta-Analysis of the Effect of Gum Chewing After Gynecologic Surgery

OBJECTIVE

To describe the scientific evidence related to gum chewing to reduce ileus after gynecologic surgery.

DATA SOURCES

A literature search was performed using Ovid Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases.

STUDY SELECTION

Inclusion criteria included randomized controlled trials (RCTs) on the use of gum chewing after gynecologic surgery in which the main outcomes measured were time to first flatus, time to defecation, and length of hospital stay.

DATA EXTRACTION

Data on authors, country, randomization method, the type of disease, surgical and anesthetic methods, sample characteristics such as age and body mass index, gum chewing program, and study results were extracted from selected articles.

DATA SYNTHESIS

Of 493 publications, eight RCTs conducted between 2013 and 2017 involving 1,077 women were included in our meta-analysis. Weighted mean differences (WMDs) with 95% confidence intervals were calculated for the eight studies with the use of Cochrane Review Manager Version 5.3 (RevMan; 2014). The pooled results showed that gum chewing was superior to no gum chewing, with a reduction in WMD for time to first flatus of -6.20 hours (95% confidence interval [CI] [-9.51, -2.88]), WMD for time to first defecation of -9.03 hours (95% CI [-14.02, -4.04]), and WMD for length of hospital stay of -0.36 days (95% CI [-0.72, -0.01]).

CONCLUSION

Gum chewing significantly reduced the time to first flatus and defecation after gynecologic surgery and should be recommended by health care providers.

Enhanced recovery pathways in thoracic surgery from Italian VATS group: nursing care program

Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened patient recovery and reduced time in hospital. Nursing staff play a key role in the implementation of enhanced recovery protocols. This issue focalizes the role of nurses in ERAS program for patients submitted to Thoracic Surgery, in particular for cases of major lung resection performed by a minimally invasive surgical approach (VATS, video assisted thoracic surgery).

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.

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.

Enhanced Recovery After Surgery for Advanced Ovarian Cancer: A Systematic Review of Interventions Trialed

Objectives

We sought to summarize the evidence for interventions aiming at enhanced recovery after surgery (ERAS) in ovarian cancer through a systematic review.

Methods

We searched MEDLINE, EMBASE, and The Cochrane Library for studies testing ERAS interventions in patients undergoing surgery for ovarian cancer. Study selection and data extraction were done independently by 2 reviewers with disagreements resolved by discussion with a senior, third reviewer.

Results

We identified 25 studies including 1648 participants with ovarian cancer. Nine observational studies addressed ERAS protocols. Four of them were prospective, and 3 included historical controls. The other 16 studies reported single interventions, for example, early feeding, omission of pelvic drains, early orogastric tube removal, Doppler-guided fluid management, and patient-controlled epidural analgesia. Early feeding protocols were tested in 7 of the 12 randomized trials. Early feeding appeared to be safe and was associated with significantly faster recovery of bowel function.

Conclusions

Few studies have specifically studied ERAS interventions in ovarian cancer. All studies on protocols including multiple interventions were susceptible to bias. Early feeding is the intervention that is best supported by randomized trials. Application of evidence for ERAS derived from nonovarian cancer is challenged by the differences not only in the scope of surgery but also in ovarian cancer patients’ comorbidities. Postoperative morbidity is particularly high in these patients because of their poor nutritional status, perioperative fluids shifts, and long operating times. These patients may also show excessive response to surgical stress. Innovative, randomized trials are needed to reliably determine the feasibility, safety, and effectiveness of specific ERAS interventions in ovarian cancer.

Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial

BACKGROUND

Paralytic ileus that develops after elective surgery is a common and uncomfortable complication and is considered inevitable after an intraperitoneal operation.

OBJECTIVE

The purpose of this study was to investigate whether coffee consumption accelerates the recovery of bowel function after complete staging surgery of gynecologic cancers.

