Journal oI Wound, Ostomy & Continence Nursing:

March/April 2010 - Volume 37 - Issue 2 - p 140146

doi: 10.1097/WON.0b013e3181d0b92b
Evidence-Based Report Card
Does Chewing Gum Shorten the Duration of Postoperative Ileus in
Patients Undergoing Abdominal Surgery and Creation of A Stoma?
Hocevar, Barbara J.; Robinson, Bruce; Gray, Mikel

Introduction
Postoperative ileus (POI) is deIined as a temporary disturbance in gastric and bowel motility Iollowing
surgery.
1-3
Transient POI is recognized as an expected outcome oI any major abdominal surgery,
especially when the peritoneum is entered, or the bowel is extensively manipulated or reconstructed. POI
is a signiIicant risk Ior patients undergoing gastrointestinal and urinary ostomy surgery because both
procedures require surgical manipulation and reconstruction oI the bowel. In addition, ostomy surgery
may occur aIter resection oI signiIicant segments oI bowel, such as colectomy Ior colorectal cancer.
While transient POI is considered an inevitable consequence oI major abdominal surgery, prolonged ileus
is a clinically relevant postoperative complication associated with morbidity and prolonged hospital
stays.
1-3
However, no standardized deIinition exists that clearly diIIerentiates prolonged POI Irom the
inevitable and transient period oI impaired motility Iollowing abdominal surgery. In an observational
study oI 88 patients undergoing abdominal surgery, Artinyan and coworkers
3
noted that the median
duration oI POI was 6 days (interquartile range 36 days). Based on this observation, they advocate that
bowel dysIunction persisting Ior more than 6 days should be deIined as prolonged, although other authors
deIined prolonged POI when dysIunction persists Ior more than 3 days.
Clinical maniIestations oI POI vary considerably. Some patients report Iew noticeable symptoms, but the
majority experience nausea, vomiting, abdominal pain, bloating, and absent passage oI Ilatus or Iormed
stool. In severe cases, patients may experience bloating and bilious emesis. Physical assessment usually
reveals abdominal distension and a tympanic response is noted when the abdomen is percussed.
Auscultation typically reveals Iew or absent bowel sounds, but it must be remembered that only a weak
correlation exists between the presence oI bowel sounds on auscultation and dissipation oI POI. Similarly,
while the passage oI Ilatus or stool heralds the end oI POI, clinical experience and limited clinical
evidence suggest that many patients are able to tolerate oral intake beIore these signs appear. No
deIinitive diagnostic test exists Ior the diagnosis oI POI; evaluation typically relies on ongoing
monitoring oI symptoms and empiric trials to determine tolerance oI Iood.
Factors associated with an increased incidence oI POI (possible risk Iactors) include postoperative use oI
opioid analgesics, blood loss during surgery, use oI inhaled anesthesia, peritonitis, pain, anxiety, extended
time without oral intake, and prolonged bedrest. Bowel-related Iactors include preexisting inIlammatory
bowel disease such as Crohn's disease, iatrogenic bowel injury, and manipulation or reconstruction oI the
bowel during surgery. Metabolic disorders also inIluence the likelihood oI POI; they include
hyperhydration leading to bowel edema, hypokalemia, hyponatremia, acidosis, and hypoxia.
Pathophysiology
The pathophysiology oI POI is only partially understood. Gastrointestinal motility in the healthy
individual is inIluenced by a number oI Iactors, including dietary intake, the autonomic nervous system,
multiple hormones, and inIlammatory mediators. During the immediate postoperative period, the
peristaltic activity oI smooth muscle within the small bowel slows to irregular contractile waves
commonly labeled migrating motor complexes. Recovery Irom POI Iollows a stepwise pattern, beginning
with the small bowel, and progressing to the stomach and Iinally, the colon. The precise mechanisms that
regulate recovery are not entirely understood. Parasympathetic nerve activity, modulated by the vagus
nerve, is hypothesized to play a primary role in postoperative recovery.

Individual neurotransmitters,
including substance P that promotes motility and nitric oxide that play an inhibitory role, have also been
shown to exert considerable inIluence over gastric and bowel motility Iollowing surgery. In contrast, the
inIluence oI vasoactive intestinal polypeptide and motilin, 2 hormones known to play a signiIicant role in
motility during a normal, Ied state, remains unclear and attempts to modulate POI via exogenous hormone
replacement have shown little apparent eIIect.
