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Meta-Analysis
. 2015 Feb 20;2015(2):CD006506.
doi: 10.1002/14651858.CD006506.pub3.

Chewing gum for postoperative recovery of gastrointestinal function

Vaneesha Short  1 , Georgia Herbert, Rachel Perry, Charlotte Atkinson, Andrew R Ness, Christopher Penfold, Steven Thomas, Henning Keinke Andersen, Stephen J Lewis
Affiliations
Meta-Analysis

Chewing gum for postoperative recovery of gastrointestinal function

Vaneesha Short et al. Cochrane Database Syst Rev. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

CA, ARN, SJL and ST were involved in one of the trials included in this review (Atkinson 2014). CP was involved in the main analyses of this trial, and VS is involved in secondary analysis of data from this trial.

GH, RP and HKA: No conflict of interests.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Control, outcome: 1.1 Time to first flatus [Hours].
5
5
Funnel plot of comparison: 1 Control, outcome: 1.1 Time to first flatus [Hours].
6
6
Forest plot of comparison: 1 Control, outcome: 1.2 Time to first bowel movement [Hours].
7
7
Funnel plot of comparison: 1 Control, outcome: 1.2 Time to first bowel movement [Hours].
8
8
Forest plot of comparison: 1 Control, outcome: 1.3 Length of hospital stay [Days].
9
9
Funnel plot of comparison: 1 Control, outcome: 1.3 Length of hospital stay [Days].
10
10
Forest plot of comparison: 1 Control, outcome: 1.4 Time to first bowel sounds [Hours].
11
11
Funnel plot of comparison: 1 Control, outcome: 1.4 Time to first bowel sounds [Hours].
1.1
1.1. Analysis
Comparison 1 Control, Outcome 1 Time to first flatus.
1.2
1.2. Analysis
Comparison 1 Control, Outcome 2 Time to first bowel movement.
1.3
1.3. Analysis
Comparison 1 Control, Outcome 3 Length of hospital stay.
1.4
1.4. Analysis
Comparison 1 Control, Outcome 4 Time to first bowel sounds.
See this image and copyright information in PMC

