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Nursing and Midwifery Research Journal, Vol-9, No.3, July 2013 108

Effectiveness of chewing gum on bowel motility among the patientswho have undergone Abdominal Surgery

Nimarta, Neena Vir Singh, Shruti, Rajesh Gupta

Abstract : Postoperative ileus limits early hospital discharge for patiets who had undergoneabdominal surgery. Literature indicates that chewing gum is evaluated as a convenient method toenhance postoperative recovery from postoperative ileus after abdominal surgery. The present studywas aimed to evaluate the efficacy of chewing gum on bowel motility among patient who hadundergone abdominal surgery with null hypotheses that there was no significant difference in earlyreturn of first bowel sound, passage of flatus and return of appetite with the administration of chewinggum. A total of 60 patients who underwent elective abdominal surgery with general anaesthesiawere 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 literatureand validated by experts from field of nursing and department of General Surgery. Tools used in thestudy were interview schedule and check list to assess the bowel sounds, passage of first flatusand return of appetite. The patients in the experimental group as per planned protocol were administeredchewed gum three times a day for 15-20 min starting from the first postoperative day till the passageof first flatus. The times of the return of the first bowel sounds, passage of first flatus, return ofappetite was recorded in checklist. Patients with severe postoperative haemorrhage, intraoperativeand postoperative complications requiring emergency intervention, history abdominal blunt trauma,perforation etc were excluded from this study. Bowel sounds were checked by a single person. Themean duration of return of first bowel sounds, passage of first flatus and return of appetite wassignificantly 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 inthe postoperative period and it is a safe method to stimulate bowel motility and reduce the postoperativeileus.

Keywords :Chewing gum,abdominal surgery, postoperative ileus

Correspondance at

NimartaM.Sc(N) Final Year Student,PGIMER, [email protected]

IntroductionPostoperative ileus (POI) is a very

common and unavoidable outcome of majorabdominal surgery, primarily due to poorlyunderstood multifactorial pathophysiology,that may lead to significant patient morbidity,and is a common reason forgastroenterological consultation. POI may begenerally defined as transient inhibition of


normal gastrointestinal motility in thepostoperative setting, typically lasting 3-5days after surgery1.

Ileus is defined in Dorland's IllustratedMedical Dictionary simply as "obstruction ofthe intestines".2 Under this definition, fully 40%of patients undergoing laparotomy experienceprolonged postoperative ileus3. POI may begenerally characterized by abdominaldistension, lack of bowel sounds, and lack ofpassage of flatus or stool, worsened bypostoperative pain, nausea and vomiting,delay in resuming enteral nutrition, andprolonged hospitalization. Other postoperativecomplications including, deconditioning,malnutrition, increased risk of nosocomialinfections and pulmonary complications,decreased patient satisfaction and increasedhealth care costs.3,4

In United States the incidence ofpostoperative ileus occurs in approximately50% of clients who underwent majorabdominal surgery. In India 60 to 70% ofclients with major abdominal surgery developpostoperative complication due topostoperative paralytic ileus which becomesthe root cause for discomfor t, prolongedhospital stay and economic burden.5

POI affects all par ts of thegastrointestinal tract to varying degrees. Thesmall intestine recovers the normal functionfirst, usually within the first 24 hrs, followedby the stomach about 12-24 hrs later; andrecovery of the normal large intestine functionusually takes between 48 to 72 hrs. Thus, inuncomplicated ileus, gastrointestinal motilityis re-established within 3 days. If POI lastslonger than 3 days, it is thought to be

complicated and may be termed aspostoperative paralytic ileus.6

Conventionally, POI has been managedby gastric decompression through Ryle'stube, keeping the patient nil per orally,intravenous fluid supplementation till ileusresolves, and patient passes flatus. However,very few improvements in the understandingof POI have occurred in the past 100 years,and therefore therapies have been changedlittle.6

While working with the patientundergoing abdominal surgery it isresponsibility of nurse to prevent thepostoperative ileus. There are manynonpharmacologic treatment such as earlyenteral nutrition, early mobilization,laparoscopic surgery, psychologicalpreoperative preparation among them the useof chewing gum also has emerged as a new,simple, readily available and cost effectivemodality for decreasing POI. It acts bystimulating intestinal motility through cephalicvagal reflex and by increasing the productionof gastrointestinal hormones associated withbowel motility that result in early return ofbowel sounds, passage of flatus and returnof appetite. Hence the researcher has takenup the study to evaluate the efficacy ofchewing gum on bowel motility af terabdominal surgery.

