A Randomized Control Trial on Efficacy of Gum Chewing in early Return of Bowel Function Among Patients Undergone Elective Abdominal Surgery at Selected Hospital, Ludhiana, Punjab

Ms. Kuldeep Kaur¹, Dr. Suresh K Sharma², Mr. Anurag B. Patidar³, Dr. Satpal Singh⁴,

Dr. (Mrs.) Jasbir Kaur⁵

¹M.Sc. Nursing (Student), Dept. Medical Surgical Nursing, DMC & Hospital, College of Nursing, Ludhiana.

²Professor –Cum-Principal, College of Nursing, AIIMS, Rishikesh, Uttrakhand

³Lecturer, Bhopal Nursing College, BMHRC, Bhopal MP

⁴Professor, Dept. of Gastroenterology Surgery, DMC & Hospital, Ludhiana.

⁵Principal, DMC & Hospital, College of Nursing, Ludhiana.

Corresponding Author Email: kuldeepkaur15@gmail.com

ABSTRACT:

Aims and Objective: To assess the efficacy of bubble gum chewing in early return of bowel function among patients undergone elective abdominal surgery.

Background: Delay in early return of bowel functions (Paralytic ileus) is a common side effect of various types of surgical procedure results in constipation and bloating commonly known as postsurgical ileus. The main reason of impaired bowel function after abdominal surgeries include electrolyte imbalances, gastroenteritis, appendicitis, pancreatitis, surgical complications, and obstruction of the mesenteric artery, which supplies blood to the abdomen. Certain drugs and medications, such as opioids and sedatives, can cause ileus by slowing bowel peristalsis, the contractions that propel food through the digestive tract.² Conventionally, POI has been managed by gastric decompression by Ryle's tube, keeping the patient nil per orally, intravenous fluid supplementation till ileus resolves, and patient passes flatus. In recent years, the use of gum chewing has emerged as a new and simple 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.

Design: A randomized, parallel control trial

Method: It was conducted in January 2014 in selected surgery recovery and surgery units at DMC & Hospital, Ludhiana. Out of total 60 subjects, 30 in both experimental and control group were selected by convenience sampling technique. The tool consists of three parts:

§ Section A: Socio-demographic sheet.

§ Section B: Clinical profile sheet.

§ Section C: Bowel movement assessment sheet.

§ Section D: Bowel sound auscultation sheet.

Results: As seen first bowel sound heard by auscultation within 21.35±17.58 hours in experimental group which is less than control group i.e 24.96±21.91 hours. Time taken for first flatus passed and tolerance of oral feeds was also comparatively less in experimental group i.e. 37.91±24.40 and 61.62±39.06 respectively as compare to control group i.e. 42.68±27.64 and 73.93±60.69. In addition to it, post-Operative length of hospital stay (in days) was also shorter in experimental group 07.63±03.25 as compare to control group 09.43±5.01. On the other hand, time taken in case of first stool passed and return of appetite is more in experimental group (75.44±37.41 and 37.94±31.03) as compare of control group (69.72±34.75 and 34.16±34.78 respectively).

Conclusion: Although there is difference in mean time but there is no statistical significant difference found in return of bowel functions among experimental and control group.

Relevance to Clinical Practice:

§ Chewing gum can reduce the occurrence of postoperative paralytic ileus.

§ Nurses can use this therapy as a effective measure to prevent postoperative paralytic ileus.

§ Administration of chewing gum can provide mouth freshness to the postoperative clients.

· Chewing gum can reduce the mental stress and provides relaxation to the post operative clients.

· Chewing gum serves as a divertional activity too.

KEY WORDS: Efficacy of chewing gum, Early return of bowel function, Elective abdominal surgery.

