post-op bowel function

8/13/2019 post-op bowel function

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Research for PracticeChristina CrainicKathie EricksonJanet GardnerSheri Haberman

Pam P attenPat ThomasVictoria H ays

Comparison of M ethods Facilitate Postoperative Bowel

FunctionImproving postoperativereturn of bowel functionafter abdominal surgery isan important nursing andmedical goal. One promising intervention to achievethis goal is to have patientschew gum several times perday in the early postoperative period to stimulate thecephalic vagal reflex andbowel peristalsis. A study todetermine if return of gastrointestinal function afterabdominal surgery could behastened by the simpleintervention of chewing gum orsucking on h ard candy threetimes per day isdescribed.

atients undergoing abdominal surgery experience reduced gastroin-testinal (GO peristalsis due to surgical manipulation of the bowel andadministration of opioid medications after surgery (Baig Wexner, 2004;Behm Stollman, 2003; Steinbrook, 2005). Traditional interventions toprevent postoperative ileus or stimulate bowel function after surgeryinclude decompression of the stomach until return of bowel function witha nas oga stric tub e (Nelson, Tse, Edw ards, 2005), redu ction in opioiduse, and early mobilization of the patient to stimulate bowel function(Behm Stollman, 2003). Another promising intervention is early postop-erative feeding, which is hypothesized to activate the cephalic-vagalreflex. Cephalic phase hormonal release occurs through the activation ofvagal-efferent fibers in response to food-related sensory stimuli. Thus,tasting and chewing food elicits hormonal release prior to nutrientabsorp tion and stimulates secretion of GI horm ones , which in turnincrease bowel peristalsis and time to return of normal GI function (DiFronz, Cymerman, O'Connell, 1999; Miedema Johns on, 2003).Another intervention proposed to activate the cephalic-vagal reflex isthe chewing of gum in the early postoperative period (Asao et al., 2002).One study found significant decreases in the time to return of GI function

Christina Crainic RN C is AssistantHead Nurse, Surgical Unit, ProvidencePortland Medical Center, Portland, OR.Kathie Erickson RN is a Staff Nurse,Surgical Unit, Providence PortlandMedical Center, Portland, OR.Janet Gardner BSN RN is a StaffNurse, Surgical Unit, ProvidencePortland Medical Center, Portland, OR.Sheri Haberman RN C is a Staff Nurse,Intensive Care Unit, ProvidencePortland Medical Center, Portland, OR.Pam Patten BA RN C is a Staff Nurse,Surgical Unit, Providence PortlandMedical Center, Po rtland, OR.

Pat Thom as CNA is a NursingAssistant, Surgical Unit, ProvidencePortland Medical Center, Po rtland, OR.Victoria Ha ys MN RN CNS APRN BCis a Clinical N urse Specialist, Wound cindOstomy Nurse Manager, ProvidencePortland Medical Center, Portland, OR.Acknowledgment: Special thanks toMarianne Chulay, PhD, RN, FA\N, whoprovided assistance with study design,data analysis, and manuscript develoj>ment.


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after open abdominal surgery(Asao et al., 2002). Several m ethod-ological problems with the studydesign (e.g., small sample size[N=19],lack of correc tion for us eofmultiple i-tests) and poor descrip-tion of study methods limit thefindings. Study results for hospitallength of stay (LOS; 14 days forcontrol and experimental groups)after laparoscopic abdominal sur-gery also raises concerns thatpostoperat ive management inJapan may differ from the UnitedStates, which has much shorterLOS after abdo min al s urgery.These issues limit the generaliz-ability of the Japanese studyresults to U.S. patient care situa-tions. A second Japan ese studypublished by the same authors inpatients after laparoscopic abdom-inal surgery a few years later hadsimilar methods and results as theearlier study (Hirayama, Suzuki,Ide,Asao, Kuwano, 2006).

The findings of the twoJapanese studies are in contrast totwo recently published U.S.studieswhich also evaluated gum chewingthree times per day as a method tostimulate GI function after openabdominal surgery (Matros et al.,2006; Miedema Johnson, 2003;Schuster, Grewal, Greamey,Waxman, 2006). Matros and col-leagues used appropriate statisticalanalyses and controlled for multi-ple comparisons, but did not findsignificant differences in time to fla-tus,bowel movement, or discharge.Schuster and colleagues also foundno significant difference in returnofGIfunction but re porte d LOS in thegum chew ing group was significant-ly shorter thcin the control group.The authors did not correct for theuse of multiple Mests in their dataanalysis; this finding of sho rte r LOSwould not have been significant if acorrection for multiple compar-isons had been performed.

Additional research is neededto determine the impact of thissimple intervention to improvepostoperative GI outcomes. Thepurpose of this study was to com-pare two different methods tostimulate GI function elfter GI sur-gery (chewing gum or suckinghard candy) to usual postopera-tive care (no GI stimulant).

