CLINICAL OUTCOME OF CHEWING GUM ON BOWEL MOTILITY AMONG PATIENTS UNDERGOING ABDOMINAL SURGERY

Postopera ve ileus is a one of the important and consistent effect of major abdominal surgery. While the pathophysiology is mul factorial and not well understood, it leads to significant morbidity, and is a frequently leads to gastroenterological referral. It is defined as transient inhibi on of normal gastrointes nal mo lity in the postopera ve se ng, typically las ng 35 days a er surgery [1]. 40% of pa ents undergoing laparotomy are met with postopera ve ileus [2]. It is characterized by abdominal


INTRODUCTION
Postopera ve ileus is a one of the important and consistent effect of major abdominal surgery. While the pathophysiology is mul factorial and not well understood, it leads to significant morbidity, and is a frequently leads to gastroenterological referral. It is defined as transient inhibi on of normal gastrointes nal mo lity in the postopera ve se ng, typically las ng 3-5 days a er surgery [1]. 40% of pa ents undergoing laparotomy are met with postopera ve ileus [2]. It is characterized by abdominal them the use of chewing gum also has emerged as a new, simple, readily available and cost effec ve modality for decreasing POI. It acts by s mula ng intes nal mo lity through cephalic vagal reflex and by increasing the produc on of gastrointes nal hormones associated with bowel mo lity that result in early return of bowel sounds, passage of flatus and return of appe te. Hence the researcher has taken up the study to evaluate the efficacy of chewing gum on bowel mo lity a er abdominal surgery [6]. Hence the present study was done at our ter ary care centre to evaluate the efficacy of chewing gum on bowel mo lity among pa ents who have undergone abdominal surgery. Aim & Objec ve: To evaluate the efficacy of chewing gum on bowel mo lity among pa ents who have undergone abdominal surgery.

MATERIALS AND METHODS
Study design: Non randomized clinical trial Ethics approval: The study was conducted a er approval of ethics commi ee approval and informed consent was taken from the all par cipants. Exclusion criteria: Pa ents who were pregnant or lacta ng, who did not develop paraly c ileus post operavely, who were cri cally ill with mul -organ failure were excluded from the study. Sample size: Considering a confidence level of 95% and confidence interval of 7 the number of pa ents in our study to achieve sta s cal significance is 196. This was calculated by Survey System. Hence a sample size of 200 was considered adequate for our study. Grouping: Divided into 2 grouping based on the received chewing gum or not in addi on to standard postopera ve care.

Methodology
The details of pa ents along with diagnosis, comorbidi es, dura on of anesthesia & surgery and postopera ve stay were recorded. According to whether the pa ent received chewing gum, the pa ents were grouped as Cases (that received chewing gum in addion to standard postopera ve care) and Control (that received standard postopera ve care). The pa ents were observed for Peristal c Sounds, Flatus passed, Stool Passed, return of appe te and me was recorded.

RESULTS
A hospital based compara ve study was conducted with 200 pa ents to evaluate the efficacy of chewing gum on bowel mo lity among pa ents who have undergone abdominal surgery. Each group consisted of 100 pa ents.

Figure 1: Distribu on of pa ents according to Age
Majority of the pa ents in Cases Group were in the age group of 40-50 years (42%) followed by 51-71 years (34%), 25-40 years (16%) and 21-25 years (8%). The mean age of the pa ents was 47.3±12.97 years. Majority of the pa ents in Control Group were in the age group of 40-50 years (45%) followed by 51-71 years (33%), 25-40 years (15%) and 21-25 years (7%). The mean age of the pa ents was 47.0±12.35 years. There was no significant difference between the groups as per Student t-test (p>0.05).

Figure 2: Distribu on of pa ents according to Sex
There were 40 (40%) male and 60 (60%) female paents in Cases Group while there was 45 (45%) male and 55 (55%) female pa ents in Control Group. There was no significant difference between the groups as per Fisher test (p>0.05). 7 (23.3%) pa ents in Cases Group had hypertension while 5 (16.7%) pa ents had diabetes mellitus. 8 (26.8%) pa ents in Control Group had hypertension while 4 (13.4%) pa ents had diabetes mellitus. There was no significant difference between the groups as per Chi-Square test (p>0.05). There was no significant difference between the groups as per Chi-Square test (p>0.05).