Objectives

To evaluate the efficacy of chewing gumon bowel motility among patients who haveundergone abdominal surgery.


Materials and methods

The present study was conducted toevaluate the efficacy of chewing gum onbowel motility among patients who haveundergone abdominal surgery. The nullhypotheses proposed was that there wasno significant difference in early return of firstbowel sound, passage of flatus and return ofappetite with the administration of chewinggum at 0.05 level of significance. The studywas conducted in General male and femalesurgical wards of Nehru hospital at PostGraduate Institute of Medical Education andresearch (PGIMER), Chandigarh which is apremier institute of medical education andresearch, which include 60 patients whounderwent abdominal surgery(cholecystectomy, restoration of bowelcontinuity, colectomy etc) under generalanaesthesia af ter obtaining approval ofInstitute Ethics Committee and informedwritten consent was taken from all enrolledpatients. The following tools and protocolswere used for data collection. Socio-demographic data sheet of the subjects,protocol for administration of chewing gum,protocol for auscultation of bowel sounds , acheck list to assess the bowel sounds,passage of first flatus and the return ofappetite. Tools were validated by experts inthe field of nursing & surgery. Baseline datawere collected with the help of interviewschedule for socio demographic data,preoperative history of patients related tosurgery, post operative assessment of thepatients. A total of sixty patients were enrolledby purposive sampling. 30 patients each inthe experimental and the control group.

In the experimental group , the patientswere ask to chew two sticks of commerciallyavailable sugar free chewing gum( orbit) thriceduring a day for 15-20 min each time startingfrom 16 hours of the surgery till the passageof first flatus and Patients in the controlgroup(n=30)received routine postoperativecare.

To study the effect of chewing gum onthe experimental group and routinepostoperative management in the controlgroup, bowel sounds were auscultated every2 hourly and subjects were asked regardingpassage of first flatus and return of appetiteand same findings were documented in thecheck list for the experimental group as wellas the control group.

Analysis was done by "StatisticalPackage for the Social Sciences"(SPSS) 15version. For descriptive analysis, percentage,mean, standard deviation was used. Chisquare (2) and independent t test was usedas inferential statistics.

Results

Socio -demographic profile of both thegroups

Table 1 depicts that as per socio-demographic data, summarized in the table1, the subjects were in the range of 21 to 77years with mean age 43.9 12.53 years inthe experimental group compared to thecontrol group that was in range of 22- 65years with mean age of 43.5713.8 years.Half of the subjects (53.4%) were in the agegroup of 36- 55 years in the experimentalgroup and less than half (46.6%) were in theage group of 36-55years in control group.


As per gender, 18(60%) and 16(53.3%)of the subjects were female in theexperimental and the control grouprespectively.

As per the occupation, 18(60%)subjects in the experimental group and17(56.7%) in the control group were in theprivate services. Eight (26.6%) and 10(33.3%)subjects were unemployed in the experimentaland the control group respectively.

On the basis of education half of thesubjects 15(50%) were graduates in theexperimental group and only 11(36.7%) weregraduates in the control group. Both thegroups were homogenous as per sociodemographic profile i.e. age, gender,occupation, educational status as per 2 test(p>0.05)

Variable Experimental Control 2,dfGroup Group p value(n=30) (n=30)n(%) n(%)

Age(years)*

25 3(10.0) 4(13.4) 0.37,426-35 6(20.0) 6(20.0) 0.98

36-45 8(26.7) 7(23.3)

46-55 8 (26.7) 7(23.3)

56 and above 5(16.6) 6(20.0)

Gender

Male 12(40) 14(46.7) 0.27,1

Female 18(60) 16(53.3) 0.60

Occupation

Govt. service 04(13.3) 03(10.0) 0.39,2

Private service 18(60.0) 17(56.7) 0.82

Unemployed 8(26.6) 10(33.3)

Education Status

Illiterate 3(10.0) 3(10.0) 3.17,4

Primary 7(23.3) 11(36.7) 0.53

Secondary 1(3.3) 3(10.0)

Senior secondary 4 (13.3) 2(6.7)

Graduate 15(50.0) 11(36.7)

*Mean age(years) SD: 43.9 12.53 in experimental group and 43.5713.818 in the control group andRange is 21-77 years in experimental group and 22- 65 yrs in control group

Socio -demographic profile of both the groups

N=60


Distribution of the subjects as per diagnosis,previous history of surgery, constipation andcomorbities in both the groups

Table 2 depicts the distribution of thesubjects as per diagnosis .On the basis of thediagnosis 14(46.7%) and 13(43.3%) subjectshad hepatobiliary diseases in the experimentaland control group respectively. Only 3(10%)subjects from both the groups had pancreaticdisease and 13(43.3%) and 14(46.7%)

subjects had enterocolon diseases in theexperimental and the control grouprespectively. Both the groups are comparableas per 2 test (p>0.05).

