Chewing gum for declining ileus and accelerating gastrointestinal recovery after appendectomy

After the majority of surgeries, the activity of the gastrointestinal tract is inhibited and this causes abdominal distention, a buildup of gas, nausea, and vomiting. Extended and large abdominal surgery leads to more harshness of this disruption.¹ Paralytic ileus is a critical disruption arising following abdominal surgery and is defined as the delayed regain of the synchronized intestinal motility. This disturbance makes the progress delayed and increases the hospital days of stay.² Apart from the fiscal concerns, the patient’s lack of comfort and other problems such as the hospital-acquired infections are major concerns.³

Postoperative ileus occurs due to the drop of intestinal movement and the reduction of the activity of the parasympathetic nervous system.⁴ Ileus occurs in cases of opioid and drug interaction and abdominal operations, especially in surgeries with extreme manipulation, and transiently contribute to impeding peristalsis (bowel movement); the related mechanism is possibly dysfunction in the parasympathetic system (inhibitory neurons) activity.⁵

Postoperative ileus increases to be a cause of morbidity and the primary reason for the extended hospitaldays of stay post abdominal surgery such as an appendectomy. The useful and safe encouragement of the improvement of gastrointestinal function post abdominal operation and avoidance of postoperative problems have initiated a prevalent apprehension between medical and nursing staff.⁶ Ileus resolution is habitually defined by the passage of flatus (gas) or feces or both. These are signs that intestinal function is being restored to normal, and the end points of postoperative ileus are usually measured.⁷

At this moment, a number of techniques have been deliberated for the lessening of the postoperative ileus phase, among which one can pass on to employ epidural anesthesia, the diminution of utilizing narcotic perfusion by recommending non-steroidal anti-inflammatory drugs, laparoscopic surgery, and using high carbohydrate drinks post the operation.⁸ Numerous studies sustain the belief that chewing gum improves postoperative ileus in general.⁹ Chewing gum can increase the bowel motility as it directly activates the cephalic–vagal reflex, which in turn activates intestinal myoelectric motion, and indirectly stimulates the secretion of gastrointestinal hormones that increase the release of saliva and pancreatic juice. This reaction leads to likewise humeral and nervous activation of bowel motility.¹⁰

A number of theories have been proposed for chewing as a type of sham feeding that enhances the plasma concentration of gastrin, neurotensin, pancreatic polypeptide, and duodenal alkaline secretion.¹¹ The mechanism of improved revival from postoperative gastrointestinal dysfunction with the assistance of chewing gum is thought to be the cephalic–vagal stimulation of digestion, which enhances the capability of neural and humoral factors that operate on different portions of the gastrointestinal tract.¹² Chewing gum proceeds by stimulating intestinal motility coupled with bowel motility that causes early return of bowel sounds, a passage of flatus, and arrival of appetite.¹³

It is accentuated that adding together to postoperative nursing concern, nurses should also utilize consistent, cheap, accessible, and valuable practices in order to condense the negative property of problems that patients face. Practices such as postoperative standing up in the early hours, gum chewing, and early fluid drinking, which are accessible, inexpensive, and steadfast after abdominal surgeries are utilized traditionally in recent times. These approaches are considered to reduce the recovery period and length of time to discharge from the hospital.¹⁴ Consequently, gum chewing as an artificial feeding manner named as sham feeding is utilized in order to begin bowel movements in a short time in various studies; therefore, the researchers have taken up this study to evaluate the effect of chewing gum on gastrointestinal function after appendectomy surgery.

Following abdominal surgeries, the reduction of gastrointestinal system motility and the alteration of dietary habits may cause progress of ileus symptoms, such as nausea, vomiting, abdominal distension, and hiccup, which leads to severe pain for the patient/individual after operation.¹⁵ Postoperative ileus is the most major postabdominal surgery crisis that extends the interval of hospital stay, causes pain and distension, hinders oral feeding, causes respiratory troubles, and increases hospital expenses.^{16, 17}

Consequently, resumption of the intestinal function is an essential feature that necessitates appropriate awareness.¹⁸ Chewing gum can augment bowel movements and decrease the temporary phase of paralysis.¹⁹ Using chewing gum as one of the non-pharmacological interferences and an economical method that can be used to activate the stomach improves gastric secretion, enhances peristaltic bowel movements, and finally accelerates retrieval of intestinal function.²⁰

