Comparison of the Effect of Chewing Gum and Honey on Postoperative Recovery and Complications in Ileostomy Reversal
Phase: NA
Conditions: Ileostomy Closure, Gum Chewing, Honey, Postoperative Recovery, Postoperative Complications After Gastrointestinal Operations
Sponsor: Mayo Hospital Lahore

0 
 
 
Dated: 20-08-2025 
 
 
 
 
 
 
 
 
 
<COMPARISON OF THE EFFECT OF CHEWING GUM AND HONEY  
ON POSTOPERATIVE RECOVERY AND COMPLICATIONS IN 
ILEOSTOMY REVERSAL= 
 
BY 
 
 
DR. SHAHROZE WAJID 
MBBS  
Resident FCPS-II General Surgery 
 
West Surgical Ward 
KEMU/ Mayo Hospital Lahore 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1 
 
INTRODUCTION 
Ileostomy reversal is associated with postoperative morbidities, such as postoperative 
intestinal obstruction, wound infection, anastomotic leakage (AL), intestinal perforation and 
peritonitis. Another common clinical manifestation is postoperative functional ileus causing 
delayed gastrointestinal function recovery GIFR (1,2). Delayed GIFR raises the risk of 
intestinal blockage and dysregulation of the gastrointestinal flora and can cause gas and 
effusion to build up in the lumen of the gastrointestinal tract. Delay in flatus or defecation, 
abdominal pain, distension, nausea, vomiting, and postoperative intestinal blockage, which 
often requires nasogastric tube intubation, are the primary clinical manifestations of delayed 
GIFR (3). 
Postoperative care has always been oriented around adequate nutrition (4). The 
Enhanced Recovery After Surgery (ERAS) program recommends shorter periods of starvation 
in adults both before and after surgery (5,6). By using this method, anastomotic leaks are 
avoided, and the bowel anastomosis is allowed to heal. Early postoperative enteral feeding not 
only lowers postoperative morbidity and mortality, but may also shorten the duration of 
postoperative ileus and length of stay after surgery (2,7). The surgical technique utilized, the 
use of analgesics, the existence of an underlying condition, and the type of postoperative care 
given are factors connected to postoperative ileus following colon resection (8).  
 
Sham feeding is the practice of stimulating gastrointestinal peristalsis without actually 
ingesting any food into the digestive system (9). Chewing gum is used in postoperative sham 
feeding to encourage the return of gastrointestinal peristalsis. The physiologic theory that 
underlies chewing gum with regards to promoting peristalsis and shortening the time to 
postoperative intestinal recovery includes the idea that oral and masticatory stimulation 
provided by gum chewing sufficiently simulates food ingestion to stimulate a neurohumoral 
reflex that increases gastrointestinal fluid secretion. In addition, the vagus nerve, which is 
involved in promoting peristalsis, may be stimulated by oral stimulation and chewing (10). 
According to studies, chewing gum reduces the risk of postoperative ileus and shortens the time 
it takes for the first postoperative flatus and defecation (9–14). By contrast, some studies of 
patients undergoing surgery have indicated that chewing gum has not been found to 
significantly reduce average hospital stay days, shorten the onset of the first postoperative flatus 
and feces, or prevent postoperative nausea, vomiting, or bloating in studies of patients 
undergoing surgery (10). 
Numerous studies have proven that honey has protective properties for the 
gastrointestinal system. The gut microbiota after honey ingestion showed changes in lactic acid 
bacteria, which may suggest that honey has a role in regulating gut microbiota (15–17). Honey 
taken orally guards against gastrointestinal infections such as gastritis, duodenitis, and gastric 
ulceration brought on by bacteria and rotavirus (18). Oral honey and water administration can 
reduce the incidence and severity of postoperative nausea and vomiting (19,20). Preoperative 
intake of honey drink results in significantly less wound infections (21). Literature search could 
not find any previous study about the postoperative use of honey in stoma reversal or intestinal 
anastomosis patients. However, studies done in rats showed a statistically significant increase 
in tensile strength of colon anastomosis, decrease in peritoneal adhesion and improved wound 

