|Year : 2016 | Volume
| Issue : 2 | Page : 25-30
Effect of chewing gum therapy on selected postoperative outcomes in patients undergoing abdominal surgery
Arockiaseeli M Annarani1, Selva T Chacko2, Valliammal Babu3, Sukriya Nayak4
1 Lecturer, College of Nursing, CMC, Vellore, India
2 Professor, College of Nursing, CMC, Vellore, India
3 Professor (Rtd.), College of Nursing, CMC, Vellore, India
4 Professor. Dept of Surgery, CMC, Vellore, India
|Date of Web Publication||9-Jun-2020|
Source of Support: None, Conflict of Interest: None
People can tell a measure of their health by their bowel movement. Patients experience delayed bowel movement after the abdominal surgery because of an inevitable response to surgical trauma called postoperative ileus/paralytic ileus. Chewing gum is known to activate the cephalic phase of digestion mediated by vagus nerve, reducing the incidence of ileus. Postoperative ileus is also associated with prolonged hospitalization. Hence, a quasi experimental research was conducted to assess the effect of chewing gum therapy on selected postoperative outcomes among patients undergoing abdominal surgery in selected surgical wards of a tertiary hospital in South India. Totally 45 patients who underwent abdominal surgery were chosen by convenience sampling method. Patients shifted to intensive care unit and who had ileostomy/colostomy postoperatively were excluded. The participants in control group were given regular post operative care and observed for first three weeks. In the later three weeks of period, the experimental group were given one sugarless chewing gum three times a day along with regular post operative care till the participants were discharged. A bowel motility chart and an observation checklist were used to assess the effectiveness of chewing gum therapy in regard to the occurrence of bowel movement. The thirst distress scale and oral hygiene index were used to measure intensity of thirst and oral hygiene of the participants respectively from both control and experimental group. Results demonstrated that the mean time taken to pass first flatus and stool by the participants in the experimental group was 55.71 hours and 84.11 hours, and in the control group was 51.84 hours and 80.79 hours. The difference in the time taken to pass first flatus and stool in the experimental and control group was not statistically significant. The oral hygiene of the participants in the experimental group was significantly better in the control group (p <. 001). Thirst experienced by the participants in the experimental group with regards to dry mouth was significantly less than the control group (p < .05). There was a statistically significant association between the type of surgery and duration of surgery with postoperative ileus (p < .05). The study findings highlighted the advantages of having chewing gum therapy in the regular post operative care with the improved oral hygiene and reduced discomfort from thirst.
Keywords: chewing gum therapy, postoperative outcomes, postoperative ileus, thirst, oral hygiene, early discharge
|How to cite this article:|
Annarani AM, Chacko ST, Babu V, Nayak S. Effect of chewing gum therapy on selected postoperative outcomes in patients undergoing abdominal surgery. Indian J Cont Nsg Edn 2016;17:25-30
|How to cite this URL:|
Annarani AM, Chacko ST, Babu V, Nayak S. Effect of chewing gum therapy on selected postoperative outcomes in patients undergoing abdominal surgery. Indian J Cont Nsg Edn [serial online] 2016 [cited 2021 May 8];17:25-30. Available from: https://www.ijcne.org/text.asp?2016/17/2/25/286295
| Introduction|| |
Surgery and its complications are inevitable. Postoperative ileus (POI) is defined as a disruption of normal coordinated movements of the gastro intestinal tract resulting in failure of intestinal propulsion; it affects almost all patients undergoing abdominal surgery (Sandhiya, 2006). Although POI is a self limiting condition there may be changes that might facilitate the recovery of gastrointestinal function after abdominal surgery. Recovery after surgery depends on various factors like age, general health of the patient, the type of anesthesia, and the surgical site (Carlson & Dark, 2010).
The annual incidence of POI among patients who underwent abdominal surgery in United States is reported to be 14.9% in large bowel and 19.2% with small bowelsurgeries. Surgery done with anastomosis of small to small intestine is 13.7%, large to large intestine is 14.4% and small to large intestine is 27.8% (Goldstein, et al., 2007).
Chewing gum was first introduced in 1848 by John B. Curtis in North America. It is known to activate the cephalic phase of digestion mediated by the vagus nerve. The cholinergic system is activated via the vagus nerve, decreasing the release of pro-inflammatory cytokines and thus reducing the incidence of inflammatory condition like postoperative ileus (Hocevar, Robinson & Gray, 2010).
Gum chewing was found to be effective in reducing POI after colorectal surgery. A systematic review from five studies done in Netherlands showed that the time difference between both the groups was 20 hours to first flatus and 29 hours to passing stool. Length of hospital stay was significantly shorter than the control group (De Castro et al., 2008).
