Research for Practice

Christina Crainic Kathie Erickson Janet Gardner Sheri Haberman Pam Patten Pat Thomas Victoria Hays

Comparison of Methods To Facilitate Postoperative Bowel Function

Improving postoperative return of bowel function after abdominal surgery is an important nursing and medical goal. One promising intervention to achieve this goal is to have patients chew gum several times per day in the early postoperative period to stimulate the cephalic-vagal reflex and bowel peristalsis. A study to determine if return of gastrointestinal function after abdominal surgery could be hastened by the simple intervention of chewing gum or sucking on hard candy three times per day is described.

atients undergoing abdominal surgery experience reduced gastrointestinal (GO peristalsis due to surgical manipulation of the bowel and administration of opioid medications after surgery (Baig & Wexner, 2004; Behm & Stollman, 2003; Steinbrook, 2005). Traditional interventions to prevent postoperative ileus or stimulate bowel function after surgery include decompression of the stomach until return of bowel function with a nasogastric tube (Nelson, Tse, & Edwards, 2005), reduction in opioid use, and early mobilization of the patient to stimulate bowel function (Behm & Stollman, 2003). Another promising intervention is early postoperative feeding, which is hypothesized to activate the cephalic-vagal reflex. Cephalic phase hormonal release occurs through the activation of vagal-efferent fibers in response to food-related sensory stimuli. Thus, tasting and chewing food elicits hormonal release prior to nutrient absorption and stimulates secretion of GI hormones, which in turn increase bowel peristalsis and time to return of normal GI function (Di Fronz, Cymerman, & O'Connell, 1999; Miedema & Johnson, 2003). Another intervention proposed to activate the cephalic-vagal reflex is the 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 Assistant Head Nurse, Surgical Unit, Providence Portland Medical Center, Portland, OR. Kathie Erickson, RN, is a Staff Nurse, Surgical Unit, Providence Portland Medical Center, Portland, OR. Janet Gardner, BSN, RN, is a Staff Nurse, Surgical Unit, Providence Portland Medical Center, Portland, OR. Sheri Haberman, RN,C, is a Staff Nurse, Intensive Care Unit, Providence Portland Medical Center, Portland, OR. Pam Patten, BA, RN,C, is a Staff Nurse, Surgical Unit, Providence Portland Medical Center, Portland, OR. Pat Thomas, CNA, is a Nursing Assistant, Surgical Unit, Providence Portland Medical Center, Portland, OR.
Victoria Hays, MN, RN, CNS, APRN BC,

is a Clinical Nurse Specialist, Wound cind Ostomy Nurse Manager, Providence Portland Medical Center, Portland, OR. Acknowledgment: Special thanks to Marianne Chulay, PhD, RN, FA\N, who provided assistance with study design, data analysis, and manuscript develoj> ment.

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after open abdominal surgery (Asao et al., 2002). Several methodological problems with the study design (e.g., small sample size [N=19], lack of correction for use of multiple i-tests) and poor description of study methods limit the findings. Study results for hospital length of stay (LOS; 14 days for control and experimental groups) after laparoscopic abdominal surgery also raises concerns that postoperative management in Japan may differ from the United States, which has much shorter LOS after abdominal surgery. These issues limit the generalizability of the Japanese study results to U.S. patient care situations. A second Japanese study published by the same authors in patients after laparoscopic abdominal surgery a few years later had similar methods and results as the earlier study (Hirayama, Suzuki, Ide, Asao, & Kuwano, 2006). The findings of the two Japanese studies are in contrast to two recently published U.S. studies which also evaluated gum chewing three times per day as a method to stimulate GI function after open abdominal surgery (Matros et al., 2006; Miedema & Johnson, 2003; Schuster, Grewal, Greamey, & Waxman, 2006). Matros and colleagues used appropriate statistical analyses and controlled for multiple comparisons, but did not find significant differences in time to flatus, bowel movement, or discharge. Schuster and colleagues also found no significant difference in return of GI function but reported LOS in the gum chewing group was significantly shorter thcin the control group. The authors did not correct for the use of multiple Mests in their data analysis; this finding of shorter LOS would not have been significant if a correction for multiple comparisons had been performed. Additional research is needed to determine the impact of this simple intervention to improve postoperative GI outcomes. The purpose of this study was to compare two different methods to stimulate GI function elfter GI surgery (chewing gum or sucking hard candy) to usual postoperative care (no GI stimulant).

