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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2015 Jun;15(Suppl 1):e6162 doi: 10.5867/medwave.2015.6162
Does chewing gum improve recovery after an abdominal surgery? –First update
Gabriel Rada, José Viñuela
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Resumen

Este resumen Epistemonikos (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) es una actualización del resumen publicado en Noviembre de 2014, basado en 4 nuevas revisiones sistemáticas aparecidas con posterioridad. El íleo postoperatorio es una condición común que retrasa la recuperación luego de una cirugía abdominal. El uso precoz de goma de mascar, como método de alimentación fingida, estimularía la peristalsis permitiendo una alimentación más precoz.


 
Sobre la actualización

Este resumen Epistemonikos (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) es una actualización del resumen publicado en Noviembre de 2014 (doi: 10.5867/medwave.2014.11.6058), basado en cuatro nuevas revisiones sistemáticas aparecidas con posterioridad, incluyendo una revisión Cochrane que aporta 58 estudios controlados aleatorizados no identificados por ninguna de las revisiones previas.

La nueva evidencia incorporada en este resumen lleva a un aumento en la certeza de la evidencia para el desenlace principal de baja a moderada, y a una estimación levemente mayor de la magnitud del beneficio, con la consecuente modificación en los mensajes clave y las consideraciones para la toma de decisión.

Problema

El íleo postoperatorio es una condición común entre los pacientes sometidos a cirugía, especialmente intraabdominal. Esta alteración se debe a un estado de obstrucción intestinal transitorio por un defecto en la actividad propulsiva de todo o parte del tubo digestivo.

Si bien la mayor parte de los casos se resuelve a los poco días, en algunos puede prolongarse el período de recuperación, constituyendo un íleo paralítico postoperatorio, el cual se acompaña de náuseas, vómitos, distensión abdominal y dolor, aumentando los días de hospitalización, gasto de insumos, días de ayuno, entre otros.

El uso precoz de goma de mascar, como método de alimentación fingida, sería beneficioso para estimular la peristalsis y disminuir el tiempo de recuperación del íleo post operatorio y la incidencia de íleo paralítico, permitiendo una alimentación más precoz y eventualmente una disminución de la estadía hospitalaria.

Métodos

Utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, para identificar revisiones sistemáticas y sus estudios primarios incluidos. Con esta información generamos un resumen estructurado, siguiendo un formato preestablecido, que incluye mensajes clave, un resumen del conjunto de evidencia (presentado como matriz de evidencia en Epistemonikos), metanálisis del total de los estudios, tablas de resumen de resultados con el método GRADE, y tabla de otras consideraciones para la toma de decisión.

Mensajes clave

 

  • El uso de goma de mascar probablemente disminuye el tiempo de hospitalización luego de una cirugía abdominal.
  • Por tratarse de una intervención de bajo costo y sin efectos adversos, la relación beneficio/riesgo y beneficio/costo son probablemente favorables.

 
Acerca del conjunto de evidencia para esta pregunta

Cuál es la evidencia. 
Véase matriz de evidencia en Epistemonikos más abajo.

Encontramos 18 revisiones sistemáticas [1-18] que en conjunto identificaron 83 estudios (reportados en 98 referencias [19-116], incluyendo 81 estudios controlados aleatorizados).

La información en esta tabla y el resumen en general hacen referencia a estos últimos.

Qué tipo de pacientes incluyeron los estudios

Veinte estudios evaluaron pacientes sometidos a cirugía colorrectal, 15 a cesárea, tres a apendicectomía, cuatro a colecistectomía, y los 39 restantes incluyeron pacientes con otras cirugías abdominales o no se restringieron a un solo tipo de cirugía.

Todos los estudios excepto dos [35],[114], evaluaron población adulta.

Qué tipo de intervenciones incluyeron los estudios

La goma de mascar se administró durante cinco minutos a una hora (mediana 20 minutos).

La frecuencia fue 12 veces al día en siete estudios, ocho veces al día en dos, seis veces al día en tres, cuatro veces al día en 11, tres veces en 55 estudios y en un estudio fue administrado solo por una vez (mediana tres veces al día).

Qué tipo de desenlaces   midieron

Tiempo hasta la expulsión de gases por boca, tiempo hasta tener deposiciones, tiempo hasta el primer movimiento intestinal, tiempo de hospitalización, complicaciones, tolerancia de la goma de mascar, costos.

 

Resumen de los resultados

 La información sobre los beneficios de la goma de mascar está basada en  81 estudios aleatorizados, de los cuales 56 reportan el desenlace tiempo de hospitalización, que en total incluyen 5278 pacientes.

  • El uso de goma de mascar probablemente disminuye el tiempo de hospitalización luego de una cirugía abdominal. La certeza de la evidencia es moderada.