Gum chewing is considered to be an inexpensive method which may help to decrease ileus in post operative patients who have undergone abdominal surgery which could indirectly reduce the length of hospital stay. It could also decrease pain, emesis and morbidity for patients. There are no indications of risks associated with gum chewing as an adjunct therapy along with standard post operative interventions (Kalmanm, 2010). Therefore the present study was conducted with the following objectives:
- To assess the effectiveness of chewing gum therapy (CGT) in selected postoperative outcomes such as post operative ileus, oral hygiene, feeling of thirst and early discharge of patients undergoing abdominal surgery.
- To identify the association between selected demographic and clinical variables on the post operative outcomes.
| Conceptual framework|| |
The conceptual framework used was based on Donabedian’s structure, process and outcome model.
In this study, the structure include the group of patients undergoing abdominal surgery with selected measurable variables such as age, gender, body mass index, type of surgery, duration of surgery, and type of analgesia. Process refers to interventions done on study participants by the investigator. Preoperative instructions regarding pre and post operative care and administering intervention of chewing gum therapy postoperatively were carried out on study participants by the investigator. Outcome in this study refers to reduction of postoperative ileus, feeling of thirst, improved oral hygiene, and shortened hospital stay following abdominal surgery in the experimental group in comparison to the control group.
| Methods|| |
A quasi experimental research design was adopted. Patients who underwent elective open abdominal surgery, who were able to chew well, understand the instructions regarding chewing gum therapy, who could speak in Tamil, English, Hindi, and Bengali and patients who were willing to give consent to participate in the study were included. Patients who were admitted to ICU, on mechanical ventilator, or had a stoma (ileostomy or colostomy) and patients who underwent major gastrointestinal surgery (the operating time exceeded 6 hours) were excluded from the study.
The sample size estimated according to the power analysis based on a study by Faul, Felder, and Buchner (2007), was 33 in each group. The sample consisted of 45 patients who underwent abdominal surgery and fulfilled the inclusion criteria chosen by convenience sampling method and allocated into control group  and experimental group .
The instruments for data collection was developed by the researcher based on literature review and was validated by nursing and medical experts. The first component of the instrument included demographic and clinical variable proforma. The second component was a bowel motility chart to assess the effectiveness of chewing gum therapy in regard to the occurrence of bowel movement. Thirdly, Thirst Distress Scale (TDS) was used to measure the intensity of thirst and lastly, Oral Hygiene Index (OHI) was used to assess the oral hygiene. The participants in control group were given regular post operative care and the experimental group were given one sugarless chewing gum three times a day along with regular post operative care till the participants were discharged. The time of passing first flatus and first stool after surgery and the duration from post surgery to discharge were calculated in minutes. The duration of hospitalization was measured in days. The TDS had minimum score of 5 and a maximum score of 25. The results were grouped as severe thirst ,,,,,, moderate thirst ,,,,, mild thirst ,,,, , and normal ,,,,. The Oral Hygiene Index had an observation checklist which consisted of four items and a questionnaire which consisted of five items with an option of yes = score of 1 and no = score of 0. The minimum score is 0 and the maximum score is 9. Grading was done as good oral hygiene ,,,, and bad oral hygiene ,,,,.The content validity of the instrument was ensured based on opinion from experts. Reliability was checked by conducting a pilot study.
Protection of Human Rights
Ethical clearance was obtained from the Dissertation Committee of the College of Nursing. Written permission from the Nursing Superintendent and the Heads of the department of General Surgery was obtained. Written consent was obtained from all the participants prior to the data collection.
Data collection procedure
Subjects who fulfilled the inclusion criteria and gave consent during the first three weeks of data collection period were included in the control group. Subsequently the next three weeks subjects were recruited into the experimental group. On the preoperative day, the participants who consented to participate in the study were selected from the surgery list. Demographic and clinical data were collected and conducted a short session on regular post operative care. The procedure was similarly carried out for the experimental group except that a short session was conducted on the usage of CGT. All subjects were asked to note down the exact time of passing flatus for the first time and the first stool after surgery.
The TDS questionnaire was administered to the participants postoperatively before commencing oral fluids. Oral hygiene was assessed by administering OHI questionnaire and an observation was also made by the investigator at the same time. Participants were followed till discharge.