Materials and Methods

This study was approved by the institutional review board and conducted on a surgical unit of a 483-bed nonprofit community hospital in the Pacific Northwest. Study design. An experimental design was used to compare different methods for stimulating the return of GI function after elective abdominal surgery. Subjects were assigned randomly to one of three different methods for stimulating GI function (chewing gum, sucking on hard candy, no GI stimulant) using a computer-generated randomization sequence. Dependent variables were time to first flatus and first bowel movement, tolerance of fluid intake, and hospital discharge. Sample selection. Subjects for this study were drawn from a convenience sample of GI surgical patients admitted to a postoperative, general surgery patient care unit. Inclusion criteria included ages 18-85, English speaking, laparoscopic or exploratory colectomy (sigmoid, transverse, anterior, or hemicolectomy), and ability to chew gum or suck on hard candies safely after surgery. Exclusion criteria included a return to surgery, postoperative transfer to another clinical unit, administration of chemotherapy within 7 days of surgery, and disease and/or swelling of the oral cavity (e.g., temporomandibular joint disease, oral abscess). The IRB approval of the study included a waiver of informed consent because the study met federal guidelines for this waiver. Subjects were informed about the nature of the study in a written information sheet provided to them after surgery. Sample size was calculated a priori using power analysis for analysis of variance (ANOVA) with three groups. Effect size was calculated to detect a 24-hour difference in time to bowel movement between the control and experimental groups using data from a prior study (Asao et al., 2002). Calculated effect size was 0.4 and power was set at 0.8, with level of significance of. 0.05, resulting in a sample size requirement of 66 subjects (Cohen, 1977; Foul & Erdfleder, 2007).

A total of 97 subjects were enrolled in the study, with 31 subjects eliminated from final data analysis for the following reasons: research protocol not followed by nursing staff (n=8), subject returned to surgery (n=5), subject refused to chew gum/suck on hard candy (n=4), subject transferred to another unit before discharge (n=3), developed an ileus with discontinuation of intervention (n=3), and other (n=8). The reasons for non-inclusion in data analysis were spread evenly throughout the three groups. Study procedure. All patients who met study eligibility criteria were assigned randomly to one of three groups within 4 hours of admission to the postoperative surgical care unit. Subjects in group 1 were scheduled to chew gum for 30 minutes three times a day until their first bowel movement. Subjects in group 2 were scheduled to suck on hard candy until dissolved three times a day until their first bowel movement. Subjects in group 3 were not given any form of GI stimulant. One stick of sugarless gum (Extra Sugarless Gum, Wrigley Jr. Company, Chicago, IL) or one piece of sugarless candy (Sugarless Life Savers, Wrigley Jr. Company, Chicago, IL) was administered as a medication three times a day by the nursing staff. Research nursing staff documented the date and time candy or gum was administered on the data collection form only. Subjects were allowed ice chips as needed and as tolerated upon arrival to the inpatient unit. Every 24 hours, the occurrence of the first flatus and bowel movements was determined by an investigator asking the subject whether either of these two events had occurred within the last day. Tolerance to fluids was determined by review of intake and output in the medical record, and documented as present with the first consumption of at least 8 ounces of fluids postoperatively without the presence of nausea or vomiting for a period of 8 hours. Time to first flatus and first bowel movement, and postoperative LOS were calculated based on the time of admission to the surgical care unit

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Table 1. Average ( SEM) Hours to Gl Function for Three Different Groups of Gl Stimulant Interventions (Chewing Gum, Sucking on Hard Candy, No Gl Stimulant) in 66 Abdominal Surgery Patients
Group Assignment Dependent Variable Chewing Gum All subjects Time to Tolerance of Oral Fluid Open procedure only Laparoscopic procedure only All subjects Time to First Flatus Open procedure only Laparoscopic procedure only All subjects Time to Bowel Movement Open procedure only 53.6 9.3 (n=20) 65.7 13.2 (n=9) 43.8 12.7 (n=11) 80.2 5.5 (n=17) 82.8 7.5 (n=9) 77.3 8.5 (n=8) 90.9 5.8 (n=19) 102.5 8.6 {n=9) Sucking on Hard Candy 55.7 7.5 (n=22) 65.4 14.4 (n=7) 51.1 8.8 (n=15) 60.5 8.5 {n=16) 69.4 13.7 (n=7) 53.5 10.8 (n=9) 82.2 7.5 (n=19) 103.6 10.9 (n=4) No Gi Stimulant 61.2 7.6 (n=24) 64.7 15.1 (n=9) 59.1 8.5 (n=15) 72.5 6.4 (n=23) 71.1 12.2 {n=8) 73.3 7.6 (n=15) 92.7 9.1 (n=20) 86.3 13.3 (n=8)

until first notation of flatus and bowel movement, and time of hospital discharge, respectively. Data analysis. Data were summarized with descriptive statistics (see Table 1). ANOVA was used to determine if the use of GI stimulants affected the time to first flatus or first bowel movement, tolerance of oral intake, and LOS. Scheffe's multiple comparison test was used to determine specific group differences. The level of significance for all tests was p < 0.05.

