World Journal of Surgery

, Volume 33, Issue 12, pp 2557–2566

Systematic Review and Meta-Analysis of Chewing-Gum Therapy in the Reduction of Postoperative Paralytic Ileus Following Gastrointestinal Surgery

Article

Abstract

Background

Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.

Methods

A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI).

Results

Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI −21.49 to −3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI −34.32 to −11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI −53.29 to +5.53; P = 0.11). There were no significant differences in complication rates.

Conclusions

Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

Supplementary material

268_2009_104_MOESM1_ESM.doc (32 kb)
Supplementary material 1 (DOC 32 kb)
268_2009_104_MOESM2_ESM.doc (41 kb)
Supplementary material 2 (DOC 41 kb)

References

  1. 1.
    Delaney C (2005) Introduction, definitions, and clinical importance of postoperative ileus. Semin Colon Rectal Surg 16:182–183CrossRefGoogle Scholar
  2. 2.
    Salvador C, Sikirica M, Evans A et al (2005) Clinical and economic outcomes of prolonged postoperative ileus in patients undergoing hysterectomy and hemicolectomy. Pharm Ther (P&T) 30:590–595Google Scholar
  3. 3.
    Bosio R, Delaney C, Senagore A (2005) Economic impact of POI and prolonged length of stay. Semin Colon Rectal Surg 16:235–238CrossRefGoogle Scholar
  4. 4.
    Kehlet H, Williamson R, Buchler MW et al (2005) A survey of perceptions and attitudes among European surgeons towards the clinical impact and management of postoperative ileus. Colorectal Dis 73:245–250CrossRefGoogle Scholar
  5. 5.
    Kehlet H (2001) Review of postoperative ileus. Am J Surg 182(Suppl):3–10CrossRefGoogle Scholar
  6. 6.
    Luckey A, Livingston E, Tache Y (2003) Mechanisms and treatment of postoperative ileus. Arch Surg 138:206–214CrossRefPubMedGoogle Scholar
  7. 7.
    Person B, Wexner S (2006) The management of postoperative ileus. Curr Probl Surg 43:12–65CrossRefGoogle Scholar
  8. 8.
    Carr CS, Ling KD, Boulos P et al (1996) Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ 312:869–871PubMedGoogle Scholar
  9. 9.
    Lewis S, Egger M, Sylvester P et al (2001) Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and metaanalysis of controlled trials. BMJ 323:1–5CrossRefGoogle Scholar
  10. 10.
    Stewart BT, Woods RJ, Collopy BT et al (1998) Early feeding after elective open colorectal resections: a prospective randomized trial. Aust N Z J Surg 68:125–128CrossRefPubMedGoogle Scholar
  11. 11.
    Chou S, Lin C, Hsieh H et al (2006) Gum chewing in patients with subtotal gastrectomy. Chir Gastroenterol 22:269–271CrossRefGoogle Scholar
  12. 12.
    Quah H, Samad A, Neathey A et al (2006) Gum chewing and postoperative ileus following open colectomy. Colorectal Dis 8:64–70CrossRefPubMedGoogle Scholar
  13. 13.
    Matros E, Rocha F, Zinner M et al (2006) Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg 202:773–778CrossRefPubMedGoogle Scholar
  14. 14.
    Schuster R, Grewal N, Greaney GC et al (2006) Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg 141:174–176CrossRefPubMedGoogle Scholar
  15. 15.
    Hirayama I, Suzuki M, Ide M et al (2006) Gum-chewing stimulates bowel motility after surgery for colorectal cancer. Hepatogastroenterology 53:206–208PubMedGoogle Scholar
  16. 16.
    Schluender S, Gurland B, Divino C et al (2005) Gum chewing does not enhance the return of bowel function in patients undergoing elective colon resection in a randomized blinded pilot study. Colorectal Dis 92(Suppl 1):P143Google Scholar
