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Published on June 19, 2015 | http://doi.org/10.5867/medwave.2015.6162

Does chewing gum improve recovery after an abdominal surgery? –First update

¿Sirve la goma de mascar para acelerar la recuperación luego de una cirugía abdominal? – Primera actualización

Gabriel Rada , José Viñuela

Abstract

This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in November 2014, based on four new systematic reviews published since then. Postoperative ileus is common condition that delays recovery after an abdominal surgery. Early use of sham feeding with chewing gum stimulates peristalsis and would allow an earlier nutrition. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 18 systematic reviews including 81 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded that chewing gum probably reduces the length of hospital stay after an abdominal surgery.

About the update

This article updates the November 2014 Living FRISBEE (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) (doi: 10.5867/medwave.2014.11.6058) by including four new systematic reviews appeared after publication of the original summary, including a Cochrane review that brings 58 randomized controlled trials not previously identified by the existing reviews.

The new evidence incorporated in this summary led to an upgrade in the certainty of the evidence for the main outcome from low to moderate, and a small increase in the estimate of the magnitude of effect with the corresponding changes on key messages and considerations for decision-making. 

Problem

Postoperative ileus is a common complication in patients undergoing abdominal surgery. This condition is due to a transient functional intestinal obstruction secondary to impaired propulsory activity.

Most cases resolve within a few days but some can evolve to a state known as postoperative paralytic ileus which is associated to nausea, vomiting, abdominal distension and pain, and also to an increase in time of hospitalization and  costs.

Early use of chewing gum as a sham feeding method would stimulate peristalsis and decrease postoperative ileus recovery time and postoperative paralytic ileus, allowing earlier feeding and shortening hospitalization time.

Methods

We used Epistemonikos database, which is maintained by screening more than 30 databases, to identify systematic reviews and their included primary studies. With this information we generated a structured summary using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.

Key messages

  • Chewing gum probably reduces the length of hospital stay after an abdominal surgery.
  • Considering it is a low-cost intervention without side effects, the benefit/risk and benefit/cost ratio of chewing gum for abdominal surgery are probably favorable.

About the body of evidence for this question

What is the evidence.See evidence matrix  in Epistemonikos later

We found 18 systematic reviews [1-18] that overall identified 83 studies (reported in 98 references [19-116]) including 81 randomized controlled trials.

This table and the summary in general are based on the latter.

What types of patients were included

Twenty studies evaluated patients undergoing colorectal surgery, 15 cesarean section, three appendectomy, four holecystectomy, and the remaining 39 included patients with other abdominal surgeries or were not restricted to a single type of surgery.

All studies except two [22,24]  evaluated adult population.

What types of interventions were included

Chewing gum was administered for five minutes to one hour (median 20 minutes).

The frequency was 12 times a day for seven studies, eight times a day in two, six times a day in three, four times a day in 11, three times a day in 55 studies and in one study it was administered once (median three times a day).

What types of outcomes were measured

Time to flatus, time to have a bowel movement, time to first bowel movement, length of stay, complications, tolerance of chewing gum, costs.

 

Summary of findings

The information on the effects of chewing gum is based on 81 randomized controlled trials, from which 56 report length of hospitalization outcome, including 5,278 patients.

  •  Chewing gum probably reduces the length of hospital stay after an abdominal surgery. The certainty of the evidence is moderate.

Other considerations for decision-making

To whom this evidence does and does not apply
  • Since studies evaluated different types of abdominal surgery this evidence is applicable to a wide group of patients.
  • Even though it can be posed there is not enough direct evidence for most evaluated surgeries and it has not been tested in several surgical procedures, it is reasonable to think the effect will be larger in surgeries with longer postoperative recovery, based on clinical and pathophysiological arguments.
About the outcomes included in this summary
  • This summary considers the time of hospitalization as the only critical outcome for decision making. This is based on the opinion of the authors because we haven’t found studies that have determined the relative importance of the outcomes after surgery, or some other method of establishing what outcomes are more relevant for decision making.
  • Other outcomes of less importance to the patient have not been considered, including time to eliminate gas or stool, assuming its importance derives from their impact on time of hospitalization.
Balance between benefits and risks, and certainty of the evidence
  • It is difficult to make a proper risk/benefit balance, because although the risks are few or nonexistent, there is low certainty about the benefits. [11]
  • It is reasonable to anticipate the benefits outweigh the risks, although the magnitude of benefit can be considered more or less important in different circumstances.
What would patients and their doctors think about this intervention
  • Since this is an acceptable and inexpensive measure, it is likely that most patients and their attending physicians will be inclined to use the intervention despite the low certainty of the evidence.
Resource considerations
  • Two studies reported costs but the certainty of the evidence is too low to make any conclusion  [35],[41]. Considering the low cost of the intervention and the abscence of important complications, it is probably a cost-saving intervention.
Feasibility and implementation
  • The fact that it is not a drug can make the intervention not available, at least initially, in hospital pharmacies, making it necessary to ask to relatives or find another delivery mechanism.
  • Considering how entrenched is the concept of avoiding food by mouth in the postoperative period (chewing increases saliva production that reaches the stomach), there may be resistance in the different health professionals integrating health teams.

Differences between this summary and other sources
  • The key messages of our summary are consistent with the conclusions of individual systematic reviews identified.
  • We haven’t found clinical guidelines used in this area that mention this intervention.
Could this evidence change in the future?
  • There is a high probability that future evidence change what we know about the benefits of chewing gum in postoperative abdominal surgery, especially in relation to the magnitude of benefit and the effect on specific subgroups.
  • There are many ongoing studies evaluating this intervention in different types of surgery, either as isolated or as a component intervention of rapid recovery protocols.

How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence

;;;;Matrix of evidence
Full size

Follow the link to access the interactive version Chewing gum for the amelioration of postoperative ileus

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier. After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

The details about the methods used to produce these summaries are described here http://dx.doi.org/10.5867/medwave.2014.06.5997.

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

These summaries follow a rigorous process of internal peer review.

Conflicts of interest
The authors do not have relevant interests to declare.

This work is licensed under a Creative Commons Attribution 4.0 International License. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

Authors

Gabriel Rada

radagabriel@epistemonikos.org

Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile

José Viñuela

Figures

;;;;Matrix of evidence View in article Full size

Forum

No messages

History

Citation Rada G, Viñuela J. Does chewing gum improve recovery after an abdominal surgery? –First update. Medwave 2015;15(05):e6162 doi: 10.5867/medwave.2015.6162

Submission date 01/01/1970

Acceptance date 01/01/1970

Publication date 19/06/2015

Metrics

Not available at the moment.

Notes

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