Postoperative ileus is common after abdominal opera- tions in Africa. It is a cause of prolonged stay in hospitals after surgery.


Introduction

Postoperative ileus is common after abdominal opera- tions in Africa. It is a cause of prolonged stay in hospitals after surgery. It is one of the factors increasing postoper- ative morbidity in our milieu. This was observed after abdominal surgery like colectomy, gastrectomy and even appendectomy. Many treatments have been used to fight against postoperative ileus. Among them, the use of naso- gastric intubation was for many years the mainstay of treatment ; but recent studies conclude that nasogastric decompression does not shorten the time to first bowel movement or decrease the time to adequate oral intake (1). In the same way, some drugs have proved their efficiency : KREIS et al. (2) recently found that neostig- mine therapy significantly increased colonic motility in the early postoperativeperiod in patients undergoing col- orectal surgery. For their part, KEHLET et al. used early feeding to tackle postoperative ileus and stimulate gut motility (3). An alternative approach to stimulate bowel function in the postoperative period was described by ASAO et al. and consisted of sham feeding in the form of chewing gum following laparoscopic colectomy (4), which resulted in earlier hospital discharge.

In Africa, and especially in Cameroon, postoperative ileus is common after abdominal surgery. Morbidity is higher because of the delay to consult, a prolonged hos- pital stay, all of which leads to high cost whereas most of the people are poor. All those means that could facilitate the postoperative evolution therefore seem useful. Our concern is appendectomy, which is the most common surgical operation in our milieu. The purpose of our study was to compare two groups of patients : the first group chewing gum after open appendectomy, the sec- ond group being a control group in order to measure the time it takes for bowel function to resume, the length of hospital stay, and complications.

Methods

This was a randomized and prospective study. It started in January 2006 and was conducted in the Yaounde General Hospital. Patients were recruited from outpatient consultations and also from the emergency unit. They were chosen from among those complaining of abdomi- nal pain. Patients eligible for the study were those who clearly

consented to participate in the study, who had undergone

Acta Chir Belg, 2010, 110, 195-199

Chewing Gum Reduces Postoperative Ileus after Open Appendectomy

M. N. Ngowe**, V. C. Eyenga**, B. H. Kengne*, J. Bahebeck***, A. M. Sosso****

*Department of Surgery, **Senior Lecturer in Surgery, ***Assistant Professor of Surgery, ****Professor of Surgery, Head of Department of Surgery, Faculty of Medicine and Biomedical Sciences (F.M.B.S.), Yaounde General Hospital, PMB : 5408 Yaounde, Cameroon.

Key words. Chewing gum ; appendectomy ; ileus ; flatus.

Abstract. Hypothesis : It is suggested that chewing gum may accelerate postoperative intestinal transit recovery. Chewing gum may therefore produce the same result after open appendectomy. Design and setting : Prospective, randomized study in a University teaching hospital. Patients : 46 patients operated on by open appendectomy due to acute catarrhal appendicitis, appendicular abscess and appendicular generalized peritonitis. Main outcome measures : Interest was in occurrence of first flatus, first bowel movement, hospital duration and compli- cations. Results : A total of 46 patients were randomly divided into two groups : a chewing gum group (n = 23) and a control group (n = 23). In the first group, patients chewed sugarless gum for 30 minutes thrice daily until resumption of intes- tinal transit. Patient demographics, intra-operative, and postoperative care were the same for both groups. Chewing gum was well tolerated by all the patients. The first passage of flatus occurred on postoperative day 2.2 in the gum-chewing group and on day 3.0 in the control group (P < 0.0001). The first bowel movement occurred at postoperative day 2.3 in the chewing gum group and at post- operative day 3.3 in the control group (P < 0.0001). Five complications were noted overall. Hospital stay was shorter in the chewing gum group (4.9 days.) than in the control group (6.7 days), (P < 0.0001). Conclusion : Chewing gum ameliorates recovery after open appendectomy by reducing postoperative ileus. It is a cheap and helpful treatment to be recommended in developing countries in Africa.

