Effectiveness of chewing gum on bowel motility among the patients who have undergone Abdominal Surgery Nimarta, Neena Vir Singh, Shruti, Rajesh Gupta Abstract : Postoperative ileus limits early hospital discharge for patiets who had undergone abdominal surgery. Literature indicates that chewing gum is evaluated as a convenient method to enhance postoperative recovery from postoperative ileus after abdominal surgery. The present study was aimed to evaluate the efficacy of chewing gum on bowel motility among patient who had undergone abdominal surgery with null hypotheses that there was no significant difference in early return of first bowel sound, passage of flatus and return of appetite with the administration of chewing gum. A total of 60 patients who underwent elective abdominal surgery with general anaesthesia were par ticipated in the study. Each patient was assigned purposively to one of two groups: Experimental group (n=30). The tools and protocol were developed through review of relevant literature and validated by experts from field of nursing and department of General Surgery. Tools used in the study were interview schedule and check list to assess the bowel sounds, passage of first flatus and return of appetite. The patients in the experimental group as per planned protocol were administered chewed gum three times a day for 15-20 min starting from the first postoperative day till the passage of first flatus. The times of the return of the first bowel sounds, passage of first flatus, return of appetite was recorded in checklist. Patients with severe postoperative haemorrhage, intraoperative and postoperative complications requiring emergency intervention, history abdominal blunt trauma, perforation etc were excluded from this study. Bowel sounds were checked by a single person. The mean duration of return of first bowel sounds, passage of first flatus and return of appetite was significantly shorter in the experimental group as compared to the control patients as per t test. Hence the null hypotheses was rejected. No adverse effects were observed with chewing gum in the postoperative period and it is a safe method to stimulate bowel motility and reduce the postoperative ileus.
Keywords :Chewing gum, abdominal surgery, postoperative ileus
Correspondance at Nimarta M.Sc(N) Final Year Student, PGIMER, Chandigarh
[email protected]
Introduction Postoperative ileus (POI) is a very common and unavoidable outcome of major abdominal surgery, primarily due to poorly understood multifactorial pathophysiology, that may lead to significant patient morbidity, and is a common reason for gastroenterological consultation. POI may be generally defined as transient inhibition of
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normal gastrointestinal motility in the postoperative setting, typically lasting 3-5 days after surgery1. Ileus is defined in Dorland's Illustrated Medical Dictionary simply as "obstruction of the intestines".2 Under this definition, fully 40% of patients undergoing laparotomy experience prolonged postoperative ileus3. POI may be generally characterized by abdominal distension, lack of bowel sounds, and lack of passage of flatus or stool, worsened by postoperative pain, nausea and vomiting, delay in resuming enteral nutrition, and prolonged hospitalization. Other postoperative complications including, deconditioning, malnutrition, increased risk of nosocomial infections and pulmonary complications, decreased patient satisfaction and increased health care costs.3,4 In United States the incidence of postoperative ileus occurs in approximately 50% of clients who under went major abdominal surgery. In India 60 to 70% of clients with major abdominal surgery develop postoperative complication due to postoperative paralytic ileus which becomes the root cause for discomfort, prolonged hospital stay and economic burden.5 POI affects all par ts of the gastrointestinal tract to varying degrees. The small intestine recovers the normal function first, usually within the first 24 hrs, followed by the stomach about 12-24 hrs later; and recovery of the normal large intestine function usually takes between 48 to 72 hrs. Thus, in uncomplicated ileus, gastrointestinal motility is re-established within 3 days. If POI lasts longer than 3 days, it is thought to be
complicated and may be termed as postoperative paralytic ileus.6 Conventionally, POI has been managed by gastric decompression through Ryle's tube, keeping the patient nil per orally, intravenous fluid supplementation till ileus resolves, and patient passes flatus. However, very few improvements in the understanding of POI have occurred in the past 100 years, and therefore therapies have been changed little.6 While working with the patient undergoing abdominal surger y it is responsibility of nurse to prevent the postoperative ileus. There are many nonpharmacologic treatment such as early enteral nutrition, early mobilization, laparoscopic surgery, psychological preoperative preparation among them the use of chewing gum also has emerged as a new, simple, readily available and cost effective modality for decreasing POI. It acts by stimulating intestinal motility through cephalic vagal reflex and by increasing the production of gastrointestinal hormones associated with bowel motility that result in early return of bowel sounds, passage of flatus and return of appetite. Hence the researcher has taken up the study to evaluate the efficacy of chewing gum on bowel motility af ter abdominal surgery. Objectives To evaluate the efficacy of chewing gum on bowel motility among patients who have undergone abdominal surgery.
