Barbara J. Hocevar

Does chewing gum shorten the duration of postoperative ileus in patients undergoing abdominal surgery and creation of a stoma

BACKGROUND Postoperative ileus is a temporary disturbance in gastric and bowel motility following surgery. The risk for postoperative ileus following gastrointestinal and urinary ostomy surgery is significant because both procedures require extensive surgical manipulation and reconstruction of the bowel. Chewing gum is advocated for treatment because it acts as sham feeding, potentially stimulating gastric and bowel motility through repetitive stimulation of the cephalic-vagal complex. OBJECTIVES This Evidence-Based Report Card reviews and evaluates evidence related to the safety and efficacy of chewing gum as an intervention to reduce the duration of postoperative ileus. SEARCH STRATEGY We systematically reviewed the electronic databases CINAHL and MEDLINE from January 1996 to November 2009, using the terms “ileus” and “chewing gum.” We also searched the ancestry of the 21 articles returned by this review and searched Google Scholar. We included any study or meta-analysis of multiple studies that compared chewing gum to no treatment in patients undergoing abdominal surgery and creation of an intestinal or urinary stoma. We evaluated the following outcome measures: (1) time to passage of flatus, (2) time to passage of stool, or (3) length of hospital stay. Three meta-analyses and 4 studies met inclusion criteria. RESULTS Results of meta-analyses support the use of chewing gum for treatment of postoperative ileus. Chewing gum was consistently found to reduce time to passage of flatus and stool. One meta-analysis found that chewing gum reduced hospital stay but two found no difference. Analysis of studies reveal mixed results when chewing gum was compared to standard postoperative care in patients undergoing surgical reconstruction including ostomy surgery or creation of an orthotopic neobladder. The studies we reviewed were characterized by multiple limitations in design quality including small sample sizes, absence of multicenter trials, and lack of subanalyses of patients undergoing ostomy surgery. IMPLICATIONS FOR PRACTICE Current best evidence suggests that chewing gum should be offered to selected patients with the intent of decreasing postoperative ileus. A careful nursing assessment of the patients mental status, aspiration risk, and dentition is needed before initiating the intervention. In addition, further research is needed to develop more clearly defined parameters for chewing gum including frequency and duration of chewing and its use in patients with nasogastric tubes.

Management of fistulae in the abdominal region.

OBJECTIVE We evaluated a new fistula and wound management system; ostomy and wound care nurses were queried about willingness to use the product in future patients, product wear time and pouch leakage, perifistular skin condition, access for wound care, pouching time, patient mobility and comfort, odor management, pouch flexibility, adhesiveness, and erosion. A health economic assessment was also done. METHOD Twenty-two patients (5 males and 17 females) with an abdominal fistula participated in the study. Participants tested 75 pouches, representing an average of 3.4 pouches per subject. The investigator at each site who performed the pouch changes completed a questionnaire at baseline, during the test, and after testing the pouches. Participants also completed a set of questions after each test pouch was removed. RESULTS In 21 of 22 cases, the nurses would consider using the new system on future patients. After each pouch removal, patients were asked whether they were able to move around while wearing the test pouch and they answered yes 95% of the time. The new system was found to have significantly longer wear time than traditional systems (P = .003), but the average time spent on changing the pouches was not significantly different (P = .07). Access for fistula and wound care was rated as excellent in the new pouching system, and comfort was rated as very good. CONCLUSION The results of the study suggest that all of the key requests received from nurses for an improved system for fistula and wound management were met by the new system.

Serious pouch fitting challenge in a patient with an ileal conduit.

The patient was a 65-year-old widowed female who had undergone a cystectomy with creation of a loop end ileal conduit in order to manage bladder cancer. Surgery was performed at an outside hospital 2 weeks prior to presentation to our clinic. Her major complaint at the time of this visit was pouch leakage. She did not have access at her local hospital to a WOC nurse, but she was willing to drive 5 hours from her home to our institution to establish such a relationship. Her medical and surgical history included hypothyroidism, depression, obesity (height, 5 6 ; weight, 89.812 kg/198 lb; BMI, 31.96), and remote hysterectomy. On initial assessment, her ileal conduit measured 1 in diameter, flush at skin level, while her abdominal contour was concave and her peristomal supportive tissue was very soft with a heavy upper ledge superior to the stoma that became firmer with position changes. She was using a flat, 2-piece pouching system with skin barrier wedges to the creases as well as skin barrier paste and powder. She was changing this system 4 to 5 times per day. There was also a superficial mucocutaneous separation from 4 to 8 o’clock. Her current system did not address the concavity or firmness of her abdominal contours, so she was changed into a soft, flexible convex pouching system (Marlen UltraLite Deep Convex Urostomy pouch, Marlen Manufacturing & Development Company, Bedford, OH), with a skin barrier washer, cloth tape picture frame, and belt. Initially, this system worked very well. The next few months were quite challenging. She became severely depressed and had difficulty coping with her urostomy on a psychological level. She coped by eatColeen Potts, BSN, RN, CWOCN, Staff Nurse, ET/WOC Nursing, Cleveland Clinic, Cleveland, Ohio. Barbara J. Hocevar, BSN, RN, CWOCN, Nurse Manager, ET/WOC Nursing, Cleveland Clinic, Cleveland, Ohio. Corresponding author: Barbara J. Hocevar, BSN, RN, CWOCN, ET/WOC Nursing, Cleveland Clinic, 9500 Euclid Ave, Mailcode NA-40, Cleveland, OH 44195 (Hocevab1@ccf.org). ing and experienced a weight gain of nearly 100 lb. In addition, she again experienced pouch leakage. As a result, she returned to our clinic for reassessment and revision of her pouching system (Figures 1A and B). Physical examination revealed a woman who remained 5 6 tall but now weighed 295 lb (134 kg), with a BMI of 47.68. The concavity around her stoma had deepened. Her pouching system was revised by adding 2 convex barrier rings (Adapt Rings, Hollister Inc, Libertyville, IL), cement, and skin barrier paste to her usual pouch. She continued to use a belt and cloth tape to picture frame the pouch. This system allowed her to obtain a wear time of 1 week, but the magnitude of convexity caused a pressure ulcer. This was treated with a hydrofiber and transparent film dressing, which healed the ulcer completely. The patient reported that her quality of life had improved, both physically and psychologically until the summer of 2008. At this time obtaining a pouch seal became nearly impossible! She experienced additional weight gain to 310 lb (140.6 kg) and her BMI was now 50.03. She also developed a parastomal hernia. These factors resulted in pouch leakage at least once a day and sometimes as often as 4 times daily. She reported there was no predictability to her pouch wear time, which caused her to withdraw from her usual activities. This withdrawal drastically impaired her quality of life. She made several trips to our outpatient clinic, resulting in numerous modifications to her pouching system. Her urologist was consulted about the possibility of a surgical revision and hernia repair, but it was thought any surgery of this type would fail secondary to her obesity. She looked to the WOC nursing staff for psychological support and encouragement through this especially distressing time. In CHALLENGES IN PRACTICE

WOC nurse consult: nonhealing peristomal ulcer.

Ulcer history: Sharon is unsure what had caused the ulcer. She remembered a dark purple dot on her skin that enlarged and became the ulcer. The ulcer began about 5 months ago; her primary physician had prescribed oral antibiotics and triple antibiotic ointment to the ulcer and recommended that she switch to a different pouching system. The ulcer continued to get bigger with a serosanguinous exudate. She had to change her pouching system 1 to 2 times per day.

Ostomy-Stomal/Peristomal Complications: 3438

RESULTS: Laboratory research unequivocally concludes that polymeric membrane dressings inhibit the nociceptor response at the application site and that this can result in significantly diminished pain and inflammation. The facility-based evaluations found that pain, spasticity and bruising are decreased and patient mobility is increased when polymeric membrane dressings are used. 92.5% of all patients in peer-reviewed case studies using polymeric membrane dressings experienced reductions in inflammation and/or wound pain. CONCLUSION: Polymeric membrane dressings definitely can inhibit the nociceptor response at the application site. This has exciting implications for both pain relief and wound healing.

A look at the year

Virtually everyone reports to a boss, a board, or an oversight committee and many of us report to more than one. In my position as Editor of the Journal of Wound, Ostomy and Continence Nursing, I serve at the pleasure of the Officers and Directors of the WOCN Society. The Journal is a significant benefit for WOCN members (part of your Society dues pay for an annual subscription), and it is part of the Society’s estate (along with other enduring legacies). In addition to reporting regularly to the leadership of the WOCN, I believe it proper to report to the larger board, our subscribers. Reports to the WOCN Board, as you might expect, largely focus on matters of administrative process, costs, and profits. In contrast, my report to you, our readers, will primarily focus on the editorial process, followed by a call for papers designed to provide some insights into the priorities for Volume 35, which will begin with Issue 1 in January, 2008.