 

 

196 M. N. Ngowe et al.

open appendectomy, be it elective or in emergency, irre- spective of sex, and aged more than 16 years old. All patients less than 16 years old were excluded. Patients undergoing abdominal surgery without appendectomy were also excluded. A questionnaire was designed to record patients’ data. For the study, patients were randomly assigned to

chew gum, or not, after surgery. We did a simple random- ization by allocating the first patient into the chewing gum group and the next one into the control group, this being repeated over and over until 46 cases were obtained. We had problems to get sugarless chewing gum

because there was limited stock available in our main town of Yaounde. We bought all the stock available in a supermarket, comprising a box of 25 sugarless chewing gum. Two of these chewing gums were spoiled and we were left with 23 of them, limiting our sample to these 23 chewing gum patients in the chewing gum group. We decided to complete the sample by selecting 23 patients to constitute the control group, for a final sample of 46 patients. For the patients selected for the chewing gum group, we made sure that they would chew the sug- arless gum by asking a member of the surgical team to give the gum as soon as the patient became conscious (generally a nurse in the intensive care unit where all the patients were first admitted after surgery). After giving each dose of chewing gum, the nurse had to note this on the patient’s questionnaire. The time it was given and the chewing time could therefore be checked by the medical doctor. Patients chewed sugarless gum for 30 minutes thrice daily i.e., morning, afternoon, and evening. All the patients were operated on by laparotomy, via the sub- umbilical route through a McBurney incision or a midline incision. In all the cases appendectomy was done, associated with or without drainage and in some cases we performed adhesiolysis. General anaesthesia was used in all cases, consisting

of Thiopental, Fentanyl or Vecuronium bromide ; no epidural anaesthesia was applied. In the postoperative

period, feeding started after the passage of the first fla- tus, beginning with fluids on the first day, followed the next day by a semi-fluid diet to reach the normal diet on the third day. Postoperative analgesia was achieved with Paracetamol infusions started at the end of the surgery : a 100 cc infusion was given twice or thrice a day depend- ing on the patient’s weight, for a total dose of 60 mg/kg/day. The first flatus, first bowel movement and postoperative findings were recorded every day on the patient’s questionnaire. The mobilization of the patients started on day one after surgery. Statistical analysis was done using a Mann-Whitney

U test, considering statistical significance at the level of P < 0.05 for compared variables. The software used for this purpose was the Statistical Package for the Social Sciences (SPSS) version 10.1.

Results

Forty-six patients were chosen for the study : 23 patients were randomly allocated to the chewing gum group and 23 patients to the control group. We had 26 men and 20 women (sex ratio : 1.3). Their ages ranged from 17 to 73 years. There were no differences in age and sex between the two groups. Among the patients, 31 lived in town and 15 came from rural areas. Clinical features are summarized in Table I. In all the cases appendectomy was performed : anterograde appendectomy was done in 38 cases (20 cases in the control group and 18 in the chewing gum group) whereas the retrograde tech- nique was applied in eight cases (four cases in each group) (Table II). Other surgical modalities comprised adhesiolysis (moderate or extensive) and drainage of the right iliac fossa). The duration of surgery varied from 95 to 150 minutes with means of 112.6 (15.7) and 109.1 minutes (13) for each group (P = 0.537). No intra- operative complication was encountered. (Table III). Postoperative analgesia consisted of intravenous infu- sions of Paracetamol, a non-morphinic drug. All the 23 patients selected for chewing gum tolerated it well

Table I

Patient clinical features

Characteristic Control Group (n = 23) Chewing gum Group (n = 23)

Age (years) Mean (SD) 43.7 (10) 42.4 (8.6) Female-male ratio 10:13 10:13 City dwellers 16 15 Rural dwellers 8 7 Catarrhal appendicitis 10 17 Appendicular abscesses 6 6 General peritonitis 4 3

Abbreviation : SD = standard deviation.

 

 

Chewing Gum Reduces Postoperative Ileus 197

until bowel function resumed. Mobilization for all patients began on the first postoperative day. The first passage of flatus occurred at postoperative day 2.2 (0.4) in the chewing gum group and at day 3.6 (0.6) in the control group (P < 0.0001). The first bowel movement occurred at post operative day 2.3 (0.3) in the chewing gum group and at day 3.3 (0.4) in the control group (P < 0.0001). There were five cases of surgical complica- tions ; all were parietal abscesses, three in the chewing gum group and two in the control group. All of them were treated with local daily dressings and elective antibiotics. Concerning the postoperative period, we found a mean time of 4.9 days (0.8) for the chewing gum group whereas we noticed a longer period in the control group with a mean time of 6.7 days (1) with P < 0.0001 (Table IV). Statistical analyses are summarized in Table V.

