Does Sugared or Sugar Free Chewing Gum Reduces Postoperative Ileus After Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is now very common procedure to remove the gall bladder from abdomen. After this procedure many patients suffer from the non functioning of intestine and stomach which is very common after any abdominal surgery. Many efforts tried to reduce this non functioning period or postoperative ileus but non of them was superior later on. The investigators want to evaluate the role of chewing gum for reducing postoperative ileus. The investigators hypothesis is that Chewing gum after laparoscopic cholecystectomy reduces postoperative ileus and sugared preparations are more effective to reduce it.

Study Overview

• Status: Completed
• Conditions: Postoperative Ileus.
• Intervention / Treatment: Drug: Tab. Midazolam 7.5 mg; Drug: Inj. Midazolam 0.7mg/kg 45 min before surgery; Drug: Inj. Propofol 2.5mg/kg; Drug: Inj. Atracurium 0.5 mg/kg; Drug: Sevoflurane 2.5 vol %; Drug: Inj. Cefuroxime 1.5 g IV; Drug: Inj. Ketorolac 30 mg IV; Drug: Inj. Zantac 50mg IV; Other: sugared chewing gum; Other: sugar free chewing gum

Detailed Description

Laparoscopic cholecystectomy is considered now the gold standard for gall stone disease. Postoperative ileus after any abdominal surgery is common complication, it is considered as physiological response and is the main cause of postoperative abdominal pain, discomfort and increased duration of hospital stay. Postoperative ileus (POI) may last up to 5 days after uncomplicated abdominal surgery. Activity of small intestine returns within 24 hours while stomach and large intestine take up to 36 and 72 hours to regain motility.3 The use of early feeding, medications like cisapride etc. have been used to reduced POI but none of them has been significantly useful on further research work.

Gum chewing after abdominal surgery reduces the duration of POI, pain and discomfort. Gum chewing also reduces halitosis, dental caries, elevates mood and reduces stress which are additional benefits. Many studies proved that the chewing gum has only placebo effect after surgery in adults and children. Sugar-free chewing gum has been focused mainly in studies. Perioperative role of glucose intake has shown many benefits like reducing insulin resistance.

In this study the investigators wanted to evaluate the role of chewing gum in reducing POI in laparoscopic cholecystectomy and further exploration to see the whether which chewing gum is more beneficial, sugar-free or sugared. If the study proves the beneficial effect of chewing gum then the investigators can have better management of patients postoperatively by sugared chewing gum which is readily available and inexpensive.

After meeting inclusion and exclusion criteria, All patients were given Tab. Midazolam 7.5 mg PO at night before surgery and received same standard general anesthesia with endotracheal intubation. Inj. Midazolam IV 0.7 mg/kg was given 45 min before surgery as premedication. Anesthesia was induced by propofol (2.5 mg/kg) after 3 minutes of preoxygenation. Muscle relaxation was achieved by atracuium (0.5 mg/kg). Anesthesia was maintained with sevoflurane (2.5 vol %) and oxygen in air mixture (0.50 ratio). Ventilation was controlled mechanically and end tidal normocapnia was maintained by keeping pCO2 at 35-38 mmHg.

Following medications were given to patients during the process.

• Inj. Cefuroxime 1.5 gm. IV (2 doses, 1st dose 30-60 min before surgery and 2nd dose 6 hours after surgery)
• Inj. Ketorolac 30mg IV (3 doses total, 1st dose immediate postop, 2nd and 3rd at 8 and 16 hours after surgery respectively)
• Inj. Zantac 50 mg IV (2 doses total, 1st immediate postop and 2nd at 12 hours after surgery) All patients were operated by the consultant surgeons. Duration of surgery was noted. Patients were divided randomly into 3 groups equally; at the end each contained 30 patients each. Group A was the control group, group B received sugar-free chewing gum (Orbit) and group C received sugared chewing gum (Dingdong chewing gum from hilalcandy). Both B and C groups were asked to start chew gum 4 hours after surgery then continue it 8 hourly (20-25 minutes each time) until oral feeding was started. Onset of hunger, bowel movements, flatus passing and defecation were noted. Bowel movements were examined via stethoscope hourly after surgery. All patients received same standard postoperative care.