3

Clinical experience and limited clinical evidence strongly suggest that the release oI inIlammatory
cytokines play an important role in reestablishing bowel motility aIter surgery.
6
For example, while
inIlammation oI the bowel due to peritonitis or extensive surgical manipulation tends to result in
especially severe and prolonged POI; the use oI minimally invasive surgical techniques and
administration oI the nonsteroidal anti-inIlammatory drug ketorolac tend to alleviate symptoms and
hasten the return oI gastric and bowel motility.
Treatment
The goals oI treatment Ior POI are to alleviate bothersome symptoms and adverse side eIIects oI motility
dysIunction, and to promote restoration oI normal gastrointestinal Iunction as soon as possible.
Management oI transient ileus traditionally relied on temporarily 'resting the bowel with or without
decompression via a nasogastric tube. Allowing the bowel to rest involves withholding solid Ioods during
the immediate postoperative period, and reintroducing Ioods slowly, beginning with sips oI clear liquids
and gradually increasing intake to solid Ioods based on ongoing clinical evaluation oI tolerance to
beverages and solid Ioods. Nasogastric tube decompression was oIten routinely employed Iollowing
major abdominal procedures, especially those that require signiIicant manipulation or reconstruction oI
the bowel. Gentle suction is used to decompress the bowel, and prevent distension, bloating, and
vomiting. AIter major abdominal surgery, the nasogastric tube may be leIt in place Ior 3 to 5 days, until
the patient passes Ilatus or experiences a bowel movement. While both oI these strategies were thought to
shorten POI by resting the bowel, emerging evidence suggests that neither strategy promotes the return oI
motility. In addition, a systematic review and meta-analysis oI the eIIects oI routine decompression via a
nasogastric tube Iound evidence that these tubes not only Iailed to reduce the duration oI POI, but they
were also associated with an increased risk oI adverse side eIIects such as aspiration and pneumonia.
11

More recent approaches to treatment have Iocused on eIIorts to restore gastric and bowel motility by
avoiding or alleviating Iactors associated with prolonged or severe ileus, and by implementing
interventions thought to stimulate bowel motility. Intraoperative strategies designed to alleviate Iactors
associated with prolonged POI include use oI regional anesthetic techniques rather than inhaled agents.
Surgeons can reduce the risk oI prolonged POI by use oI minimally invasive techniques whenever
Ieasible, by avoiding or gently manipulating the bowel during surgery, and by taking actions to minimize
blood loss.
During the immediate postoperative period, the duration oI POI may be diminished by limiting the use oI
opioid analgesics. As an alternative, some providers advocate administration oI nonsteroidal anti-
inIlammatory agents such as ketorolac in order to control pain and minimize inIlammation oI the bowel.
CareIul attention to Iluid and electrolyte homeostasis as well as avoidance oI metabolic acidosis is
recommended. Early ambulation is recommended because oI its potential to stimulate peristaltic activity.
In contrast to conventional wisdom, early Ieeding and selective use oI nasogastric tubes are also
advocated.
The use oI prokinetic drugs has long been advocated, and a number oI agents have been evaluated Ior
their potential role in the treatment oI POI. Recently, alvimopan (Entereg, Adolor, Glaxo-Smith Kline
Exton, PA and London, UK) has gained approval Irom the US Food and Drug Administration Ior
treatment oI POI. Alvimopan is a &b.mu;-opioid receptor agonist that acts peripherally to prevent the
adverse eIIects oI opioid analgesic agents on bowel motility without reversing the desired centrally acting
analgesic eIIects. The drug is administered as a 12-mg capsule twice daily Ior up to 7 days Iollowing
surgery. SaIety and eIIicacy oI the drug have been evaluated in multiple randomized controlled trials
(RCT), and it has been Iound to reduce POI by a range oI 7.5 to 22 hours. The most common adverse side
eIIects were constipation, dyspepsia, Ilatulence, anemia, hypokalemia, back pain, and urinary retention.