2 
 
healing (22–25). Human clinical trials need to be performed to better understand the effect of 
honey intake following intestinal surgery. 
The current practice in stoma reversal and intestinal anastomosis patients in the surgical 
department of Mayo Hospital Lahore is to allow early water sips, chewing gum and honey 
intake from the 1st or 2nd postoperative day onwards and to allow full soft oral feeds after the 
passage of flatus or stool and bowel sounds on auscultation, usually on the 3rd or 4th 
postoperative day. This practice has yielded apparent improvements in postoperative outcomes, 
but no research or clinical trials have been performed yet to prove significant differences in 
results. 
Previous literature is deficient in directly comparing chewing gum and honey as 
effective and cost-effective methods to alleviate or prevent postoperative complications 
following ileostomy reversal and to improve patient recovery. To fully understand their role in 
the restoration of intestinal function following surgery, more RCTs are necessary (11). 
 
RATIONALE 
 
The rationale of this study is to investigate and identify interventions that can positively 
impact the postoperative outcomes of patients undergoing ileostomy reversal. After ileostomy 
reversal, patients may experience complications such as postoperative ileus, delayed bowel 
function, or anastomotic leakage. Exploring interventions such as chewing gum and honey 
could help find simple and cost-effective methods to mitigate these postoperative 
complications. Previous studies have hinted at the potential benefits of interventions like 
chewing gum or honey in improving postoperative recovery in various surgical procedures 
(7,10,29,30,11,14–16,20,26–28).  
Previous literature is deficient in exploring the role of honey intake in gastrointestinal 
surgery and specifically ileostomy reversal, so honey is being investigated in our study to bring 
novelty and uniqueness to the topic. Although it is a common practice to start early oral intake 
of honey before starting full feeds in our clinical setup, there is deficiency of literature to prove 
its efficacy in improving postoperative recovery and reducing complications. This study aims 
to specifically evaluate the efficacy of honey and chewing gum in the context of ileostomy 
reversal. Identifying interventions to shorten hospital stays, lower the frequency of 
complications, or enhance patient recovery may have an impact to maximize the effectiveness 
and economy of healthcare resources. 
OBJECTIVE 
To compare the effect of chewing gum and honey on postoperative recovery and 
complications in ileostomy reversal (as mentioned below). 
OPERATIONAL DEFINITIONS 
1. Early enteral nutrition: Defined as oral intake started on the first postoperative day. 
In contrast, the traditional way of normal enteral nutrition is nothing by mouth until the 
resolution of ileus, then a fluid diet, followed by a regular diet (27). 

3 
 
2. Ileostomy reversal: When the ileum previously used to form the stoma i.e. Loop 
Ileostomy, Double Barrel Ileostomy, Ileocolostomy or End Ileostomy is reconnected to 
the remainder of the bowel internally (31). 
 
3. Postoperative recovery and complications: 
• Time to bowel sounds: Defined as the time, in hours, between the completion of 
surgical closure and the first audible auscultation of non-continuous, high-pitched 
bowel sounds originating from the reconnected intestine, documented by a trained 
healthcare professional using a stethoscope placed over the lower quadrants of the 
abdomen (32,33). 
• Time to pass flatus: Defined as the time, in hours, between the completion of 
surgery and the documented passage of the first objectively confirmed flatus by 
auscultation or direct observation (33). 
• Time to pass feces: Defined as the time, in hours, between the completion of 
surgery and the documented first independent bowel movement, excluding any 
stool manually evacuated or stimulated by laxatives (33). 
• Time to full feeds: Defined as the time, in hours, between the surgery and the first 
point at which the patient tolerates and consumes a regular, unrestricted diet without 
experiencing any significant postoperative gastrointestinal complications (e.g., 
nausea, vomiting, abdominal pain, ileus) for a predetermined timeframe (i.e., 24 
hours) (7,26) 
• Postoperative pain: Postoperative pain in stoma reversal surgery was defined as 
the subjective pain intensity experienced by the patient at rest or during movement, 
assessed using the Visual Analog Scale (VAS). The VAS consists of a 10 cm 
horizontal line anchored by "no pain" (score of 0) and "worst imaginable pain" 
(score of 10), with patients marking the point on the line that best represented their 
pain intensity (4). 
• Postoperative ileus: Postoperative ileus is an abnormal pattern of slow or absent 
gastrointestinal motility in response to surgical procedures. It is measured as the 
absence of flatus/stool and inability to tolerate an oral diet within 3 days after 
surgery (34) (35). 
• Postoperative nausea and vomiting (PONV): PONV is defined as documented 
postoperative nausea/emesis or administration of a rescue antiemetic (36).  
• Length of postoperative stay: Defined as the time, in hours, from completion of 
reversal surgery to the time of discharge from the hospital (14). 
 
