Effectiveness of chewing gum on bowel motility among the patients

who have undergone Abdominal Surgery

Nimarta, Neena Vir Singh, Shruti, Rajesh Gupta
Abstract : Postoperative ileus limits early hospital discharge for patiets who had undergone
abdominal surgery. Literature indicates that chewing gum is evaluated as a convenient method to
enhance postoperative recovery from postoperative ileus after abdominal surgery. The present study
was aimed to evaluate the efficacy of chewing gum on bowel motility among patient who had
undergone abdominal surgery with null hypotheses that there was no significant difference in early
return of first bowel sound, passage of flatus and return of appetite with the administration of chewing
gum. A total of 60 patients who underwent elective abdominal surgery with general anaesthesia
were 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 literature
and validated by experts from field of nursing and department of General Surgery. Tools used in the
study were interview schedule and check list to assess the bowel sounds, passage of first flatus
and return of appetite. The patients in the experimental group as per planned protocol were administered
chewed gum three times a day for 15-20 min starting from the first postoperative day till the passage
of first flatus. The times of the return of the first bowel sounds, passage of first flatus, return of
appetite was recorded in checklist. Patients with severe postoperative haemorrhage, intraoperative
and postoperative complications requiring emergency intervention, history abdominal blunt trauma,
perforation etc were excluded from this study. Bowel sounds were checked by a single person. The
mean duration of return of first bowel sounds, passage of first flatus and return of appetite was
significantly 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 in
the postoperative period and it is a safe method to stimulate bowel motility and reduce the postoperative
ileus.

Keywords :Chewing gum,

abdominal surgery, postoperative ileus

Correspondance at
Nimarta
M.Sc(N) Final Year Student,
PGIMER, Chandigarh
nimartarana@gmail.com

Introduction
Postoperative ileus (POI) is a very
common and unavoidable outcome of major
abdominal surgery, primarily due to poorly
understood multifactorial pathophysiology,
that may lead to significant patient morbidity,
and is a common reason for
gastroenterological consultation. POI may be
generally defined as transient inhibition of

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108

normal gastrointestinal motility in the

postoperative setting, typically lasting 3-5
days after surgery1.
Ileus is defined in Dorland's Illustrated
Medical Dictionary simply as "obstruction of
the intestines".2 Under this definition, fully 40%
of patients undergoing laparotomy experience
prolonged postoperative ileus3. POI may be
generally characterized by abdominal
distension, lack of bowel sounds, and lack of
passage of flatus or stool, worsened by
postoperative pain, nausea and vomiting,
delay in resuming enteral nutrition, and
prolonged hospitalization. Other postoperative
complications including, deconditioning,
malnutrition, increased risk of nosocomial
infections and pulmonary complications,
decreased patient satisfaction and increased
health care costs.3,4
In United States the incidence of
postoperative ileus occurs in approximately
50% of clients who under went major
abdominal surgery. In India 60 to 70% of
clients with major abdominal surgery develop
postoperative complication due to
postoperative paralytic ileus which becomes
the root cause for discomfort, prolonged
hospital stay and economic burden.5
POI affects all par ts of the
gastrointestinal tract to varying degrees. The
small intestine recovers the normal function
first, usually within the first 24 hrs, followed
by the stomach about 12-24 hrs later; and
recovery of the normal large intestine function
usually takes between 48 to 72 hrs. Thus, in
uncomplicated ileus, gastrointestinal motility
is re-established within 3 days. If POI lasts
longer than 3 days, it is thought to be

complicated and may be termed as

postoperative paralytic ileus.6
Conventionally, POI has been managed
by gastric decompression through Ryle's
tube, keeping the patient nil per orally,
intravenous fluid supplementation till ileus
resolves, and patient passes flatus. However,
very few improvements in the understanding
of POI have occurred in the past 100 years,
and therefore therapies have been changed
little.6
While working with the patient
undergoing abdominal surger y it is
responsibility of nurse to prevent the
postoperative ileus. There are many
nonpharmacologic treatment such as early
enteral nutrition, early mobilization,
laparoscopic surgery, psychological
preoperative preparation among them the use
of chewing gum also has emerged as a new,
simple, readily available and cost effective
modality for decreasing POI. It acts by
stimulating intestinal motility through cephalic
vagal reflex and by increasing the production
of gastrointestinal hormones associated with
bowel motility that result in early return of
bowel sounds, passage of flatus and return
of appetite. Hence the researcher has taken
up the study to evaluate the efficacy of
chewing gum on bowel motility af ter
abdominal surgery.
Objectives
To evaluate the efficacy of chewing gum
on bowel motility among patients who have
undergone abdominal surgery.