Results were analyzed using descriptive statistics such as frequency and percentage to describe the demographic and clinical variables and inferential statistics like independent t test to find the effectiveness of chewing gum therapy, analysis of variance (ANOVA) and independent test were used to find association between the selected demographic and clinical variables with post operative ileus.
| Results and Discussion|| |
The baseline data showed that 45.8% of participants in the control group belonged to the age group of < 40 years whereas 42.9% belonged to age group 41 -60 years. Male and female were equally distributed in both groups. Majority of the participants (45.8%) from control group had upper gastrointestinal surgery where as in the experimental group majority (38.1%) of them had lower gastrointestinal surgery or incisional hernioplasty (33.3%) (see [Figure 1]. Of the participants, 25% in the control group and 47.6% from the experimental group had duration of surgery within 2 hours.
|Figure 1: Distripution of participants based on the surgery done in both the groups|
Click here to view
The mean time taken to pass first flatus and stool by the participants in the experimental group was 55.71 hours and 84.11 hours, and in the control group it was 51.84 hours and 80.79 hours respectively (see [Table 1]. The difference in the time taken to pass first flatus and stool in the experimental and control group was not statistically significant.
Similar findings were reported in a study conducted by Quah, Samad, Neathey, Hay, and Maw (2006) among 38 patients who underwent an open colectomy for left sided colon and rectal cancer. The difference in the time taken to pass first flatus and stool were not significant between the control and experimental group. In contrast to the above findings, a meta analysis of seven randomized clinical trials done among 272 patients who underwent GI surgery showed 12.6 hours Mean Weighted Difference (MWD) to first flatus (p = .005) and 23.1 hours of MWD to pass first stool (p < .001) between the control and gum chewing groups (Fitzgerald & Ahmed, 2009).
The non significant findings of the this study, indicating no effect of CGT on POI could possibly be due to the heterogeneity of the subjects with regard to the type of abdominal surgery. In the control group,25% of the participants underwent lower GI surgery, while a majority (45.8%) underwent upper GI surgery for whom enteral feeding was initiated early via feeding jejunostomy by the second post operative day irrespective of the bowel movement. Whereas, commencement of oral fluids was only by second or third day in the experimental group, since a major proportion underwent lower GI surgery (33.3%).
In this study, it was found that there was a significant difference in the mean scores of thirst distress between the experimental and control group. The difference was found to be statistically significant (p=.001) (see [Table 2]. Most of the participants in the gum chewing group were comfortable and experienced less thirst.
These significant findings could be attributed to the effect of chewing gum therapy in stimulating the salivary flow hence reducing the feeling of thirst among participants in the experimental group. These findings are in line with a study in which gum was used as a saliva substitute showing a significant effect in decreased level of perception of thirst (p= .005) (Bots et al., 2005). Although there is a paucity of studies on effect of CGT on thirst among patients undergoing surgery, the results of this study imply the potential use of CGT in reducing the feeling of thirst in patients undergoing abdominal surgeries.
The oral hygiene was assessed in terms of odour, coated tongue, redness and lack of integrity of oral mucous membrane. The mean Oral Hygiene Index score (OHI) was 2.43 in the experimental group compared to the control group which was 4.88. This difference is significant at p < .001.
These results are consistent with the study findings where improved oral hygiene was found with the use of chewing gum among healthy young adults (Szoke, Banoczy, & Proskin. 2001”). There is little evidence to support the effectiveness of chewing gum therapy in improving oral hygiene among patients undergoing abdominal surgery and further studies are needed to support these findings.
It is noteworthy that in this study the mean length of hospital stay in the experimental group was significantly less compared to the control group (p=.029) (see [Table 4].
The study findings are supported by Schuster, Grewal, Greaney, and Waxman (2006) study in which it was observed that the total length of hospital stay was shorter in the gum-chewing group (day 4.3) compared to the control group (day 6.8) (p=.01).
However, the study findings are in contrast to a Cochrane review which has showed a non-significant trend towards chewing gum therapy (CGT) (p = 0.11). It was found that CGT following open gastrointestinal surgery had nosignificant reduction in length of hospital stay(Fitzgerald & Ahmed, 2009).
Although the study results reveal a significant reduction in the length of hospital stay many other confounding factors could have contributed to this difference. The delay in discharge for subjects in control group could not be solely attributed to the absence of intervention, because most of the participants in the control group had upper GI surgery and were required to stay in the ward till 10[th] post operative day in order to undergo a barium study before the commencement oforal fluids. A few discharges were delayed due to necessary clearance procedure such as billing and payments. Hence this significant difference in the length of stay could be due to other such factors.
The study showed that demographic variables such as age, gender, and body mass index had no significant association with post operative ileus.
There was a significant association between the type of surgery and the time taken to pass first flatus (p = .001) and stool (p = .005). It was noted that the mean hours of first flatus and stool in participants who underwent upper GI surgery (68.89 hours and 95.92 hours) was considerably higher than the patients who underwent Incisional hernioplasty (33.05 hours and 59.47 hours).