HYPOTHESIS 
There is a significant difference in the effect of chewing gum and honey on 
postoperative recovery and complications in ileostomy reversal.  

4 
 
MATERIALS AND METHODS 
METHODS 
Trial Design: Prospective single-blinded randomized controlled trial. Parallel design with 
allocation ratio 1:1 will be used. This manuscript is a protocol for the pilot RCT. 
Participants: Patients presenting to the outdoor and ward of West Surgical Department with 
an Ileostomy and undergoing Ileostomy reversal surgery in the operation theatre. 
Study Setting and Location: Male and Female Ward, West Surgical Department, Mayo 
Hospital, Lahore 
 
Sample Size:  
 
Due to deficiency of literature about the use of honey in gastrointestinal surgery and 
specifically intestinal anastomosis, it was decided that pretesting with a pilot study would be conducted 
to calculate the sample size. The overall sample size of 30 participants for the pilot trial was selected 
according to the Rule of Thumb for pilot trial sample size calculation. 15 participants in each group, i.e. 
Group A for chewing gum and Group B for honey, were allocated randomly using the lottery method. 
The primary outcome variable was time to pass flatus. The results of the pilot trial for the primary 
outcome variable showed that the mean time to pass flatus in Group A was 67.73 ± 8.481 hours and 
Group B was 75.73 ± 9.968 hours. 
Outcome Variable 
Group A 
Group B 
Population SD 
(ơ) 
Sample Size 
(n) 
Mean 
SD 
Mean 
SD 
Bowel sounds 
51.20 
9.937 
59.20 
8.970 
9.466 
31 
Time to pass flatus 
67.73 
8.481 
75.73 
9.968 
9.254 
29 
Time to pass stools 
100.80 
11.632 119.47 
12.994 
12.332 
10 
Time for full feeds 
79.47 
10.239 
93.33 
11.178 
10.719 
13 
 
The means and standard deviations of the pilot trial data was used to calculate the sample size 
using WHO Sample Size Calculator using the formula for hypothesis tests for two population 
means (one-sided test) as follows: 
 
Where, 
n = Sample size = 60 
ơ = Population standard deviation = 9.2245 
ơ2 = Variance = 85.0914 

5 
 
Z1-α = Confidence level 95% = 1.96 
Z1-β = Power of test = 95% 
µ1 = Population mean Group A = 67.73 
µ2 = Population mean Group B = 75.73 
 
A total sample size of 60 patients (30 patients in each group) is estimated by using 5% level of 
significance and 95% power of test with expected mean value time to pass flatus in Group A 
(Chewing Gum) as was 67.73 ± 8.481 hours and Group B (Honey) as 75.73 ± 9.968 hours in 
the pilot study. 
Sampling Technique: Non-probability purposive sampling. Patients admitted to the hospital 
for stoma reversal procedure will be assigned into Group A or B using a lottery method, 
ensuring that the sample population is divided into the two groups equally and randomly 
regardless of their characteristics (33).  
Sample Selection: 
Inclusion Criteria: 
• All patients of age more than 18 years with an Ileostomy 
• Undergoing surgery involving reversal of an Ileostomy i.e., Loop Ileostomy, Double 
Barrel Ileostomy, Ileocolostomy or End Ileostomy  
• Time from fashioning of ileostomy to its reversal is of a duration greater than 1 month 
Exclusion Criteria: 
• Patients with existing complications as mentioned above in the operative definition of 
postoperative complications 
• Patients with malignancy 
• Patients with inflammatory bowel disease 
• Patients who cannot communicate well 
• Patients who have difficulty chewing or swallowing 
• Patients who are prohibited from oral intake by the surgeon 
• Patients having undergone Ileostomy reversal more than 1 day before being included in 
the study 
Outcome Measures: 
• Primary Outcome 
o Time to pass flatus 
• Co-primary Outcomes 
o Time to bowel sounds 
o Time to pass feces 
• Secondary Outcomes 

