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April 20, 2009

Sham-Feed or Sham?

Arch Surg. 2009;144(4):382. doi:10.1001/archsurg.2009.33

We read with interest the meta-analysis by Purkayastha et al1 on gum chewing and gut function in patients who have undergone colorectal surgery. We performed a similar meta-analysis of randomized controlled trials (RCTs)2 and recently updated it with an additional RCT.3 With the use of Comprehensive Meta-Analysis by Biostat (Biostat, Englewood, New Jersey), our updated meta-analysis included 6 RCTs and 256 patients (136 chewing gum; 120 controls). A random-effects model was used owing to significant study heterogeneity, and significant reductions in time to flatus and time to feces were identified, but we did not observe identifiable differences in hospital or postoperative complications as Purkayastha et al did. No complications were associated with gum chewing and only 1 patient failed to tolerate gum owing to ill-fitting dentures. Hence, gum chewing appears to be a very safe and well-tolerated option. However, while we applaud Purkayastha et al for clarifying the evidence base for gum chewing, in our understanding of the existing literature, we would question the value of additional larger studies on gum chewing.

Colorectal resection within an enhanced recovery program has become an accepted standard. Early feeding is a key element in stimulating gut function and reducing metabolic stress. In our meta-analysis, 2 RCTs included laparoscopy but only 1 study used an enhanced recovery program, though the mean times taken to tolerate food in the gum chewing and control groups were 39 hours and 48 hours, respectively. (We would anticipate an earlier dietary intake in the context of an enhanced recovery program.) We propose that early feeding be regarded as the cost-effective option in stimulating gut function with wider benefits to the perioperative patient and that gum chewing may serve a role in patients in whom a prolonged postoperative ileus occurs, a question that has not been answered in any of the included studies.

Correspondence: Dr Jenkins, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G32 2ER, Scotland (mrianjenkins@hotmail.com).

Financial Disclosure: None reported.

Purkayastha  STilney  HSDarzi  AWTekkis  PP Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy.  Arch Surg 2008;143 (8) 788- 793PubMedGoogle ScholarCrossref
Parnaby  CNMacDonald  AJJenkins  JT Sham-feed or sham? a meta-analysis of randomised clinical trials assessing the effect of gum-chewing on gut function after colorectal surgery [abstract].  Colorectal Dis 2007;9 ((suppl 3)) 13- 60Google ScholarCrossref
Watson  HGriffiths  PLamaparelli  MWatson  M Does chewing (gum) aid recovery after bowel resection? a randomised controlled trial.  Colorectal Dis 2008;10 (1) 6Google Scholar