Results
A toted of 66 subjects was studied over 14 months. The majority of subjects were female (60%) ages 2285 (mean SEM of 58.7 1.8 years). Two thirds of the subjects had a laparoscopic surgical procedure, with the remaining subjects having open surgical incision. All subjects assigned to the chewing gum or sucking on hard candy groups began these interventions within 24 hours of surgery. Time to tolerance of oral fluids was 8-143 hours (see Table 1). Time to first flatus and bowel movement was 9.5-140 hours and 9.5-168.9 hours, respectively. Time to discharge ranged from 37.5 to 240 hours. Eight subjects did not report
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flatus (n=2 for gum, n=3 for candy, n=3 for control group) and nine subjects did not report a bowel movement (n=3 for gum, n=3 for candy, n=3 for control group) during their hospitalization. These were reported as missing values. The average ( SEM) time to tolerance of oral fluid, first flatus, first bowel movement, and hospital discharge was 57.3 ( 4.6) hours, 71.4 ( 4.0) hours, 87.2 ( 4.6) hours, and 128.6 ( 4.4) hours, respectively (see Table 1). ANOVA found no significant differences among the chewing gum, sucking on hard candy, and no GI stimulant treatment groups for any of the dependent variables [tolerance of orsd fluids (p = 0.79), first flatus (p = 0.16), flrst bowel movement (p=0.58), and hospital discharge (p=0.85)]. Anecdotal findings during the study included comments by 20% (13 of 66 subjects) of patients that chewing on gum or sucking on hard candy increased their nausea. Times to first flatus and bowel movements, tolerance of fluids, and hospital discharge were shorter for subjects with a laparoscopic procedure compared to those with an open abdominal surgical procedure. ANOVA found no significant differences between the laparoscopic or

open abdominal procedure and each of the dependent vciriables (p<0.05).

Discussion
This study compared two methods to stimulate GI function after abdominal surgery: chewing gum and sucking on hcird candy. In the 66 subjects studied, there was no difference in return of GI function (tolerance of oral fluids, time to first postoperative flatus, and/or bowel movement) or time to discharge compared to the control group. Similar to the two recent studies done in the United States (Matros et al., 2006; Schuster et al., 2006), this study found no significant difference in return of GI function when patients chewed gum three times a day for 30 minutes. In addition, this study is the flrst to report the effect of an additional method for stimulating GI function (sucking on hard candy). Researchers included hard candy as a method for stimulating GI function because many patients, pcirticularly older adults, may prefer candy to gum as a postoperative intervention. Results with hard candy, though, also found no improvement in return of GI function. Interesting differences exist
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between the two Japanese studies (Asao et al., 2002; Hirayama et al., 2006) that found significant improvement in GI function with gum chewing, and the U.S. studies that did not (Matros et al., 2006; Schuster et al., 2006). The length of time to bowel movement is much longer in the Japanese studies (approximately 136 hours) following both open (Hirayama et al., 2006) and laparoscopic (Asao et al., 2002) procedures than was seen in the control group for the U.S. studies (approximately 90 hours) (Matros et al., 2006; Schuster et al., 2006). Control group times for the current study involving open and laparoscopic surgeries were similar to the other U.S. studies. While reasons for the 2-day difference in time to bowel movement in the earlier studies are not clear, a question is raised regarding the generalizability of the Japanese study results to U.S. patients. Significant variations in other postoperative routines could be a reason accounting for the longer times to bowel movement, such as the timing and frequency of mobilization and/or advancement of oral intake after surgery.
Limitations of the study. This

of gum or sucking on hard candy. This would seem to be an important component for future studies because anecdotal comments made by 20% of the subjects in this study indicated a perceived link between chewing gum and increased nausea.
Nursing Implications. Gum chew-

