Cochrane Database of Systematic Reviews Chewing gum for postoperative recovery of gastrointestinal function (Review) Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, Thomas S, Andersen HK, Lewis SJ Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, Thomas S, Andersen HK, Lewis SJ. Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD006506. DOI: 10.1002/14651858.CD006506.pub3. www.cochranelibrary.com Chewing gum for postoperative recovery of gastrointestinal function (Review) Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 6 OBJECTIVES ..................................... 7 METHODS ...................................... 7 Figure1. ..................................... 9 RESULTS....................................... 11 Figure2. ..................................... 13 Figure3. ..................................... 14 Figure4. ..................................... 17 Figure5. ..................................... 18 Figure6. ..................................... 19 Figure7. ..................................... 20 Figure8. ..................................... 21 Figure9. ..................................... 22 Figure10. ..................................... 23 Figure11. ..................................... 24 ADDITIONALSUMMARYOFFINDINGS . 26 DISCUSSION ..................................... 28 AUTHORS’CONCLUSIONS . 31 ACKNOWLEDGEMENTS . 32 REFERENCES ..................................... 32 CHARACTERISTICSOFSTUDIES . 41 DATAANDANALYSES. 173 ADDITIONALTABLES. 174 WHAT’SNEW..................................... 177 HISTORY....................................... 177 CONTRIBUTIONSOFAUTHORS . 178 DECLARATIONSOFINTEREST . 178 SOURCESOFSUPPORT . 179 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 179 NOTES........................................ 179 INDEXTERMS .................................... 180 Chewing gum for postoperative recovery of gastrointestinal function (Review) i Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Chewing gum for postoperative recovery of gastrointestinal function Vaneesha Short1, Georgia Herbert1, Rachel Perry1, Charlotte Atkinson1, Andrew R Ness1, Christopher Penfold1, Steven Thomas2, Henning Keinke Andersen3, Stephen J Lewis4 1NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK. 2Head & Neck Surgery, University Hospitals Bristol NHS Trust, Bristol, UK. 3The Cochrane Colorectal Cancer Group, Bispebjerg Hospital, Building 39N, Copenhagen, Denmark. 4Dept of Gastroenterology, Level 7, Derriford Hospital, Plymouth, UK Contact address: Vaneesha Short, NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Upper Maudlin Street, Bristol, Avon, BS2 8AE, UK. [email protected]. Editorial group: Cochrane Colorectal Cancer Group. Publication status and date: New, published in Issue 2, 2015. Review content assessed as up-to-date: 17 June 2014. Citation: Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, Thomas S, Andersen HK, Lewis SJ. Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD006506. DOI: 10.1002/14651858.CD006506.pub3. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo-vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand-searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and metaRegister of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and Chewing gum for postoperative recovery of gastrointestinal function (Review) 1 Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta-analyses using a random-effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta-regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias’ assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: -11.9, -8.9): 12.5 hours (95% CI: -17.2, -7.8) in CRS, 7.9 hours (95% CI: -10.0, -5.8) in CS, 10.6 hours (95% CI: -12.7, -8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: -14.5, -10.9): 18.1 hours (95% CI: -25.3, -10.9) in CRS, 9.1 hours (95% CI: -11.4, -6.7) in CS, 12.3 hours (95% CI: -14.9, -9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: -0.8, -0.5): 1.0 days in CRS (95% CI: -1.6, - 0.4), 0.2 days (95% CI: -0.3, -0.1) in CS, 0.8 days (95% CI: -1.1, -0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: -6.4, -3.7): 3.21 hours (95% CI: -7.0, 0.6) in CRS, 4.4 hours (95% CI: -5.9, - 2.8) in CS, 6.3 hours (95% CI: -8.7, -3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well-tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta-regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors’ conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. PLAIN LANGUAGE SUMMARY Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again.