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References

References to studies included in this review

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Sun 2005 {published data only}
    1. Sun L, Gong S, Gong H, Zhang Y. Chewing gum used in abdominal surgery and postoperative care observation [Chinese]. Today Nurse 2005;7:11‐2.
Tan 2011 {published data only}
    1. Tan Y, Tang X. Chewing gum after abdominal surgery for gynecological promote recovery of gastrointestinal function [Chinese]. Today Nurse 2011;10:47‐8.
Terzioglu 2013 {published data only (unpublished sought but not used)}
    1. Terzioglu F, Simsek S, Karac, K, Sariince N, Altunsoy P, Salman MC. Multimodal interventions (chewing gum, early oral hydration and early mobilisation) on the intestinal motility following abdominal gynaecologic surgery. Journal of Clinical Nursing 2013;22:1917‐25. - PubMed
Tian 2013 {published data only}
    1. Tian M. Effect of chewing gums on gastrointestinal function of rectal cancer patients undergoing surgical operations [Chinese]. Modern Clinical Nursing 2013;12(2):45‐7.
Wang 2008 {published data only}
    1. Wang X, Liao H, Gao L, Ma Y, Zhang L. Chewing gum on recovery of gastrointestinal function after abdominal surgery impact [Chinese]. Journal of Nurses Training 2008;23(10):938‐9.
Wang 2009a {published data only}
    1. Wang H. Chewing gum to promote recovery of bowel movement after abdominal surgery observation [Chinese]. Journal of Qiqihar Medicine 2009;30(4):492.
Wang 2011a {published data only}
    1. Wang S, Hou Y, Dong S. A randomized controlled trial of chewing gum to promote postoperative bowel recovery for patients with rectal cancer [Chinese]. Sichuan Medical Journal 2011;32(12):1956‐8.
Wang 2011b {published data only}
    1. Wang X, Ren Y, Qin X, Dai X. Influence of sham feeding on motilin and evacuating time after accepting cesarean section [Chinese]. Chinese Nursing Research 2011;25(8):682‐3.
Watson 2008 {published and unpublished data}
    1. Watson H, Griffiths P, Lamparelli M, Watson M. Does chewing (gum) aid recovery after bowel resection? A randomized controlled trial (RCT). Colorectal Disease 2008;10(Suppl. 1):6.
Webster 2007 {published data only (unpublished sought but not used)}
    1. Webster B, Corcoran A, Smaldone M, Morrisroe S, Stockton B, Jackman S, Averch T. Does gum chewing reduce postoperative ileus following urologic laparoscopy? A prospective randomized controlled trial. Journal of Endourology 2007;21(Supp 1):A137.
Yang 2011 {published data only}
    1. Yang H. Influence of gum chewing on recovery of intestinal motility after ecphyadectomy surgery in children. Journal of Nursing Science 2011;26(6):23.
Yi 2013 {published data only}
    1. Yi Y, Guo H, Xian W, Chen Y. Bile duct exploration postoperative recovery chewing gum promote peristalsis clinical observation [Chinese]. Laboratory Medicine and Clinic 2013;10(10):1270‐1.
Zaghiyan 2013 {published data only}
    1. Zaghiyan K, Felder S, Ovsepyan G, Murrell Z, Sokol T, Moore B, Fleshner P. A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding. Diseases of the Colon & Rectum 2013;56(3):328‐35. - PubMed
Zamora 2012 {published and unpublished data}
    1. Zamora BBB, Kalalo RE. Gum chewing versus traditional feeding on the early return of bowel motility after cesarean delivery: A prospective randomized controlled trial. International Journal of Gynecology and Obstetrics 2012;119:S525.
Zhang 2008 {published data only}
    1. Zhang Q, Zhao P. Influence of gum chewing on return of gastrointestinal function after gastric abdominal surgery in children. European Journal of Pediatric Surgery 2008;18(1):44‐6. - PubMed
Zhao 2008 {published data only}
    1. Zhao P, Zhang Q. The influence of chewing gum on the return of intestinal motility after abdominal surgery in children and its mechanism of action [Chinese]. Journal of Clinical Pediatric Surgery 2008;7(3):24‐6.
Zhong 2009 {published data only}
    1. Zhong Z, Ye F, Lin J. A study on how chewing action promotes gastrointestinal functions recovery after colorectal cancer surgery. Chinese Journal of Gastrointestinal Surgery 2009;12(6):632‐3.

