Running head: REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN 1

Reducing Postoperative Ileus Using a Prescribed Chewing Gum Regimen

Hope Hindmarch
University of South Florida

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

Abstract
Clinical Problem: Postoperative patients are at risk for developing postoperative ileus (POI),
which can lead to severe complications and extended hospital stays.
Objective: To discuss whether chewing gum postoperatively reduces the incidence of POI in
patients following abdominal surgery. PubMed and CINAHL databases were used to obtain
randomized control trials and guidelines on the effects of chewing gum and POI. The key search
terms used were chewing gum, postoperative ileus, postoperative guidelines, and postoperative
ileus: strategies for reduction.
Results: Current practice suggests withholding anything by mouth until signs that bowel function
has returned. The literature suggests that chewing gum postoperatively can stimulate a faster
return of bowel function and reduce POI.
Conclusion: Patients who chew gum postoperatively have a lower risk of developing a POI. The
literature did not provide statistically conclusive evidence that chewing gum reduces time to first
flatus or length of hospital stay. Further research is needed to evaluate if chewing gum is an
effective method to reduce POI after all types of surgery involving anesthesia.

Reducing Postoperative Ileus Using a Prescribed Chewing Gum Regimen

Postoperative ileus (POI) is a common complication following abdominal surgery, that
develops in approximately 40% of laparoscopic patients (Lubawski & Sclarides, 2008). The
development of a POI can increase the risk of complications, morbidity, and length of hospital
stay. Methods to reduce the rate of POI could therefore improve the mortality of patients
undergoing abdominal surgery, decrease hospital length of stay, and reduce hospital cost. It is

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

averaged that POI costs Americans $750 million per year (Wronski, 2014). Current methods to
reduce the incidence of POI include bowel rest, early ambulation, and abdominal decompression
via a nasogastric tube (Wronski, 2014). Before investigating new ways to decrease the rate of
POI, it is important to understand: What are signs and symptoms of a POI? What causes a POI?
This paper will evaluate the effectiveness of chewing gum on reducing POI. In postoperative
patients (P) how does chewing gum (I) compared to standard postoperative feeding protocol
alone (C) reduce the rate of POI (O) over three months (T)?
Literature Search
PubMed and CINAHL databases were used to obtain randomized control trials on the
effects of chewing gum and POI. The key search terms used were chewing gum, postoperative
ileus, and postoperative ileus: strategies for reduction. The search was conducted to return only
randomized control trials (RCT) from the years 2011 through 2016. The search was widened to
include years 2006 through 2016 for literature other than RCTs.
Literature Review
Three RCTs and one clinical guideline were assessed to evaluate the effectiveness of
using chewing gum to reduce POI. Using a RCT Choi et al. (2011) sought to evaluate if chewing
gum postoperatively promoted recovery of bowel function, and if it had varying effects
depending on the operative method used for radical cystectomy patients. Thirty-two open radical
cystectomy patients were randomized into a control (n=17) and gum chewing group (n=15).
Twenty-eight robot assisted radical cystectomy patients were randomized into a control (n=13)
and gum chewing group (n=15). Both intervention groups achieved flatus sooner than control
groups (p<.01). The intervention groups also were able to produce a bowel movement sooner
than the control group (p<.01). No statistically significant results were seen in length of hospital
stay. Weaknesses of this trial included that it was completed in a single study site, and a
relatively small sample size was used. A strength of the study was that inclusion and exclusion

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

criteria were used during participant recruitment. Patients were excluded from the trial if they
had inflammatory bowel disease, abdominal radiation, more than one bowel anastomosis, or
prior abdominal bowel surgery. Additional strengths included participant randomization to both
the control and experimental groups, rationale for patient attrition was provided, participants
were analyzed in the group to which they were assigned, and the surgical teams were blind to the
study group.
Heijkant et al. (2014) conducted a RCT to determine the effect of chewing gum on POI,
length of hospital stay, and inflammatory markers. The study measured the length of hospital
stay and POI, defined as lack of flatus or stool and intolerance of oral nutrition for 24 hours.
Patients over 18 years of age undergoing colonic and colorectal surgery were randomized into
the control group (n=62) and the chewing gum group (n=58). Length of hospital stay was
reduced in the intervention group, but was not statistically significant (p= .067). The incidence of
POI was lower in the gum chewing group than the control group (p= .02). A weakness of this
study was the small sample size. Another weakness was that inclusion criteria changed during
recruitment to include individuals who were scheduled for colorectal surgery. Previously only
patients scheduled for colonic surgery were eligible. This new inclusion criterion was initiated
after 11 patients were already recruited into the study. At that juncture, block randomization was
stopped and patients were included on a 1:1 basis from both study sites. An additional weakness
is that providers were not blind to the study group. Strengths for the study included patients were
randomly assigned to the control and intervention groups, participants were blind to the study
group, reasons for patient attrition were provided, the study took place at multiple sites, the
control and interventions groups were appropriate and of similar demographics, and follow up
assessments were conducted at an appropriate time.

