Postoperative ileus is a possibly deadly complication that occurs after many abdominal surgeries and operations. An ileus is where the bowels “fall asleep” after trauma and fail to “awaken” for quite some time following surgery. Postoperative ileus can affect patient nutrition, comfort and especially length of stay, which results in a major cost to insurance companies and hospitals. According to Chan and Law (2007), the economic burden resulting from postoperative ileus is $7.5 billion per year in the United States alone not including the expense of missed work. Clearly, the issue of postoperative ileus duration is one that deserves attention and necessitates a solution. Right now, doctors are forced to offer motility agents, trials with early feeding, and hopeful reassurance that bowel function will return shortly.
Each of these methods have their own set of complications and risks, such as nausea and vomiting, and are not proven to be significantly effective at reducing postoperative ileus duration. Recent clinical trials show that chewing gum postoperatively may hold promise in reducing postoperative ileus and thereby decrease length of stay. Therefore, the purpose of this paper is to use the Stetler Model of Research Utilization to examine the research regarding the use of gum chewing to reduce the duration of postoperative ileus in abdominal surgery patients. Validation
The articles used to draw conclusions from included two primary articles and two systematic reviews. Before comparing the findings, it is important to examine each individual study and examine the specific parts of all studies in question. In the study by Matros, et al. (2006), the authors tested a directional hypothesis and were trying to develop a predictive level of knowledge. This experiment examined to see if gum chewing was more effective at decreasing recovery time from a postoperative ileus as compared against the standard practice and a placebo. The authors stratified, randomized and blinded all of the participants in order to remove any bias. They used computer software in order to divide the participants into groups. The authors identified what was already known about this subject from the study by Asao, Kuwano, Nakamura, Morinaga, & Hirayama, (2002), but also identified a few weaknesses in that study that necessitated another trial to determine if significant evidence supported gum chewing and its negative effect on duration of ileus. The weaknesses identified in the experiment by Asao, et. al. (2002) were that the study lacked a placebo or blinding process.
The placebo in this experiment was an pressure point bracelet. The researchers measured the times to passage of first flatus postoperatively, first passage of stool postoperatively, and length of time till discharge postoperatively following open colectomy patients, and compared the medians from the different studied groups. The nurses’ documentation of the different events was the method of collection of data. The authors used ANOVA and Kruskal-Wallis tests in order to contrast the continuous variables, and a Chi-square test was used to compare categorical data. Statistical significance was measured by using a two sided p value of .025. At this level, there was not statistically significant findings to support the hypothesis that gum chewing is more effective at reducing postoperative ileus time as compared to standard practice or a placebo. The authors did point out the fact that in their trial, patients with open colectomies were selected to be studied, an in the Asao, et. al. (2002) study, they examined laparoscopic colectomy patients, which could be one reason for conflicting findings between the two studies. This is a strongly made article that evokes level one data, that is almost irrefutable.
Quah, Samad, Neathey, Hay, and Maw (2006), also designed a study to verify if chewing gum could reduce the time of postoperative ileus. The authors utilized a randomized control trial, in which 19 patients received standard postoperative care and another 19 received the standard care and used chewing gum. The patients were selected according to the type of surgery, open colectomy for left-sided colon and rectal cancer, patients that required “postoperative ventilation or planned intensive care therapy due to co-morbid conditions were excluded from the study,” the eligible subjects were randomly selected to either the control or treatment group, and peri-operative treatment was standardized (Quah et al, 2006, p. 65). Outcome measures were time to first flatus and feces, and length of hospital stay, and a blinded “independent specialist colorectal nurse practitioner” evaluated the progress (Quah et al, 2006, p. 65). Researchers utilized the Mann-Whitney U-test and the X2 test to analyze the data entered into statistical software, and measured statistical significance using a two-sided p value of 0.05.
The two groups were homogeneous “in terms of age, gender co-morbid disease, history of previous abdominal surgery, site of tumor and tumor stage” (Quah et al, 2006, p. 65). The researchers findings were not significant enough to support the intervention; the mean time to first flatus was 2.7 days for the control group and 2.4 days for the experimental group a p value of 0.56, the mean time to first feces was 3.9 days for the control group and 3.2 for the experimental group a p value of 0.38, and length of hospital stay was 11.2 days for the control group and 9.4 days for the experimental group a p value of 0.75. Patients in the experimental group had tolerated the gum chewing well, reporting that it “helped to keep their mouth moist and gave them a sense of well being” (Quah et al, 2006, p. 67). This study has many strengths, including being a randomized control trial, having a clearly defined inclusion and exclusion criteria, and blinding of the clinician following the progress of the patients. The weaknesses in this study consist of a small sample size, and the increased possibility of a type II error. The systematic review by Vasquez, Hernandez, & Garcia-Sabrido (2009), consisted of six randomized clinical trials. Along with this systematic review a meta-analysis was done among the various studies.
After all six articles were reviewed it was found that chewing gum is a cheap, physiological, and secure intervention that is found to significantly improve an ileus after a elective colorectal surgery (Vasquez, Hernandez, Garcia-Sabrido, 2009). The gum chewing was found to stimulate the appetite and increase the sensation of well-being during the post-operative period. Three variables were studied including time to flatus, length of hospital stay and the passage of feces; each of these variables were used along with standard treatment and then compared to standard treatment alone. Of the six trials four of them showed a significant reduction in the time to first flatus, while only two of the trials showed significance in reduction in time to passage of first feces and in the length of hospital stay. The meta-analysis concluded that the time to first flatus was significantly reduced with gum chewing by fourteen hours with a p value of p=0.001; all six trials were heterogeneous to this outcome with a p value of p=0.01. For the time to first passage of feces the time was decreased by twenty five hours and the p value was p=0.01; four of the six trials were used in this analysis and they were heterogeneous with a p value of p=0.05.