References to studies excluded from this review

Alcántara 2010 {published data only}
    1. Alcántara B, Luis A. Benefit of chewing gum vs metoclopramide in the prevention of postoperative ileus ofter laparotomy [Spanish] [Beneficio de la goma de mascar vs metoclopramide en la prevención del íleo postoperatorio de laparotomía]. Revista Venezolana de Cirugía 2010;63(1):32‐41.
Alper 2006 {published data only}
    1. Alper BS. Evidence‐based medicine. Gum chewing may reduce postoperative ileus. Clinical Advisor for Nurse Practitioners 2006;9(7):141.
Anon 2006a {published data only}
    1. Anon. Gum chewing may speed colon surgery recovery. Mayo Clinic Health Letter 2006;24(9):4. - PubMed
Anon 2006b {published data only}
    1. Anon. By gum, it might be good for you. Recent studies show that gum chewing may speed recovery from bowel surgery. Harvard Health Letter 2006;31(10):5. - PubMed
Anon 2006c {published data only}
    1. Anon. Medical matters. Gum chewing speeds surgery recovery. Consumer Reports on Health 2006;18(12):7.
Anon 2008 {published data only}
    1. Anon. Chewing gum could change practice. Gastrointestinal Nursing 2008;6(2):6.
Apostolopoulos 2008 {published data only}
    1. Apostolopoulos P, Kalantzis C, Gralnek IM, Liatsos C, Tsironis C, Kalantzis, N. Clinical trial: effectiveness of chewing‐gum in accelerating capsule endoscopy transit time ‐ a prospective randomized, controlled pilot study. Alimentary Pharmacology and Therapeutics 2008;28(4):405‐11. - PubMed
Chathongyot 2010 {published data only}
    1. Chathongyot N, Thongkhruea C, Borwornpadungkitti S, Predanon C. Effect of gum chewing to reduce postoperative ileus following anatrophic nephrolithotomy or nephrectomy [Thai] [ผลของการเคี้ยวหมากฝรั่งต่อการลดอาการท้องอืดในผู้ป่วยผ่าตัด Anatrophic Nephrolithotomy หรือ Nephrectomy]. Journal of Health Science 2010;19(3):457‐66.
Darvall 2011 {published data only}
    1. Darvall JN, Simmons SW, Leslie K. Acceptability of chewing gum for postoperative nausea and vomiting prevention in high risk patients: a pilot study. Anaesthesia and Intensive Care 2011;39(3):515‐6. - PubMed
Duluklu 2012 {unpublished data only}
    1. Duluklu B. The role of gum chewing early return of intestinal functions after left column and/or rectal surgery intestinal functions [Turkish] [Sol kolon velveya rectum cerrahisi sonrası bağırsak fonksiyonlarının başlamasında sakız çiğnemenin rolü]. Unpublished surgical nursing masters thesis, Ankara, Turkey 2012.
Harma 2009 {published data only}
    1. Harma MI, Barut A, Arikan II, Harma M. Gum‐chewing speeds return of first bowel sounds but not first defecation after cesarean section. Anatolian Journal of Obstetrics & Gynecology 2009;1:1‐3.
Hwang 2013 {published data only}
    1. Hwang DY, Kim HY, Kim JH, Lee IG, Kim JK, Oh ST, Lee YS. Effect of gum chewing on the recovery from laparoscopic colorectal cancer surgery. Annals of Coloproctology 2013;29(6):248‐51. - PMC - PubMed
Keenahan 2014 {published data only}
    1. Keenahan, M. Does gum chewing prevent postoperative paralytic ileus?. Nursing 2014;44(6):1‐2. - PubMed
Kim 2010 {published data only}
    1. Kim SS, Lee EN, Kim HS, Kim MK, Lee KS, Nam HJ, Kim MY. Effects of gum‐chewing on the recovery of bowel motility and length of hospital stay after surgery for colorectal cancer [Korean]. Journal of Korean Oncology Nursing 2010;10(2):191‐8.
Li 2007b {published data only}
    1. Li L, Cai L, Xia W, Even Y. Postoperative gastrointestinal diseases chewing gum effect observed [Chinese]. Shandong Medical Journal 2007;47(6).
Nimarta 2013 {published data only}
    1. Nimarta NVS, Shruti RG. Effectiveness of chewing gum on bowel motility among the patients who have undergone abdominal surgery. Nursing and Midwifery Research Journal 2013;9(3):108‐17.
Slim 2014 {published data only}
    1. Slim K, Demartines N, Fearon KC, Lobo DN, Ramirez J, Scott M, Ljungqvist O. Beyond ERAS?. Colorectal Disease 2014;16(3):219‐20. - PubMed
Starly 2009 {unpublished data only}
    1. Starly DJ. Bubble gum chewing helps in early return of bowel function after abdominal surgery. Unpublished surgical nursing masters dissertation, Bangalore, India 2009.
Svarta 2012 {published data only}
    1. Svarta S, Ou G, Enns RA. The effect of chewing gum on small bowel transit time: a prospective randomized trial. Gastrointestinal Endoscopy 2012;75(4):124. - PubMed
Takagi 2012 {published data only}
    1. Takagi K, Teshima H, Arinaga K, Yoshikawa K, Hori H, Kashikie, H, Nakamura K. Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery. Surgery Today 2012;42(8):759‐64. - PubMed
Utli 2013 {published data only}
    1. Utli H, Caliskan N. The effect of chewing gum on post‐cesarean intestine functions [Turkish] [SAKIZ ÇİĞNEMENİN SEZARYEN SONRASI BAĞIRSAK FONKSİYONLARINA ETKİSİ]. Anatolian Journal of Clinical Investigation 2013;7(4):215‐21.
Wang 2003 {published data only}
    1. Wang L. Chewing gum to promote recovery of gastrointestinal function after abdominal surgery clinical observation [Chinese]. Journal of Huaihai Medicine 2003;21(5):378‐9.
Wang 2009b {unpublished data only}
    1. Wang K. Chewing gum in the recovery of gastrointestinal function after caesarean section’s role [Chinese]. Unpublished masters dissertation, Shanghai, China 2009.