In addition to these interventions, chewing gum has been evaluated as a treatment Ior POI. Chewing gum
is advocated because it mimics the act oI eating, which is hypothesized to stimulate gastric and bowel
motility through repetitive stimulation oI the cephalic-vagal complex. Chewing gum is especially
attractive as a nursing intervention because it is potentially as eIIective as early Ieeding, inexpensive, and
not associated with serious adverse side eIIects. ThereIore, the purpose oI this Evidence-Based Report
Card is to review and evaluate evidence related to the saIety and eIIicacy oI chewing gum as an
intervention to reduce the duration oI POI.
ethods
In order to identiIy evidence Iocusing on the saIety and eIIicacy oI chewing gum on POI, we
systematically reviewed the literature Irom January 1996 to November 2009. We began our search using
the electronic databases CINAHL and MEDLINE. We combined the key term 'ileus with the term
'chewing gum. This search returned 21 citations. We then searched the Cochrane Library, using the
same key terms; this review returned a single uncompleted review. We hand searched the ancestry oI
pertinent research reports and review articles in order to identiIy additional studies; this review returned 2
unique citations not identiIied during our search oI the electronic databases identiIied in the previous text.
We also searched the Internet, using the Google Scholar search engine. This search revealed no novel
citations.
Inclusion criteria was (1) any study or meta-analysis oI multiple studies that compared chewing gum to no
treatment in patients undergoing abdominal surgery and creation oI an intestinal or urinary stoma.
Outcome measures evaluated were (1) time to passage oI Ilatus, (2) time to passage oI stool, or (3) length
oI hospital stay. Exclusion criteria were studies that did not measure at least one oI the outcome measures
oI interest, studies that did not speciIically include or speciIy that some or all subjects were undergoing
abdominal surgery and creation oI an ostomy. We also excluded studies that were not written in English.
Case studies, multiple case series, and descriptive studies were excluded. No study was eliminated Irom
consideration based on methodological quality alone, but quality considerations were weighed when the
level oI evidence was derived, and when recommendations Ior practice were generated. Each oI the
authors reviewed identiIied studies Ior inclusion or exclusion; disagreements were resolved by discussion.
Three meta-analyses and 4 studies that met inclusion criteria were reviewed.
Question: Does chewing gum shorten the duration oI POI in patients undergoing abdominal surgery and
creation oI a stoma?
Noble and colleagues reported a meta-analysis oI 437 patients who underwent a variety oI major
abdominal surgeries including radical cystectomy with creation oI an ileal conduit or orthotopic
neobladder, and laparoscopic or open colectomy with creation oI an intestinal stoma. Their systematic
literature review identiIied 9 published RCT comparing chewing gum to various types oI 'standard
postoperative care. Subjects randomly allocated to the active treatment chewed sugar Iree gum 3 to 4
times daily; the period oI chewing varied Irom 5 to 35 minutes. While no signiIicant diIIerences were
noted on demographic or pertinent clinical characteristics when intervention and control subjects were
compared in any oI the trials, considerable variability in the use oI other treatments designed to reduce the
duration oI POI, including Ieeding patterns, administration oI Iluids, and use oI prokinetic drugs was
Iound. In addition, the time oI randomization varied among studies, and one study included a sham group
who received an acupressure bracelet on the dorsum oI the wrist. Despite the heterogeneity oI Iindings
Irom these studies, meta-analysis oI pooled data revealed that chewing gum reduced the passage oI Ilatus
by an average interval oI 14 hours (95 CI 20 hours to 8 hours, ! .001). Chewing gum reduced the
time to passage oI stool by a average oI 23 hours compared to control subjects (95 CI 32 hours to 15
hours, ! .001). The intervention was also associated with a shorter length oI stay; subjects who chewed
gum were discharged on an average oI 1.1 days sooner than subjects who did not (95 CI 1.9 days to
0.2 days, ! .016).
Purkayastha and coworkers
31
reported results oI a meta-analysis oI pooled data extracted Irom 158
persons participating in 5 RCT that evaluated the eIIect oI chewing gum on the duration oI POI, including
2 studies that enrolled subjects undergoing Iormation oI an intestinal stoma. All oI the trials incorporated
into this systematic review
30
were also included in the analysis reported by Noble's group.