The results are in keeping with data from U.S. office of Federal Register of Health and Financing Administration which stated that the overall incidence of ileus varied among different types of surgeries viz common abdominal surgery (8.5%), abdominal hysterectomy (4.1%), large bowel resection (14.9%), and small bowel surgery (19.2%) (Mukheijee, 2011).
The results of this study indicate a significant association between duration of surgery and POI (p = .001). Participants who underwent surgery for less than two hours took less time to pass first flatus (31.98 hours) and stool (68.10 hours) compared to those who had longer duration of surgery lasting for 4-5 hours (96.18 hours, 121.05 hours).
The study was limited to patients who underwent elective open abdominal surgery. Other limitations include small sample size, hetrogenous nature of the type of bowel surgeries, self report by the patients, and errors in recall. These are the limitations which restrict the generalizability of findings in this study.
Implications for nursing practice and research: The study has resulted in enhanced patient’s outcome in terms of less thirst and improved oral hygiene post operatively. As chewing gum therapy is simple to administer and an inexpensive method of treatment, it might help patients to utilize this therapy effectively and facilitate the post operative outcome. Studies can be replicated focusing on homogenous type of open or laparoscopic abdominal surgery with a large sample size. A true experimental study can be done to determine the effectiveness of CGT, for increased credibility. Further research is needed to develop more clearly defined parameters for chewing gum administration including frequency and duration of chewing.
| Conclusion|| |
Postoperative ileus is a complication that poses a major challenge to the recovery of patients undergoing abdominal surgery. Since postoperative ileus is common in patients undergoing gastrointestinal surgery and their duration of hospital stay depends on the returning of bowel function, it is essential to give importance to reducing this complication. Although the study did not show the effectiveness of chewing gum therapy on reducing POI, it has highlighted the advantages in reducing discomfort due to thirst and improving oral hygiene. Chewing gum can be therefore be suggested for patients after abdominal surgery.
Conflicts of Interest: The authors have declared no conflicts of interest.
| References|| |
Bots , C.P. Brand, H. S., Veerman, E. C., Korevaar, J. C., Valentijn-Benz, M., Bezemer, P. D., … & Nieuw Amerongen, A. V. (2005). Chewing gum and a saliva substitute alleviate thirst and xerostomia in patients on haemodialysis. Nephrology Dialysis Transplantation, 20(1)
Carlson, G. L., & Dark, P. (2010). Acute intestinal failure. Current Opinion in Critical Care, 16(4)
De Castro, S. M. M., van den Esschert, J. W., van Heek, N. T., Dalhuisen, S., Koelemay, M. J. W., Busch, O. R. C., & Gouma, D. J. (2008). A Systematic Review of the Efficacy of Gum Chewing for the Amelioration of Postoperative Ileus. Digestive Surgery, 25(1)
Fitzgerald, J. E. F., & Ahmed, I. (2009). Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery. World Journal of Surgery, 33(12)
Faul, F., Felder, E., & Buchner, A. G. (2007). G*power 3: A flexible Statistical power analysis program for the social, behavioral, and biomedical sciences. Behaviour Research Methods, 39(2)
Goldstein, J. L., Matuszewski, K. A., Delaney, C. P., Senagore, A., Chiao, E. F., Shah, M., & Bramley, T. (2007). Inpatient economic burden of post operative ileus associated with abdominal surgery in the U.S. P&T, 32
(2), 82 90.
Hocevar, B. J., Robinson, B., & Gray, M. (2010). Does Chewing Gum Shorten the Duration of Postoperative Ileus in Patients Undergoing Abdominal Surgery and Creation of a Stoma? Journal of Wound, Ostomy and Continence Nursing,
Quah, H. M., Samad, A.,Neathey, A. J., Hay, D. J., & Maw, A. (2006). Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Disease: The Official Journal of the Association of Coloproctology of Great Britain and Ireland, 8
Sandhiya, S. (2006). Alvimopan: A novel peripheral opioid receptor antagonist. Indian Journal of Pharmacology, 38
(6), 442. doi: 10.4103/0253-7613.28220
Schuster, R., Grewal, N., Greaney, G. C., and Waxman, K. (2006). Gum chewing reduces ileus after elective open sigmoid colectomy. Archives of Surgery, 141
(2), 174- 176.
Szoke, J., Banoczy, J., & Proskin, H. M. (2001). Effect of After-meal Sucrose-free Gum-chewing on Clinical Caries .Journal of Dental Research, 80
[Table 1], [Table 2], [Table 3], [Table 4]