INTRODUCTION:

The paralytic movement of smooth muscles of bowels and intestine can be delayed due to various surgical procedure more commonly when the intestinal handling is too much. The individual cannot eat or drink until the (ileus resolves) bowel function return normal, usually within a few days. Obstruction of the bowels can happen after the surgery when scar tissue or adhesions developed after the surgery. Adhesions can cause the bowel to twist or kink so that nothing can pass through it. Surgery on the bowel can cause scar tissue that concentrically blocks the bowel at the level of the surgery. Often, surgical repair is necessary to correct the problem.³

Delay in early return of bowel functions (Paralytic ileus) is a common side effect of various types of surgical procedure results in constipation and bloating commonly known as postsurgical ileus.⁴ The small bowel normally resumes activity several hours after surgery, the stomach 24 to 48 hours after surgery, and the colon 3 to 5 days after surgery. When Delay in normal bowel function (postoperative ileus) persists longer than this, it can be considered pathologic and is sometimes called paralytic ileus.⁵ As the result of delay in return of normal bowel function, the intestinal content of this portion is unable to move forward, food or drink should be avoided until peristaltic sound is heard from auscultation of the area (all four quadrants) where this portion lies.⁴

There is general consensus among surgeons that some degree of abnormal delay in return of normal bowel function (postoperative ileus) is a normal obligatory and physiologic response to abdominal and non-abdominal surgery. For example, the average time to resolution of POI after major abdominal surgery depends in part on the section of the GI tract affected by the surgery.

However, the incidence of POI is greatest after bowel surgery (15-20%), it also occurs after hysterectomy (4%), Cholecystectomy (8.5%), appendectomy (6%) and averages 9% for other procedures for an overall incidence of about 8.5% for all procedures ⁶ After orthopedic procedures an incidence of 1.3% after hip replacement surgery and 1.2% after spine procedures has been reported.⁵

The main reason of impaired bowel function after abdominal surgeries include electrolyte imbalances, gastroenteritis, appendicitis, pancreatitis, surgical complications, and obstruction of the mesenteric artery, which supplies blood to the abdomen. Certain drugs and medications, such as opioids and sedatives, can cause ileus by slowing bowel peristalsis, the contractions that propel food through the digestive tract.¹ Prolonged delays in oral feeding may compromise postoperative nutrition, which can lead to greater postoperative catabolism, poorer wound healing, increased susceptibility to infection, and the need for parenteral nutrition.^{8 9} These problems contribute to prolonged hospitalizations and are a significant burden on the health system. In fact, it was estimated that in 2000 alone, POI was responsible for more than one billion dollars in direct health care costs in the United States.¹⁰

All of these issues have been addressed and methods devised to reduce their impact. With nearly 350,000 colorectal and small bowel resections occurring annually, at an average stay of almost 11 days at a bill to the healthcare system of greater than US $20 billion, the cost savings could be substantial if length of stay was reduced by only 1 to 2 days in each case (Healthcare Costs 2005).¹¹

Conventionally, POI has been managed by gastric decompression by Ryle's tube, keeping the patient nil per orally, intravenous fluid supplementation till ileus resolves, and patient passes flatus.¹³ However, very few improvements in the understanding of POI have occurred in the past 100 years, and therefore therapies have changed little. To date, no definite treatment for POI has been approved by the US Food and Drug Administration. In recent years, the use of gum chewing has emerged as a new and simple 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. ¹⁴Therefore, the hypothesis suggested herein is that the content of maxitols in 'sugar-free' chewing gums may play a role in the amelioration of ileus after surgery, and should be added to the list of probable mechanisms involved in the observed phenomena.¹⁵ The published literature reveals that gum chewing in the postoperative period is a safe method to stimulate bowel motility and it has been shown to reduce ileus after elective colonic anastomosis.^12-14 However, there are very few reports on the role of gum chewing in improving POI following abdominal surgeries.¹⁵

Hence this study is planned to evaluate the role of gum chewing in early return of bowel function among patients underwent elective abdominal surgeries and compare it with a similar control group to measure the early return of bowel function .

MATERIAL AND METHOD:

A randomized control trial was employed using ‘parallel group design’ to carry out the study to assess the efficacy of bubble gum chewing in early return of bowel function among patients undergone elective abdominal surgery at selected hospital, Ludhiana, Punjab. The target population comprised of patients who had undergone elective abdominal surgery in post operative recovery and surgical wards at DMC & Hospital, Ludhiana. After established participants eligibility as per inclusion and exclusion criteria, informed written consent was obtained from study subjects/ relatives. Convenience sampling technique was used to draw sample from target population. The total 60 patients who were planned for abdominal surgery admitted in selected units of DMC & Hospital were selected by convenience sampling and were then randomized into two groups i.e. 30 in control group and 30 in experimental group Data was collected during 1^st January to 31^st January 2014 In the experimental group, the patients were ask to chew two sticks of commercially available sugar free chew gum (orbit) thrice a day for 1 hour each time starting from 6 hours of surgery till the passage of first flatus.