Although working with the patient undergoing abdominal operation it is the duty of the nurse to avert the postoperative ileus, there are many non-pharmacological treatments, such as early enteral nutrition, early mobilization, and psychological preoperative training, and among them, the utilization of chewing gum has appeared as a latest, effortless, willingly obtainable, and inexpensive modality for lessening postoperative ileus.¹³ This intervention has been revealed to be successful in the postoperative time of gastrointestinal surgery.^{21, 22} Moreover, the outcome of such a topic in our Egyptian context is necessary; thus, this study is carried out to explore whether chewing gum after appendectomy accelerates the recovery of gastrointestinal function. Appendectomy patients who chew sugar-free gum recover their gastrointestinal functions earlier than those who do not.

Table 1 presents personnel characteristics of the studied participants in both intervention and control groups. It is seen that there was no significant statistical difference between intervention and control groups regarding their age, sex, educational qualification, residence, and occupational status.

Table 2 shows the studied participants’ anthropometric measurements in both intervention and control groups, which reveals that there was no significant statistical difference between the two groups regarding their weight, height, and body mass index.

Table 3 shows the studied participants’ pre- and intraoperative indicators in both intervention and control groups, which reveals that there is no significant statistical difference between the two groups regarding their duration of complaint, fasting hours before surgery, and duration of surgery.

Table 4 indicates the resumption of bowel function measures between intervention and control groups, which illustrates that there are highly statistically significant differences between both groups regarding the first time of bowel sound, the passage of flatus, defecation, feeling of hunger, and length of hospital stay.

Table 5 shows that there are highly significant statistical differences between intervention and control groups concerning the occurrence of postoperative ileus and its related symptoms such as feeling of abdominal distention, nausea, and vomiting.

Assessment of gastrointestinal function after abdominal surgeries is an important responsibility of the nurses. They should assess the function of the gastrointestinal tract by frequent auscultation of the bowel movement until the regain of ordinary peristaltic movement in all quadrants of the abdomen. The nurses have to be alert about signs related to decreased bowel movement, which include missing or deferred bowel sounds, abdominal distention, and stoppage to pass gas or stool.²⁷

Results of this study demonstrate that there are no significant statistical differences between the chewing gum group and the control group regarding their personal characteristics, such as age, sex, educational level, residence, and occupation. Also, there is no significant difference between the intervention and control groups regarding their anthropometric measurements such as weight, mass index, as well as their pre- and intraoperative indicators such as duration of complaining, fasting hours before surgery, and time of surgery. These findings mean that the intervention group and the control group are homogenous and comparable. Our findings are congruent with the results of previous studies that found no significant discrepancy between the control and sugar-free gum chewing groups in terms of demographic characteristics, duration of surgery, body mass index, and fasting time before the surgery.^{6, 28}

Pertaining to postoperative parameters, findings of this study indicated that there were significant statistical differences between the chewing gum and control groups regarding postoperative parameters of the gastrointestinal function, whereas the mean time of the onset of bowel sound, the onset of the gas passage, the onset of defecation, the first feeling of hunger, and the length of hospital stay was significantly lower in the chewing gum group than in the control group. These findings recommended that chewing gum enhances gastrointestinal function among patients with appendectomy. According to the significant literature, gum chewing promotes food digestion and secretion of salivary and hepatic glands through vagus nerve stimulation, and thus gum chewing directly augments intestinal stimulation through the release of gastrointestinal hormones that increase the secretion of saliva and pancreatic juices and subsequently promotes ileus recovery.¹¹