DISCUSSION
In the present study, majority of the pa ents in Cases Group were in the age group of 40-50 years (42%) followed by 51-71 years (34%), 25-40 years (16%) and 21-25 years (8%). The mean age of the pa ents was 47.3±12.97 years. Majority of the pa ents in Control Group were in the age group of 40-50 years (45%) followed by 51-71 years (33%), 25-40 years (15%) and 21-25 years (7%). The mean age of the pa ents was 47.0±12.35 years. There was no significant difference between the groups as per Student t-test (p>0.05). There were 40 (40%) male and 60 (60%) female paents in Cases Group while there was 45 (45%) male and 55 (55%) female pa ents in Control Group. There was no significant difference between the groups as per Fisher test (p>0.05). Neena et al 6  were in the age group of 36-55 years in the experimental group and less than half (46.6%) were in the age group of 36-55years in control group. As per gender, 18(60%) and 16(53.3%) of the subjects were female in the experimental and the control group respecvely. In our study, 7 (23.3%) pa ents in Cases Group had hypertension while 5 (16.7%) pa ents had diabetes mellitus. 8 (26.8%) pa ents in Control Group had hypertension while 4 (13.4%) pa ents had diabetes mellitus. There was no significant difference between the groups as per Chi-Square test (p>0.05). Neena et al [6] found 6(20%) and 9(30%) of subjects had comorbidi es (Hypertension, Tuberculosis, diabetes) in the experimental group and the control group respec vely. It showed homogeneity of subjects in the control and the experimental groups with reference to their previous history of abdominal surgery and comorbidi es. In the present study, 47 (47%) pa ents in Cases Group had enterocolon diseases while 43 (43%) and 10 (10%) pa ents had hepatobiliary and pancrea c diseases respec vely. 46 (46%) pa ents in Control Group had enterocolon diseases while 45 (45%) and 9 (9%) pa ents had hepatobiliary and pancrea c diseases respec vely. There was no significant difference between the groups as per Chi-Square test (p>0.05). Neena et al [6] in a study evalua ng the efficacy of chewing gum on bowel mo lity among pa ents who have undergone abdominal surgery reported on the basis of the diagnosis 14(46.7%) and 13(43.3%) subjects had hepatobiliary diseases in the experimental and control group respec vely. Only 3(10%) subjects from both the groups had pancrea c disease and 13(43.3%) and 14(46.7%) subjects had enterocolon diseases in the experimental and the control group respec vely. Both the groups are comparable as per c2 test (p>0.05). The mean dura on of induc on of anesthesia in our study was 27.08±0.89 minutes and 28.16±1.14 minutes in Cases and Control Group respec vely. The difference between groups was sta s cally not significant as per Student t-test (p>0.05). The mean dura on of surgery was 2.67±0.21 hours and 2.44±0.19 hours in Cases and Control Group respec vely. The difference between groups was sta s cally not significant as per Student ttest (p>0.05). Neena et al [6] found mean dura on of induc on of anesthesia in minutes was 27 ±7.7 minutes and 28 ±8.4 minutes in the experimental and the control group respec vely and mean dura on of surgery was 2.68 ± 1.74 hours and 2.44 ± 0.820 hours in the experimental and the control group respec vely. Both the groups were homogenous as per t test (p >0.05).