The subjects in control group, standard postoperative treatment was given as per intervention protocol of DMC & H. The content validity has been checked by Various experts from medicine, surgery, anesthesia, nursing and research fields have been consulted to compose an applicable tool for the purpose of data collection. Reliability of the tool was established with inter-rated and test-retest method before use. Analysis of data was done in accordance with the objectives of the study using descriptive and inferential statistics. Calculation has been done using statistical software SPSS (16). Significance of effect or difference was established at the level of 0.05 levels.

RESULTS:

The mean age of patients was in control group 46.40±16.28 and in experimental group was 40.57±12.62, (Range: 20-85 years). Table 1 depicts the frequency and percentage distribution of subjects as per their socio-demographic characteristics It can be observed that both control and experimental group shared equal number of subject at 11(36.7) in the age group of 40-59 years, account for 36.7% of total sample. While, maximum number of subjects belonged to 20-39 years age group at 27(45%) from which 11(36.7%) of control group and 16(53.3%) of experimental group, whereas 11 (18.3%) subject were included in ≥60 years. Further, it was found that majority of subjects were male 34 (56.7%) as compared to females 26 (43.3%). Whereas, slightly more than 50% were working whilst 34(56.7%) subjects were having family income ≤ 10,000. Among the subjects, 32(53.3%) were vegetarian and 28 (46.7) subjects were non-vegetarian. Preoperatively, maximum of patients 26(43.3%) reported their average bowel habits as once in a day, whereas only 02(03.3%) had once in a three days bowel habits pattern. It was found that two groups i.e. experimental and control group were statistically identical (homogenous) as their age, gender, occupation, total family income (in rupees.) dietary habits, life style and average bowel habits (preoperatively) was concerned (p>0.05). as shown in table 1.

Table 1: Frequency and percentage distribution of subjects as per their socio-demographic characteristics among experimental and control group. N=60

Variables

Control Group (n=30)

Exp. Group (n=30)

Total (N=60)

χ²Statistics

f(%)

f (%)

Age(in years)

20-39

40-59

≥60

11 (36.7)

08 (26.6)

16 (53.3)

11 (36.7)

03 (10.0)

27 (45.0)

22 (36.7)

11 (18.3)

3.199

df =2

p=0.202^NS

Gender

Male

Female

16 (53.3)

14 (46.7)

18 (60.0)

12 (40.0)

34 (56.7)

26 (43.3)

0.271

df=1

p=0.602^NS

Occupation

Not Working

Working

14 (46.7)

16(53.3)

14 (46.7)

16(53.3)

28 (46.7)

32(53.3)

0.00

df=1

p=1.000^NS

Total family income (Rs.)

≤10,000

10,001-20,000

20,001-30,000

≥30,001

17(56.7)

09(30.0)

01(03.3)

03(10.0)

17(56.7)

05(16.7)

03(10.0)

05(16.7)

34(56.7)

14(23.3)

04(06.7)

08(13.3)

2.643

df=3

p=0.450^NS

Dietary habits

Vegetarian

Non vegetarian

18 (60.0)

12(46.0)

14 (46.7)

16 (53.3)

32 (53.3)

28 (46.7)

1.071

df=1

p=0.301^NS

Life style

Sedentary

Moderate

Heavy work

26(86.7)

04(13.3)

00(00.0)

25 (83.3)

04(13.3)

01(03.3)

51(85.0)

08 (13.3)

01 (01.7)

1.020

df=2

p=0.601^NS

Average Bowel Habits preoperatively

Once in a day

Twice in a day

≥thrice in a day

Once in three days

15(50.0)

08(26.7)

06(20.0)

01(03.3)

11(36.7)

10(33.3)

08(26.7)

01(03.3)

26(43.3)

18(30.0)

14(23.3)

02(03.3)

1.123

df=3

p=0.771^NS

Mean age ±SD control group 46.40±16.28and experimental group was 40.57±12.62,

NS=non significant

Table 2: Frequency and percentage distribution of subjects as per their clinical profile among both the control and experimental group. N=60

Variables

Control Group (n=30)