As per abdominal surgery history,15(50%) and 13(43.3%) of the subjects hadhistory of previous abdominal surgery in theexperimental and the control grouprespectively.

Variable Experimental Control 2,dfGroup Group p value

Diagnosis (n=30) (n=30)n(%) n(%)

Diagnosis

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)

History

Previous abdominal 15(50.0) 13(43.3) 0.268,1

surgery 0.605

Previous constipation** 6(20.0) 1(3.3) 4.043,1

0.044

Comorbities** 6(20.0) 9(30) 0.80,1

(Hypertension, 0.371Tuberculosis, diabetes

* Diseases of the small and large intestines** No. of subjects without symptoms are not depicted in table

Table 2: Distribution of the subjects as per diagnosis, previous history of surgery,constipation and comorbities in both the groups

N=60

As per the history of constipation,significantly higher number 6(20%) ofsubjects in the experimental group and only1(3.3%) subject in the control group hadhistory of constipation (p


Duration of Anesthesia during Surgery andduration of Surgery in both the groups

Table 4 depicts the mean duration ofinduction of anesthesia in minutes among thesubjects. It was 27 7.7 minutes and28 8.4 minutes in the experimental and the

control group respectively and mean durationof surgery was 2.68 1.74 hours and 2.44 0.820 hours in the experimental and thecontrol group respectively. Both the groupswere homogenous as per t test (p >0.05).

Variable Group n Mean SD t value, df p value

Duration of anesthesia (min) Experimental 30 277.72 0.478,58 0.64

Control 30 288.46

Duration of surgery (hrs.) Experimental 30 2.681.749 -0.676,58 0.502

Control 30 2.440.820

Table 4: Distribution of the subjects as per duration of anesthesia during surgery in boththe groups

N=60

Comparison of the subjects as per return offirst bowel sounds, Passage of first flatus,return of appetite among both the groups

Table 5 depicts return of bowel soundsbefore 24 hours were significantly in higherpercentage in the experimental group27(90%) as compared to the control group19(63.3%) as per 2 test (p


Variable Experimental Control 2,dfGroup Group p value(n=30) (n=30)n(%) n(%)

Return of bowel sound(hr)

24 hr 27(90) 19(63.3) 4.57,1>24hr 3(10) 11(36.7) 0.03*

Passage of flatus (hr)60 hrs 20(66.7) 7(23.3) 11.3,1>60hrs 10(33.3) 23(76.7) 0.001*

Return of appetite (hr)60hr 17(56.7) 4(13.3) 10.5,1>60hr 13(43.3) 26(86.7) 0.001*

Table 5: Comparison of the subjects as per return of first bowel sounds, Passage of firstflatus, return of appetite between both the groups

N=60

Variable Experimental Control t value p valueGroup GroupMean time S.D Mean time S.D(in hour) (in hour)

Return of bowel sound(hr) 21.42.8 23.72.8 3.19 0.002*

Passage of flatus(hr) 58.29.3 65.66.4 3.57 0.001*

Return of appetite(hr) 59.99. 867.27.6 3.22 0.002*

Table: 6 Comparison of mean duration of return of first bowel sounds, passage of flatusand return of appetite between both the groups

N=60

*P


Sham feeding (when food is smelledor chewed not swallowed) has beendemonstrated to be one of the methods toincrease bowel motility. It causes both vagalstimulation and hormonal release; either oneor both could modulate the bowel motility.Gum chewing, as an alternative to shamfeeding, provides the benefits ofgastrointestinal stimulation without thecomplications associated with feeding. Inrecent years, the use of chewing gum toreduce the postoperative paralytic ileus hasbeen extensively reviewed in variousrandomized controlled trials on electiveintestinal anastomosis and has been foundto be beneficial in reducing POI.7-10