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109

Materials and methods

The present study was conducted to
evaluate the efficacy of chewing gum on
bowel motility among patients who have
undergone abdominal surgery. The null
hypotheses proposed was that there was
no significant difference in early return of first
bowel sound, passage of flatus and return of
appetite with the administration of chewing
gum at 0.05 level of significance. The study
was conducted in General male and female
surgical wards of Nehru hospital at Post
Graduate Institute of Medical Education and
research (PGIMER), Chandigarh which is a
premier institute of medical education and
research, which include 60 patients who
under went
abdominal
surger y(
cholecystectomy, restoration of bowel
continuity, colectomy etc) under general
anaesthesia after obtaining approval of
Institute Ethics Committee and informed
written consent was taken from all enrolled
patients. The following tools and protocols
were used for data collection. Sociodemographic data sheet of the subjects,
protocol for administration of chewing gum,
protocol for auscultation of bowel sounds , a
check list to assess the bowel sounds,
passage of first flatus and the return of
appetite. Tools were validated by experts in
the field of nursing & surgery. Baseline data
were collected with the help of interview
schedule for socio demographic data,
preoperative history of patients related to
surgery, post operative assessment of the
patients. A total of sixty patients were enrolled
by purposive sampling. 30 patients each in
the experimental and the control group.

In the experimental group , the patients

were ask to chew two sticks of commercially
available sugar free chewing gum( orbit) thrice
during a day for 15-20 min each time starting
from 16 hours of the surgery till the passage
of first flatus and Patients in the control
group(n=30)received routine postoperative
care.
To study the effect of chewing gum on
the experimental group and routine
postoperative management in the control
group, bowel sounds were auscultated every
2 hourly and subjects were asked regarding
passage of first flatus and return of appetite
and same findings were documented in the
check list for the experimental group as well
as the control group.
Analysis was done by "Statistical
Package for the Social Sciences"(SPSS) 15
version. For descriptive analysis, percentage,
mean, standard deviation was used. Chi
square (2) and independent t test was used
as inferential statistics.
Results
Socio -demographic profile of both the
groups
Table 1 depicts that as per sociodemographic data, summarized in the table
1, the subjects were in the range of 21 to 77
years with mean age 43.9 12.53 years in
the experimental group compared to the
control group that was in range of 22- 65
years with mean age of 43.5713.8 years.
Half of the subjects (53.4%) were in the age
group of 36- 55 years in the experimental
group and less than half (46.6%) were in the
age group of 36-55years in control group.

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110

As per gender, 18(60%) and 16(53.3%)

of the subjects were female in the
experimental and the control group
respectively.
As per the occupation, 18(60%)
subjects in the experimental group and
17(56.7%) in the control group were in the
private services. Eight (26.6%) and 10(33.3%)
subjects were unemployed in the experimental
and the control group respectively.

On the basis of education half of the

subjects 15(50%) were graduates in the
experimental group and only 11(36.7%) were
graduates in the control group. Both the
groups were homogenous as per socio
demographic profile i.e. age, gender,
occupation, educational status as per 2 test
(p>0.05)

Socio -demographic profile of both the groups

N=60
Experimental
Group
(n=30)
n(%)

Control
Group
(n=30)
n(%)

2,df

2 5
26-35
36-45
46-55
56 and above

3(10.0)
6(20.0)
8(26.7)
8 (26.7)
5(16.6)

4(13.4)
6(20.0)
7(23.3)
7(23.3)
6(20.0)

0.37,4
0.98

Gender
Male
Female

12(40)
18(60)

14(46.7)
16(53.3)

0.27,1
0.60

Occupation
Govt. service
Private service
Unemployed

04(13.3)
18(60.0)
8(26.6)

03(10.0)
17(56.7)
10(33.3)

0.39,2
0.82

Education Status
Illiterate
Primary
Secondary
Senior secondary
Graduate

3(10.0)
7(23.3)
1(3.3)
4 (13.3)
15(50.0)

3(10.0)
11(36.7)
3(10.0)
2(6.7)
11(36.7)

3.17,4
0.53

Variable

p value

Age(years)*

*Mean age(years) SD: 43.9 12.53 in experimental group and 43.5713.818 in the control group and
Range is 21-77 years in experimental group and 22- 65 yrs in control group
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Distribution of the subjects as per diagnosis,

previous history of surgery, constipation and
comorbities in both the groups

subjects had enterocolon diseases in the

experimental and the control group
respectively. Both the groups are comparable
as per 2 test (p>0.05).