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

Jernigan et al. (2014) designed a RCT to evaluate if chewing gum prevents POI after
undergoing gynecologic surgery. The trial measured the outcomes of time to first flatus,
abdominal distention, and presence of POI defined as the absence of bowel sounds and/or a
minimum of two episodes of emesis of a minimum of 100 mL. Patients age 17-76 years were
randomly assigned to the gum chewing group (n=51) or routine care (n=58) by a number
generator. The chewing gum group had a lower incidence of POI than the routine care group
(p=.007). Time to passage of first flatus was shorter in the gum chewing group but not
statistically significant (p= .08). A strength of this trial was that it was conducted in two different
facilities over greater than a one-year time frame. Inclusion and exclusion criteria for
participation was also noted as a strength for this trial. Patients were excluded from the trial if
they had pre-existing bowel disease, bowel perforation, active intra-abdominal malignancy, or a
history of bowel irradiation. Additional strengths included a method to control for variables,
patients were randomly assigned to the control and intervention groups, reasons for patient
attrition were provided, follow up assessments were conducted at an appropriate time, and
individuals tasked with reviewing the patients records were blind to the study groups. A
weakness of this study was that the patients and providers were not blind to the study group. An
additional weakness was the study did not account for differences in patients compliance in
reporting time of first flatus. The study also did not account for the possible difference in nursing
interpretation of abdominal distention.
Cerantola et al. (2013) created guidelines for enhanced recovery after radical cystectomy.
These guidelines endorse the use of chewing gum to reduce POI, noting this intervention as a
strong recommendation. The guidelines also suggest resumption of oral feedings four hours after

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

surgery, oral magnesium, and early patient ambulation as additional methods to reduce
postoperative complications.
Synthesis
Choi et al. (2011) found that the passage of first flatus and bowel movement occurred
significantly faster among the groups receiving gum chewing therapy (p<.01), indicating a lower
incidence of POI. Heijkant et al. (2014) showed that the incidence of POI was reduced in the
gum chewing group (27%), compared to the control group (48%) (p= .02). In the gum chewing
group, more participants were able to have a bowel movement within four days of surgery
compared to the non-gum chewing group (85%) (57%) (p= .006). Jernigan et al. (2014) found
that fewer chewing gum participants experienced a POI (p= .007), and that the type of surgery
did not influence the incidence of POI (p= .4). Guidelines from Cerantola et al. (2013) suggest
that chewing gum should be utilized along with current practices, such as early ambulation, in
order to reduce the rates of POI.
The literature shows that chewing gum postoperatively can increase bowel motility and
reduce the incidence of POI. The RCTs reviewed were conducted considering different types of
abdominal surgeries suggesting that the type of surgery does not effect the efficacy of chewing
gum on POI reduction. Initiation of chewing gum postoperatively as standard practice would
provide better outcomes for patients by minimizing the rates of POI, and therefore has the
potential for decreasing both hospital and patient costs. More research is needed to determine
whether chewing gum reduces the length of hospital stay. Additional research should also be
conducted to evaluate the best time to initiate gum chewing, and duration in order to produce the
best possible outcomes.
Clinical Recommendations

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

For practice to be evidence-based, the research suggests that the use of a prescribed
chewing gum regimen would provide for better patient outcomes by reducing the incidence of
POI. Early ambulation and early resumption of oral feeding will also aid in prevention of POI.
Further research is needed to evaluate if chewing gum is an effective method to reduce POI after
all types of surgery involving anesthesia. Additional studies should also provide evidence to
dictate feeding protocol following the use of chewing gum postoperatively

References
Cerantola, Y., Valerio, M., Persson, B., Jichlinski, P., Ljungqvist, O., Hubner, M., . . . Patel, H. R.
(2013). Guidelines for perioperative care after radical cystectomy for bladder cancer:
Enhanced Recovery After Surgery (ERAS) society recommendations. Clinical
Nutrition, 32(6), 879-887. doi:10.1016/j.clnu.2013.09.014
Choi, H., Kang, S. H., Yoon, D. K., Kang, S. G., Ko, H. Y., Moon, D. G., . . . Cheon, J. (2011).
Chewing gum has a stimulatory effect on bowel motility in patients after open or robotic
radical cystectomy for bladder cancer: A prospective randomized comparative study.
Urology, 77(4), 884-890. doi:10.1016/j.urology.2010.06.042

REDUCING POSTOPERATIVE ILEUS WITH CHEWING GUM REGIMEN

Heijkant, T. C., Costes, L. M., Van Der Lee, D. C., Aerts, B., Jong, M. O., Rutten, H. R., . . .
Luyer, M. D. (2014). Randomized clinical trial of the effect of gum chewing on
postoperative ileus and inflammation in colorectal surgery. British Journal of
Surgery, 102(3), 202-211. doi:10.1002/bjs.9691
Jernigan, A. M., Chen, C. C., & Sewell, C. (2014). A randomized trial of chewing gum to prevent
postoperative ileus after laparotomy for benign gynecologic surgery. International
Journal of Gynecology & Obstetrics, 127(3), 279-282. doi:10.1016/j.ijgo.2014.06.008
Lubawski, J., & Sclarides, T. (2008). Postoperative ileus: Strategies for reduction. Therapeutics
and Clinical Risk Management, 4(5): 913917.
Wronski, S. (2014). Chew on this. Nursing., 44(8), 19-23.
doi:10.1097/01.nurse.0000451535.63211.a8