Effects

of Chewing Gum Against Postoperative

Ileus After Pancreaticoduodenectomy A
Randomized Controlled Trial
Thomas Andersson, Kristofer Bjersa, Kristin Falk, and Monika Fagevik Olsn

Preceptor: Jennifer Davis MS, RD, CSO, LD

Rotation: Oncology
Intern: Mike Daniels
Date: 3/10/16

Background Pancreatic Cancer1

4th leading cause of cancer death in the US
Most common type of pancreatic cancer is adenocarcinoma (85% of pancreatic cancer), which
predominantly occurs in exocrine portion of pancreas.
5-Year Survival Rate: 5-6% for all stages combined
Early stages of pancreatic cancer are usually symptomless, thus its usually caught late.
Risk Factors:

Smoking
Diabetes
Chronic Pancreatitis
Obesity
Family History

Treatments:

Radiation
Chemotherapy
Targeted Therapy
Surgery: Pancreaticoduodenectomy

Figure 1. Exocrine and Endocrine Pancreas

TNM Staging Diagrams1

T1 T2 T3 T4

N1

M1

Background Pancreaticoduodenectomy - Whipple

Procedure2

Very extensive surgery that typically involves the

removal of of the duodenum, lower part of the
stomach, the head of the pancreas, and the
gallbladder.
Only around 20% of pancreatic cancer patients
are eligible for procedure.
Best to get procedure done by surgeon with
experience; around 15% of patients die from
surgery complications when performed in small
hospitals or by surgeons with less experience
compared to 5% when procedure is done by
surgeon with experience and in cancer center.

Figure 1. Whipple Procedure

Can be performed laparoscopically.

Background Ileus + Gum3

Definition: Intolerance of oral intake related to nonmechnical factors that interrupt
normal GI function, typically following abdominal surgery.
Symptoms:

Abdominal distention and bloating

Abdominal pain
Nausea
Vomiting
Inability to pass gas or stool

Can lead to discomfort, increased hospital length of stay, and prolonged NPO status.
May require TPN if it doesnt resolve.
Previous studies have shown that chewing gum can significantly reduce post-operative
ileus, time to first flatus/stool, and length of hospital stay.
Potential Mechanism: Chewing gum is a type of sham-feeding that increases neuroendocrine
influence on GI function without the passage of food or fluid to the stomach.

Purpose4
To investigate the effects of chewing gum treatment on patients
undergoing pancreaticoduodenectomy ad modum whipple due to
pancreatic or periampullary cancer.

Design/Intervention4
Phase III Randomized Controlled Trial:

Patients with pancreatic or periampullary cancer who received Whipple pancreaticoduodenectomies and met
the following inclusion/exclusion criteria:

Speak Swedish
Without neurological disease that affects swallowing or gastric function
Without ongoing treatment for mental illness
Without alcohol and drug abuse
Without chewing gum allergy

All patients spent 24 hours in the ICU setting after surgery and received the following treatments:

Perioperative nasogastric tube for suctioning In for 7 days

Continuous thoracic epidural infusion of Bupivacaine (local anesthetic) 1 mg/ml
Fentanyl 2 mg/ml
Adrenaline 2 mg/mll combined with IV acetaminophen
PPI for entire hospital stay
Somatostatin for 7 days postoperatively
Patients received PN (Smofkabiven - Amino acids 5.1%, lipids 3.8%, glucose 12.7% & electrolytes 0.7%) based on individual
needs.
When the NG tube was removed, patients were allowed to drink clear liquids, then full liquids, then easily digestible food like
fish J.

Design/Intervention Continued4
1)Gum Group
Organic gum with sugar given to patients the day after surgery only after they transferred
from ICU to ward.
Gum was administered every 4 hours (08:00 12:00, 12:00-16:00, and 16:00-20:00)
Chewed 2 pieces of gum every 4 hours for 30 minutes for the remainder of hospital stay

2)Control Group
Received 3.6 g/day of glucose in 12 ml mixture per day.
Comparable to the amount of glucose in gum.

Participants/Setting4
Sahlgrenska University Hospital in Sweden.
A total of 28 patients were randomized to the treatment group(n=14)
or the control group(n=14).

Outcome Measures4
Primary Outcome:
Time to first flatus/stool

Secondary Outcomes:
Length of hospital stay
Start of clear/full liquids

Statistical Analyses Performed4

Statistical power based on prior study mean time to first flatulence
was 17.9 hours for gum group vs. 24.4 hours for control group.
For power of 80% and level of significance at 0.05, 18 patients were needed
for both groups.

Mann Whitney U test and Chi 2 test

Results4

Study was terminated early because study protocol differed

significantly from newer guidelines that came out.
7 dropped out from treatment group and 4 dropped out from control group.

Authors Conclusions4
No significant differences between the groups
May be related to small sample size and to type of surgery.
We also noted the importance of choosing the optimal chewing gum,
considering texture, and of offering different flavours. Here, we used a
biodynamic manufactured chewing gum containing glucose and not a sugar
free alternative. This chewing gum had a somewhat different texture, and
this might not appeal to everyones taste, thus resulting in drop-outs from
the study.

Limitations and Implications4

Power needed per group:
37 for Length of Hospital Stay
46 for time to first flatus
53 for start of clear/full liquids
160 for first defecation
__________________________
7 in Gum Group
10 in Control Group

Other Studies5-7

References
1. http://www.uptodate.com/contents/pancreatic-cancer-beyond-the-basics
Figure 1. Exocrine and Endocrine Pancreas. Taken from http://www.ncbi.nlm.nih.gov/books/NBK54134/?report=printable
TNM Staging. Taken from http://www.cancerresearchuk.org/about-cancer/type/pancreatic-cancer/treatment/surgery/surgery-totry-to-cure-pancreatic-cancer.
2. http://www.cancerresearchuk.org/about-cancer/type/pancreatic-cancer/treatment/surgery/surgery-to-try-to-cure-pancreaticcancer
3. http://www.uptodate.com/contents/postoperative-ileus?source=search_result&search=Ileus&selectedTitle=1~150#references
4. Andersson T, Bjers K, Falk K, Olsn MF. Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy--a
randomized controlled trial. BMC Res Notes. 2015;8:37. doi:10.1186/s13104-015-0996-0.
5. Short V, Herbert Ge, Perry R, et al. Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database Syst
Rev. 2015;(2):CD006506. doi:10.1002/14651858.CD006506.pub3.Copyright.
6. Vasquez W, Hernandez A V., Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? a systematic
review and meta-analysis of randomized clinical trials. J Gastrointest Surg. 2009;13(4):649-656. doi:10.1007/s11605-008-0756-8.
7. Li S, Liu Y, Peng Q, Xie L, Wang J, Qin X. Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis
of 17 randomized controlled trials. J Gastroenterol Hepatol. 2013;28(7):1122-1132. doi:10.1111/jgh.12206.