Int. j. clin. biomed. res. 2017;3(4S):96-100
It was observed in our study that the mean dura on of return of Bowel Sound was significantly lesser in Cases Group as compared to Control Group (9.9±1.37 vs. 36.1±6.72 hours). The difference between groups was sta s cally significant as per Student t-test (p<0.05). Neena et al [6] found return of bowel sounds before 24 hours were significantly in higher percentage in the experimental group 27(90%) as compared to the control group 19(63.3%) as per c2 test (p <0.05). Craciunas L et al [7] in a meta-analysis on Chewing gum in preven ng postopera ve ileus in women undergoing caesarean sec on reported me to first bowel sounds in the chewing gum group was significantly less than that in the control group. It was observed in our study that the mean dura on of first passage of flatus was significantly lesser in Cases Group as compared to Control Group (14.8±2.13 vs. 81.1±5.47 hours). The difference between groups was sta s cally significant as per Student t-test (p<0.05). Neena et al [6] found passage of flatus before 60 hours was significantly higher percentage in the experimental group (66.7%) as compared to the control group (23.3%) as per c2 test (p <0.05). The mean dura on of me to first faeces in our study was significantly lesser in Cases Group as compared to Control Group (36.1±7.28 vs. 107.6±6.87 hours). The difference between groups was sta s cally significant as per Student t-test (p<0.05). Craciunas L et al [7] in a meta-analysis on Chewing gum in preven ng postopera ve ileus in women undergoing caesarean sec on reported compared with the control group, the chewing gum group was associated with a significantly shorter me to first defeca on. Rajakumar V et al [8] in a study on Effec veness of chewing gum in increasing bowel mo lity found Mean difference of peristal c sound in experimental and control group was 10.267 and the't' test value was 7.93, mean difference of passing of gas in experimental and control group was 10.67 and 't' test value was 7.697, mean difference of defeca on in experimental and control group was 17.233 and 't' test value was 7.572. All the't' test values were significant. Quah HM et al [9] in a study on chewing gum helps to reduce the onset of postopera ve paraly c ileus a er the open colectomy for the le sided colon and rectal cancer showed that in control group pa ents passed flatus in the mean of 2.7 days and defeca on by 3.9 days. In the experimental group it took 2.4 days for passing flatus and 3.2 days for defeca on. Schuster R et al [10] study on chewing gum reducing postopera ve paraly c ileus a er elec ve open sigmoid colectomy reported Experimental group pa ents chewed the sugar free chewing gum three mes per day for one hour each me un l ge ng discharge from the hospital. The passage of flatus commenced on 65.4 hours in the experimental group and 80.2 hours in control group. The first peristal c sounds heard at 63.2 hours in experimental group and 89.4hours in control group. Feeling of hunger occurred in 63.5 hours in experimental group and 72.8 hours in control group. It showed that chewing gum therapy was helpful for the earlier return of the bowel func on and helps to reduce the onset of paraly c ileus. Hong J et a. [11] in a study on Effects of Chewing Gum on Recovery of Bowel Mo lity a er Laparoscopic Colorectal Surgery found the me to the first passage of flatus was shorter in the gum chewing experimental group than in the non-gum chewing control group, the me to the first passage of flatus was 2.96 ± 1.25 days in the experimental group and 5.37 ± 1.23 days in the control group; the difference in these values was sta s cally significant (t = 7.716, p < .001). It was observed in our study that the mean duraon of return of appe te was significantly lesser in Cases Group as compared to Control Group (19.3±2.13 vs. 87.6±5.47 hours). The difference between groups was sta s cally significant as per Student t-test (p<0.05). Neena et al [6] found return of appe te before 60 hours was significantly higher percentage in the experimental group (56.7%) as compared to the control group (13.3%) as per c2 test (p <0.05). Hong J et al [11] in a study on Effects of Chewing Gum on Recovery of Bowel Mo lity a er Laparoscopic Colorectal Surgery found the me to the first meal (including beverage) was shorter in the experimental group than in the control group was verified by using the t-test, the me to sipping water was found to be 4.4 ± 2.04 days in the experimental group and 5.59 ± 1.24 days in the control group (t = 2.658, p = .010) and me to liquid diet intake was found to be 5.25 ± 0.91 days in the experimental group and 6.46 ± 1.26 days in the control group; the differences in these values were found to be sta s cally significant (t = 4.404, p < .001). The dura on of post-opera ve hospital stay in the present study was significantly lesser in Cases Group as compared to Control Group (72.1±7.28 vs. 155.6±6.87 hours). The difference between groups was sta s cally significant as per Student t-test (p<0.05). Neena et al [6] found significant difference in the return of first bowel sounds, passage of flatus and return of appe te between the experimental & the control group. The mean me of return of bowel sounds a er surgery was significantly lesser (21.4±2.8hr) in the experimental group than in the control group (23.7±2.8 hr). Similarly the mean me of passage of flatus a er surgery was significantly lesser in (58.2±9.3hr) in the experimental group than in the control group (65.6±6.4 hr). The mean me of return of appe te a er surgery was significantly lesser (59.9±9.8 hr) in experimental group than in the control group (67.2±7.6 hr).
Andersson T et al [12] reported there was a numerical difference in mean me to first flatus, first defeca on, start of clear fluids, start of liquid diet and length of hospital stay in favour of the interven on group, although not strong enough to be sta s cally significant. Hong J et al [11] in a study on Effects of Chewing Gum on Recovery of Bowel Mo lity a er Laparoscopic Colorectal Surgery found the length of postopera ve hospital stay was shorter in the experimental group than in the control group, the length of postopera ve hospital stay was found to be 11.21 ± 2.63 days in the experimental group and 15.15 ± 7.41 days in the control group; the difference in these values was sta s cally significant (t = 2.829, p = .006). Craciunas L et al [7] in a meta-analysis on Chewing gum in preven ng postopera ve ileus in women undergoing caesarean sec on found Compared with the control groups, chewing gum was associated with shorter lengths of hospitaliza on (SMD 0.26; 95% CI 0.76 to 0.25; z = 1.00; P = 0.32;), but the difference was not sta s cally significant. CONCLUSION In conclusion, the study found that gum chewing in paents undergoing abdominal surgery can be an effecve interven on to facilitate the passage of flatus and feces, shorten the me to dietary intake, and shorten the length of hospital stay by promo ng bowel mo lity. Sugges on: Chewing gum a er major abdominal surgery is a simple and effec ve method to treat postopera ve paraly c ileus. Chewing gum aids in early recovery from postopera ve paraly c ileus and is an inexpensive, simple, effec ve and physiologic measure for promo ng the bowel func on. Chewing gum should be added as an adjuvant treatment method in postoperave care because it might contribute to increase the early return of gastrointes nal func on a er major abdominal surgery. Therefore nurses working in postopera ve ward should encourage the clients to chew chewing gum a er major abdominal surgery.