All the data was recorded on specially designed Performa. Statistical analysis: Data was analyzed using SPSS version 12. Mean and standard deviation were calculated for quantitative data like age, duration of surgery, time of onset of hunger, bowel movements, flatus passing and defecation. Frequency and percentages were calculated for qualitative data like gender. The results were finally analyzed and compared for the three groups using one way ANOVA. The data of any two groups (A versus B, A versus C, B versus C) was analyzed by independent sample t test. Pearson correlation was used to see the correlation between duration of surgery and bowel movements. A p value <0.05 was considered significant

• Study Type: Interventional
• Enrollment (Actual): 90
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Punjab
    • Rawalpindi, Punjab, Pakistan, 46000
      • General Surgery Dept. Benazir Bhutto Hospital Rawalpindi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 23 years to 53 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria

1. Patients undergoing elective laparoscopic cholecystectomy for gallstone disease.
2. Patients with age range of 25 to 55 years

Exclusion Criteria

1. H/O chronic illness like DM, IHD, CRF, CLD
2. Immunocompromised patients.
3. Previous history of any chemotherapy or radiotherapy, any history of repeated infections, pneumonia.
4. Patients with H/O concurrent intestinal illnesses like Tuberculosis, ulcerative colitis, Crohn's disease, acute or chronic diarrhea, constipation etc.
5. Previous hepatobilliary surgery.
6. H/O use of antispasmodics, or drugs affecting the intestinal motility within last 72 hours before and after surgery (tricyclic antidepressants, antipsychotics)
7. Patients who develop the postop complications like wound infection, intra-abdominal collections etc.
8. Complicated cholecystectomy in which laparoscopic cholecystectomy is converted to open cholecystectomy.
9. Cholecystectomy in which the biliary leakage was complication, either in the drain or later on detected via ultrasound

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: no chewing gum.; the no chewing gum group was control and receive no chewing gum postoperatively. While they received all other medications like anesthesia, antibiotics etc	Drug: Tab. Midazolam 7.5 mg; Tab. Midazolam 7.5 mg will be given to all patients at night before surgery.; Drug: Inj. Midazolam 0.7mg/kg 45 min before surgery; Inj . Midazolam 0.7 mg/kg given as premedication.; Drug: Inj. Propofol 2.5mg/kg; It was given to induce anesthesia after 3 min of pre oxygenation.; Drug: Inj. Atracurium 0.5 mg/kg; It was given to induce muscle relaxation during anesthesia.; Drug: Sevoflurane 2.5 vol %; It was given to maintain anesthesia during surgery alongwith oxygen in air mixture; Drug: Inj. Cefuroxime 1.5 g IV; It was given as prophylactic antibiotic. 2 doses given. 1st 30-60 min before surgery. 2nd 6 hours after surgery; Drug: Inj. Ketorolac 30 mg IV; 3 doses for analgesia. 1st immediate postoperative, 2nd at 8 hours postoperative and 3 rd at 16 hours postoperative period.; Drug: Inj. Zantac 50mg IV; 2 doses. 1st at immediate postoperative and 2nd 12 hours after surgery
Experimental: sugar free chewing gum; sugar free chewing was given to patients 4 hours after surgery then continue it 8 hourly (20 to 25 minutes each time) until oral feeding is started.	Drug: Tab. Midazolam 7.5 mg; Tab. Midazolam 7.5 mg will be given to all patients at night before surgery.; Drug: Inj. Midazolam 0.7mg/kg 45 min before surgery; Inj . Midazolam 0.7 mg/kg given as premedication.; Drug: Inj. Propofol 2.5mg/kg; It was given to induce anesthesia after 3 min of pre oxygenation.; Drug: Inj. Atracurium 0.5 mg/kg; It was given to induce muscle relaxation during anesthesia.; Drug: Sevoflurane 2.5 vol %; It was given to maintain anesthesia during surgery alongwith oxygen in air mixture; Drug: Inj. Cefuroxime 1.5 g IV; It was given as prophylactic antibiotic. 2 doses given. 1st 30-60 min before surgery. 2nd 6 hours after surgery; Drug: Inj. Ketorolac 30 mg IV; 3 doses for analgesia. 1st immediate postoperative, 2nd at 8 hours postoperative and 3 rd at 16 hours postoperative period.; Drug: Inj. Zantac 50mg IV; 2 doses. 1st at immediate postoperative and 2nd 12 hours after surgery; Other: sugared chewing gum; Sugared chewing gum (singsong bubble gum) was given to patients. They were asked to chew it 4 hours after surgery and continue to chew it 8 hourly for 20 to 25 min each time until oral feeding was started.; Other Names: Dingdong bubble gum.
Experimental: sugared chewing gum; sugared chewing gum will be given 4 hours after surgery then continue it 8 hourly (20 to 25 minutes each time) until oral feeding is started	Drug: Tab. Midazolam 7.5 mg; Tab. Midazolam 7.5 mg will be given to all patients at night before surgery.; Drug: Inj. Midazolam 0.7mg/kg 45 min before surgery; Inj . Midazolam 0.7 mg/kg given as premedication.; Drug: Inj. Propofol 2.5mg/kg; It was given to induce anesthesia after 3 min of pre oxygenation.; Drug: Inj. Atracurium 0.5 mg/kg; It was given to induce muscle relaxation during anesthesia.; Drug: Sevoflurane 2.5 vol %; It was given to maintain anesthesia during surgery alongwith oxygen in air mixture; Drug: Inj. Cefuroxime 1.5 g IV; It was given as prophylactic antibiotic. 2 doses given. 1st 30-60 min before surgery. 2nd 6 hours after surgery; Drug: Inj. Ketorolac 30 mg IV; 3 doses for analgesia. 1st immediate postoperative, 2nd at 8 hours postoperative and 3 rd at 16 hours postoperative period.; Drug: Inj. Zantac 50mg IV; 2 doses. 1st at immediate postoperative and 2nd 12 hours after surgery; Other: sugar free chewing gum; Sugar free chewing gum (orbit) was given to patients. They were asked to chew it 4 hours after surgery and continue to chew it 8 hourly for 20 to 25 min each time until oral feeding was started.; Other Names: Orbit