The findings of this study are congruent with numerous relevant studies. The first was a meta-analysis of randomized clinical trials assessing the effect of gum chewing on gut function after elective colorectal surgery;²⁹ the second was meta-analysis to examine if gum chewing reduces postoperative ileus;³⁰ the third was a similar study on patients with open appendectomy to study if chewing gum reduces postoperative ileus after open appendectomy, and they found that the first passage of flatus occurred earlier in the chewing gum group than in the control group; the first bowel movement occurred earlier in the chewing gum group than in the control group; and hospital stay was shorter in the chewing gum group than in the control group³¹. Also, two meta-analyses that assessed the gum chewing as another simple possible method for more rapid enhancement of postoperative gastrointestinal function showed reduction in time of hearing first intestinal sound, passing flatus, defecation, and length of hospital stay.^{22, 32} Two studies examined the effect of gum chewing on postoperative ileus and inflammation in colorectal surgery,^{33, 34} as well, and one study determined the effect of gum chewing on postoperative ileus after cholecystectomy surgery,¹⁹ demonstrating that chewing the sugar-free gum will lead to the decrease of the time to gas passing, defecation, and bowel sound hearing time. Moreover, another study noted that the time to passage of first flatus was 7 hours earlier than those in the “typical care” control group; the time to passage of feces occurred on average 9 hours shorter in the intervention group; the average duration of hospital stay was shorter in the intervention group compared to the control group; and the first intestinal sounds were heard earlier in the intervention group than in the control group.³⁵

In contrast to the results of this study, in a study carried out to evaluate the effect of chewing sugared gum in combination with early enteral feeding on the recovery of gastrointestinal (GI) function after major colorectal surgery, it was demonstrated that there was no significant difference in time to tolerating a low-residue diet, time to flatus, time to bowel movement, length of postoperative hospital stay, and postoperative complications.³⁶ The discrepancy may be due to two main factors. The first factor is the starting of early enteral feeding, which activates the gastrointestinal motility. The second factor is the use of sugared gum in their study, which differs in its effect from sugarless gum. In addition, chewing gum composition; sugar-free gum uses sugar substitutes (e.g., sorbitol and xylitol). These sugar surrogates can improve gut function by causing a nonstimulant laxative effect. This represents another factor, which may influence gut motility in the gum-chewing group of patients.³⁷

The findings of this study are supported by the findings of previous researchers regarding the feeling of hunger after appendectomy, which was faster among the chewing gum group than the control group. These studies concluded that the feeling of hunger was earlier among the chewing gum group in the other one.^{13, 28, 38} Also, one study discovered that the first hungry feeling was statistically significantly faster in favor of the study group contrasted to the control group.³⁹ On the other hand, there is another study that found no significant difference between the gum-chewing group and the other group with respect to time to start the diet. The discrepancy between these results and results of this study may be attributed to the differences that existed between sample, type, and time of surgery.²⁵

Concerning ileus and its signs and symptoms, results of this study discovered that there was a significant statistical reduction in the occurrence of postoperative ileus and related symptoms such as nausea, vomiting, and distention favoring the chewing gum group than the other one. In this respect, a previous study pointed out that chewing gum improves recovery after open appendectomy by reducing postoperative ileus among appendectomy patients.³¹ These results are in line with many studies that conducted meta-analysis for the relation between chewing gum and postoperative ileus and demonstrated a significant effect suggesting that chewing gum following abdominal surgery offers benefits in reducing the time of postoperative ileus.^{22, 30, 40, 41, 42} In addition, one study noted that gum chewing reduced postoperative ileus and inflammation among colorectal surgery patients³³ and another one reported a reduction of paralytic ileus following cholecystectomy by chewing gum.¹⁹

Some studies contradict the findings of this study. One study reported that there was no benefit to sugared chewing gum in comparison with no gum in patients undergoing major colorectal surgery managed with early feeding regarding postoperative pain, nausea, or appetite.³⁶ Also, there are two previous studies that found no effect of sugared chewing gum for patient with colorectal surgery compared to no gum chewing in their study conducted for the effect of sugared chewing gum on the return of gastrointestinal function after major surgery.^{25, 43} The negative results are possibly due to their practice of early enteral feeding, which may already fasten the postoperative recovery of gastrointestinal function. In addition, the pathophysiology of postoperative ileus may be different for various operative techniques and anatomical portions of the GI tract.⁴⁴

Supported by the overall findings of this study, we conclude that chewing gum is an accessible, effortless, safe, harmless, cheap, and effective method in declining ileus and accelerating gastrointestinal recovery after appendectomy.

Based on the findings of this study, the following recommendations are suggested: