Anatolian Journal of Obstetrics & Gynecology
ISSN: 1308-8254
Anatol J Obstet Gynecol 2009; 1: 1 ©2009 Harma et al.; licensee ALKIM BASIN YAYIN Ltd. Research article Gum-chewing speeds return of first bowel sounds but not first defecation after
cesarean section
Mehmet Ibrahim HARMA, Aykut BARUT, I. Ilker ARIKAN, Muge HARMA
Zonguldak Karaelmas University School of Medicine, Department of Obstetrics & Gynecology, Zonguldak, Turkey Address for Correspondence:
Mehmet Ibrahim HARMA, MD.
Zonguldak Karaelmas Üniversitesi, Tıp Fakültesi,
Kadın Hastalıkları ve Doğum Anabilim Dalı,
Esenköy, Kozlu, 67600 Zonguldak, Türkiye.
Tel: +90 532 466 49 91, Fax:+90 372 261 01 55.
E-mail: mehmetharma@superonline.com Anatolian Journal of Obstetrics & Gynecology
Gum chewing after cesarean section
Harma et al.
Research article
Anatol J Obstet Gynecol 2009; 1: 1
www.AnJOG.com
ISSN: 1308-8254
©2009 Harma et al.; licensee ALKIM BASIN YAYIN Ltd. ABSTRACT
Objective: To evaluate effects of gum-chewing on duration of ileus after cesarean section
and differences in effects of sugar-free gum and sugar-substituted gum.
Materials and Methods: Seventy-six women with no prior abdominal or cesarean surgery
were consecutively allocated after elective cesarean section under general anesthesia to a)
control (no-gum) group, b) sugar-free gum group, or c) sugar-substituted gum group (gum
containing xylitol, sorbitol, and aspartame). Beginning 2 hours postoperatively, gumchewing patients chewed gum for 15 minutes every 2 hours. Times to first bowel sounds,
flatus, and defecation were recorded, and means ± SD compared.
Results: Statistically significant decrease in time to first bowel sounds in sugar-substituted
gum group (6.3 ± 2.0 h) compared to sugar-free gum group (8.8 ± 1.9 h, p < 0.05). Sugarsubstituted group had significantly lower time to first bowel sounds than controls (11.2 ±
1.0 h, p < 0.05). No significant difference was noted among groups in times to first flatus or
defecation.
Conclusion: In gum-chewing patients without prior abdominal operation who had cesarean
under general anesthesia, no difference occurred in timing of first flatus or defecation. Given
the previously demonstrated effectiveness of gum-chewing in ileus resolution after laparoscopic colon surgery, gum trials under epidural anesthesia or with medicated gums are warranted.
Key words: Abdominal surgery, cesarean section, postoperative ileus, gum-chewing. Introduction Materials and methods Postoperative ileus causes significant patient discomfort
and is the main factor determining the length of hospitalization after abdominal surgery [1]. Since there is no practical benefit to the gastrointestinal dysmotility that results
from intraoperative peritoneal irritation, investigators have
tried variety of methods to shorten its duration [1]. One
simple intervention is sham feeding [1, 2]. Several investigators have recently evaluated chewing gum as a sham
feeding; notably, gum-chewing after laparoscopic colectomy is associated with earlier flatus, defecation, and hospital
discharge [2, 3]. We conducted a prospective trial to evaluate the effects of gum-chewing on gastrointestinal recovery after cesarean section, and to determine whether sugarfree gum or sugar-substituted gum had different effects on
postoperative ileus. This prospective study recruited 76 women who had had no
previous abdominal surgery or cesarean section and who
underwent elective cesarean section under general anesthesia. All subjects volunteered for the study. Written informed consent was obtained from all participants, who
were consecutively allocated into three groups. The first
group, control patients, did not chew gum postoperatively
(controls, N = 23). The second group of patients chewed
sugar-free gum postoperatively (sugar-free group, N = 28).
The third group of patients chewed sugar-substituted gum
postoperatively (sugar-substituted group, N = 25).
The same surgeon, who was blinded to group assignment, performed all operations. Due to differences in gum
taste and consistency, patients could not be blinded to their
group assignment. After surgery, all patients were given
nothing by mouth until passage of the first propulsive bowel movement, when they began a liquid diet. A standar- ©2009 Harma et al.; licensee ALKIM BASIN YAYIN Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/3.0/). Research article
dized dose of tramadol, which did not differ among the
groups, was used for analgesia.
Beginning two hours postoperatively, subjects in the
gum-chewing groups chewed the assigned gum for 15
minutes every two hours until the first passage of flatus.
All patients were evaluated hourly after surgery by the
same resident physicians, who precisely recorded times of
first bowel sounds, first flatus and first defecation.
The sugar-free gum group used a commercially available gum with no artificial sweeteners (Falim®), manufactured by Dandy A.S., Istanbul, Turkey. The sugarsubstituted gum group used another commercially available