Purkayastha's group use the same outcome measures (time to Iirst passage oI Ilatus, time to Iirst stool,
hospital length oI stay) as Noble's group, but they limited their analysis to RCT oI patients undergoing
colectomy, with or without an intestinal stoma. Subjects allocated to the active intervention chewed
sugar-Iree gum 5 to 45 minutes 3 times daily. Despite these limitations in study design, Purkayastha and
coworkers
31
also reported heterogeneity within data extracted Ior meta-analysis. Similar to Noble's group,
they Iound that patients randomly allocated to chewing gum experienced a shorter time to passage oI
Ilatus (0.66 days compared to controls, 95 CI 1.11 days to 0.2 days, ! .005) and time to passage
oI stool (1.10 days compared to controls, 95 CI 1.79 days to 0.42 days, ! .02). However, subjects
who chewed gum did not have a signiIicantly shorter hospital stay when compared to those who did not
(1.25 days compared to controls, 95 CI 3.27 days to 0.77 days, ! 0.23). OI note, a secondary
analysis limited to 3 studies evaluated as having the highest methodologic quality Iound statistically
signiIicant diIIerences in all 3 outcomes (time to passage oI Ilatus, time to passage oI stool, and hospital
length oI stay). This additional analysis is worthy oI consideration because meta-analysis oI these selected
studies eliminated the heterogeneity measured during the initial analysis. It revealed an average reduction
in time to passage oI Ilatus oI 0.29 days (95 CI 0.44 days to 0.15 days, ! .001), an average
reduction in time to passage oI stool oI 1.76 days (95 CI 2.18 days to 0.71 days, ! .001), and an
average reduction in hospital length oI stay oI 2.46 days (95 CI 31.4 days to 1.97 days, ! .001).
Castro and associates systematically reviewed the literature and pooled data Irom the same 5 RCT
analyzed by Purkayastha's group. As anticipated, they reported similar results, with statistically
signiIicant reductions in time to passage oI Ilatus and stool in patients allocated to the gum chewing
intervention but no statistically signiIicant diIIerence in hospital length oI stay. Curiously, they used a
diIIerent technique Ior analyzing heterogeneity in the data and reported homogeneity in their pooled data;
this diIIers Irom the analyses reported by both Noble's group and Purkayastha's group.
Collectively the results oI these meta-analyses provide evidence that chewing gum reduces the duration oI
POI based on reductions in time to passage oI Ilatus and time to passage oI stool. Noble and
colleagues also Iound that patients who were randomly allocated to chewing gum had shorter hospital
length oI stay. Purkayastha and coworkers Iound no statistically signiIicant diIIerence in a meta-analysis
oI 5 studies oI patients undergoing colectomy with or without creation oI an ostomy, but they did report a
diIIerence during a secondary analysis oI 3 studies ranked as highest methodological quality. OI note,
analysis oI data within these studies revealed homogeneity, which was not Iound on either oI the larger
meta-analyses. Methodological weaknesses in these studies include considerable variability in individual
Iacility's approach to 'standard management oI POI. This variability included diIIerences in time oI Iirst
Ieeding, use oI prokinetic drugs, and time to ambulation that may have exerted a conIounding eIIect when
data were pooled Ior meta-analysis.
Watson and coinvestigators reported an abstract oI an RCT oI 53 patients undergoing colon resection,
with or without creation oI a colostomy. Twenty-six subjects were randomly allocated to standard
postoperative care (control) and 27 were allocated to standard postoperative care plus gum chewing 3
times daily Ior a period oI 30 minutes. No signiIicant diIIerences were detected when demographic
characteristics oI the groups were compared but diIIerences in some clinical characteristics were noted,
including the number oI patients undergoing ostomy surgery, and analgesia use. Subjects in the chewing
gum group experienced a shorter time to passage oI stool (74 hours vs 112.5 hours, ! .034). DiIIerences
in time to passage oI Ilatus (47 hours vs 67 hours, ! .062) and hospital length oI stay 130 hours vs 147
hours, ! .11) were not statistically signiIicant. OI note, the researchers also reported that patients who
chewed gum also experienced a shorter time to tolerate solid Ioods (39 hours vs 48 hours, ! .042). No
adverse side eIIects associated with chewing gum were reported.
Kouba and colleagues examined a group oI 102 patients undergoing radical cystectomy and creation oI an
ileal conduit or orthotopic neobladder in 102 patients undergoing treatment oI localized bladder cancer.
FiIty-one subjects were randomly allocated to a control group who received 'standard postoperative care
and 51 were allocated to gum chewing. Subjects in the intervention group were given 5 sticks oI sugar-
Iree chewing gum and directed to chew a piece every 2 to 4 hours; subjects were not directed to chew Ior
a speciIic period. No diIIerences were detected between groups based on demographic or pertinence
clinical characteristics. Subjects who chewed gum had signiIicantly reduced time to passage oI Ilatus (2.4
days vs 2.9 days,! .001) and time to passage oI stool (3.2 days vs 3.9 days, ! .001). However, the
length oI stay Ior the groups was not statistically signiIicant (4.7 days vs 5.1 days, ! .067).
