Dear Editor,

It is with great interest that I read the study of Bhatti et al. [1] on the effects of chewing gum on the duration of postoperative ileus (POI) in patients undergoing surgery for stoma closure and small gut anastomosis.

I would like to draw your attention to some confounders, which should be taken into consideration while interpreting the results of the study.

The prolonged administration of antimycobacterial agents including a relatively broad-spectrum antibiotic such as rifampin exerts a profound effect on the gut microbiome [2]. The iatrogenic microbial dysbiosis could negatively affect gastrointestinal and colonic motility [3] and might have played a potential role in the delayed POI resolution time in the tuberculosis versus typhoid perforation cohorts—see Table 5 for results [1].

Additionally, the study is an investigator-sponsored trial, and all patients were recruited at a single research site, thereby reducing the generalizability of these interesting and valuable results.