News from the 2005 Clinical Congress

SAN FRANCISCO—Patients who chew a stick of gum for a few minutes a day can speed up the return of bowel function and get out of the hospital a day earlier after undergoing elective laparoscopic colectomy (surgical removal of a portion of the large intestine using the keyhole technique), according to research findings presented at the 2005 annual Clinical Congress of the American College of Surgeons. Consequently, the act of gum chewing among this patient population may save millions of dollars a year in hospital costs by alleviating a condition known as postoperative ileus.

Postoperative ileus is a temporary loss of propulsive bowel activity that can cause colicky pain, abdominal distention, constipation, vomiting, and dehydration. It is the most common reason for prolonged hospitalization following abdominal surgery, and its economic impact is estimated to be about $750 million to $1 billion a year in the United States alone, according to Harry Papaconstantinou, MD, assistant professor in the department of surgery at the University of Texas Southwestern, Dallas.

Postoperative ileus, which disrupts gut motility (the movement of material in the intestinal tract), is considered to be inevitable after colon resection and other forms of intestinal surgery. "There are multiple stimuli that can affect the gut motility after surgery, and some of these are manipulation of the bowel during surgery, the type of anesthetic used, any inflammation that might be caused by the surgery, as well as alterations in the autonomic [peripheral] nervous system, the release of neurotransmitters [chemical substances that influence the transfer of nerve impulses to muscle] and gut hormones. When patients undergo colectomy, all of these factors can be significant stimuli that results in postoperative ileus," Dr. Papaconstantinou explained.

Results from the study indicate that gum chewing is an inexpensive measure that may reduce postoperative ileus. "For 30 cents for a pack of gum and two to three packs of gum for each patient, we're talking about spending less than a dollar to facilitate discharge from the hospital one day earlier," Dr. Papaconstantinou said. "Daily hospital cost is estimated to be between $500 and $750. With all the laparoscopic colectomies being performed in the United States, if we could save $500 for each of them, the savings would be quite significant," he explained.

The study included 102 patients who underwent colectomy at one of three sites: the University of Texas Southwestern Medical Center, Dallas; Western Pennsylvania Hospital, Pittsburgh; and Presbyterian Hospital, Dallas. Patients were randomized into one of two groups. The control group was limited to having sips of clear liquids following the operation. The experimental group chewed one stick of gum for 15 minutes four times a day.

In the study, bowel movements returned 3.5 days after the operation among patients in the control group and 2.9 days postoperatively for patients who chewed gum. Patients in the control group went home 5.2 days postoperatively compared with 4.4 days for patients in the gum-chewing group. Since laparoscopic colectomy may have influenced outcomes, the investigators further classified patients into open colectomy and laparoscopic colectomy groups. There was no difference in the time to return of bowel movement or length of hospital stay among patients who had an open surgical procedure; the first postoperative bowel movement occurred 3.6 days after operation for gum-chewers and control patients, and patients who chewed gum were discharged 5.9 days post-operatively compared with 5.3 days for patients who served as controls.

"The major difference occurred in patients who had colectomies performed by laparoscopic (keyhole) surgery. The first postoperative bowel movement occurred approximately one day sooner for patients in the gum-chewing group: 2.5 days versus 3.2 days in the control group. Hospital discharge was a full day earlier; the length of stay was 3.8 days for patients in the gum-chewing group and 5.1 days for patients in the control group," Dr. Papaconstantinou said.

"At this time, we do not know what facilitates the return of postoperative bowel function with gum chewing," Dr. Papaconstantinou said. "However, we speculate that it may be secondary to the effects of sham feeding." He explained that patients cannot tolerate full feeding immediately after colon surgery; they become bloated and nauseated. However, the absence of feeding likely delays the return of normal bowel function. Other investigators have shown that sham feeding, or the act of chewing without swallowing, may be an effective intermediate measure. "Gum chewing may be an inexpensive easy method of stimulating enteric [intestinal] motility," he said.

Gum chewing may prevent postoperative ileus following other forms of abdominal surgery. "We chose to look specifically at colon surgery because we didn't want to introduce other variables by including patients who had other types of surgery, such as small bowel resection. But this is something that needs to be investigated with other surgical procedures," Dr. Papaconstantinou concluded.

Joining Dr. Papaconstantinou in the study were James T. McCormick, DO; R. Gavin, MD; Philip Caushaj, MD; Clifford Simmang, MD, FACS; Sharon Gregorcyk, MD, FACS; Philip J. Huber, Jr., MD, FACS; Floyd Clark Odom, MD, FACS; John Marcus Downs, MD, FACS; and Thomas Read, MD.

Press Release Index