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Materials and methods The present study was conducted to evaluate the efficacy of chewing gum on bowel motility among patients who have undergone abdominal surgery. The null hypotheses proposed was that there was no significant difference in early return of first bowel sound, passage of flatus and return of appetite with the administration of chewing gum at 0.05 level of significance. The study was conducted in General male and female surgical wards of Nehru hospital at Post Graduate Institute of Medical Education and research (PGIMER), Chandigarh which is a premier institute of medical education and research, which include 60 patients who under went abdominal surger y( cholecystectomy, restoration of bowel continuity, colectomy etc) under general anaesthesia after obtaining approval of Institute Ethics Committee and informed written consent was taken from all enrolled patients. The following tools and protocols were used for data collection. Sociodemographic data sheet of the subjects, protocol for administration of chewing gum, protocol for auscultation of bowel sounds , a check list to assess the bowel sounds, passage of first flatus and the return of appetite. Tools were validated by experts in the field of nursing & surgery. Baseline data were collected with the help of interview schedule for socio demographic data, preoperative history of patients related to surgery, post operative assessment of the patients. A total of sixty patients were enrolled by purposive sampling. 30 patients each in the experimental and the control group.
In the experimental group , the patients were ask to chew two sticks of commercially available sugar free chewing gum( orbit) thrice during a day for 15-20 min each time starting from 16 hours of the surgery till the passage of first flatus and Patients in the control group(n=30)received routine postoperative care. To study the effect of chewing gum on the experimental group and routine postoperative management in the control group, bowel sounds were auscultated every 2 hourly and subjects were asked regarding passage of first flatus and return of appetite and same findings were documented in the check list for the experimental group as well as the control group. Analysis was done by "Statistical Package for the Social Sciences"(SPSS) 15 version. For descriptive analysis, percentage, mean, standard deviation was used. Chi square (χ2) and independent t test was used as inferential statistics. Results Socio -demographic profile of both the groups Table 1 depicts that as per sociodemographic data, summarized in the table 1, the subjects were in the range of 21 to 77 years with mean age 43.9 ±12.53 years in the experimental group compared to the control group that was in range of 22- 65 years with mean age of 43.57±13.8 years. Half of the subjects (53.4%) were in the age group of 36- 55 years in the experimental group and less than half (46.6%) were in the age group of 36-55years in control group.
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As per gender, 18(60%) and 16(53.3%) of the subjects were female in the experimental and the control group respectively. As per the occupation, 18(60%) subjects in the experimental group and 17(56.7%) in the control group were in the private services. Eight (26.6%) and 10(33.3%) subjects were unemployed in the experimental and the control group respectively.
On the basis of education half of the subjects 15(50%) were graduates in the experimental group and only 11(36.7%) were graduates in the control group. Both the groups were homogenous as per socio demographic profile i.e. age, gender, occupation, educational status as per χ2 test (p>0.05)
Socio -demographic profile of both the groups N=60 Experimental Group (n=30) n(%)
Control Group (n=30) n(%)
χ2,df
≤2 5 26-35 36-45 46-55 56 and above
3(10.0) 6(20.0) 8(26.7) 8 (26.7) 5(16.6)
4(13.4) 6(20.0) 7(23.3) 7(23.3) 6(20.0)
0.37,4 0.98
Gender Male Female
12(40) 18(60)
14(46.7) 16(53.3)
0.27,1 0.60
Occupation Govt. service Private service Unemployed
04(13.3) 18(60.0) 8(26.6)
03(10.0) 17(56.7) 10(33.3)
0.39,2 0.82
Education Status Illiterate Primary Secondary Senior secondary Graduate
3(10.0) 7(23.3) 1(3.3) 4 (13.3) 15(50.0)
3(10.0) 11(36.7) 3(10.0) 2(6.7) 11(36.7)
3.17,4 0.53
Variable
p value
Age(years)*
*Mean age(years) ± SD: 43.9 ±12.53 in experimental group and 43.57±13.818 in the control group and Range is 21-77 years in experimental group and 22- 65 yrs in control group Nursing and Midwifery Research Journal, Vol-9, No.3, July 2013
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Distribution of the subjects as per diagnosis, previous history of surgery, constipation and comorbities in both the groups
subjects had enterocolon diseases in the experimental and the control group respectively. Both the groups are comparable as per χ2 test (p>0.05).
