International Journal of Surgery 14 (2015) 49e55

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International Journal of Surgery

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Original research

Chewing gum and postoperative ileus in adults: A systematic

literature review and meta-analysis
Bruce U. Su'a a, *, Terina T. Pollock a, Daniel P. Lemanu a, Andrew D. MacCormick a,
Andrew B. Connolly b, Andrew G. Hill a
a
South Auckland Clinical School, The University of Auckland c/-Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland, 1640, New Zealand
b
Department of General Surgery, Middlemore Hospital, Counties-Manukau District Health Board, Auckland, New Zealand

h i g h l i g h t s

Chewing gum is a safe and well tolerated method to reduce time to improve POI.

The degree of improvement is small and of limited clinical significance.

The role of chewing gum in ERAS is less clear.

Patients in established POI may benefit from chewing gum.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Post-operative ileus (POI) is a major problem following elective abdominal surgery. Several
Received 27 August 2014 studies have been published investigating the use of chewing gum to reduce POI. These studies however,
Received in revised form have produced variable results. Thus, there is currently no consensus on whether chewing gum should be
18 November 2014
widely instituted as a means to help reduce POI.
Accepted 24 December 2014
Available online 7 January 2015
Methods: We performed a systematic literature review to evaluate whether the use of chewing gum
post-operatively improves POI in abdominal surgery. A comprehensive review of the literature was
conducted according to the guidelines in the PRISMA statement. The following databases were searched:
Keywords:
Postoperative
MEDLINE, PUBMED, EMBASE, SCOPUS, Science Direct, CINAHL and the Cochrane Central Register of
Surgery Controlled Trials. Clinical outcomes were extracted and meta-analysis was performed.
Ileus Results: There were 1019 patients from 12 randomised controlled studies included in this review. Only
Chewing gum one study was conducted in an Enhanced Recovery after Surgery (ERAS) environment. Seven of the
twelve studies concluded that chewing gum reduced post-operative ileus. The remaining five studies
found no clinical improvement.
Overall, there was a small benefit in reducing time to flatus, and time to bowel motion, but no difference
in the length of stay or complications.
Conclusion: Chewing gum offers only a small benefit in reducing time to flatus and time to passage of
bowel motion following abdominal surgery. This benefit is of limited clinical significance. Further studies
should be conducted in a modern peri-operative care environment.
© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction to occur in up to 25% of patients. This can lead to significant post-

Post-operative ileus (POI) poses a major problem following
elective abdominal surgery [1]. It is a common condition reported
* Corresponding author. Department of Surgery, South Auckland Clinical School,
University of Auckland, c/o Middlemore Hospital, Private Bag 93311, Otahuhu,
Auckand, 1640, New Zealand.
E-mail address: bruce.sua@gmail.com (B.U. Su'a).
operative morbidity and a prolonged length of hospital stay [2]. It
is associated with a higher risk of developing post-operative
complications and places a significant financial burden on health
care facilities [1]. The aetiology for POI remains unclear, although a
subset of aetiological risk factors have been described [3].
Early feeding after surgery has been associated with earlier re-
turn of bowel function [4,5]. The literature however, reports the
reluctance of many practitioners to institute this method due to

http://dx.doi.org/10.1016/j.ijsu.2014.12.032
1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
50 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55

Table 1 mildly improve recovery from POI [10e14]. With the recent advent
Search terms. of Early Recovery after Surgery (ERAS), there has been a shift to-
Hits per database Search terms wards early feeding in the post-operative period [15e17]. These
MEDLINE: 61
early feeding regimes have made the role of sham feeding less clear
PUBMED: 41 Gum OR Chewing Gum in the post-operative phase.
EMBASE: 48 AND There is still however, no consensus on whether chewing gum
C1NAHL: 4 Ileus OR Postoperative Ileus OR complications should be widely instituted as a means to reduce POI. We there-
SCOPUS: 49 AND
fore decided to update current knowledge and perform a sys-
CENTRALa: 7 Surgery OR Colorectal OR Bowel OR General
Science Direct: 74 Surgery tematic literature review and meta-analysis of randomised
a
controlled trials to evaluate the efficacy and safety of chewing gum
CENTRAL ¼ Cochrane Central Register of Controlled Trials.
in treating POI.