Table 2 depicts the distribution of the

subjects as per diagnosis .On the basis of the
As per abdominal surgery history,
diagnosis 14(46.7%) and 13(43.3%) subjects 15(50%) and 13(43.3%) of the subjects had
had hepatobiliary diseases in the experimental history of previous abdominal surgery in the
and control group respectively. Only 3(10%) experimental and the control group
subjects from both the groups had pancreatic respectively.
disease and 13(43.3%) and 14(46.7%)
Table 2: Distribution of the subjects as per diagnosis, previous history of surgery,
constipation and comorbities in both the groups
N=60
2
,df
Variable
Experimental
Control
Group
(n=30)
n(%)

Group
(n=30)
n(%)

p value

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)

Previous abdominal
surgery
Previous constipation**

15(50.0)

13(43.3)

6(20.0)

1(3.3)

Diagnosis
Diagnosis

History

Comorbities**
6(20.0)
(Hypertension,
Tuberculosis, diabetes
* Diseases of the small and large intestines
** No. of subjects without symptoms are not depicted in table

As per the history of constipation,

significantly higher number 6(20%) of
subjects in the experimental group and only
1(3.3%) subject in the control group had
history of constipation (p<0.05).
On the basis of comorbities, 6(20%)
and 9(30%) of subjects had comorbities

9(30)

0.268,1
0.605
4.043,1
0.044
0.80,1
0.371

(Hypertension, Tuberculosis, diabetes) in the

experimental group and the control group
respectively.
It shows homogeneity of subjects in the
control and the experimental groups with
reference to their previous histor y of
abdominal surgery and comorbities.

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control group respectively and mean duration

of surgery was 2.68 1.74 hours and 2.44
0.820 hours in the experimental and the
control group respectively. Both the groups
were homogenous as per t test (p >0.05).

Duration of Anesthesia during Surgery and

duration of Surgery in both the groups
Table 4 depicts the mean duration of
induction of anesthesia in minutes among the
subjects. It was 27 7.7 minutes and
28 8.4 minutes in the experimental and the

Table 4: Distribution of the subjects as per duration of anesthesia during surgery in both
the groups
N=60
Variable

Group

Mean SD

t value, df

p value

Duration of anesthesia (min)

Experimental
Control

30
30

277.72
288.46

0.478,58

0.64

Duration of surgery (hrs.)

Experimental
Control

30
30

2.681.749
2.440.820

-0.676,58

0.502

Comparison of the subjects as per return of

first bowel sounds, Passage of first flatus,
return of appetite among both the groups

Comparison of mean duration of return of

first bowel sounds, passage of flatus and
return of appetite among both the groups

Table 5 depicts return of bowel sounds

before 24 hours were significantly in higher
percentage in the experimental group
27(90%) as compared to the control group
19(63.3%) as per 2 test (p <0.05).

Table 6 highlights that there is

significant difference in the return of first
bowel sounds, passage of flatus and return
of appetite between the experimental & the
control group. The mean time of return of
bowel sounds after surgery was significantly
lesser (21.42.8hr) in the experimental
group than in the control group (23.72.8
hr).

Similarly passage of flatus before 60

hours was significantly higher percentage in
the experimental group (66.7%) as compared
to the control group (23.3%) as per 2 test
(p <0.05).
The table also depicts that return of
appetite before 60 hours was significantly
higher percentage in the experimental group
(56.7%) as compared to the control group
(13.3%) as per 2 test (p <0.05).

Similarly the mean time of passage of

flatus after surgery was significantly lesser
in (58.29.3hr ) in the experimental group
than in the control group (65.66.4 hr).
The mean time of return of appetite after
surgery was significantly lesser (59.99.8
hr) in experimental group than in the control
group (67.27.6 hr).

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Table 5: Comparison of the subjects as per return of first bowel sounds, Passage of first
flatus, return of appetite between both the groups
N=60
Experimental
Group
(n=30)
n(%)

Control
Group
(n=30)
n(%)

2,df

24 hr
>24hr

27(90)
3(10)

19(63.3)
11(36.7)

4.57,1
0.03*

Passage of flatus (hr)

60 hrs
>60hrs

20(66.7)
10(33.3)

7(23.3)
23(76.7)

11.3,1
0.001*

Return of appetite (hr)

60hr
>60hr

17(56.7)
13(43.3)

4(13.3)
26(86.7)

10.5,1
0.001*

Variable

p value

Return of bowel sound(hr)

Table: 6 Comparison of mean duration of return of first bowel sounds, passage of flatus
and return of appetite between both the groups
N=60
Variable

Experimental
Group
Mean time S.D
(in hour)

Control
t value
Group
Mean time S.D
(in hour)

p value

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*

*P<0.05

Discussion
Postoperative ileus (POI) occurs
commonly after abdominal operations and is
one of the limiting factors which prevent early
hospital discharge. The pathophysiology of
POI includes spinal and local sympathetic
neural reflexes, local as well as systemic
inflammatory mediators released during
surgery as part of the stress response.6

The potential complications of

prolonged POI includes increased
postoperative pain, increased nausea and
vomiting, pulmonary complications, poor
wound healing, delay in resuming oral intake,
delay in postoperative mobilization, prolonged
hospitalization, and increased health-care
costs.7