Complication rates did diIIer between the groups (18 vs 20). OI note, 3 patients in the gum-chewing
group were described as having persistent ileus, and one required reinsertion oI a nasogastric tube. Two
patients in the control group experienced persistent POI and required reinsertion oI a nasogastric tube.
Matros and coinvestigators reported results oI an RCT oI 66 undergoing colectomy Ior colorectal cancer
or benign gastrointestinal disorders, including inIlammatory bowel disease. Subjects were randomly
allocated to 1 oI the 3 groups: (1) a control standard postoperative management that included sips oI
Iluids on postoperative day 1, (2) a placebo intervention group who received sips plus an acupressure
wrist bracelet, and (3) and an active intervention group who received sips and chewing gum. Patients
allocated to the gum intervention chewed a stick oI sugar-Iree gum Ior a period oI 45 minutes 3 times
daily. Twenty-one subjects were randomly assigned to the control group (sips alone), 23 to the placebo
group (sips plus wrist bracelet), and 22 to the active-therapy group (gum chewing). Subjects assigned to
gum chewing did not experience signiIicantly reduced time to passage oI Ilatus, passage oI stool, or
hospital length oI stay when compared with control or placebo group. No adverse side eIIects directly
related to gum chewing were reported. However, in a subsequent letter to the editor, LowenIels observed
that subjects allocated to gum chewing or the acupressure wrist bracelet had lower overall complication
rates than subjects in the control group (47 vs 11, ! .001).
Quah and associates reported results oI an RCT oI 38 subjects who underwent leIt-sided colectomy Ior
colorectal cancer, including 21 who underwent colostomy (3 6) or ileostomy (3 15). Nineteen subjects
were randomly allocated to standard postoperative treatment and 19 to gum chewing 3 times daily Ior
more than 5 minutes. Analysis revealed no diIIerences between the groups based on demographic or most
clinical characteristics, but subjects in the active intervention group were more likely to have undergone
preoperative radiation than were subjects in the control group. In addition, 3 subjects in the active
intervention did not receive chewing gum because oI the occurrence oI intercurrent postoperative
complications that precluded participation in the trial. No diIIerences in time to passage oI Ilatus, time to
passage oI stool, or hospital length oI stay were Iound when intervention and control group subjects were
compared. No adverse side eIIects directly related to chewing gum were reported; overall complication
rates between groups were not signiIicantly diIIerent.
Collectively, the Iindings oI these studies reveal mixed results when chewing gum is compared to
standard postoperative care in patients undergoing surgical reconstruction including creation oI a
colostomy, ileostomy, ileal conduit, or orthotopic neobladder. Two studies Iound statistically signiIicant
diIIerences in time to passage oI Ilatus and stool, but none revealed statistically signiIicant diIIerences in
hospital length oI stay. While these Iindings are suggestive, we do not yet have suIIicient evidence to
determine whether chewing gum reduces the duration oI POI in patients undergoing major abdominal
surgery including reconstruction oI the bowel in order to create an ostomy or orthotopic neobladder. The
studies are characterized by multiple limitations in design quality including small sample sizes, absence
oI multicenter trials, and lack oI subanalyses oI patients undergoing ostomy surgery. OI note, the single
study with the largest sample size and the only study that evaluated cystectomy and urinary diversion
Iound signiIicant diIIerences on 2 outcomes (time to passage oI Ilatus and stool) but no diIIerences in
length oI stay. In contrast, 2 oI the 3 studies that enrolled patients undergoing colectomy and ileostomy or
colostomy Iound no diIIerences and none Iound a signiIicant diIIerence in hospital length oI stay.
Whether these diIIerences reIlect the more substantial gastrointestinal reconstruction required Ior creation
oI an intestinal stoma versus the surgical manipulation necessary Ior resecting colorectal cancer or a
diseased bowel segment associated with inIlammatory bowel disease or diverticulitis is not known.