fears over safety and complications [6]. Furthermore, up to 20% of 2. Methods

patients do not tolerate early feeding [7]. Because of these concerns,
methods of sham feeding have been investigated to see whether
they confer the same advantages of early recovery of bowel func-
tion whilst minimising harm.
There has been recent interest in using chewing gum as a form
of sham feeding to reduce rates of POI [8,9]. Sham feeding, using
chewing gum, is thought to work via cephalic vagal stimulation.
This results in increased salivary and pancreatic secretions with
resultant improvement in gut motility [6]. Previous systematic
literature reviews and meta-analyses have found chewing gum to
2.1. Search strategy
A comprehensive review of the literature was conducted by two
authors according to the guidelines in the PRISMA statement [18].
The following databases were searched from February 2013 to April
2013: MEDLINE, PUBMED, EMBASE, SCOPUS, Science Direct,
CINAHL and Cochrane Central Register of Controlled Trials. The
combinations of search terms used are shown in Table 1. The
reference lists of all relevant articles were searched manually to
identify further relevant studies.

Fig. 1. PRISM A flow diagram.

 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55 51

Table 2
Summary of study characteristics.

Author (year) Jadad Population (n) Post operative ileus assessment Results
Score [19]

Matros 2006 [21] 3 Elective partial colectomy patients (66) Median time to flatus Median time to No reduction in ileus
bowel motion
Abd-EI- Maeboud 2009 2 Caesarean sections (200) Intestinal sounds heard Passage of Decreased time to recovery of
[23] flatus Passage of bowel motion GI function
(meantime)
Asao 2002 [6] 1 Elective laparoscope colectomy for Time to first flatus Time to defaecation Decreased time to recovery of
colorectal cancer (19) GI function
Zaghiyan 2013 [29] 3 Major colorectal surgery (114) Time to tolerating low residue diet Time No reduction in post op era we
to first flatus Time to first bowel motion ileus in an early feeding setting
Choi 2011 [25] 1 Open or laparoscope radical cystectomy Time to first flatus Time to first bowel Decreased time to first flatus
patients (64) motion and bowel motion
Crainic 2009 [24] 3 GI surgical patients laparoscopic or Time to first flatus Time to first bowel No reduction in postoperative
exploratory colectomy (66) motion ileus
Marwah 2012 [26] 3 Ileostomy closures performed for Time to first flatus Time to first bowel Decreased time to first flatus
typhoid ileal perforation (100) motion and bowel motion
Schuster 2006 [7] 3 Elect We open sigmoid resections for First feelings of hunger Time to first Decreased time to first flatus
diverticulitis or cancer (34) flatus Time to first bowel movement and bowel motion
Jakkaew 2013 [27] 3 Cesarean sections (50) Passage of first flatus First hunger Decreased time to first passage
interval First meal interval Nausea of flatus
Vomiting Abdominal distension
Mohsenza deh Ledari 2 Caesarean sections (100) Passage of first flatus First defaecation Decreased time to first passage
2012 [30] The first feeling of hunger of flatus
Quah 2006 [22] 3 Patients with left sided colorectal Time to first passage of flatus Time to No improvement in ileus
cancer requiring elective resection (38) first defaecation
Lim 2013 [28] 3 Patients undergoing colorectal Time to first flatus Time to first bowel No improvement of ileus in an
resection surgery (168) motion accelerated feeding setting

2.2. Study selection
Papers were considered for review if they investigated whether
use of chewing gum after abdominal surgery reduced POI. Exclu-
sion criteria were as follows: the paper was not available in full text,
published in a foreign language, published prior to the year 2000,
studies conducted in non-surgical settings, and studies conducted
in children. Study design was limited to randomised controlled
trials (RCTs). Papers were assessed for inclusion independently by
two authors and any disagreement over inclusion or exclusion was
resolved in consultation with other authors.
2.3. Assessment of validity
the meta-analysis were assessed using mean difference (MD) or
risk ratio (RR) for continuous and dichotomous outcomes respec-
tively with 95% confidence intervals derived from a fixed effects
model. The inverse variance method was used for continuous
outcomes and the Mantel-Haenzsel method for dichotomous out-
comes. Medians were converted to means using the method
described by Hozo et al. [20] Forest plots were constructed with
results considered statistically significant when p < 0.05. Statistical
heterogeneity was evaluated using the I2 statistic and a c2 test for
heterogeneity was performed with results considered statistically
significant when p < 0.10. Funnel plots were used to screen for
publication bias.

Quality assessment of the studies was applied independently by 3. Results

two authors using the Jadad criteria [19]. Both authors were blin-
ded to the journal title, article title and study authors.
2.4. Data extraction
Data extraction was carried out using predefined electronic
templates. The primary outcome was whether chewing gum would
result in a decrease in POI compared to control. There were no
limits as to how POI was assessed. The chewing gum regime
received by participants in the intervention arm of each study was
recorded.
Studies that presented their data as median and range values
were contacted for their mean and Standard Deviation (SD) data.
For authors that did not reply within a 2 week time-frame, median
values were converted to estimated mean and SD values using
methodology described in Hozo et al. [20].
Twelve RCTs met the inclusion criteria and had sufficient data to
be included in the meta-analysis [6,7,21e30]. Eight studies were
conducted in a colorectal setting, three studies in an obstetric
setting, and one study in a urological setting.
3.1. Study characteristics
The PRISMA flow diagram showing selection of articles is pre-
sented in Fig. 1. The study characteristics of the included studies are
described in Table 2. A total of 1019 patients were included in this
review, with 594 patients from a colorectal setting, 350 from an
obstetric setting and 60 from a urological setting.
3.2. Validity assessment

2.5. Statistical analysis The results of quality assessment using the Jadad Score are
shown in Table 2. Overall, included studies were of poor to medium
Meta-analysis was performed using Review Manager version 5.1 quality with Jadad scores ranging from 1 to 3. Results of the
(The Nordic Cochrane Centre, Copenhagen, Denmark). Results of Cochrane Risk of Bias Assessment Tool are shown in Fig. 2.
52 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55
Fig. 2. Cochrane risk of bias assessment tool.
3.3. Post-operative ileus
The included studies had varying definitions of POI. Five of the
included twelve studies gave a description of POI [21,23,25,26,30].
The remaining seven studies did not provide a definition for POI.
3.4. Chewing gum regime and patient tolerance
Eleven of the twelve studies utilised commercially available
sugar free gum whilst one study [29] used sugared gum. Nine of the
twelve studies [6,7,21,22,24e26,29,30] asked patients to chew gum
three times per day for between 5 and 45 min. Two of the studies
[27,28] asked patients to chew gum for 15e30 min four times a day
whilst one study [23] asked patients to chew gum for 15 min every
2 h except overnight when sleeping. Four papers reported that
chewing gum was well tolerated by the participants [6,7,22,23]. The
remaining eight studies did not report data on this outcome.
3.5. Outcomes
3.5.1. Time to flatus and first bowel motion
All included studies used time to first passage of flatus and time
to first bowel motion as surrogate measures for return of normal
bowel function (Table 3). Chewing gum was associated with a sig-
nificant reduction in mean time to flatus (MD ¼ 6.78 h; 95%
CI: 7.64, 5.92; p < 0.01) with significant heterogeneity (I2 ¼ 88%;
p < 0.01) shown in Fig. 3.
There was a significant reduction in the time to first bowel
motion (MD ¼ 8.38 h; 95% CI: 9.52, 7.23; p < 0.01) with sig-
nificant heterogeneity (I2 ¼ 75%; p < 0.01). Results are shown in
Fig. 4. Both funnel plots were symmetrical.
One study used time to tolerance of a low residue diet as the
main measure as they felt it was more clinically applicable [29].
Three papers included time to first feelings of hunger as primary
outcomes [7,27,30].
3.5.2. Length of stay
Eight studies reported data for length of hospital stay (LOS).
Chewing gum was associated with a small but statistically signifi-
cant reduction in LOS (MD ¼ 0.25 h; 95% CI: 0.34, 0.16;
p < 0.01) with significant heterogeneity (I2 ¼ 90%; p < 0.01). Results
are shown in Fig. 5. The Funnel plot was symmetrical.
3.5.3. Complications
Eight studies presented data on 30-day complications (Fig. 6).
Chewing gum did not reduce postoperative morbidity
(RR ¼ 0.80 h; 95% CI: 0.60, 1.06; p ¼ 1.02) with low heteroge-
neity (I2 ¼ 0%; p ¼ 0.78). The Funnel plot was symmetrical
(Figs. 7e10).
4. Discussion
This study systematically reviewed the efficacy and safety of
chewing gum in treating post-operative ileus (POI) in adults
following abdominal surgery. Our results suggest that, while
chewing gum is a safe and well tolerated method to reduce time to
resolution of POI, the degree of improvement is small and of limited
clinical significance. Furthermore, the intervention has not been
well investigated in the context of an optimised perioperative care
environment.
Given the well-known effects of opioids and epidural analgesia
on post-operative ileus [31], there was a lack of description of
perioperative care regimens used amongst the studies. Addition-
ally, there was not one widely accepted definition of post-operative
ileus. This is despite studies using its resolution as the primary
outcome measure. Furthermore, the chewing gum regimes used
varied from 5 min thrice daily to 15 min every 2 h. No correlation
was found between duration of chewing gum and resolution of
symptoms.
Due to differences in patient population, surgical modality, and
disease processes involved, this meta-analysis is limited by the
significant heterogeneity of the included studies. Eight studies
were conducted in a colorectal setting, three in an obstetric setting,
and one in a urological setting.
There was a lack of blinding in several studies which may have
led to bias by surgical teams recording results. Blinding participants
would be difficult in this setting. However blinding observers is
possible and would lend weight to the findings.
With the recent advent of early recovery after surgery (ERAS)
protocols, patients are encouraged to resume normal eating
 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55 53

Table 3
Summary of main outcome measures.

Author Time to flatus gum (mean Time to flatus control (mean P value Time to defaecation gum (mean Time to defaecation control (mean P value
hrs) hrs) hrs) hrs)

Abd-EI- Maeboud 17.9 24.4 <0.001 21.1 30 <0.001

Jakkaew 36.37 41.33 0.02 N/A N/A N/A
Mohsenzade h 24.8 30.0 0.016 30.7 38.4 0.0001
Ledari
Marwah 58.48 73.12 0.006 84.96 109.2 0.004
Choi Median Median <0.01 Median Median <0.01
Open Open Open Open
64.3 80.3 83.8 lap 104 lap
Lap48.8 Iap60.3 69.1 84.6
Asao 2.1 3.2 <0.01 3.1 5.8 <0.01
Schuster 65.4 80.2 0.05 63.2 89.4 0.04
Matros Median Median 0.384 Median Median 0.384
60 67 80 88
Crainic 80.2 72.5 Not 90.9 92.7 Not
reported reported
Quah 2.4days 2.7 days 0.56 3.2days 3.9days 0.38
Lim 42.75 50.97 0.134 89.6 98.6 0.333
Zaghiyan 48.6 47.4 0.66 59.9 63.2 0.40

Fig. 3. Time to flatus.

Fig. 4. Time to first bowel motion.

Fig. 5. Length of stay.

54 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55

Fig. 6. BO day total Complications.

Fig. 7. Funnel Plot for Time to first flatus. Fig. 9. Funnel Plot for length of stay.

processes after surgery. This makes the role of chewing gum and
other forms of sham feeding less clear in the postoperative period.
Only one study was conducted in an ERAS environment [28]. This
study showed chewing gum does not enhance bowel recovery
following abdominal surgery in an ERAS environment.
In summary, chewing gum offers a small benefit in reducing
time to flatus and time to passage of bowel motion following sur-
gery. This benefit is of limited clinical significance especially
because early feeding is now common in ERAS protocols. Patients
who cannot tolerate early feeding seem most likely to be those who
would benefit. Research is also needed to determine its role in

Fig. 10. Funnel Plot for 30 day total complications.

patients with established ileus, where oral intake is limited.

Ethical approval

None.

Funding

This review was conducted whilst the main author was a sala-
ried employee of the University of Auckland in a research fellow
Fig. 8. Funnel Plot for time to first bowel motion. role.
 B.U. Su'a et al. / International Journal of Surgery 14 (2015) 49e55
Author contribution
Su'a BU e Writing and data analysis.
Pollock TT e Data collection and analysis.
Lemanu DP e Data collection and analysis.
MacCormick AD e Study design.
Connolly AB e Study design and writing.
Hill AG e Study design and writing, final approval before
submission.
Conflicts of interest
None.
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