  17. 17.
    McCormick J, Garvin R, Caushaj P et al (2005) The effects of gum-chewing on bowel function and hospital stay after laparoscopic vs open colectomy: a multi-institution prospective randomized trial. J Am Coll Surg 201(Suppl 1):66–67CrossRefGoogle Scholar
  18. 18.
    Asao T, Kuwano H, Nakamura J et al (2002) Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy. J Am Coll Surg 195:30–32CrossRefPubMedGoogle Scholar
  19. 19.
    Moher D, Cook DJ, Eastwood S et al (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement—quality of reporting of meta-analyses. Lancet 354:1896–1900CrossRefPubMedGoogle Scholar
  20. 20.
    Higgins J, Green S (2006) Cochrane handbook for systematic reviews of intervention, version 4.2.6, 4th edn. Cochrane Collaboration Secretariat, Oxford, UKGoogle Scholar
  21. 21.
    Jadad AR, Moore RA, Carroll D et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled Clin Trials 17:1–12CrossRefPubMedGoogle Scholar
  22. 22.
    Kouba EJ, Wallen EM, Pruthi RS (2007) Gum chewing stimulates bowel motility in patients undergoing radical cystectomy with urinary diversion. Urology 70:1053–1056CrossRefPubMedGoogle Scholar
  23. 23.
    Zhang Q, Zhao P (2008) Influence of gum chewing on return of gastrointestinal function after gastric abdominal surgery in children. Eur J Pediatr Surg 18:44–46CrossRefPubMedGoogle Scholar
  24. 24.
    Chan MK, Law WL (2007) Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review. Dis Colon Rectum 50:2149–2157CrossRefPubMedGoogle Scholar
  25. 25.
    De Castro SM, van den Esschert JW, van Heek NT et al (2008) A systematic review of the efficacy of gum chewing for the amelioration of postoperative ileus. Dig Surg 25:39–45CrossRefPubMedGoogle Scholar
  26. 26.
    Senagore AJ (2007) Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health Syst Pharm 64(Suppl 13):S3–S7CrossRefPubMedGoogle Scholar
  27. 27.
    Fukuda H, Tsuchida D, Koda K et al (2007) Inhibition of sympathetic pathways restores postoperative ileus in the upper and lower gastrointestinal tract. J Gastroenterol Hepatol 22:1293–1299CrossRefPubMedGoogle Scholar
  28. 28.
    Luckey A, Wang L, Jamieson PM et al (2003) Corticotropin-releasing factor receptor 1-deficient mice do not develop postoperative gastric ileus. Gastroenterology 125:654–659CrossRefPubMedGoogle Scholar
  29. 29.
    The FO, Boeckxstaens GE, Snoek SA et al (2007) Activation of the cholinergic anti-inflammatory pathway ameliorates postoperative ileus in mice. Gastroenterology 133:1219–1228CrossRefPubMedGoogle Scholar
  30. 30.
    Traut U, Brugger L, Kunz R et al (2008) Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database Syst Rev (Online) 1:CD004930Google Scholar
  31. 31.
    Kraft MD (2007) Emerging pharmacologic options for treating postoperative ileus. Am J Health Syst Pharm 64(Suppl 13):S13–S20CrossRefPubMedGoogle Scholar
  32. 32.
    Yuan CS, Wei G, Foss JF et al (2002) Effects of subcutaneous methylnaltrexone on morphine-induced peripherally mediated side effects: a double-blind randomized placebo-controlled trial. J Pharmacol Exp Ther 300:118–123CrossRefPubMedGoogle Scholar
  33. 33.
    Yuan CS, Foss JF (2000) Oral methylnaltrexone for opioid-induced constipation. JAMA 284:1383–1384CrossRefPubMedGoogle Scholar
  34. 34.
    Delaney CP, Wolff BG, Viscusi ER et al (2007) Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of Phase III studies. Ann Surg 245:355–363CrossRefPubMedGoogle Scholar
  35. 35.
    Reisine T, Pasternak G (1996) Opioid analgesics and antagonists. In: Hardman J, Limbird L (eds) Goodman & Gilman’s the pharmacological basis of therapeutics. McGraw-Hill, New YorkGoogle Scholar