Clinical Implications
Given individual variability and the multiple clinical Iactors that alter the return oI bowel Iunction aIter
abdominal and, in particular, colorectal surgery, it is not surprising that there is no standard deIinition oI
POI. Nevertheless, our clinical experience suggests that the 'working deIinition oI 6 or more days
without intestinal Iunction advocated by Artinyan and coworkers
3
appears reasonable. Allowance oI 6
days coincides with a clinically signiIicant increase in nutritional risk and the need to evaluate options to
provide supplemental nutrition in a patient with POI. Additionally, our clinical experience strongly
suggests that POI lasting Ior more than 6 days may be indicative oI a surgical complication such as an
adhesive band, volvulus, or abdominal sepsis.
From a clinical perspective, the use oI chewing gum to help decrease POI is intriguing. It is a simple
modality, inexpensive, with no known adverse eIIects as evidenced by the clinical studies reviewed. At
the Cleveland Clinic, we established a protocol several years ago Ior 'Iast tracking patients. This
management plan includes no routine use oI a nasogastric tube, ambulation 5 times a day, beginning the
Iirst postoperative day; the use oI nonopioid analgesia Ior management oI pain using patient controlled
analgesia; and early Ieeding, beginning with sips oI clears on the day oI surgery and advancing to what
we term a GI soIt diet, Ioods that digest easily without Iibrous residue, as tolerated. Initially, a sugarless
chewing gum was used as part oI this plan, being given to patients 4 times a day and chewed Ior a Iew
minutes. In recent times, the chewing gum is not being routinely given but oIIered on an as-needed basis,
mainly Ior patient comIort.
It seems reasonable that chewing gum be oIIered to selected patients with the intent oI decreasing POI.
Nevertheless, questions about the use oI chewing gum persist such as its role in reducing the duration oI
POI in patients who have had complex surgeries, such as multiple anastomosis and those requiring
extended intraoperative times. The role oI chewing gum Ior those with abdominal sepsis and its eIIicacy
among individuals with a nasogastric tube is also unclear. However, Ior the majority oI patients with a
straightIorward operation, routine use oI chewing gum seems reasonable. Our review oI existing evidence
reveals that chewing gum lessens time to postoperative Ilatus and stool passage, and, in some cases,
shortened length oI stay. In addition, we Iound no reports oI serious adverse side eIIects Irom gum
chewing. Chewing gum can also be advocated based on the lack oI expense associated with its
implementation. Early return oI bowel Iunction increases patient comIort, so, even though length oI stay
may not be impacted to a level oI statistical signiIicance, the use oI chewing gum is beneIicial when
viewed Irom a nursing perspective.
We advocate careIul selection oI patients managed by chewing gum. A careIul nursing assessment should
evaluate mental status (ie, is the patient alert enough to chew the gum?), aspiration risk, and dentition (do
they have suIIicient teeth to eIIectively chew the gum or, iI dentures are used, are they available?). From
the data reviewed, no deIinitive parameters Ior the use oI chewing gum have been identiIied; studies
varied Irom chewing a stick oI sugarless gum 3 to 4 times per day Ior 5 to 45 minutes to using a total oI 5
sticks a day every 2 to 4 hours with no speciIic 'chew time. The mechanism oI action Ior gum chewing
decreasing POI is thought to be a 'sham Ieeding, deriving the beneIit oI chewing while not actually
adding Iood to the intestinal system. II that is so, an additional question arises, once a diet is tolerated, is
there any role Ior gum chewing? Would this diet include clear liquids, Iull liquids, or soIt solid Ioods? II a
diet is tolerated on postoperative day 1, is gum chewing still beneIicial? Further research to Iind the most
appropriate protocols as well as the role oI gum chewing with initiation oI early Ieeding is clearly needed.
As noted earlier, alvimopan, also known as Entereg, has been Iound to accelerate the time to
gastrointestinal motility Iollowing small- or large-bowel resection by a range oI 7.5 to 22 hours. It is
recommended that Entereg be used as an adjunct along with early mobility, removal oI the nasogastric
tube within 24 hours oI surgery, and early oral Ieeding. It would be interesting to determine whether the
addition oI a planned schedule oI chewing gum along with alvimopan would Iurther decrease the time to
the passing oI Ilatus and stool with a potential Ior decreasing length oI stay.