6 
 
o Time to full feeds 
o Postoperative pain 
o Postoperative nausea and vomiting 
o Length of postoperative stay /Time to discharge 
 
Data Collection Procedure: 
After the approval to carry out this study from the Research Evaluation Unit (REU) 
College of Physicians and Surgeons Pakistan and the Institutional Review Board (IRB) King 
Edward Medical University, subjects meeting the operational definitions and the inclusion & 
exclusion criteria will be enrolled in the study after informed consent.  
 
Randomization: 
Allocation: Patients will be randomly allocated in group A or B: A for the Oral Chewing Gum 
group and B for the Oral Honey group using the lottery method by the principal investigator.  
Sequence Generation: The lottery method is a simple form of simple randomization used to 
assign participants into the two groups in a way that ensures unbiased allocation. Each 
participant will be assigned a case number from 1 onwards based on their induction into the 
study by the principal investigator. 30 identical paper slips will be made and Group A will be 
written in 15 slips and Group B will be written on the other 15 slips. The slips will be folded to 
conceal the written text. The slips will be mixed thoroughly and drawn randomly, and the 
participants will be assigned to a group based on the identifier on the slip, i.e. either Group A 
(chewing gum) or Group B (honey). 
Concealment: The identifier <Group A= or <Group B= will be written on identical slips of 
paper and the slips will be folded to conceal the written text, ensuring blinding by making them 
indistinguishable. 
 
Implementation:  
The random allocation will be done by the principal investigator. The participants presenting 
to the out-patient clinic for ileostomy reversal will be admitted to the ward and enrolled into 
the study after fulfilling the inclusion criteria and passing the exclusion criteria by the principal 
investigator.  
After a period of 24 hours from the ileostomy reversal surgery, the patients will be asked to 
start early water sips intake according to the ERAS protocol (6). Group A patients will be asked 
to chew gum for 5 minutes every 4 hours. Group B patients will be asked to eat one half 
tablespoon of natural honey every 4 hours. The outcome parameters will be assessed and 

7 
 
documented every 8 hours in the case report form by the doctor on duty in the ward. As the 
data collection schedule will be 8 hourly, the doctor on duty in the ward for each day will be 
responsible for data collection. The doctors on duty in the ward will be trained by the principal 
investigator about the data collection procedure. The bowel sounds will be auscultated using a 
stethoscope placed on the right iliac fossa of the patient’s abdomen. The patients will be 
questioned about whether they have passed flatus and feces and at what time they did so. The 
patients will be questioned about their last time taking full feeds, nausea, vomiting episodes. A 
visual analog scale for pain will be used to assess the pain score from 0 to 10 i.e. from no pain 
to the worst possible pain, subjective to each patient. The postoperative antibiotic, IV fluid, 
analgesic and PPI regimen will be standardized across the study participants. Relevant 
investigations to confirm the presence of complications will be carried out. All this information 
will be recorded in the case report form (attached).  
Blinding: Selection bias will be addressed by randomly assigning the participants to the groups. 
Performance bias could not be eliminated due to different surgeons performing the ileostomy 
reversal surgery. Detection bias will be addressed by keeping the participants unaware of what 
group they are assigned to and because of the objective nature of the outcome variables. There 
will still be some detection bias in some respects involving the subjective opinion of the 
participants e.g. pain score.  Intention-to-treat analysis will be done to address attrition bias.  
Follow-up: The primary and secondary outcomes will be assessed at 8 hourly intervals after 
starting either oral chewing gum or honey 24 hours postoperatively and the data will be written 
manually in the case report form. The final assessment point will be till the time of discharge 
or a maximum of 5 days/144 hours postoperatively. Data collection will be concluded when 
the patients will be discharged by the consultant orders in the ward round. Oral chewing gum 
or honey intake will be stopped on discharge and the patients will be recommended to continue 
taking oral meals at home. Further follow-up will be not done after the patients are discharged 
from the hospital. 
 