ing or sucking on hard candies does not appear to have any clinical advantage to increasing GI function over usual postoperative care after abdominal surgery. Additional studies are needed, particularly in different postoperative populations, to determine if these interventions have any clinical merit. Addressing some of the limitations in prior studies may improve the impact of these interventions on GI function, resulting in improved patient care outcomes.
References
Asao,T., Kuwano, H., Nakamura, J., iVIorinaga, N., Hirayama, I., & Ide, M. (2002). Gum ciiewing enhances early recovery from postoperative ileus after laparoscopic coiectomy. American Coliege of Surgeons, 195, 30-32. Baig, M., & Wexner, D. (2004). Postoperative ileus: A review. Diseases Colon Rectum, 47, 516-526. Behm, B., & Stoilman, N. (2003). Postoperative iieus: Etioiogies and interventions. Clinicai Gastroenterology Hepatology, 1(2), 71-80.

study, as all previous studies, relied on nurses to distribute the gum/candy and subjects' compliance with chewing on gum or sucking on hard candies for the 30minute period three times a day. A possible lack of adherence by nurses to provide the gum/candy and/or patients to chew the gum or suck on the candy may have weakened the strength of the intervention. If so, results of this study reflect the realities of clinical practice, where not all patients comply with medical and surgical interventions. Another limitation in all the studies to date is the need to rely on self-report by the patient of when flatus or bowel movements first occur. Querying the patient hours after an event as to the exact time the event occurred may lead to errors in recall because his or her sense of time may be distorted by medications or other postoperative factors. None of the studies to date have attempted to obtain information systematically from the patient on the reaction or response to chewing
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Cohen, J. (1977). Statistical power analysis for the behavioral sciences (2nd ed.). New Yori<: Academic Press. Di Fronz, L.A., Cymerman, J., & O'Conneli, T (1999). Factors affecting eariy postoperative feeding following elective open colon resection. Archives Surgery, 134, 941944 Foui, F, & Erdfieder, E. (2007). GPOWER: A priori, post-hoc, and compromise power analysis for MS-DOS. Retrieved July 17, 2007, from iittp://www.psycho.uni-dues seidorf.de/aap/projects/gpower/ Hirayama, i., Suzuki, M., Ide, M., Asao, T, & Kuwano, H. (2006). Gum chewing stimulates bowei motility after surgery for coiorectal cancer. Hepato-Gastroenterology, 53, 206-208. Matros, E., Rocfia, F, Zinner, M., Wang, J., Ashley, S., Breen, E., et al. (2006). Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, piacebo-controiled triai. Journal American College of Surgery, 202, 773778. Miedema, B.W., & Johnson, J. (2003). Methods for decreasing postoperative gut dysmotility. Lancet Oncology, 4, 365-371. Neison, R., Tse, B., & Edwards, S. (2005). Systematic review of prophylactic nasogastric decompression after abdominal operations. British Journal Surgery, 92, 673-680. Schuster, R., Grewal, N., Greamey, G.C., & Waxman, K. (2006). Gum chewing reduces iieus after elective open sigmoid coiectomy. Archives Surgery, 141, 174176. Steinbrook, R. (2005). Postoperative ileus: Why we should treat. Contemporary Surgery, 61(Suppl.), 4-7.

From AMSN
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the National Database of Nursing Quality Indicators (NDNQI) and the National Quality Forum (NQF). State boards of nursing define the lawful scope of nursing practice. Professional nursing organizations such as the Academy of MedicalSurgical Nurses provide the nurse with professional development opportunities and mentoring relationships, connect research to practice through scholarly publications, facilitate networking, and are a repository for resources to assist and support the nurse throughout his or her career. All of these environmental resources make sense.

The practice of nursing includes selecting nursing strategies and implementing interventions to best meet the individual needs of each patient situation. Dialoging at professional staff meetings about ways to enhance, codify, and articulate nursing practice to patients and colleagues promotes creativity and communicates a culture of accountability. As quality outcomes and high patient satisfaction will bring the dollars, it makes perfect sense, in the complex world of health care, for the medical-surgical nurse to take responsibility for bringing the common sense.
References
American Nurses Association (ANA). (2004). Considering nursing? Retrieved July 18, 2009, from http://www.nursingworid.org/ EspecialiyForYou/StudentNurses.aspx Wisdom Quotes. (2009). Harriet Beecher Stowe. Retrieved July 20, 2009, from http://www.wisdomquotes.com/cat_ common_sense.htmi

Taking Responsibility
Harriet Beecher Stowe observed, "Common sense is the knack of seeing things as they are, and doing things as they ought to be done" (Wisdom Quotes, 2009).

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