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
onset of hunger	the patients were asked when they felt first feeling of hunger. this time was noted in terms of hours after surgery.	4 hours after surgery until patient feels first feeling of hunger. an expected average of 12 hours.
onset of bowel movements	the patients were examined by resident doctor hourly after surgery for presence of bowel sounds by a stethoscope. Additional all patient were asked when they felt first bowel sounds. the time at which the first bowel activity was present was noted in terms of hours after surgery.	4 hours after surgery until the bowel sounds are present. an expected average of 10 hours.
onset of flatus passing	the patients were asked when they passed first flatus. this time was noted in terms of hours after surgery.	4 hours after surgery until patient passes flatus. an expected average of 18 hours.
onset of defecation	the patients were asked when they passed stool first time after surgery. that time was noted in terms of hours after surgery.	4 hours after surgery until patient defecated. an expected average of 24 hours.

Secondary Outcome Measures

Outcome Measure	Time Frame
time of surgery	skin incision to skin closure time of surgery. an expected average of 1 hour

Collaborators and Investigators

• Sponsor: Benazir Bhutto Hospital, Rawalpindi
• Investigators: Principal Investigator: Fazal Hussain Shah, FCPS-I, Benazir Bhutto Hospital, Rawalpindi; Study Chair: Aurangzeb Khan, FCPS, Benazir Bhutto Hospital, Rawalpindi; Study Chair: Muhammad Bilal Habshi, FCPS-I, Benazir Bhutto Hospital, Rawalpindi; Study Chair: Arslan Zahid, FCPS-I, Benazir Bhutto Hospital, Rawalpindi; Study Chair: Muhammad Zubair Saeed, FCPS-I, Benazir Bhutto Hospital, Rawalpindi

