Karmali S, Jenkins N, Sciusco A, John J, Haddad F, Ackland G L
Centre for Anaesthesia, University College London Hospitals NHS Trust, London, UK.
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK.
Br J Anaesth. 2015 Nov;115(5):727-35. doi: 10.1093/bja/aev283. Epub 2015 Aug 30.
Enhanced recovery, in part, aims to reduce postoperative gastrointestinal dysfunction (PGID). Acquired - or established- vagal dysfunction may contribute to PGID, even for surgery not involving the gastrointestinal tract. However, direct evidence for this is lacking. We hypothesized that chewing gum reduces morbidity (including PGID) by preserving efferent vagal neural activity postoperatively after elective orthopaedic surgery.
In a two-centre randomized controlled trial (n=106), we explored whether patients randomized to prescribed chewing gum for five days postoperatively sustained less morbidity (primary outcome, defined by the Postoperative Morbidity Survey), PGID and faster time to become morbidity free (secondary outcomes). In a subset of patients (n=38), cardiac parasympathetic activity was measured by serial Holter monitoring and assessed using time and frequency domain analyses.
Between September 2011 and April 2014, 106 patients were randomized to chewing gum or control. The primary clinical outcome did not differ between groups, with similar morbidity occurring between patients randomized to control (26/30) and chewing gum (21/28; absolute risk reduction (ARR):13% (95%C I:- 6-32); P=0.26). However, chewing gum reduced PGID (ARR:20% (95% CI: 1-38); P=0.049). Chewing gum reduced time to become morbidity-free (relative risk (RR): 1.62 (95% CI: 1.02-2.58); P=0.04) and was associated with a higher proportion of parasympathetic activity contributing to heart rate variability (11% (95% CI: 1-20); P=0.03).
Chewing gum did not alter overall morbidity, but reduced PGID. These data show for the first time that prescription of sham feeding preserves vagal activity in surgery not directly involving the gastrointestinal tract.
ISRCTN20301599.
加速康复部分旨在减少术后胃肠功能障碍（PGID）。即使对于不涉及胃肠道的手术，获得性或已确立的迷走神经功能障碍也可能导致PGID。然而，缺乏对此的直接证据。我们假设，咀嚼口香糖通过在择期骨科手术后保留传出迷走神经活动来降低发病率（包括PGID）。
在一项双中心随机对照试验（n = 106）中，我们探讨了术后随机分配接受规定咀嚼口香糖五天的患者是否发病率更低（主要结局，由术后发病率调查定义）、PGID发生率更低以及无病时间更快（次要结局）。在一部分患者（n = 38）中，通过连续动态心电图监测测量心脏副交感神经活动，并使用时域和频域分析进行评估。
2011年9月至2014年4月期间，106例患者被随机分配至咀嚼口香糖组或对照组。两组的主要临床结局无差异，随机分配至对照组（26/30）和咀嚼口香糖组（21/28）的患者发病率相似；绝对风险降低（ARR）：13%（95%CI：-6 - 32）；P = 0.26）。然而，咀嚼口香糖可降低PGID（ARR：20%（95%CI：1 - 38）；P = 0.049）。咀嚼口香糖缩短了无病时间（相对风险（RR）：1.62（95%CI：1.02 - 2.58）；P = 0.04），并且与副交感神经活动对心率变异性的贡献比例更高相关（11%（95%CI：1 - 20）；P = 0.03）。
咀嚼口香糖并未改变总体发病率，但降低了PGID。这些数据首次表明，假饲疗法可在不直接涉及胃肠道的手术中保留迷走神经活动。
ISRCTN20301599。