Results
Results oI meta-analyses support the use oI chewing gum Ior treatment oI postoperative ileus. Chewing
gum was consistently Iound to reduce time to passage oI Ilatus and stool. One meta-analysis Iound that
chewing gum reduced hospital stay but two Iound no diIIerence. Analysis oI studies reveal mixed results
when chewing gum was compared to standard postoperative care in patients undergoing surgical
reconstruction including ostomy surgery or creation oI an orthotopic neobladder. The studies we reviewed
were characterized by multiple limitations in design quality including small sample sizes, absence oI
multicenter trials, and lack oI subanalyses oI patients undergoing ostomy surgery.

SUARY:
Postoperative ileus is a temporary disturbance in gastric and bowel motility Iollowing surgery. The risk
Ior postoperative ileus Iollowing gastrointestinal and urinary ostomy surgery is signiIicant because both
procedures require extensive surgical manipulation and reconstruction oI the bowel. Chewing gum is
advocated Ior treatment because it acts as sham Ieeding, potentially stimulating gastric and bowel motility
through repetitive stimulation oI the cephalic-vagal complex.
This Evidence-Based Report Card reviews and evaluates evidence related to the saIety and eIIicacy oI
chewing gum as an intervention to reduce the duration oI postoperative ileus.
We systematically reviewed the electronic databases CINAHL and MEDLINE Irom January 1996 to
November 2009, using the terms 'ileus and 'chewing gum. We also searched the ancestry oI the 21
articles returned by this review and searched Google Scholar. We included any study or meta-analysis oI
multiple studies that compared chewing gum to no treatment in patients undergoing abdominal surgery
and creation oI an intestinal or urinary stoma. We evaluated the Iollowing outcome measures: (1) time to
passage oI Ilatus, (2) time to passage oI stool, or (3) length oI hospital stay. Three meta-analyses and 4
studies met inclusion criteria.
Results oI meta-analyses support the use oI chewing gum Ior treatment oI postoperative ileus. Chewing
gum was consistently Iound to reduce time to passage oI Ilatus and stool. One meta-analysis Iound that
chewing gum reduced hospital stay but two Iound no diIIerence. Analysis oI studies reveal mixed results
when chewing gum was compared to standard postoperative care in patients undergoing surgical
reconstruction including ostomy surgery or creation oI an orthotopic neobladder. The studies we reviewed
were characterized by multiple limitations in design quality including small sample sizes, absence oI
multicenter trials, and lack oI subanalyses oI patients undergoing ostomy surgery.
It is commonly but incorrectly assumed that a clinician who is successIul in medical practice can easily
transIer those skills to the duties oI managing (or leading) a surgical suite. However, leadership and
management in Iields such as medicine require speciIic talents, study, and experience. It is necessary Ior
nurses to manage patient`s needs Irom the day oI admission to the Operating Room until prevention oI
Post Operative complications. It is a help Ior the patient to alleviate signs oI pains and discomIorts due to
surgery.
Surgical stress is a primary contributor to POI; thereIore, strategies that minimize surgical trauma and
bowel manipulation should theoretically reduce the duration or extent oI POI. A meta-analysis oI 25
studies (3526 patients) oI colorectal surgery demonstrated earlier passage oI Ilatus (1 day), earlier bowel
movement (0.9 days), a signiIicant reduction in postoperative pain as assessed by visual analog scale
(Iirst postoperative day), and shortened hospital length oI stay (1.5 days) associated with laparoscopic
compared with open surgery. Limitations associated with laparoscopic surgery include the specialized
training required Ior perIorming such surgeries, operative time may be longer Ior laparoscopic
procedures, and not all procedures are amenable to the laparoscopic approach. Implementation oI Iast-
track, multimodal surgical protocols may also minimize some oI the previously demonstrated diIIerences
between open and laparoscopic surgeries.
ey Points
There is suIIicient evidence to conclude that chewing gum shortens time to passage oI Ilatus and stool
in patients undergoing abdominal surgery (Level oI evidence: 1).
There is insuIIicient evidence to determine whether chewing gum reduces hospital length oI stay.
Mixed Iindings suggest that the intervention may reduce length oI stay but additional research is needed
beIore a deIinitive conclusion can be reached (Level oI evidence: 3).
There is insuIIicient evidence to determine whether chewing gum reduces the duration oI POI in
patients undergoing ostomy surgery. Mixed Iindings suggest that the intervention may be eIIective in
patients undergoing cystectomy and creation oI an ileal conduit or orthotopic neobladder. Mixed Iindings
suggest that the intervention may be less eIIective in patients undergoing the more extensive bowel
reconstruction needed to treat colorectal cancer or benign disorders and creation oI an intestinal stoma
(Level oI evidence: 3).