gum (First®), also manufactured by Dandy A.S., which
contained the additives sorbitol E 420, xylitol E 967, and
aspartame E 951. Both gums are approved by the Turkish
Food Codex.
Non-parametric tests, Kruskal-Wallis test and MannWhitney U test, were used to compare means and to evaluate differences between groups. Data are reported as
mean ± standard deviation. A p value less than 0.05 was
considered significant. Results
Demographic and operative characteristics of patients are
noted in Table 1. There were no significant differences
among groups in age, gravidity or parity, gestational age,
duration of surgery, estimated blood loss, injectable opioid
analgesic, or timing of hospital discharge. Indications were
similar in the both groups.
Outcomes of participants are summarized in Table 2.
The difference in return of first bowel sounds was statistically significant between the sugar-substituted (6.3 ± 2.0 h)
and sugar-free groups (8.8 ± 1.9 h, p < 0.05), and between
the sugar-free and control groups (11.2 ± 1.0 h, p < 0.05).
Specifically, patients who chewed sugar-substituted gum experienced return of bowel sounds more promptly than
patients in the sugar-free group (p < 0.05). Postoperative
timing of first flatus was a median of 18.0 ± 5.3 h in the
sugar-free group, 19.7 ± 4.5 h in the sugar-substituted
group, and 19.4 ± 5.4 h in the control group (p > 0.05). Timing of first defecation was similar in the sugar-free group,
sugar-substituted group, and control group (respectively,
34.0 ± 10.0 h, 34.6 ± 12.5 h, and 37.4 ± 13.9 h) with no statistical significance (p > 0.05). Discussion
Recovery of gastrointestinal function after gastrointestinal
surgery is clinically important because paralytic ileus may
contribute pain, nausea, vomiting, and pulmonary dysfunction. Food intake has been reported to stimulate bowel
motility. Gum-chewing is postulated to work because it
mimics food intake, i.e. sham feeding. Our study is the first
to evaluate the effect of gum-chewing as a sham feeding on
duration of ileus following cesarean section. We found no
effect on timing of first defecation after cesarean, in contrast to the decreased time to stool passage in gum-chewing
patients after laparoscopic colon surgery found by McCormick et al. [2] and Asao et al. [3] However, we did identify
a statistically significant decrease in time to first bowel
sounds in patients who used sugar-substituted gum. We
noted an inexplicably longer to first bowel sounds in the
sugarless gum group compared to controls.
Sham feeding, such as the chewing activity in our study,
stimulates gastric, duodenal and rectal motility [3]. Gumchewing may increase gastrointestinal motility via a combination of cephalic-vagal reflexes, release of gastrointestinal hormones, and increase in salivary and pancreatic
secretion [3]. Of note, salivary flow rates with gumchewing remain above basal rates even after two hours of
continuous gum-chewing [4]. Table 1. Demographic and operative characteristics of participants
Control group
(n=23)
Mean ± SD Sugar-free chewing
gum group
(n=28)
Mean ± SD Sugar-substituted
chewing gum group
(n=25)
Mean ± SD 30.3 ± 5.9 28.5 ± 6.6 29.1 ± 5.3 NS Gravidity 4.6 ± 2.9 3.7 ± 2.7 3.1 ± 2.4 NS Parity 2.9 ± 2.6 2.1 ± 2.3 1.6 ± 1.6 NS Gestational age (wk) 39.1 ± 4.7 38.7 ± 2.8 39.3 ± 3.1 NS Duration of surgery (min) 42.3 ± 6.3 43.7 ± 8.7 41.8 ± 7.9 NS Estimated blood loss (ml) 202.1 ± 141.8 278.5 ± 164.6 196.8 ± 123.1 NS Injectable opioid analgesic
(mg) 113.0 ± 34.4 125.0 ± 57.7 124.0 ± 63.4 NS 3.0 ± 0.2 3.2 ± 0.4 3.0 ± 0.5 NS Characteristic Age (y) Hospital discharge (d) P SD, standard deviation; NS, not significant
2 Harma et al. Gum chewing after cesarean section Anatol J Obstet Gynecol 2009; 1: 1 Anatolian Journal of Obstetrics & Gynecology | www.AnJOG.com
Table 2. Gastrointestinal outcomes of participants Outcome Control group
(n=23)
Mean ± SD Sugar-free chewing gum
group
(n=28)
Mean ± SD Sugar-substituted
chewing gum group
(n=25)
Mean ± SD P Return of first bowel
sounds (h) 11.2 ± 1.0b 8.8 ± 1.9b 6.3 ± 2.0a First passage of flatus (h) 19.4 ± 5.4 18.0 ± 5.3 19.7 ± 4.5 NS First defecation (h) 37.4 ± 13.9 34.0 ± 10.0 34.6 ± 12.5 NS <0.05 SD, standard deviation; NS, not significant
a, b
Statistically significant difference was observed between different superscripts. The decreased time to return of bowel sounds in our
sugar-substituted gum group could be explained by the
additives sorbitol and xylitol. These sugar alcohols are
absorbed slowly and incompletely from the intestinal tract
[5, 6]. Xylitol increases gastric emptying and intestinal
transit time [7]. Osmotic effects and colonic fermentation
may cause diarrhea if individuals ingest more than 10 mg of
sorbitol, or more than 0.5 g/kg body weight of xylitol, per
day [6, 8].
Of interest as a comparison to sham feeding, Patolia et