Experimental Group (n=30)

Total (N=60)

χ²Statistics

f(%)

Any previous GI surgery

Yes

15(50.0)

11(36.7)

19(63.3)

26(43.3)

34(56.7)

1.086

df=1

p=0.297^NS

Type of surgery

Open

Laproscopic

29(96.7)

01(03.3)

29(96.7)

01(03.3)

58(96.7)

02(03.3)

0.000

df=1

p=1.000^NS

Name of surgery

Intestinal surgeries

Other GI surgery*

LSCS

Exp. Laprotomy

14(46.67)

04(13.33)

06(20.00)

14(46.67)

05(16.67)

06(20.00)

05(16.67)

28(46.67)

09(15.00)

12(20.00)

11(18.33)

0.202

df=3

p=0.977^NS

Duration of surgery (in hrs.)

< 2

2 – 4

≥ 4

10(33.3)

18(60.0)

02(06.6)

8(26.6)

18(60.0)

4(13.33)

18(30.0)

36(60.0)

06(10.0)

8.89

df=2

p=0.641^NS

Intraoperative complications

Yes

00(00.0)

30(100)

00(00.0)

30(100)

00(00.0)

60(100.)

Extensive adhesiolysis done

Yes

14(46.7)

16(53.3)

7(23.3)

23(76.7)

21(35.0)

39(65.0)

3.590

df=1

p=0.058^NS

Type of Anaesthesia

General

Spinal

21(70.0)

09(30.0)

22(73.3)

08(26.7)

43(71.7)

17(28.3)

0.082

df=1

p=0.774^NS

*Gastrosplenectomy, Esophagectomy, partial Gastrectomy, Cholecystectomy and pancreatic surgeries.

NS = Non significant

Table 3: Comparison of mean time taken to return of bowel functions among control and experimental group. N=60

Variables	Control group (n=30)		Exp. Group (n=30)		t Value	P Value
Variables	Mean ± SD	Range	Mean ± SD	Range	t Value	P Value
First bowel sound heard by Auscultation (in hrs.)	24.96±21.91	2.83-92.25	21.35±17.58	04-69.75	0.70	0.49^NS
First flatus passed (in hrs.)	42.68±27.64	8.0-126.75	37.91±24.40	8.5-95.25	0.71	0.48^NS
First stool passed (in hrs.)	69.72±34.75	15-131.75	75.44±37.41	18.5-138	0.61	0.54^NS
Return of appetite (in hrs.)	34.16±34.78	02-165.25	37.94±31.03	1-88	0.44	0.66^NS
Started tolerance of oral feeds. (in hrs.)	73.93±60.69	21-287.33	61.62±39.06	9.5-164	0.93	0.35^NS
Post-operative length of hospital Stay (in days).	09.43±5.01	04-23	07.63±03.25	3-19	1.65	0.10^NS

NS= Not significant df =58

On the other hand, time taken in case of first stool passed and return of appetite is more in experimental group (75.44±37.41 and 37.94±31.03) as compare of control group (69.72±34.75 and 34.16±34.78 respectively). Although there is difference in mean time but there is no statistical significant difference found in return of bowel functions among experimental and control group. Mean age ±SD control group 46.40±16.28and experimental group was 40.57±12.62,

NS=non significant.

DISCUSSION:

Postoperative paralytic ileus refers to obstipation and intolerance of oral intake due to non-mechanical factors that disrupt the normal coordinated propulsive motor activity of the gastrointestinal tract following abdominal or non-abdominal surgery.^16,31 There is general consensus that some degree of postoperative ileus is a normal obligatory and physiologic response to abdominal surgery¹⁷ ¹⁸

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.

