Study of the Effect of Early Feeding, Chewing Gums, and Laxative on Ileus in Patients Who Underwent Open Cholecystectomy

Objective: The Latin word ileus originated from the Greek term Eileos—intestinal colic, which is derived from the verb eilein—to squeeze or roll up tight. Postoperative ileus is common after abdominal operations, including colectomy. The aim of this study was to compare the effect of chewing gum, initiation of early feeding, nasogastric decompression, and NPO condition on postoperative ileus after cholecystectomy.Design: This study was carried out as clinical trial.Place and duration of study: During a 19-month period of study from July 2006 to February 2007, 97 patients who underwent uncomplicated open cholecystectomy in Golestan, Razi, and Imam Khomeini Hospital were included in this study.Patients and methods: These patients underwent surgery due to acute cholecystitis or gall stones. Patients with gangrene, empyma, or peritonitis were not included in this study. Patients were “NPO” one night before surgery. Cholecystitis was diagnosed based on history, physical examination, and sonographic findings. After surgery, patients were randomly divided in 4 groups (laxative, NPO, early feeding, and chewing gums). Data were analyzed with ANOVA and variance analysis method by SPSS version 13.0 software. Patients with gall bladder empyema or gangrene, associated cholangitis, history of chronic constipation or history of drugs affecting gastrointestinal motility were excluded from this study. All patients underwent general anesthesia with one of the following drugs: midazolam, fentanyl, thiopental sodium, atropine, neostigmine, and atracurium. All of these drugs are short-acting and have a half-life of less than 2hrs. Bowel sounds were checked by a single experienced physician with a Littmann stethoscope.Results: Patients were 29-72 years old (M=32% and F=68%). There were significant differences for the NPO group versus the feeding and gum group (P=0.01). BS recovery time was significantly different between laxative group and gum group (0.008) and laxative group versus feeding group (0.012). There was no significant difference for feeding versus gum group (P=0.9) and laxative versus NPO group (P=0.38). The average times of hospital stay were shortest for the feeding and the gum group with 1.20 and 1.21 days, respectively. All patients in the gum group were discharged in 2 days; 84% of patients in the feeding group were only 24 hrs in hospital before discharge. This percentage was 25% and 79.2% for the NPO and the gum group, respectively. There was a significant difference for the feeding and the gum group compared to the other groups for duration of hospital stay.Conclusion: As mentioned above, the gum chewing method is a safe and effective method in reducing postoperative ileus. INTRODUCTION AND AIM The Latin word ileus originated from the Greek term Eileos—intestinal colic, which is derived from the verb eilein—to squeeze or roll up tight. 1 This term, obviously, is not an accurate description of postoperative ileus, since it is a functional rather than a mechanical disorder. Post operative ileus is common after abdominal operations, including colectomy. 2 For lack of a commonly accepted standard definition, postoperative ileus is usually regarded as the transient impairment of intestinal motility occurring after operation 3 which is clinically characterized by abdominal distention, delayed passage of gas and stool, lack of bowel sounds, and accumulation of gas and fluid in the bowel that may result in nausea and vomiting. Madsen et al. indicated that clinical parameters other than bowel sounds, such as the return of flatus and the first postoperative bowel movement, are appropriate for assessing GI motility after abdominal surgery. 4 For a long time, NG tube was a treatment of choice in ileus. Recent studies have questioned the role of the NG tube 5 . Some of the adverse effects of postoperative ileus are as following: increased incidence of nausea and vomiting, delayed resumption of oral feeding, increased postoperative pain, delayed wound healing, and increased Study of the Effect of Early Feeding, Chewing Gums, and Laxative on Ileus in Patients Who Underwent Open Cholecystectomy 2 of 4 risk of postoperative complications. 6 Because of significant implications of ileus after colectomy, surgeons have devised strategies in an attempt to minimize postoperative ileus. A study by Stewart et al. showed that early feeding after colectomy hastened hospital stay. 7 Choi et al. showed that early feeding after open colon resection was safe and resulted in early hospital discharge. 8 The aim of this study was to compare the effect of chewing gum, initiation of early feeding, nasogastric decompression, and NPO condition on postoperative ileus after cholecystectomy. PATIENTS AND METHODS During the 19-month period of study from July 2006 to February 2007, 97 patients who underwent uncomplicated open cholecystectomy in Golestan, Razi, and Imam Khomeini Hospital were included in this study. These patients underwent surgery due to acute cholecystitis or gall stones. Patients with gangrene, empyma, or peritonitis were not included in this study. Patients were NPO one night before surgery. Cholecystitis was diagnosed based on history, physical examination, and sonographic findings. Patients with gall bladder empyema or gangrene, associated cholangitis, history of chronic constipation or history of drugs affecting gastrointestinal motility were excluded from this study. All patients underwent general anesthesia with the one of the following drugs: midazolam, fentanyl, thiopental sodium, atropine, neostigmin, and atracurium. All of these drugs are short-acting and have a half-life of less than 2 hrs. After surgery, patients were randomly divided in 4 groups (laxative, NPO, early feeding, and chewing gums). For patients in the laxative group, 6 hours after surgery, the laxative was initiated (15cc q8hrs). For patients which chewing gums, chewing was initiated 6hrs after surgery with 3 times a day lasting 30 minutes each. In the early feeding group, peroral feeding was initiated 6hrs after surgery with liquid and then regular diet. After extubation, bowel sounds were examined q6hrs by an experienced physician with a Littmann stethoscope. Data were analyzed with ANOVA and Variance analysis method by SPSS version 13.0 software.