al. conducted a trial of early feeding after cesarean section
under regional anesthesia [9]. Their early-fed patients had
an earlier first bowel movement and hospital discharge than
controls, but there were similar rates of mild ileus in earlyfed and control groups, and over 40% of patients with surgeries longer than 40 minutes had mild ileus [9].
Despite Matros et al.[10] and our generally negative results, additional trials of gum-chewing as a safe, inexpensive means to hasten resolution of ileus after cesarean section are warranted, given the past success of Asao et al.[3]
and McCormick et al. [2] with gum-chewing after laparoscopic colon surgery. For instance, a trial could evaluate
gum-chewing effects on ileus after cesarean section under
epidural instead of general anesthesia, since inhalational
anesthetic agents and opioids used in general anesthesia
may slow intestinal motility [1]. Alternatively, a trial could
compare gum-chewing to early feeding after cesarean section, especially considering the evidence from Patolia et al.
of frequent mild ileus in early-fed cesarean patients who
had prolonged operative time [9]. Moreover, laxativecontaining chewing gum could conceivably reduce duration
of both ileus and hospitalization, since laxatives effectively
shorten the duration of ileus [1, 11]. Different trials have
shown promising results for the efficacy of gum chewing
for the amelioration of postoperative ileus. A recent metaanalysis shows a favorable effect of gum chewing on time
to flatus and defecation but no significant effect on the
hospital stays [12].
Gum-chewing shortens postoperative ileus probably in a
multi-factorial manner and early postoperative sham feeding enhances the recovery of gastrointestinal motility after
cesarean section and this may be a safe and acceptable
treatment modality in a modern fast-track regimen. We
encourage additional trials of gum-chewing to determine
whether this simple, economical measure might promote
www.AnJOG.com | Page numbers are not for citation purposes gastrointestinal recovery after cesarean delivery or other
gynecologic procedures. References
1. Miedema BW and Johnson JO. Methods for decreasing postoperative
gut dysmotility. Lancet Oncol 2003; 4: 365-372.
2. McCormick JT, Garvin R, Caushaj P, et al. The effects of gumchewing on bowel function and hospital stay after laparoscopic vs
open colectomy: a multi-institution prospective randomized trial. J
Am Coll Surg 2005; 201: S66-S67.
3. Asao T, Kuwano H, Nakamura Ji, et al. Gum chewing enhances early
recovery from postoperative ileus after laparoscopic colectomy. J Am
Coll Surg 2002; 195: 30-32.
4. Dawes C and Kubieniec K. The effects of prolonged gum chewing on
salivary flow rate and composition. Arch Oral Biol 2004; 49: 665669.
5. Sugar alcohols fact sheet. IFIC (International Food Information
Council)
2008
[cited 2008 25.11.2008]; Available from:
http://www.ific.org/publications/factsheets/sugaralcoholfs.cfm.
6. Makinen KK. Effect of long-term, peroral administration of sugar
alcohols on man. Swed Dent J 1984; 8(3): 113-24.
7. Salminen EK, Salminen SJ, Porkka L, et al. Xylitol vs glucose: effect
on the rate of gastric emptying and motilin, insulin, and gastric inhibitory polypeptide release. Am J Clin Nutr 1989; 49: 1228-1232.
8. Hyams JS. Sorbitol intolerance: an unappreciated cause of functional
gastrointestinal complaints. Gastroenterology 1983; 84(1): 30-3.
9. Patolia DS, Hilliard RL, Toy EC, and Baker B. Early feeding after
cesarean: randomized trial. Obstet Gynecol 2001; 98: 113-116.
10. Matros E, Rocha F, Zinner M, et al. Does gum chewing ameliorate
postoperative ileus? Results of a prospective, randomized, placebocontrolled trial. J Am Coll Surg 2006; 202: 773-778.
11. Tandeter H. Hypothesis: hexitols in chewing gum may play a role in
reducing postoperative ileus. Med Hypotheses 2009; 72(1): 39-40.
12. de Castro MSM, van den Esschert JW, van Heek NT, et al. A systematic review of the efficacy of gum chewing for the amelioration of
postoperative ileus. Dig Surg 2008; 25: 39-45. Harma et al. Gum chewing after cesarean section 3

SophiaPretty

(5)

Status NEW Posted 27 Sep 2017 05:09 AM My Price 10.00

Hel-----------lo -----------Sir-----------/Ma-----------dam----------- T-----------han-----------k y-----------ou -----------for----------- yo-----------ur -----------int-----------ere-----------st -----------and----------- bu-----------yin-----------g m-----------y p-----------ost-----------ed -----------sol-----------uti-----------on.----------- Pl-----------eas-----------e p-----------ing----------- me----------- on----------- ch-----------at -----------I a-----------m o-----------nli-----------ne -----------or -----------inb-----------ox -----------me -----------a m-----------ess-----------age----------- I -----------wil-----------l b-----------e q-----------uic-----------kly-----------

Not Rated(0)

• Buy Answer