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Sham feeding (when food is smelled

or chewed not swallowed) has been
demonstrated to be one of the methods to
increase bowel motility. It causes both vagal
stimulation and hormonal release; either one
or both could modulate the bowel motility.
Gum chewing, as an alternative to sham
feeding, provides the benefits of
gastrointestinal stimulation without the
complications associated with feeding. In
recent years, the use of chewing gum to
reduce the postoperative paralytic ileus has
been extensively reviewed in various
randomized controlled trials on elective
intestinal anastomosis and has been found
to be beneficial in reducing POI.7-10

In the present study, the patients were

asked to chew the gum starting from first
postoperative day thrice during a day till
passage of first flatus it is comparable to the
study Verified by State University of New York
- Upstate Medical University, June 2009 in
which chewing gum was also given thrice a
day starting from first postoperative day. In
Marwah study patients were asked to chew
gum thrice a day for 1 hour each time starting
from 6 hours after the surger y until the
passage of first flatus but in the present study,
here the patients were asked to chew gum
thrice a day for 15- 20min starting from 16
hrs after surgery until the passage of first
flatus.6

The present study was aimed to

evaluate the effectiveness of chewing gum on
the bowel motility among patients who had
undergone abdominal surgery. Total sixty
subjects were studied prospectively for bowel
motility i.e return of first bowel sound,
passage of first flatus, return of appetite with
the administration of chewing gum to 30
subjects in the experimental group and routine
postoperative management to 30 subjects in
the control group. In the present study the
commercially available sugar-free chewing
gum (orbit) used same is used in the study
conducted by Marwah.6

The duration of surgery is also a known

factor to cause POI. In the present study, the
operating 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 was
comparable in both groups. The results of
duration of surgery are comparable with most
of the previous studies except Ibrahim Harma
et al and Marwah et al where surgeries took
shor ter duration (1-2 hrs) because of
caesarean section.In most of the studies, the
criteria for discharge of patients from hospital
were defecation, passage of gas, or feeding
tolerance. 6,12

The final outcome measures in the

present study are return of first bowel sound,
passage of first flatus and return of appetite
however, in systemic review by Hocevar et
al, the outcome measures were first time to
passage of flatus, time to passage of stool
and length of hospital stay.11

The duration of anesthesia is another

known factor to cause POI. In the present
study, the mean duration of anesthesia was
109.341.95 minutes in the experimental
group and 112.8 55.7 minutes in the control
group, but there is no previous study where
the time of anesthesia was mentioned. In

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115

present study all the patients were operated

under general anesthesia as it is comparable
with the study by Marwah S et al but not
comparable to study by Maeboud KHI et al in
which regional anaesthesia is used.6,13 Epidural
analgesia for postoperative pain was not used
in this study and it is comparable to Marwah
et al study.6
In the present study, the mean time to
return of first bowel sounds, passage of first
flatus ,return of appetite was significantly
shorter in the experimental as compared to
the control group was comparable to the
study by Park SY et al in which also mean
time of flatus and postoperative hospital stay
was shorter in the experimental group as
compared to the control group but difference
was not statistically significant14
The mean time for the appearance of
bowel sounds was significantly shorter in the
study group which was comparable to
previous studies but in Harma MI it was much
earlier in the study group may be because of
cesarean section.12
The mean time for the passage of first
flatus was significantly shorter in the study
group (P=0.001).In the previous studies15-20
majority on elective colonic anastomosis, have
also shown that patients in the study group
were able to pass flatus before the control
group. Various systematic reviews and metaanalyses have also revealed significant
reduction in time to first flatus as well as bowel
movement in the gum chewing group.7-8,10,21
The mean time taken to experience the
feeling of hunger was significantly shorter in
the experimental group in comparison to the

control group (P=0.002). This parameter has

been analyzed previously only in one of the
study by Schuster R et al with similar findings,
but the difference was not statistically
significant (P = 0.27).15
Findings of this study clearly indicate
that mean duration to return of first bowel
sound, passage of flatus and return of appetite
shorter in the experimental group. Hence the
null hypothesis is rejected at 0.05 level of
significance. So it is concluded that use of
chewing gum in the postoperative period after
is a safe and cheap method to stimulate bowel
motility and reduce the postoperative ileus
af ter abdominal surgery. The study
recommends that can be replicated on large
sample and in more advanced variables like
passage of stool, length of hospital stay and
rate of postoperative complications. The
implications of study is that nurses can
encourage the postoperative patients to chew
the chewing gum to reduce stress, enhance
relaxation and sense of well being and also
act as diversional therapy, which help in faster
recovery, preventing complications and
thereby provide cost effective care and
satisfaction to the clients.
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