References to ongoing studies

Abd‐El‐Maeboud 2010 {published data only}
    1. Abd‐El‐Maeboud K. Post‐operative gum chewing and the return of bowel motility after elective caesarean section under regional anaesthesia: a prospective randomised controlled trial. http://www.controlled‐trials.com/ISRCTN83008008 [Accessed 23/07/2014].
Andersson 2011 {published data only}
    1. Andersson T. Effect of gum chewing on postoperative ileus in patients undergoing pancreativ surgery [Effekt av tuggummituggande mot postoperativt ileus hos patienter som genomgått pankreaskirurgi [Swedish]]. http://www.researchweb.org/is/sverige/document/78631 [Accessed 23/07/2014].
Charoenkwan 2011 {published data only}
    1. Charoenkwan K. Effects of gum chewing on recovery of bowel function following abdominal surgery for endometrial and ovarian cancer. http://clinicaltrials.gov/show/NCT01389986 [Accessed 23/07/2014].
Clark 2008 {published data only}
    1. Clark JM, Hopkins M. Prevention of ileus after gynaecologic surgery using chewing gum. http://clinicaltrials.gov/show/NCT00831246 [Accessed 23/07/2014].
Fakari 2011 {published data only}
    1. Fakari FR, Abasi Z. The effect of chewing sugar‐free gum on bowel function after cesarean section. http://www.irct.ir/searchresult.php?id=10661&number=1 [Accessed 23/07/2014].
Huang 2014 {published data only}
    1. Huang Q, Wang J. Randomized Controlled Trial of Chewing Gum on Postoperative Patients' Gastrointestinal Function Recovery. http://www.chictr.org/en/proj/show.aspx?proj=7736 [Accessed 23/07/2014].
Hulme 2011 {published data only}
    1. Hulme K. In patients undergoing elective open abdominal surgery, does chewing gum reduce postoperative complications compared to standard postoperative care?. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=1261... [Accessed 23/07/2014].
Lopez 2012 {published data only}
    1. Lopez G. Chewing gum use to Reduce post‐operative ileus in pediatric patients. http://clinicaltrials.gov/show/NCT01583452 [Accessed 23/07/2014].
Lv 2011 {published data only}
    1. Lv D, Liu Q. Gum chewing stimulates bowel motility in patients undergoing laparoscopic gynecologic surgery. A prospective randomized controlled trial. http://www.chictr.org/en/proj/show.aspx?proj=81 [Accessed 23/07/2014].
Manpunya 2011 {published data only}
    1. Manopunya M. Effects of gum chewing on recovery of bowel function following benign gynecologic surgery. http://clinicaltrials.gov/show/NCT01394094 [Accessed 23/07/2014].
Prakinoff 2009 {published data only}
    1. Pranikoff T. The effect of gum chewing on postoperative ileus. http://clinicaltrials.gov/ct2/show/study/NCT00879294 [Accessed 23/07/2014].
Ryu 2013 {published data only}
    1. Ryu HG. Effect of sham feeding on postoperative ileus after elective liver transplantation. http://clinicaltrials.gov/show/NCT01956643 [Accessed 23/07/2014].
Sabo 2012 {published data only}
    1. Sabo JA. The effect of gum chewing on bowel motility in post‐operative colon resection patients. http://clinicaltrials.gov/show/NCT01613274 [Accessed 23/07/2014].
van Leersum 2012 {published data only}
    1. Leersum NJ. Chewing gum study [Dutch] [Kauwgomstudie]. https://kauwgomstudie‐nl.firstfind.nl [Accessed 23/07/214].
    1. Leersum NJ. Gum chewing and postoperative ileus. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2594 [Accessed 23/07/2014].
    1. Leersum NJ, Bonsing BA, Kroon HM, Sijp JR, Weel V. Chewing gum to prevent postoperative ileus [Dutch] [Kauwgom kauwen ter preventie van postoperatieve ileus]. Nederlands Tijdschrift voor Geneeskunde 2012;156(22):A4794. - PubMed
Weiss 2012 {published data only}
    1. Weiss E, Arancibia K, Canedo J. Does nicotine gum enhance bowel recovery after colorectal surgery?. http://clinicaltrials.gov/show/NCT01662115 [Accessed 23/07/2014].
Williams 2010 {published data only}
    1. Williams L. Interventions to decrease the impact of post‐operative ileus after liver transplant or resection surgery. http://clinicaltrials.gov/show/NCT01156129 [Accessed 23/07/2014].

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