Otras consideraciones para la toma de decisión

A quién se aplica y a quién no se aplica esta evidencia
  • Debido a que los estudios evalúan diferentes tipos de cirugía abdominal, esta evidencia es aplicable a un amplio grupo de pacientes.
  • Si bien podría argumentarse que no existe suficiente evidencia directa para muchas de las cirugías evaluadas y que no se ha probado en variados procedimientos quirúrgicos, es razonable, en base a argumentos clínicos y fisiopatológicos, pensar que el efecto será mayor en cirugías con mayor riesgo de íleo o que conllevan mayor tiempo de hospitalización. 
Sobre los desenlaces incluidos en este resumen
  • Este resumen considera el tiempo de hospitalización como único desenlace crítico para la toma de decisión. Esto se basa en la opinión de los autores, ya que no encontramos estudios que hayan determinado la importancia relativa de los desenlaces en el postoperatorio, o algún otro método de establecer qué desenlaces son más relevantes para la toma de decisión.
  • No se han incluidos otros desenlaces de baja importancia para el paciente, como tiempo hasta la eliminación de gases o presencia de deposiciones, asumiendo que su mayor importancia deriva finalmente del efecto sobre el tiempo de hospitalización. 
Balance riesgo/beneficio y certeza de la evidencia
  • La magnitud del beneficio varía dependiendo del tipo de cirugía, siendo de acuerdo a la revisión más completa un día menos en el caso de una colectomía y cerca de 5 horas en el caso de una cesárea [11]. Si bien en todos los casos parece ser que los beneficios son mayores a los riesgos, la magnitud del beneficio puede ser considerada más o menos importante en diferentes circunstancias.
Qué piensan los pacientes y sus tratantes
  • Por tratarse de una medida aceptable y de bajo costo, es probable que la mayoría de los pacientes y sus tratantes se inclinen por la intervención a pesar de que la magnitud del beneficio sea de escasa cuantía
Consideraciones de recursos
  • Dos estudios reportaron costos, pero la certeza de la evidencia es muy baja como para sacar conclusiones [35],[41]. Considerando el bajo costo de la intervención y la ausencia de complicaciones importantes, se trata muy probablemente de una intervención que genera ahorro en vez de costos.
Factibilidad e implementación
  • El hecho de que no se trate de un medicamento puede hacer que la intervención no esté disponible, al menos inicialmente, en las farmacias de los hospitales, por lo que sea necesario solicitarlo a familiares o encontrar otro mecanismo de provisión.
  • Considerando lo arraigado que se encuentra el concepto de evitar la alimentación por boca en el postoperatorio (la masticación aumenta la producción de saliva que llega al estómago), es posible que exista resistencia en los distintos profesionales que integran los equipos se salud.

Diferencias entre este resumen y otras fuentes
  • Los mensajes clave de nuestro resumen son concordantes con las conclusiones de las revisiones sistemáticas individuales identificadas.
  • No encontramos guías de práctica clínica utilizadas en esta área que mencionen esta intervención.
¿Puede que cambie esta información en el futuro?
  • Existe una baja probabilidad de que futura información cambie las conclusiones principales de este resumen, aunque podrían esperarse modificaciones en la magnitud del beneficio, los riesgos y los costos.
  • Existen estudios en curso evaluando esta intervención en diferentes tipos de cirugía, ya sea como intervención aislada o como un componente de protocolos de recuperación rápida.
Cómo realizamos este resumen

Mediante métodos automatizados y colaborativos recopilamos toda la evidencia relevante para la pregunta de interés y la presentamos en una matriz de evidencia.

Matriz de evidencia

Siga el enlace para acceder a la versión interactiva Chewing gum for the amelioration of postoperative ileus

Notas

Si con posterioridad a la publicación de este resumen se publican nuevas revisiones sistemáticas sobre este tema, en la parte superior de la matriz se mostrará un aviso de “nueva evidencia”.  Si bien el proyecto contempla la actualización periódica de estos resúmenes, los usuarios están invitados a comentar en Medwave o contactar a los autores mediante correo electrónico si creen que hay evidencia que motive una actualización más rápida.

Luego de crear una cuenta en Epistemonikos, al guardar las matrices recibirá notificaciones automáticas cada vez que exista nueva evidencia que potencialmente responda a esta pregunta. El detalle de los métodos para elaborar este resumen están descritos aquí: http://dx.doi.org/10.5867/medwave.2014.06.5997.

La Fundación Epistemonikos es una organización que busca acercar la información a quienes toman decisiones en salud, mediante el uso de tecnologías. Su principal desarrollo es la base de datos Epistemonikos (www.epistemonikos.org).

Los resúmenes de evidencia siguen un riguroso proceso de revisión por pares interno.

Declaración de conflictos de intereses
Los autores declaran no tener conflictos de intereses con la materia de este artículo.

Matriz de evidencia
Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Este resumen Epistemonikos (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) es una actualización del resumen publicado en Noviembre de 2014, basado en 4 nuevas revisiones sistemáticas aparecidas con posterioridad. El íleo postoperatorio es una condición común que retrasa la recuperación luego de una cirugía abdominal. El uso precoz de goma de mascar, como método de alimentación fingida, estimularía la peristalsis permitiendo una alimentación más precoz.

Authors: Gabriel Rada[1,2,3,4,5], José Viñuela[2,5]

Affiliation:
[1] Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[3] GRADE working group
[4] The Cochrane Collaboration
[5] Proyecto Epistemonikos
Author address:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile
Lira 63
Santiago Centro
Chile

Citation: Rada G, Viñuela . Does chewing gum improve recovery after an abdominal surgery? –First update. Medwave 2015 Jun;15(Suppl 1):e6162 doi: 10.5867/medwave.2015.6162

Publication date: 18/6/2015

PubMed record

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July 2022, Vol 22, Issue 6
icon Research papers
Association of biomarkers and severity of COVID-19: A crosssectional study

Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile

Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis

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