Data Analysis Procedure: 
Statistical analysis of the data will be carried out using IBM SPSS Statistics V26.0 for 
the Window program (IBM, Armonk, New York, USA). Qualitative variables such as gender, 
presence or absence of postoperative complications will be analyzed using frequencies and 
percentages. Quantitative variables such as age, length of postoperative stay, time to full feeds, 
time to bowel sounds, time to pass flatus and time to pass feces will be analyzed by calculating 
their mean and standard deviation. The data collected will be analyzed using descriptive 
statistics, such as frequencies, percentages, and means. Chi-Square test and logistic regression 
will be used to analyze the categorical variables whereas continuous variables will be analyzed 
using student t-test. Outcome data of the three groups will be compared to see the statistically 
significant difference, p-value of < 0.05 will be considered statistically significant. Outcome 
data will be stratified for age, gender, operative surgery, postoperative complications and post 
stratification chi square test will be applied. All qualitative data will be evaluated using 

8 
 
frequency tables. Any changes in the pre-operative and post-operative values will be calculated 
in absolute as well as percentages. The data will be explored using descriptive studies. 
 
REFERENCES 
 
1. 
Li K, Wang D, Zhang X, Yang J, Chen X. Efficacy of early enteral nutrition versus total 
parenteral nutrition for patients with gastric cancer complicated with diabetes mellitus: A 
systematic review and meta‐analysis. Nutr Diet [Internet]. 2022 Feb;79(1):129–39. Available 
from: https://onlinelibrary.wiley.com/doi/10.1111/1747-0080.12721 
2. 
de Gaay Fortman DPE, Kroon HM, Bedrikovetski S, Fitzsimmons TR, Dudi-Venkata NN, 
Sammour T. A snapshot of intraoperative conditions to predict prolonged postoperative ileus 
after colorectal surgery. ANZ J Surg [Internet]. 2022 Sep;92(9):2199–206. Available from: 
http://www.ncbi.nlm.nih.gov/pubmed/35579059 
3. 
Chu L, Wang H, Qiu S, Shao B, Huang J, Qin Q, et al. Risk Factors of Delayed Recovery of 
Gastrointestinal Function After Ileostomy Reversal for Rectal Cancer Patients. Cancer Manag 
Res [Internet]. 2021 Jun 29;13(null):5127–33. Available from: 
https://www.tandfonline.com/doi/abs/10.2147/CMAR.S311715 
4. 
Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. 
Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative 
complications and improve quality of life in colorectal cancer surgery. Cochrane database Syst 
Rev [Internet]. 2022 May 19;5(5):CD013259. Available from: 
http://www.ncbi.nlm.nih.gov/pubmed/35588252 
5. 
Yeom J, Lim HS. Effects of the Enhanced Recovery After Surgery (ERAS) Program for 
Colorectal Cancer Patients Undergoing Laparoscopic Surgery. Clin Nutr Res. 2022;11(2):75.  
6. 
Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, et al. Enhanced 
Recovery After Surgery for gastrointestinal surgery, part 1: pathophysiological considerations. 
Acta Anaesthesiol Scand [Internet]. 2015 Nov 8;59(10):1212–31. Available from: 
https://onlinelibrary.wiley.com/doi/10.1111/aas.12601 
7. 
Gil-Vargas M, Saavedra-Pacheco MS, Coral-García MÁ. Early Feeding versus Traditional 
Feeding in Children with Ileostomy Closure. J Indian Assoc Pediatr Surg [Internet]. 2022 
[cited 2022 Oct 24];27(2):223–6. Available from: https://pubmed.ncbi.nlm.nih.gov/35937106/ 
8. 
Lin Z, Li Y, Wu J, Zheng H, Yang C. Nomogram for prediction of prolonged postoperative 
ileus after colorectal resection. BMC Cancer [Internet]. 2022 Dec 6;22(1):1273. Available 
from: http://www.ncbi.nlm.nih.gov/pubmed/36474177 
9. 
Soyer T, Arslan SS, Boybeyi Ö, Demir N, Tanyel FC. The Role of Oral Feeding Time and 
Sham Feeding on Oropharyngeal Swallowing Functions in Children with Esophageal Atresia. 
Dysphagia [Internet]. 2022 May 16; Available from: 
http://www.ncbi.nlm.nih.gov/pubmed/35570211 
10. 
Hsu YC, Szu SY. Effects of Gum Chewing on Recovery From Postoperative Ileus: A 
Randomized Clinical Trail. J Nurs Res [Internet]. 2022 Oct 1 [cited 2022 Dec 9];30(5):E233. 
Available from: https://pubmed.ncbi.nlm.nih.gov/35951432/ 
11. 
Kusika NP, Hutagaol IEB, Yusuf M, Suyanto S, Tilusari SP. The Role of Chewing Gum on 
Post-operative Bowel Recovery after Gynecological Laparoscopic Surgery: A Short Report 
and Updated Review. Open Access Maced J Med Sci [Internet]. 2021 Sep 26 [cited 2022 Dec 
9];9(B):1123–7. Available from: https://oamjms.eu/index.php/mjms/article/view/7133 
12. 
Atkins CS, Tubog TD, Schaffer SK. Chewing Gum After Radical Cystectomy With Urinary 
Diversion for Recovery of Intestinal Function: A Systematic Review and Meta-Analysis. J 
perianesthesia Nurs  Off J Am Soc PeriAnesthesia Nurses [Internet]. 2022 Aug;37(4):467–73. 
Available from: http://www.ncbi.nlm.nih.gov/pubmed/35272926 
13. 
Luo J, Xia M, Zhang C. The Effects of Chewing Gum on Reducing Anxiety and Stress: A 