STUDY DESIGN

In this randomized controlled trial, 114 patients were allocated preoperatively to either postoperative coffee consumption with 3 times daily (n=58) or routine postoperative care without coffee consumption (n=56). Total abdominal hysterectomy and bilateral salpingo-oophorectomy with systematic pelvic and paraaortic lymphadenectomy were performed on all patients as part of complete staging surgery for endometrial, ovarian, cervical, or tubal cancer. The primary outcome measure was the time to the first passage of flatus after surgery. Secondary outcomes were the time to first defecation, time to first bowel movement, and time to tolerance of a solid diet.

RESULTS

The mean time to flatus (30.2±8.0 vs 40.2±12.1 hours; P<.001), mean time to defecation (43.1±9.4 vs 58.5±17.0 hours; P<.001), and mean time to the ability to tolerate food (3.4±1.2 vs 4.7±1.6 days; P<.001) were reduced significantly in patients who consumed coffee compared with control subjects. Mild ileus symptoms were observed in 17 patients (30.4%) in the control group compared with 6 patients (10.3%) in the coffee group (P=.01). Coffee consumption was well-tolerated and well-accepted by patients, and no intervention-related side-effects were observed.

CONCLUSION

Coffee consumption after total abdominal hysterectomy and systematic paraaortic lymphadenectomy expedites the time to bowel motility and the ability to tolerate food. This simple, cheap, and well-tolerated treatment should be added as an adjunct to the postoperative care of gynecologic oncology patients.

Effect of chewing gum on recovery of gastrointestinal function after splenectomy and pericardial devascularization

AIM

To investigate the effect of chewing gum on the recovery of gastrointestinal function after splenectomy and pericardial devascularization and its mechanism of action with regard to neural and humoral factors.

METHODS

This study was a randomized controlled trial conducted in 90 patients who underwent splenectomy and pericardial devascularization. The patients were randomly divided into either group A (chewing gum group) or group B (control group). Patients of group A started chewing gum from 4 h after the operation, while the control group received conventional therapy and nursing after operation. Blood samples were taken immediately after the 3^rd gum-chewing for detecting the levels of gastrin and norepinephrine. The levels of gastrin and norepinephrine, time to first bowel motion, flatus, and defecation, length of hospital stay, and bowel-related complications were compared between the two groups.

RESULTS

The mean time to bowel motion (33.82 h ± 1.52 h vs 42.82 h ± 1.30 h), mean time to flatus (60.63 h ± 2.78 h vs 67.43 h ± 2.84 h), mean time to defecation (70.13 h ± 3.12 h vs 86.39 h ± 2.43 h), and mean length of hospital stay (12.46 d ± 0.71 d vs 15.52 d ± 0.85 d) were all significantly reduced in patients who chewed gum compared with control patients (P < 0.05). There was a significant difference in nompinephrine level between the two groups (t = -11.26, P = 0.000), although blood level of gastrin showed no significant difference between the two groups (t = 1.801, P = 0.075). Fewer participants assigned to receive chewing gum developed abdominal distention compared with control patients (χ² = 5.075, P = 0.024). There were no significant differences in the rates of postoperative nausea, emesis and ileus between the two groups (P > 0.05).

CONCLUSION

Chewing gum decreases the time to recover gastrointestinal function and shorten the duration of hospitalization. It can be used as a component of comprehensive therapy for a gastrointestinal function recovery program after splenectomy and pericardial evascularization. The mechanism may be related to altering the level of blood eatecholamine.

Randomized Clinical Trial Comparing Efficacy of Simo Decoction and Acupuncture or Chewing Gum Alone on Postoperative Ileus in Patients With Hepatocellular Carcinoma After Hepatectomy