Chewing gum has not been linked to serious adverse side eIIects (Level oI evidence: 1).
In Nursing Profession,
It helps nurses to be independent and to manage patient`s needs by themselves. It encouraged nurses to be
globally competent and independent nurses. Superhuman eIIort, Ior example, rushing around on the day
oI surgery trying to reduce turnover times, can be dangerous and stressIul with little Iinancial
justiIication. On the day oI surgery, the best way to proceed is by simply taking care oI each patient in a
relaxed, cheerIul, and supportive manner, having done most oI the thoughtIul planning ahead oI time.
It is commonly but incorrectly assumed that a clinician who is successIul in medical practice can easily
transIer those skills to the duties oI managing (or leading) a surgical suite. However, leadership and
management in Iields such as nursing require speciIic talents, study, and experience.
Current best evidence suggests that chewing gum should be oIIered to selected patients with the intent oI
decreasing postoperative ileus. A careIul nursing assessment oI the patient's mental status, aspiration risk,
and dentition is needed beIore initiating the intervention.
Nurses working in the Surgical Ward should understand eIIiciency as individual knowledge and
experience applicable to the care oI the patient as well as preventing problems beIore they occur, whereas
managers understand eIIiciency in terms oI production per unit oI time or completing assignments as
planned. Nurses must also learn to reduce the risk and complications oI their patients. They must learn
how to be resourceIul and creative in caring Ior their patients.
In Nursing Research
It serves as a reIerence Ior other researches and Iurther studies to improve this approach. It is a very
interesting topic Ior improvement since it is a usual complication oI abdominal and other surgeries. Future
improvements oI this strategy will include better identiIication oI patients at risk Ior the development oI
POI, patient-centered care, pharmacologic modiIication oI the stress response to minimize the negative
eIIects on GI motility, multidisciplinary post-anesthesia care units, updated clinical pathways, and
incorporation oI services to Iacilitate postsurgical patient rehabilitation. Such improvements should help
to minimize the burden oI POI Ior the patient, but also reduce the burden oI POI on the health care
system.
Nurse Researcher must keep in mind that doing a research will help the patient avoid Irom complications,
income and money, eIIort, time, and other that will increase the burden oI the patient. It will result to the
discovery oI evidenced based and more patient centered care.
In addition, Iurther research is needed to develop more clearly deIined parameters Ior chewing gum
including Irequency and duration oI chewing and its use in patients with nasogastric tubes.
By doing these, nurses will be able to enhance patient care and the health care delivery system specially
in prevention oI complications oI a surgery. Thus, nurses will become globally competitive and evidence
based practice nurses in the Iuture.
In Nursing Education
It guides the students to learn new skills Ior the betterment oI their patients. Common to the success oI
these programs are strong and determined leadership at the advanced practice nursing level, a
commitment to patient-centered pain care, administrative support, and the ability to improve patient
outcomes
It may be suggested to the academe to include managing post operative complications such as the
postoperative ileus in subjects such as skills lecture in the Surgical Nursing. The approach to management
oI postoperative ileus includes training oI bedside nurses to serve as resource nurses Ior each patient care
area. The resource nurses educate staII and provide unit-based support Ior staII in the provision oI care.
Tools must be developed to assist the resource nurses in the education oI unit staII and student nurses. It
may be also applied to their patients in Iar communities and the knowledge will continue to spread Ior the
betterment oI the Filipino Society.
By doing so, students are trained to be a globally competitive and indispensable Surgical nurses in the
Iuture. It must be remembered that the Iormal education Ior these nurses starts at the academe. ThereIore,
trainings and seminars may also conducted to the Iaculty and staIIs oI the School oI Nursing, Ior they are
the one that are molding these students to be the Iuture heroes oI the world.
REFERENCE:
http://staging.journals.pointbridge.com/jwocnonline/Fulltext/2010/03000/DoesChewingGumShorten
theDurationoI.6.aspx
SAINT LOUIS UNIVERSITY
SCHOOL OF NURSING
BAGUIO CITY PHILIPPINES

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PREPARED BY:
GALI CHARLES 1OSEPH C.
BSN IVA1

SUBITTED TO:
R. GENEROSO PISTOLA RN
SLUCI