Publications and helpful links

General Publications

• Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. 2000 Nov;87(11):1480-93. doi: 10.1046/j.1365-2168.2000.01595.x.
• Gorski JP, Marks SC Jr, Cahill DR, Wise GE. Developmental changes in the extracellular matrix of the dental follicle during tooth eruption. Connect Tissue Res. 1988;18(3):175-90. doi: 10.3109/03008208809016806.
• Lohrmann DK, Gold RS, Jubb WH. School health education: a foundation for school health programs. J Sch Health. 1987 Dec;57(10):420-5. doi: 10.1111/j.1746-1561.1987.tb03187.x.
• Ageeva TS, Bukreeva EB, Khristoliubova EI. [Criteria and methods of etiological diagnosis of acute and chronic inflammatory processes in the lungs]. Ter Arkh. 1985;57(5):39-42. Russian.
• Choi H, Kim JH, Park JY, Ham BK, Shim Js, Bae JH. Gum chewing promotes bowel motility after a radical retropubic prostatectomy. Asia Pac J Clin Oncol. 2014 Mar;10(1):53-9. doi: 10.1111/ajco.12113. Epub 2013 Aug 12.
• Li S, Liu Y, Peng Q, Xie L, Wang J, Qin X. Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials. J Gastroenterol Hepatol. 2013 Jul;28(7):1122-32. doi: 10.1111/jgh.12206.
• De Luca-Monasterios F, Chimenos-Kustner E, Lopez-Lopez J. [Effect of chewing gum on halitosis]. Med Clin (Barc). 2014 Jul 22;143(2):64-7. doi: 10.1016/j.medcli.2013.11.038. Epub 2014 Feb 20. Spanish.
• Sasaki-Otomaru A, Sakuma Y, Mochizuki Y, Ishida S, Kanoya Y, Sato C. Effect of regular gum chewing on levels of anxiety, mood, and fatigue in healthy young adults. Clin Pract Epidemiol Ment Health. 2011;7:133-9. doi: 10.2174/1745017901107010133. Epub 2011 Aug 5. Erratum In: Clin Pract Epidemiol Ment Health. 2012;8:46.
• Miles C, Johnson AJ. Chewing gum and context-dependent memory effects: a re-examination. Appetite. 2007 Mar;48(2):154-8. doi: 10.1016/j.appet.2006.07.082. Epub 2006 Oct 19.
• Mickenautsch S, Leal SC, Yengopal V, Bezerra AC, Cruvinel V. Sugar-free chewing gum and dental caries: a systematic review. J Appl Oral Sci. 2007 Apr;15(2):83-8. doi: 10.1590/s1678-77572007000200002.
• Zaghiyan K, Felder S, Ovsepyan G, Murrell Z, Sokol T, Moore B, Fleshner P. A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding. Dis Colon Rectum. 2013 Mar;56(3):328-35. doi: 10.1097/DCR.0b013e31827e4971.
• Cavusoglu YH, Azili MN, Karaman A, Aslan MK, Karaman I, Erdogan D, Tutun O. Does gum chewing reduce postoperative ileus after intestinal resection in children? A prospective randomized controlled trial. Eur J Pediatr Surg. 2009 Jun;19(3):171-3. doi: 10.1055/s-0029-1202776. Epub 2009 Apr 9.
• Tamura T, Yatabe T, Kitagawa H, Yamashita K, Hanazaki K, Yokoyama M. Oral carbohydrate loading with 18% carbohydrate beverage alleviates insulin resistance. Asia Pac J Clin Nutr. 2013;22(1):48-53. doi: 10.6133/apjcn.2013.22.1.20.

Study record dates

Study Major Dates

• Study Start: January 1, 2013
• Primary Completion (Actual): February 1, 2014
• Study Completion (Actual): February 1, 2014

Study Registration Dates

• First Submitted: June 6, 2014
• First Submitted That Met QC Criteria: June 11, 2014
• First Posted (Estimate): June 12, 2014

Study Record Updates

• Last Update Posted (Estimate): January 13, 2015
• Last Update Submitted That Met QC Criteria: January 11, 2015
• Last Verified: January 1, 2015

More Information

Terms related to this study

• Keywords: cholecystectomy; postoperative; chewing gum; laparoscopic; ileus
• Additional Relevant MeSH Terms: Digestive System Diseases; Gastrointestinal Diseases; Intestinal Diseases; Intestinal Obstruction; Ileus; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Central Nervous System Depressants; Peripheral Nervous System Agents; Cholinergic Antagonists; Cholinergic Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Anti-Inflammatory Agents; Antirheumatic Agents; Platelet Aggregation Inhibitors; Cyclooxygenase Inhibitors; Anti-Bacterial Agents; Tranquilizing Agents; Psychotropic Drugs; Hypnotics and Sedatives; Adjuvants, Anesthesia; Anti-Anxiety Agents; GABA Modulators; GABA Agents; Anesthetics, Inhalation; Neuromuscular Agents; Nicotinic Antagonists; Neuromuscular Nondepolarizing Agents; Neuromuscular Blocking Agents; Midazolam; Propofol; Ketorolac; Sevoflurane; Cefuroxime; Cefuroxime axetil; Atracurium
• Other Study ID Numbers: BenazirBH