Table 2 depicts the distribution of the subjects as per diagnosis .On the basis of the As per abdominal surgery history, diagnosis 14(46.7%) and 13(43.3%) subjects 15(50%) and 13(43.3%) of the subjects had had hepatobiliary diseases in the experimental history of previous abdominal surgery in the and control group respectively. Only 3(10%) experimental and the control group subjects from both the groups had pancreatic respectively. disease and 13(43.3%) and 14(46.7%) Table 2: Distribution of the subjects as per diagnosis, previous history of surgery, constipation and comorbities in both the groups N=60 2 χ ,df Variable Experimental Control Group (n=30) n(%)
Group (n=30) n(%)
p value
Hepatobiliary diseases
14(46.7)
13(43.3)
0.07,2
Pancreatic diseases
03(10.0)
03(10.0)
0.96
Enterocolon diseases*
13(43.3)
14(46.7)
Previous abdominal surgery Previous constipation**
15(50.0)
13(43.3)
6(20.0)
1(3.3)
Diagnosis Diagnosis
History
Comorbities** 6(20.0) (Hypertension, Tuberculosis, diabetes * Diseases of the small and large intestines ** No. of subjects without symptoms are not depicted in table
As per the history of constipation, significantly higher number 6(20%) of subjects in the experimental group and only 1(3.3%) subject in the control group had history of constipation (p<0.05). On the basis of comorbities, 6(20%) and 9(30%) of subjects had comorbities
9(30)
0.268,1 0.605 4.043,1 0.044 0.80,1 0.371
(Hypertension, Tuberculosis, diabetes) in the experimental group and the control group respectively. It shows homogeneity of subjects in the control and the experimental groups with reference to their previous histor y of abdominal surgery and comorbities.
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control group respectively and mean duration of surgery was 2.68 ± 1.74 hours and 2.44 ± 0.820 hours in the experimental and the control group respectively. Both the groups were homogenous as per t test (p >0.05).
Duration of Anesthesia during Surgery and duration of Surgery in both the groups Table 4 depicts the mean duration of induction of anesthesia in minutes among the subjects. It was 27 ±7.7 minutes and 28 ±8.4 minutes in the experimental and the
Table 4: Distribution of the subjects as per duration of anesthesia during surgery in both the groups N=60 Variable
Group
n
Mean ± SD
t value, df
p value
Duration of anesthesia (min)
Experimental Control
30 30
27±7.72 28±8.46
0.478,58
0.64
Duration of surgery (hrs.)
Experimental Control
30 30
2.68±1.749 2.44±0.820
-0.676,58
0.502
Comparison of the subjects as per return of first bowel sounds, Passage of first flatus, return of appetite among both the groups
Comparison of mean duration of return of first bowel sounds, passage of flatus and return of appetite among both the groups
Table 5 depicts return of bowel sounds before 24 hours were significantly in higher percentage in the experimental group 27(90%) as compared to the control group 19(63.3%) as per χ2 test (p <0.05).
Table 6 highlights that there is significant difference in the return of first bowel sounds, passage of flatus and return of appetite between the experimental & the control group. The mean time of return of bowel sounds after surgery was significantly lesser (21.4±2.8hr) in the experimental group than in the control group (23.7±2.8 hr).
Similarly passage of flatus before 60 hours was significantly higher percentage in the experimental group (66.7%) as compared to the control group (23.3%) as per χ2 test (p <0.05). The table also depicts that return of appetite before 60 hours was significantly higher percentage in the experimental group (56.7%) as compared to the control group (13.3%) as per χ2 test (p <0.05).