To compare the efficacy of simo decoction (SMD) combined with acupuncture at the tsusanli acupoint or chewing gum alone for treating postoperative ileus in patients with hepatocellular carcinoma (HCC) after hepatectomy.In postoperative ileus, a frequent complication following hepatectomy, bowel function recovery is delayed, which increases length of hospital stay. Studies suggest that chewing gum may reduce postoperative ileus; SMD and acupuncture at the tsusanli acupoint have long been used in China to promote bowel movement.Patients with primary HCC undergoing hepatectomy between January 2015 and August 2015 were randomized to receive SMD and acupuncture (n = 55) or chewing gum (n = 53) or no intervention (n = 54) starting on postoperative day 1 and continuing for 6 consecutive days or until flatus. Primary endpoints were occurrence of postoperative ileus and length of hospital stay; secondary endpoints were surgical complications.Groups treated with SMD and acupuncture or with chewing gum experienced significantly shorter time to first peristalsis, flatus, and defecation than the no-intervention group (all P < 0.05). Hospital stay was significantly shorter in the combined SMD and acupuncture group (mean 14.0 d, SD 4.9) than in the no-intervention group (mean 16.5 d, SD 6.8; P = 0.014), while length of stay was similar between the chewing gum group (mean 14.7, SD 6.2) and the no-intervention group (P = 0.147). Incidence of grades I and II complications was slightly lower in both intervention groups than in the no-intervention group.The combination of SMD and acupuncture may reduce incidence of postoperative ileus and shorten hospital stay in HCC patients after hepatectomy. Chewing gum may also reduce incidence of ileus but does not appear to affect hospital stay. (Clinicaltrials.gov registration number: NCT02438436.).

EFFECT OF GUM CHEWING ON AIR SWALLOWING, SALIVA SWALLOWING AND BELCHING

BACKGROUND

Eructation is a physiologic event which allows gastric venting of swallowed air and most of the time is not perceived as a symptom. This is called gastric belching. Supragastric belching occurs when swallowed air does not reach the stomach and returns by mouth a short time after swallowing. This situation may cause discomfort, life limitations and problems in daily life.

OBJECTIVE

Our objective in this investigation was to evaluate if gum chewing increases the frequency of gastric and/or supragastric belches.

METHODS

Esophageal transit of liquid and gas was evaluated by impedance measurement in 16 patients with complaint of troublesome belching and in 15 controls. The Rome III criteria were used in the diagnosis of troublesome belching. The esophageal transit of liquid and gas was measured at 5 cm, 10 cm, 15 cm and 20 cm from the lower esophageal sphincter. The subjects were evaluated for 1 hour which was divided into three 20-minute periods: (1) while sitting for a 20-minute base period; (2) after the ingestion of yogurt (200 mL, 190 kcal), in which the subjects were evaluated while chewing or not chewing gum; (3) final 20-minute period in which the subjects then inverted the task of chewing or not chewing gum. In gastric belch, the air flowed from the stomach through the esophagus in oral direction and in supragastric belch the air entered the esophagus rapidly from proximal and was expulsed almost immediately in oral direction. Air swallows were characterized by an increase of at least 50% of basal impedance and saliva swallow by a decrease of at least 50% of basal impedance, that progress from proximal to distal esophagus.

RESULTS

In base period, air swallowing was more frequent in patients than in controls and saliva swallowing was more frequent in controls than in patients. There was no difference between the medians of controls and patients in the number of gastric belches and supragastric belches. In six patients, supragastric belches were seen at least once during the 20-minute base period. None of the controls had supragastric belches. In the control group, the ingestion of yogurt caused no significant alteration in the number of air swallows, saliva swallows, gastric belches and supragastric belches. In the patient group, there was an increase in the number of air swallows. If the subjects were chewing gum during this 20-minute period, there was an increase in the number of saliva swallows in both groups, without alterations of the number of air swallow, gastric belches and supragastric belches. There was no alteration in the number of the saliva swallows, air swallows, gastric belches and supragastric belches in both groups for subjects who did not chew gum in the 20-40 minute period after yogurt ingestion. When the subjects were chewing the gum, there was an increase in saliva swallows in the control and patients groups and in air swallows in the patients group.

CONCLUSION

Gum chewing causes an increase in saliva swallowing in both patients with excessive belching and in controls, and an increase in air swallowing in patients with excessive belching 20 minutes after yogurt ingestion. Gum chewing did not increase or decrease the frequency of gastric or supragastric belches.

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.

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.