Materials and MethodsThis study was approved bythe institutional review board andconducted on a surgical unit of a483-bed nonprofit community hos-pital in the Pacific Northwest.Study design An experimentaldesign was used to compare differ-ent methods for stimulating thereturn of GI function after electiveabdominal surgery. Subjects wereassigned randomly to one of threedifferent methods for stimulatingGI function (chewing gum, suckingon hard candy, no GI stimulant)using a computer-generated ran-domization sequence. Dependentvariables were time to first flatusand first bowel movement, toler-ance of fluid intake, and hospitaldischarge.Sample selection Subjects forthis study were drawn from a con-venience sample of GI surgicalpatients admitted to a postopera-tive, general surgery patient careunit. Inclusion criteria includedages 18-85, English speaking,laparoscopic or exploratory colec-tomy (sigmoid, transverse, anteri-or, or hemicolectomy), and abilityto chew gum or suck on hard can-dies safely after surgery. Exclusioncriteria included a return to sur-gery, postoperative transfer toanother clinical unit, administra-tion of chemo therapy within7daysof surgery, and disease and/orswelling of the oral cavity (e.g.,temporomandibular joint disease,oral ab scess ). The IRB approval ofthe study included a waiver ofinformed consent because thestudy met federal guidelines forthis waiver. Subjects we re informedabout the nature of the study in awritten information sheet providedto them after surgery.Sample size was calculated apriori using power analysis foranalysis of variance (ANOVA) withthre e gro up s. Effect size was calcu-lated to dete ct a 24-hour differencein time to bowel movementbetween the control and experi-mental groups using data from aprior study (Asao et al., 2002).Calculated effect size was 0.4 andpower was set at 0.8, with level ofsignificance of. 0.05, resulting in asamp le size requirement of 66 sub-jects (Cohen, 1977; FoulErdfleder, 2007).

A total of 97 subjects wereenrolled in the study, with 31 subjects eliminated from final dataanalysis for the following reasonsresearch protocol not followed bynursing staff (n=8), subjecreturned to surgery (n=5), subjecrefused to chew gum/suck on hardcandy (n=4), subject transferred toanother unit before discharge(n=3),developed an ileus with dicontinuation of intervention (n=3)and other (n=8). The reasons fonon-inclusion in data analysis werespread evenly throughout thethree groups.

Study procedure All patientswho met study eligibility criteriawere assigned randomly to one ofthree groups within 4 hours ofadmission to the postoperat ivesurgical care unit. Subjects ingroup 1 were scheduled to chewgum for 30 minutes three times aday until their first bowel movement. Subjects in group 2 werescheduled to suck on hard candyuntil dissolved three times a dayuntil their first bowel movementSubjects in group 3 were not givenany form ofGIstimulant. One stiof sugarless gum (Extra SugarlessGum, Wrigley Jr. CompanyChicago, IL) or one piece of sugarless candy (Sugarless Life SaversWrigley Jr. Company, Chicago, ILwas administered as a medicationthree times a day by the nursingst ff Research nursing staff documented th e date and time candy orgum was administered on the d atacollection form only. Subjects wereallowed ice chips as need ed and astolerated upon arrival to the inpatient unit.

Every 24 hours, the occurrence of the first flatus and bowemovements was determined by aninvestigator asking the subjecwhether either of these two eventshad occurred within the last dayTolerance to fluids was determined by review of intake and output in the m edical record, and do cumented as present with the firstconsumption of at least 8 ouncesof fluids postoperatively withouthe pr esen ce of nausea or vomitingfor a period of 8 hours. Time tofirst flatus and first bowel movement, and postoperative LOS werecalculated based on the time ofadmission to the surgical care uni


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Table 1.Average SEM) Hours to Gl Function for Three Different Groups of Gl Stimulant Interventions Chew ingGum,Sucking on H ard Candy, No Gl Stimulant) in 66 Abdominal S urgery PatientsDependent Variable Group Ass ignmentChew ing Gum Sucking on Hard Candy No Gi Stimulant

Time toTolerance ofOral Fluid

Time toFirst Flatus

Time to BowelMovement

All subjectsOpen procedureonly

Laparoscopicprocedure onlyAll subjects

Open procedureonlyLaparoscopicprocedure onlyAll subjects

Open procedureonly

53.6 9.3n=20)65.7 13.2n=9)43.8 12.7n=11)80.2 5.5n=17)82.8 7.5n=9)77.3 8.5n=8)90.9 5.8n=19)102.5 8.6{n=9)

55.7 7.5n=22)65.4 14 .4n=7)51.1 8.8n=15)60.5 8.5{n=16)

69.4 13.7n=7)53.5 10.8n=9)82.2 7.5n=19)

103.6 10 .9n=4)

61.2 7.6n=24)64.7 15.1n=9)59.1 8.5n=15)72.5 6.4n=23)

71.1 12.2{n=8)73.3 7.6n=15)92.7 9.1n=20)

