Discussion
regurgitation of gastric contents, hunger and unpleasantness, gastrointestinal motility, anxiety
In this randomized controlled study, we found that preoperative gum-chewing in addition to oral carbohydrate loading with the ERAS fasting protocol resulted in reduced preoperative anxiety without affecting gastric volume or pH values in women patients undergoing gynecologic surgery. In addition, patient-rated postoperative quality of recovery by QoR-15K was also significantly increased in the CHD with gum group.Chewing gum during preanesthetic NPO is an experimental intervention that conflicts with conventional practice. Although several studies suggest that chewing gum before anesthesia is safe and that chewing gum can be considered an exception to fasting before surgery, there are still vague concerns that chewing gum itself can stimulate oral secretions and gastric juice and affect the amount of gastric contents. The results of this study showed that chewing gum with oral carbohydrate loading was not associated with the volume or acidity of the gastric contents. Regarding oral secretion, there was no significant difference between the groups. Therefore, we confirmed that preanesthetic gum chewing with carbohydrates did not increase the risk of pulmonary aspiration or regurgitation of gastric contents.APAIS is a validated tool for assessing preoperative anxiety, and a cutoff point of 11 on the anxiety scale was regarded as sufficient for identifying anxious patients [Our previous work demonstrated that allowing gum chewing during prolonged preoperative fasting alleviated anxiety [In clinical practice, chewing gum is generally recommended only in the postoperative period to facilitate recovery of gastrointestinal motility. The results in the present study showed a shorter time to flatus in the CHD with gum group, and this result may be explained by more vigorous gum-chewing behavior in the postoperative period in the preoperative gum-allowed group. Chewing gum in the postoperative period was recommended in both groups, but patients in the CHD with gum group may have not hesitated to chew gum in the postoperative period. Chewing gum, which simulates sham feeding, was proven to promote gut motility via cephalic-vagal stimulations [Although other items of preoperative discomfort were not significantly different between groups, the degree of hunger and unpleasantness in the CHD with gum group was significantly lower than in the CHD group. Furthermore, postoperative quality of recovery rated by QoR-15K was significantly higher in the CHD with gum group. Therefore, chewing gum during pre-anesthetic fasting is a practical and safe strategy that is easy to incorporate into clinical practice and has various benefits such as preoperative anxiety relief, facilitating postoperative bowel recovery, and promoting patient well-being.This study has certain strengths. First, a wide range of data was collected prospectively by blinded clinicians. Anesthesia, postoperative care, and chewing gum data collection were performed according to preplanned standardized protocols, thus eliminating possible confounders. Second, unlike other studies that dealt with the specific effect limited to bowel recovery, this study explored the possible benefits of chewing gum in a multifaceted and detailed manner. In addition, the effects of gum chewing were evaluated comprehensively to include patient-centered outcomes.Despite these strengths, the present study also has several limitations. Due to the nature of the study design, this study lacked blinding of the patients. Second, patients may have been anxious since their surgery was confirmed or scheduled, and thus the period of gum chewing might have been short relative to the anxiety period. Finally, it is difficult to generalize the results of our study to patients with increased pulmonary aspiration risk, as these patients were excluded.In conclusion, the addition of gum chewing to oral carbohydrate loading during preoperative fasting was more effective in relieving preoperative anxiety than oral carbohydrate alone in women patients undergoing elective gynecologic surgery. In addition, this novel approach could be helpful to promote patient satisfaction and improve recovery after laparoscopic gynecologic surgery.