The present study was aimed toevaluate the effectiveness of chewing gum onthe bowel motility among patients who hadundergone abdominal surgery. Total sixtysubjects were studied prospectively for bowelmotility i.e return of first bowel sound,passage of first flatus, return of appetite withthe administration of chewing gum to 30subjects in the experimental group and routinepostoperative management to 30 subjects inthe control group. In the present study thecommercially available sugar-free chewinggum (orbit) used same is used in the studyconducted by Marwah.6

The final outcome measures in thepresent study are return of first bowel sound,passage of first flatus and return of appetitehowever, in systemic review by Hocevar etal, the outcome measures were first time topassage of flatus, time to passage of stooland length of hospital stay.11

In the present study, the patients wereasked to chew the gum starting from firstpostoperative day thrice during a day tillpassage of first flatus it is comparable to thestudy Verified by State University of New York- Upstate Medical University, June 2009 inwhich chewing gum was also given thrice aday starting from first postoperative day. InMarwah study patients were asked to chewgum thrice a day for 1 hour each time startingfrom 6 hours after the surgery until thepassage of first flatus but in the present study,here the patients were asked to chew gumthrice a day for 15- 20min starting from 16hrs after surgery until the passage of firstflatus.6

The duration of surgery is also a knownfactor to cause POI. In the present study, theoperating 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 wascomparable in both groups. The results ofduration of surgery are comparable with mostof the previous studies except Ibrahim Harmaet al and Marwah et al where surgeries tookshor ter duration (1-2 hrs) because ofcaesarean section.In most of the studies, thecriteria for discharge of patients from hospitalwere defecation, passage of gas, or feedingtolerance. 6,12

The duration of anesthesia is anotherknown factor to cause POI. In the presentstudy, the mean duration of anesthesia was109.341.95 minutes in the experimentalgroup and 112.8 55.7 minutes in the controlgroup, but there is no previous study wherethe time of anesthesia was mentioned. In


present study all the patients were operatedunder general anesthesia as it is comparablewith the study by Marwah S et al but notcomparable to study by Maeboud KHI et al inwhich regional anaesthesia is used.6,13 Epiduralanalgesia for postoperative pain was not usedin this study and it is comparable to Marwahet al study.6

In the present study, the mean time toreturn of first bowel sounds, passage of firstflatus ,return of appetite was significantlyshorter in the experimental as compared tothe control group was comparable to thestudy by Park SY et al in which also meantime of flatus and postoperative hospital staywas shor ter in the experimental group ascompared to the control group but differencewas not statistically significant14

The mean time for the appearance ofbowel sounds was significantly shorter in thestudy group which was comparable toprevious studies but in Harma MI it was muchearlier in the study group may be because ofcesarean section.12

The mean time for the passage of firstflatus was significantly shorter in the studygroup (P=0.001).In the previous studies15-20

majority on elective colonic anastomosis, havealso shown that patients in the study groupwere able to pass flatus before the controlgroup. Various systematic reviews and meta-analyses have also revealed significantreduction in time to first flatus as well as bowelmovement in the gum chewing group.7-8,10,21

The mean time taken to experience thefeeling of hunger was significantly shorter inthe experimental group in comparison to the

control group (P=0.002). This parameter hasbeen analyzed previously only in one of thestudy by Schuster R et al with similar findings,but the difference was not statisticallysignificant (P = 0.27).15

Findings of this study clearly indicatethat mean duration to return of first bowelsound, passage of flatus and return of appetiteshorter in the experimental group. Hence thenull hypothesis is rejected at 0.05 level ofsignificance. So it is concluded that use ofchewing gum in the postoperative period afteris a safe and cheap method to stimulate bowelmotility and reduce the postoperative ileusaf ter abdominal surgery. The studyrecommends that can be replicated on largesample and in more advanced variables likepassage of stool, length of hospital stay andrate of postoperative complications. Theimplications of study is that nurses canencourage the postoperative patients to chewthe chewing gum to reduce stress, enhancerelaxation and sense of well being and alsoact as diversional therapy, which help in fasterrecovery, preventing complications andthereby provide cost effective care andsatisfaction to the clients.

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of bowel motility after caesarean section. AnInternational Journal of Obstetrics & Gynaecology2009 September; 116(10):1334-9.

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18. Avupod YH, Azili MN, Karaman A, .AslanMK, Karaman I, Erdoan D, et al . Does gumchewing reduce postoperative ileus afterintestinal resection in children? A prospectiverandomized controlled trial. Eur J Pediatr Surg2009; 19: 171-3.

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