Discussion

In our study, we noticed more men than women, as is usually found in our milieu and elsewhere when dealing with appendicitis and appendectomy (5, 6). Different aetiologies were reported, the commonest of them being catarrhal appendicitis, followed by appendicular abscess- es ; this supported the emergency of the appendectomies carried out. In all the cases appendectomy was feasible alone or in association with adhesiolysis and/or drainage of the right iliac fossa (7). After open appendectomy, hospital stay was variable between 3 and 9 days (8). Long hospital stays may be associated with complica- tions. Often, many factors contribute to a long hospital

stay after laparotomy, particularly after appendectomy, the commonest factor among them being paralytic ileus. Different causes of postoperative ileus are reported,

such as the operations themselves by inhibiting the pro- motility hormones gastrin, neurotensin, and pancreatic polypeptide (9). It can also be explained by an intestinal motility default due to sympathetic stimulation dysfunc- tion with reflex inhibition (10). LUCKEY et al. (11) explained ileus as a result of a combination of factors, including the stress response to the surgery, the pain, the opiates used to treat the pain, and gut oedema. Chewing a stick of gum is thought to represent a form

of ‘sham feeding’, whereby a food substance is chewed, but does not enter the stomach ; it is thought that sham feeding accelerates bowel function. It achieves this by a combination of mechanisms, including an increase in the vagal cholinergic stimulation of the gut, which in turn leads to the release of gastrointestinal hormones such as gastrin, neurotensin and pancreatic polypeptide (12). Several studies support the opinion that chewing gum ameliorates postoperative ileus in general (13, 14, 15, 16). More specifically, chewing gum enhances bowel function after colectomy (17), laparoscopic colecto- my (18) and after cystectomy (19, 20). LEIR (21) report- ed that chewing gum may activate postoperative gastric motility. Despite the fact that laparoscopic surgery was not used in our study, our data showed first flatus return within an average of 2.2 days after elective open appen- dectomy in our chewing gum patients while it was longer in the control group with 3.0 days ; this was statistically significant. In our patients, gum chewing decreased the time to bowel movement by 1 day, and hospital stay by

Table II

Surgical procedures

Procedure Control Group (n = 23) Chewing Gum Group (n = 23)

Appendectomy Mc Burney route 19 20 Midline laparotomy 04 03

Others : Drainage 07 05 Adhesiolysis 04 03

Table III

Operative findings

Characteristic Control Group Chewing Gum Group P Value (n = 23) (n = 23)

Duration of surgery (min) Mean (SD) 109. 1 (13.8) 112.6 (15.7) 0.537 Intra-operative complications 0 0 Extensive adhesiolysis 04 03

Abbreviation : min = minutes. SD = standard deviation.

 

 

198 M. N. Ngowe et al.

1.8 days. Our study shows that bowel function after open appendectomy was enhanced by chewing gum. Our data therefore showed amelioration of post appendectomy ileus after chewing gum. This was in accord with all the previous studies we have quoted and our results were in contradiction to EVANS (22) and QUAH (23) whose studies did not find any enhancing action of chewing gum in the postoperative period. Patients who chewed gum were found to leave the hospital earlier. We found a statistical significance in the delay to obtain the first flatus, the starting time of bowel movement, and postoperative hospital stay in our study.

Conclusion

Our study carried out in Yaoundé (Cameroon) comprised 46 patients, 23 of them constituted a control group and 23 a chewing gum group. The study assessed the effect of chewing gum on postoperative ileus. It appears that gum chewing ameliorates recovery after open appendec- tomy by reducing postoperative ileus. It is a cheap and helpful treatment to recommend in developing countries in Africa.

References

1. SAGAR P. M., KRUEGENER G., MACFIE J. Nasogastric intubation and elective abdominal surgery. Br J Surg, 1992, 79 : 1127-1137.

2. KREIS M. E., KASPAREK M., ZITTEL T. T., BECKER H. D., JEHLE E. C. Neostigmine increases postoperative colonic motility in patients undergoing colorectal surgery. Surgery, 2001, 130 : 449-456.

3. KEHLET H., WILMORE D. W. Multi-modal strategies to improve surgical outcome. Am J Surg, 2002, 183 : 630-641.

4. ASAO T., KUWANO H., NAKAMURA J. I., HIRAYAMA I., IDE M. Chewing gum enhances early recovery from postoperative ileus after laparo- scopic colectomy. J Am Coll Surg, 2002, 195 : 30-32.

5. NGOWE NGOWE M., BISSOU MAHOP J., EYENGA V. C., PISOH- TANGNYM C., SOSSO A. M. Current clinical features of acute appen- dicitis in adults, in Yaounde, Cameroon. Bull Soc Pathol Exot, 2008, 101 (5) : 398.

6. MARGENTHALER J. A., LONGO W. E., VIRGO K. S. et al. Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults. Ann Surg, 2003, 238 (1) : 59-66.

7. MENEGAUX F. Acute appendicitis. In : CARLIOU P., RIOU B., TELION C. (ed.). Medico Surgical Emergencies in Adults. 2nd ed. Paris : Arnette, 2004 : 486-490.