Similarly the mean time of passage of flatus after surgery was significantly lesser in (58.2±9.3hr ) in the experimental group than in the control group (65.6±6.4 hr). The mean time of return of appetite after surgery was significantly lesser (59.9±9.8 hr) in experimental group than in the control group (67.2±7.6 hr).
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Table 5: Comparison of the subjects as per return of first bowel sounds, Passage of first flatus, return of appetite between both the groups N=60 Experimental Group (n=30) n(%)
Control Group (n=30) n(%)
χ2,df
≤24 hr >24hr
27(90) 3(10)
19(63.3) 11(36.7)
4.57,1 0.03*
Passage of flatus (hr) ≤60 hrs >60hrs
20(66.7) 10(33.3)
7(23.3) 23(76.7)
11.3,1 0.001*
Return of appetite (hr) ≤60hr >60hr
17(56.7) 13(43.3)
4(13.3) 26(86.7)
10.5,1 0.001*
Variable
p value
Return of bowel sound(hr)
Table: 6 Comparison of mean duration of return of first bowel sounds, passage of flatus and return of appetite between both the groups N=60 Variable
Experimental Group Mean time ± S.D (in hour)
Control t value Group Mean time ± S.D (in hour)
p value
Return of bowel sound(hr)
21.4±2.8
23.7±2.8
3.19
0.002*
Passage of flatus(hr)
58.2±9.3
65.6±6.4
3.57
0.001*
Return of appetite(hr)
59.9±9.
867.2±7.6
3.22
0.002*
*P<0.05
Discussion Postoperative ileus (POI) occurs commonly after abdominal operations and is one of the limiting factors which prevent early hospital discharge. The pathophysiology of POI includes spinal and local sympathetic neural reflexes, local as well as systemic inflammatory mediators released during surgery as part of the stress response.6
The potential complications of prolonged POI includes increased postoperative pain, increased nausea and vomiting, pulmonary complications, poor wound healing, delay in resuming oral intake, delay in postoperative mobilization, prolonged hospitalization, and increased health-care costs.7
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Sham feeding (when food is smelled or chewed not swallowed) has been demonstrated to be one of the methods to increase bowel motility. It causes both vagal stimulation and hormonal release; either one or both could modulate the bowel motility. Gum chewing, as an alternative to sham feeding, provides the benefits of gastrointestinal stimulation without the complications associated with feeding. In recent years, the use of chewing gum to reduce the postoperative paralytic ileus has been extensively reviewed in various randomized controlled trials on elective intestinal anastomosis and has been found to be beneficial in reducing POI.7-10
In the present study, the patients were asked to chew the gum starting from first postoperative day thrice during a day till passage of first flatus it is comparable to the study Verified by State University of New York - Upstate Medical University, June 2009 in which chewing gum was also given thrice a day starting from first postoperative day. In Marwah study patients were asked to chew gum thrice a day for 1 hour each time starting from 6 hours after the surger y until the passage of first flatus but in the present study, here the patients were asked to chew gum thrice a day for 15- 20min starting from 16 hrs after surgery until the passage of first flatus.6
The present study was aimed to evaluate the effectiveness of chewing gum on the bowel motility among patients who had undergone abdominal surgery. Total sixty subjects were studied prospectively for bowel motility i.e return of first bowel sound, passage of first flatus, return of appetite with the administration of chewing gum to 30 subjects in the experimental group and routine postoperative management to 30 subjects in the control group. In the present study the commercially available sugar-free chewing gum (orbit) used same is used in the study conducted by Marwah.6
The duration of surgery is also a known factor to cause POI. In the present study, the operating time in all patients was 2-3 hours. The mean duration of surgery was 2.68 ± 1.74 hours in the experimental group and 2.44 ± 0.82 hours in the control group, which was comparable in both groups. The results of duration of surgery are comparable with most of the previous studies except Ibrahim Harma et al and Marwah et al where surgeries took shor ter duration (1-2 hrs) because of caesarean section.In most of the studies, the criteria for discharge of patients from hospital were defecation, passage of gas, or feeding tolerance. 6,12
The final outcome measures in the present study are return of first bowel sound, passage of first flatus and return of appetite however, in systemic review by Hocevar et al, the outcome measures were first time to passage of flatus, time to passage of stool and length of hospital stay.11
