A RANDOMIZED INTERVENTIONAL STUDY ON EFFECT OF CHEWING GUM ON RECOVERY OF GASTROINTESTINAL FUNCTIONS IN POSTOPERATIVE PATIENTS FOLLOWING ABDOMINAL SURGERIES IN THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, SMS MEDICAL COLLEGE, JAIPUR

Background: Postoperative gastrointestinal dysfunction is one of the complications following abdominal surgery which results in delayed return of bowel motility. It causes discomfort, prolonged hospital stay; hospital acquired infection and enhanced treatment cost. This study was conducted with an aim to analyze the clinical outcome of effect of chewing gum mainly to avoid post-operative gastrointestinal dysfunction and to compare the different gastrointestinal variables between cases and control group. Methods: In this study 80 patients were included, 40 Cases and 40. The cases were given chewing gum for duration of 15 minutes at 2nd , 4th and 6th hour of surgery. Bowel sound was auscultated at 3rd, 5th and 7th hour of surgery and outcomes were compared with control group. Control group were given only standard post-operative care. Results: Among cases Mean duration of 1st bowel sound appeared was 9.23±2.2 hours whie among control group was 15.99±3.48 hours and with operating time <1 hour is 5.1 ± 1.04 hours in cases and 6.2 ± .66 hours in control group while with operating time >1 hour it was 5.2 ± 1.03 hours cases and 6.3 ± 0.7 hours in control group. Mean duration of 1st flatus passed among cases was 13.3±2.24 hours while among control group was 26.62 ±2.6 hours and with operating time <1 hour was 13.8 ± 1.03 hours in cases and 16.25 ± 1.5 hours in control group, while it was 13.12 ± 1.96 hours in cases and 17.12 ± 1.5 hours in control group with operating time >1 hour. Mean duration of 1st motion passed among cases was 31.33±2.24 hours and was 44.62± 2.6 hours in control group and it was 48.8 ± 1.2 hours in cases and 50.7 ± 1.27 hours in control group with operating time <1 hour, while it was 48.8 ± 1.2 hours in cases and 51.1 ± 1.46 hours in control group with operating time >1 hour. Result was statistically significant P value (0.001).


Introduction
Gastrointestinal tract dysfunction is the most common complication that occur after abdominal surgeries and associated with higher risk of post-operative paralytic ileus (POI) 1,2,3 . POI refers to severe constipation and intolerance of oral intake resulting from a non-mechanical insult that disrupts the normal coordinated propulsive motor activity of the gastrointestinal tract, it is an iatrogenic condition that occurs following abdominal surgery especially in the presence of factors like prolonged operative time, excessive bowel manipulation, immobilization, emergency procedures. This is due to malfunction of intestinal motility that results from a transient non-mechanical insult that disrupts the normal coordinated propulsive motor activity of the gastrointestinal tract 1,2,3 .
Early initiation of intestinal motility after abdominal surgery is highlighted in the "Enhanced Recovery After Surgery" ERAS Protocol, also known as the multidisciplinary approach20-21. In this protocol, particular attention has been given to early feeding regimes i.e., Sham Feeding regimes which is being investigated as a means to stimulate bowel motility and confer an advantage while actually minimising harm caused by early oral feeding especially in patients who do not tolerate the same. Sham feeding is the concept where the patient sees the food, smells food but is not given food to swallow e.g., Chewing Gum. In our study we have used sugar free chewing gum to study its effect on peristalsis. The sugar substitutes in the sugar free gum (e.g., sorbitol and xylitol) may stimulate bowel function and have a non-stimulant laxative effect. stimulates the digestive cephalic phase by imitating eating and is considered a Virtual Diet 3-5 . The pathophysiological mechanism for the enhanced recovery bowel motility is due to activation of the cephalic-vagal pathway which is stimulating intestinal myoelectric activity in an attempt to counteract activation of the gastrointestinal µ opoid receptors. This response leads to both humoral and nervous stimulation of bowel motility 25 . Chewing gum use post-operatively, has been associated with various improved outcomes, including early passage of flatus, early bowel sounds and shorter lengths of hospitalization. Given this, gum chewing might be a safe and inexpensive way to provide the benefits of early stimulation of gastrointestinal tract. Hence early return of bowel gut motility leads to early starting of oral feeding, early breast feeding following caesarean section, early ambulation and early discharge from the hospital and decreases overall cost of hospitalization. Thus, the present Randomized interventional study is aimed at assessing the effect of chewing gum on recovery of gastrointestinal tract function after abdominal surgery. 6 • Fluid and electrolyte imbalance.

Material and Methods
• Those postoperative patients who need long-term fasting or total parenteral nutrition.
• Those patients who are participating in any other study.

Results
The present Randomized interventional study is done in the Department of Obstetrics and Gynecology, SMS Medical College and Hospital, Jaipur with the aim of assessing the effect of chewing gum on recovery of gastrointestinal tract function after abdominal surgery, 40 patients are given Chewing gum after operation are grouped as Cases and 40 patients who are not given Chewing Gum are Grouped as Controls and obtained following results.  A significant difference is found between mean duration of "1 st motion passed" in between case and control group with operating time <1 hour and >1 hour both .This is evident from the T-Test performed, the p-value showed a significant (<0.05) result.

Discussion
The important complication after abdominal surgery is post-operative ileus (colonic stasis), which results in patient discomfort, prolonged length of hospital stays, and increased cost of treatment. The exact mechanism that produces postoperative ileus is unknown, but possible origins include gastrointestinal inflammatory response, stimulation of the mesenteric plexus, anesthesia, and use of opioid analgesics.. In this study total 80 patients were studied, 40 were cases and 40 were controls. The cases were given chewing gum after surgery while controls were given sonly standard postoperative care.

Conclusion
This study was conducted over 80 patients, 40 were cases who were given chewing gum chewing three times a day post operatively and 40 were controls who were not fed with chewing gum selected randomly. All patients were observed hourly for appearance of first bowel sound, First flatus passed, and first motion passed were analysed. It was found that chewing gum have significant effect over bowel motility as bowel sound appear significantly earlier in cases than control and time for first flatus passed and first bowel passed were also found significantly earlier in cases than controls with P Value (<0.01). Given this, gum chewing might be a safe and inexpensive way to provide the benefits of early stimulation of gastrointestinal tract. Hence early return of bowel gut motility leads to early starting of oral feeding, early breast feeding following caesarean section, early ambulation and early discharge from the hospital and decreases overall cost of hospitalization. Thus, through the present study chewing gum can be established as a simple intervention for early return of GI motility & thus aid in decreasing the burden of paralytic ileus & hospital stay on the community. ..