Moreover, it was found that two groups i.e. experimental and control group were statistically identical as their previous GI surgery, type of surgery, name of surgery, duration of surgery, etc were concerned (p>0.05%). The present study also highlights about the length of hospital stay (in days) among patients in control and experimental group. As it is evident, majority of subjects 50% from control group and 53.3% from experimental group were discharged between 6-10 days postoperatively. Only 3.3% subjects discharged after 14 days in experimental, on the flip side 16.7% subjects discharged after 14 days in control group. (as shown in figure 4). From the data, it can be clear that control group patients were having more length of hospital stay as compared to experimental group. (p=0.10)

These findings were supported by Marwah Sanjay, Singla Sham, and Tinna Pradeep (2012) revealed that the postoperative hospital stay was shorter in the study group, but the difference was not significant (P=0.059).³⁶

Second and third objective of the study was to assess and compare the average time taken in return of bowel function among patients in experimental and control group. Present study did not show any significant result but had difference in mean time. The major findings of the study shows the comparison of the subjects as per return of bowel function among control and experimental group. As seen first bowel sound heard by auscultation within 21.35±17.58 hours in experimental group which is less than control group i.e 24.96±21.91 hours. Although it was statistically non significant. (p=0.49) Findings of study by Nimarta, Singh NeenaVir, Shruti, Gupta Rajesh (2013) that Return of bowel sound(hr) was significantly shorter in the experimental group 21.4±2.8 as compared to control group 23.7±2.8 (0.002).⁶

Furthermore, time taken in first flatus passed and started tolerance of oral feeds was also comparatively less in experimental group i.e. 37.91±24.40 and 61.62±39.06 respectively, as compare to control group i.e. 42.68±27.64 and 73.93±60.69. Though, there is difference in mean time there is no statistical significant difference found in return of bowel functions among experimental and control group.(p=0.48) (p=0.35) Similar findings were given by Hwang Duk Yeon, Kim Ho Young, Kim Ji Hoon, (2013) The mean time first passage of gas was slightly earlier in group B(chew gum group), but did not show a significant difference. Flatus passing (postoperative day) in group A (not to chew gum) 2.47 and in group B 2.29 (P=0.266).¹⁹

On the other hand, time taken in case of first stool passed and return of appetite is more in experimental group as compare of control group. Though there is difference in mean time there is no statistical significant difference found in return of bowel functions among experimental and control group. (p=0.54) (p=0.66). Whereas, the contrary findings was given by Schuster Rob, MD; Grewal Nina, MD; C Gregory. Greaney, MD; Waxman Kenneth, MD(2008) Reveled that first feeling of hunger were felt on postoperative hour 63.5 in the gum chewing group and on hour 72.8 in control group (p=0.27).18 Thus, time taken was less in experimental group as compared to control group. According to fourth objective of the study to determine the association of efficacy of bubble gum chewing and selected socio-demographic characteristics of patients underwent elective abdominal surgery.

The present study also highlight that occupation was having statistical significance in first passage of flatus after abdominal surgeries (p=0.019), life style having statistical highly significant impaction in return of appetite (p=0.001). And, preoperatively average bowel habits also had significant relation with bowel sound heard by auscultation (p=0.032), and with passage of stool postoperatively (p=0.036). This study shows that efficacy of bubble gum chewing in early return of bowel function shows statistically highly significant result in name of surgery with first bowel sound heard by auscultation(p=0.021), return of appetite (p=0.033) and with start tolerance of oral feeds.(p=0.051). Type of anesthesia were also show significant statistically result in first bowel sound heard by auscultation (p=0.033) , first flatus passed (p=0.007) and return of appetite (p=0.021). All other clinical variables were having non statistical significant result in early return of bowel function (p>0.05).s However, no such study found showing association of bowel movement with socio-demographic variables.

CONCLUSION:

The major findings of this study revealed that there is no statistical significance difference in early return of bowel function among patients undergone elective abdominal surgery in control and experimental group. the comparison of the subjects as per return of bowel function among control and experimental group. As shown Though there is difference in mean time there is no statistical significant difference found in return of bowel functions among experimental and control group.

The present study also highlights about the length of hospital stay (in days) among patients in control and experimental group. As it is evident, majority of subjects 50% from control group and 53.3% from experimental group were discharged between 6-10 days postoperatively. Only 3.3% subjects discharged after 14 days in experimental, on the flip side 16.7% subjects discharged after 14 days in control group.

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20. Hwang Yeon Duk, Kim Young Ho, Kim Hoon, Ji , Lee isn Gyu, Kim jun ki, oh seung taek et al. Effect of Gum Chewing on the Recovery From Laparoscopic Colorectal Cancer Surgery. Ann Coloproctol. Dec 2013;29 (6):248-25

Received on 05.03.2015 Modified on 18.03.2015

Int. J. Nur. Edu. and Research 3(2): April-June, 2015; Page 183-189