8. AGUILO J., PEIRO S., MUNOZ C. et al. Adverse outcomes in the surgical treatment of acute appendicitis. Cir Esp, 2005, 78 (5) : 312-317.

9. RESNICK J., GREENWALD D. A., BRANDT L. J. Delayed gastric emptying and postoperative ileus after non-gastric abdominal surgery : part I. Am J Gastroenterol, 1997, 92 : 751-762.

10. HENRY M. H., THOMSON J. N. Frequent causes of intestinal ileus in clinical surgery. WB. Saunders, Harcourt Publishers, 2001 : 334- 335.

Table IV

Postoperative Care and Findings

Characteristic Chewing Gum Group Control Group P Value (n = 23) (n = 23)

Postoperative analgesia 23 23 (Paracetamol)

Complications Parietal sepsis 3 2

Time of first flatus (d) Mean (SD) 2.2 (0.4) 3.0 (0.6) 0.0001

Time of first bowel movement (d) Mean (SD) 2.3 (0.3) 3.3 (0.4) 0.0001

Length of hospital stay (d) Mean (SD) 4.9 (0.8) 6.7 (1) 0.0001

Abbreviation : d = day. SD = standard deviation.

Table V

Mann-Whitney U Test results

Test (a)

Duration of Surgery Hospital duration Occurrence of first flatus Occurrence of first bowel movement

Mann-Whitney U Test 236.500 51.000 69.500 95.500

Wilcoxon W 512.500 327.000 345.500 371.500

Z -0.618 -4.847 -4.703 -4.038

Significance level (bilateral) 0.537 0.000 0.000 0.000

a group criteria : VAR00002

 

 

Chewing Gum Reduces Postoperative Ileus 199

11. LUCKEY A., LIVINGSTONE E., TACHEY. Mechanisms and treatment of postoperative ileus. Arch Surg, 2003, 138 : 206-214.

12. MCCORMICK J. T., GARVIN R., CAUSHAI P. et al. The effects of gum chewing on bowel function and hospital stay after laparoscopic vs open colectomy : a multi-institution prospective randomized trial. Am J Coll Surg, 2005, 3 : 66-67.

13-VASQUEZ W., HERNANDEZ A. V., GARCIA-SABRIDO J. L. Is gum chewing useful for ileus after elective colorectal surgery ? A systematic review and meta-analysis of randomized clinical trials. J Gastro Intest Surg, 2009, 13 (4) : 649-656.

14. DE CASTRO S. M., VAN DEN ESSCHERT J. W., VAN HEEK N. T et al.A systematic review of the efficacy of gum chewing for the amelio- ration of postoperative ileus. Dig Surg, 2008, 25 (1) : 39-45.

15. CHAN M. K., LAW W. L. Use of chewing gum in reducing post – operative ileus after elective colorectal resection : a systematic review. Dis Colon Rectum, 2007, 50 (12) : 2149-2157.

16. NILOFF P. H. Does gum chewing ameliorate postoperative ileus ? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg, 2006, 203 (3) : 405.

17. PURKAYASTHA S., TILNEY H. S., DARZI A. W., TEKKIS P. P. A meta- analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg, 2008, 143 (8) : 788-793.

18. SCHUSTER R., GREWAL N., GREANEY G. C., WAXMAN K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg, 2006, 141 : 174-176.

19. MEYER J. P., FAWCETT D. The use of chewing gum for preventing postoperative ileus. BJU International, 2007, 101 (1) : 1-2.

20. KOUBA E. J., WALLEN E. M., PRUTHI R. S. Gum chewing stimulates bowel motility in patients undergoing radical cystectomy with urinary diversion. Urology, 2007, 70 (6) : 1053-1056.

21. LEIER H. Does gum chewing help prevent impaired gastric motili- ty in the postoperative period ? J Am Acad Nurse Pract, 2007, 19 (3) : 133-136.

22. MATROS E., ROCHA F., ZINNER M., WANG J., ASHLEY S., BREEN E., SOYBEL D., SHOJI B., BURGESS A., BLEDAY R., KUNTZ R., WHANG E. Does gum chewing ameliorate postoperative ileus ? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg, 2006, 202 (5) : 773-778.

23. QUAH H. M. Does gum chewing reduce postoperative ileus follow- ing open colectomy for left-sided colon and rectal cancer ? A prospective, randomized, controlled trial. Colorectal Dis, 2006, 8 (1) : 64-70.

Dr. M. N. Ngowe Faculty of Medicine and Biomedical Sciences (F.M.B.S.) Yaounde General Hospital PMB : 7951 Yaounde-Cameroon Tel. : 00 237 99 93 09 72 / 00 237 77 21 68 58. E-mail : nkouki2002@yahoo.fr

 

 

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