  36. 36.
    Carli F, Trudel JL, Belliveau P (2001) The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 44:1083–1089CrossRefPubMedGoogle Scholar
  37. 37.
    Miedema BW (2002) Postoperative ileus after laparoscopic colectomy. J Am Coll Surg 195:901 (Author reply 901–902)CrossRefPubMedGoogle Scholar
  38. 38.
    Chen HH, Wexner SD, Iroatulam AJ et al (2000) Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum 43:61–65CrossRefPubMedGoogle Scholar
  39. 39.
    Lacy AM, Garcia-Valdecasas JC, Delgado S et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229CrossRefPubMedGoogle Scholar
  40. 40.
    Delaney CP, Kiran RP, Senagore AJ et al (2003) Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 238:67–72CrossRefPubMedGoogle Scholar
  41. 41.
    Stern RM, Crawford HE, Stewart WR et al (1989) Sham feeding: cephalic-vagal influences on gastric myoelectric activity. Dig Dis Sci 34:521–527CrossRefPubMedGoogle Scholar
  42. 42.
    Waldhausen JH, Shaffrey ME, Skenderis BSII et al (1990) Gastrointestinal myoelectric and clinical patterns of recovery after laparotomy. Ann Surg 211:777–784 (discussion 785)CrossRefPubMedGoogle Scholar
  43. 43.
    Tandeter H (2009) Hypothesis: hexitols in chewing gum may play a role in reducing postoperative ileus. Med Hypotheses 72:39–40CrossRefPubMedGoogle Scholar
  44. 44.
    Tasaka A, Tahara Y, Sugiyama T et al (2008) Influence of chewing rate on salivary stress hormone levels. Nihon Hotetsu Shika Gakkai Zasshi 52:482–487CrossRefPubMedGoogle Scholar
  45. 45.
    Scholey A, Haskell C, Robertson B et al (2009) Chewing gum alleviates negative mood and reduces cortisol during acute laboratory psychological stress. Physiol Behav 97:304–312CrossRefPubMedGoogle Scholar
  46. 46.
    Apostolopoulos P, Kalantzis C, Gralnek IM et al (2008) Clinical trial: effectiveness of chewing-gum in accelerating capsule endoscopy transit time—a prospective randomized, controlled pilot study. Aliment Pharmacol Ther 28:405–411CrossRefPubMedGoogle Scholar
  47. 47.
    Hetherington M, Boyland E (2007) Short-term effects of chewing gum on snack intake and appetite. Appetite 48:397–401CrossRefPubMedGoogle Scholar
  48. 48.
    Milov D, Andres J, Erhart N et al (1998) Chewing gum bezoars of the gastrointestinal tract. Pediatrics 102:e22CrossRefPubMedGoogle Scholar
  49. 49.
    Njau S (2003) Adult sudden death caused by aspiration of chewing gum. Forensic Sci Int 139:103–106CrossRefGoogle Scholar
  50. 50.
    Thompson A, Razak S, Jayasinghe R (2007) Cardiac arrest and chewing gum: an unfortunate combination. Med J Aust 187:635PubMedGoogle Scholar
  51. 51.
    Blumenthal H, Vance D (1997) Chewing gum headaches. Headache 37:665–666CrossRefPubMedGoogle Scholar
  52. 52.
    Moneret-Vautrin D, Faure G, Bene M (1986) Chewing-gum preservative induced toxidermic vasculitis. Allergy 41:546–548CrossRefPubMedGoogle Scholar
  53. 53.
    Bauditz J, Norman K, Biering H et al (2008) Severe weight loss caused by chewing gum. BMJ 336:96–97CrossRefPubMedGoogle Scholar
  54. 54.
    Moher D, Schulz KF, Altman DG (2001) The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 357:1191–1194CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2009

Authors and Affiliations

  1. 1.Department of Gastrointestinal Surgery, Queen’s Medical CentreNottingham University Hospitals NHS TrustNottinghamUK
  2. 2.Department of SurgeryAberdeen Royal InfirmaryAberdeenScotland
  3. 3.Medical Education UnitUniversity of Nottingham Medical School, Queens Medical CentreNottinghamUK

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