The duration of anesthesia is another known factor to cause POI. In the present study, the mean duration of anesthesia was 109.3±41.95 minutes in the experimental group and 112.8 ±55.7 minutes in the control group, but there is no previous study where the time of anesthesia was mentioned. In
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present study all the patients were operated under general anesthesia as it is comparable with the study by Marwah S et al but not comparable to study by Maeboud KHI et al in which regional anaesthesia is used.6,13 Epidural analgesia for postoperative pain was not used in this study and it is comparable to Marwah et al study.6 In the present study, the mean time to return of first bowel sounds, passage of first flatus ,return of appetite was significantly shorter in the experimental as compared to the control group was comparable to the study by Park SY et al in which also mean time of flatus and postoperative hospital stay was shorter in the experimental group as compared to the control group but difference was not statistically significant14 The mean time for the appearance of bowel sounds was significantly shorter in the study group which was comparable to previous studies but in Harma MI it was much earlier in the study group may be because of cesarean section.12 The mean time for the passage of first flatus was significantly shorter in the study group (P=0.001).In the previous studies15-20 majority on elective colonic anastomosis, have also shown that patients in the study group were able to pass flatus before the control group. Various systematic reviews and metaanalyses have also revealed significant reduction in time to first flatus as well as bowel movement in the gum chewing group.7-8,10,21 The mean time taken to experience the feeling of hunger was significantly shorter in the experimental group in comparison to the
control group (P=0.002). This parameter has been analyzed previously only in one of the study by Schuster R et al with similar findings, but the difference was not statistically significant (P = 0.27).15 Findings of this study clearly indicate that mean duration to return of first bowel sound, passage of flatus and return of appetite shorter in the experimental group. Hence the null hypothesis is rejected at 0.05 level of significance. So it is concluded that use of chewing gum in the postoperative period after is a safe and cheap method to stimulate bowel motility and reduce the postoperative ileus af ter abdominal surgery. The study recommends that can be replicated on large sample and in more advanced variables like passage of stool, length of hospital stay and rate of postoperative complications. The implications of study is that nurses can encourage the postoperative patients to chew the chewing gum to reduce stress, enhance relaxation and sense of well being and also act as diversional therapy, which help in faster recovery, preventing complications and thereby provide cost effective care and satisfaction to the clients. References 1.
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Kouba EJ, Wallen EM, Pruthi RS. Gum chewing stimulates bowel motility in patients undergoing radical cystectomy with urinary diversion. Urology 2007;70:1053-6.
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Avupod YH, Azili MN, Karaman A, .Aslan MK, Karaman I, Erdoðan D, et al . Does gum chewing reduce postoperative ileus after intestinal resection in children? A prospective randomized controlled trial. Eur J Pediatr Surg 2009; 19: 171-3.
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Hirayama I, Suzuki M, Ide M, Asao T, Kuwano H. Gum chewing stimulates bowel motility after surgery for colorectal cancer. Hepatogastroenterology 2006;53: 206-8.
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Hocevar, Barbara J, Robinson, Bruce, Gray, Mikel. Does chewing gum shorten the duration of postoperative ileus in patients undergoing abdominal surgery and creation of a Stoma. Journal of Wound, Ostomy & Continence Nursing 2010; 37(2):140.
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Cormick JT, Garvin R, Caushai P, Simmang C, Gregorck S, Huber P, et al. The effects of gum chewing on bowel function and hospital stay after laparoscopic vs open colectomy: A multiinstitution prospective randomised trial. Am J Coll Surg 2005;3:66-7.
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Harma MI, Barut A, Arikan I , Harma M . Gum-chewing speeds return of first bowel sounds but not first defecation after cesarean section. Anatol J Obstet & Gynecol 2009; 1(1)
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Choi H, Kang SH, Yoon DK, Kang SG, Ko HY, Moon DG, Park JY, Joo KJ, Cheo J. Chewing gum has a stimulatory effect on bowel motility in patients after open or robotic radical cystectomy for bladder cancer. Urology 2011 Apr;77(4):88490.
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