86.3 13.3n=8)

until first notation of flatus andbowel movement, and time of hos-pital discharge, respectively.Data analysis.Data were sum-marized with descriptive statistics(see Table 1). ANOVA was used todetermine if the use of GI stimu-lants affected the time to first fla-tus or first bowel movement, toler-ance of oral intake, and LOS.Scheffe's multiple comparison testwas used to determine specificgroup differences. The level of sig-nificance for all tes ts w asp 0.05.esultsA toted of 66 subjects was stud-ied ov er 14 month s. The majorityofsub jects were female (60 ) ages 22-85 (meanSEM of 58.71.8 yea rs).Two thirds of the subjects had alaparoscopic surgical procedure,with the remaining subjects havingopen surgical incision. All subjectsassigned to the chewing gum orsucking on hard candy groupsbegan these interventions within 24hou rs of surgery.Time to tolerance of oral fluidswas 8-143 hours (see Table 1).Timeto first flatus and bowel movementwas 9.5 140 hours and 9.5-168.9hours, respectively. Time to dis-charge ranged from 37.5 to 240hours. Eight subjects did not report

flatus (n=2 for gum, n=3 for candy,n=3for control group ) and nine sub-jects did not report a bowel move-ment (n=3 for gum, n=3 for candy,n=3 for control group) during theirhospitalization. These were report-ed as missing values.The average SEM)time to tol-erance of oral fluid, first flatus, firstbowel movement, and hospital dis-charge was 57.3 ( 4.6) hours, 71.4( 4.0) hou rs, 87.2 ( 4.6) ho urs , and128.6 4.4) hou rs, respectively (seeTable 1). ANOVA found no signifi-cant differences among th e chewinggum, sucking on hard candy, and noGI stimulant treatment groups forany of the d epen dent variables [tol-erance of orsd fluids p= 0.79), firstflatus p= 0.16), flrst bowel move-ment (p=0.58), and hospital dis-charge(p=0.85)].Anecdotal findingsduring the study included com-ments by20 (13 of 66 sub jects) ofpatients that chewing on gum orsucking on hard candy increasedtheir nausea.Times to first flatus and bowelmov emen ts, tolerance of fluids, andhospital discharge were shorter forsubjects with a laparoscopic proce-dure compared to those with anopen abdominal surgical procedure.ANOVA found no significant differ-ences between the laparoscopic or

open abdominal procedure andeach of the dependent vciriables(p


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between the two Japanese studies(Asao et al., 2002; Hirayama et al.,2006) that found significantimprovement in GI function withgum chewing, and the U.S. studiesthat did not (Matros et al., 2006;Schuster et al., 2006). The length oftime to bowel movement is muchlonger in the Japanese studies(approximately 136 hours) follow-ing both open (Hirayama et al.,2006) and laparoscopic (Asao et al.,2002) procedures than was seen inthe control group for the U.S. stud-ies (approximately 90 hours)(Matros et al., 2006; Schuster et al.,2006). Control group times for thecurrent study involving open andlaparoscopic surgeries were similarto the other U.S.studies. While rea-son s for the 2-day difference in timeto bowel movement in the earlierstudies are not clear, a question israised regarding the generalizabilityof the Japa nese stud y results to U.S.patients. Significant variations inother postoperative routines couldbe a reason accounting for thelonger times to bowel movement,such as the timing and frequencyomobilization and/or advancementof oral intake after su rgery.

Limitations of the study Thisstudy, as all previous s tudies, reliedon nurses to distribute thegum/candy and subjects' compli-ance with chewing on gum or suck-ing on hard candies for the 30-minute period three times a day. Apossible lack of adherence by nurs-es to provide the gum/candy an d/orpatients to chew th e gum or suck onthe candy may have weakened thestrength of the intervention. If so,results of this study reflect the reali-ties of clinical prac tice, wh ere no t allpatients comply with medical andsurgical interve ntions.Another limitation in all thestudies to d ate is the need to rely onself-report by the patient of whenflatus or bowel movements firstoccur. Querying the patient hoursafter an event as to the exact timethe event occurred may lead toerrors in recall because his or hersense of time may be distorted bymedications or other postoperativefactors.None of the studies to da te haveattempted to obtain informationsystematically from the patient onthe reaction or response to chewing

of gum or sucking on hard candy.This would seem to be an im portantcomponent for future studiesbecause anecdotal comments madeby 20%of the subjects in this studyindicated a perceived link betweenchewing gum and increased nausea.Nursing Implications Gum chew-ing or sucking on hard ca ndies doe snot appear to have any clinicaladvantage to increasing GI functionover usual postoperative care afterabdominal surgery. Additional stud-ies are need ed, p articularly in differ-ent postoperative populations, todetermine if these interventionshave any clinical merit. Addressingsom e of the limitations in prior stud -ies may improve th e impact of theseinterventions o n GI function, result-ing in improved patient care out-comes. ReferencesAsao,T., Kuwano, H., Nakamura,J.,iVIorinaga,N., Hirayama, I., Ide, M. (2002). Gumciiewing enhances early recovery frompostoperative ileus after laparoscopiccoiectomy. American Coliege ofSurgeons,195 30-32.Baig, M., Wexner, D. (2004). Postoperativeileus: A review.Diseases Colon Rectum,47 ,516-526.Behm , B., Stoilman, N. (2003). Postoperativeiieus: Etioiogies and interventions.Clinicai Gastroenterology Hepatology,1 2),71-80.

Cohen, J . (1977). tatisticalpoweranalysisf othe behavioral sciences (2nd ed.). NewYori


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post-op bowel function