9 
 
Meta-Analysis of Randomized Controlled Trials. J Healthc Eng [Internet]. 
2022;2022:8606693. Available from: http://www.ncbi.nlm.nih.gov/pubmed/35140905 
14. 
Bhatti S, Malik YJ, Changazi SH, Rahman UA, Malik AA, Butt UI, et al. Role of Chewing 
Gum in Reducing Postoperative Ileus after Reversal of Ileostomy: A Randomized Controlled 
Trial. World J Surg [Internet]. 2021 Apr 1 [cited 2022 Dec 13];45(4):1066–70. Available 
from: https://pubmed.ncbi.nlm.nih.gov/33403448/ 
15. 
Jahangir MA, Muheem A, Anand C, Imam SS. Traditional and Modern Applications of 
Honey: An Insight BT - Therapeutic Applications of Honey and its Phytochemicals : Vol.1. In: 
Rehman MU, Majid S, editors. Singapore: Springer Singapore; 2020. p. 151–69. Available 
from: https://doi.org/10.1007/978-981-15-6799-5_8 
16. 
Iftikhar A, Nausheen R, Mukhtar I, Iqbal RK, Raza A, Yasin A, et al. The regenerative 
potential of honey: a comprehensive literature review. J Apic Res [Internet]. 2023 Jan 
1;62(1):97–112. Available from: https://doi.org/10.1080/00218839.2022.2028969 
17. 
Schell KR, Fernandes KE, Shanahan E, Wilson I, Blair SE, Carter DA, et al. The Potential of 
Honey as a Prebiotic Food to Re-engineer the Gut Microbiome Toward a Healthy State 
[Internet]. Vol. 9, Frontiers in Nutrition. 2022. Available from: 
https://www.frontiersin.org/articles/10.3389/fnut.2022.957932 
18. 
Eteraf-Oskouei T, Najafi M. Traditional and modern uses of natural honey in human diseases: 
A review. Iran J Basic Med Sci. 2013;16(6):731–42.  
19. 
Fernández-Gálvez A, Rivera S, Durán Ventura M del C, de la Osa RMR. Nutritional and 
Educational Intervention to Recover a Healthy Eating Pattern Reducing Clinical Ileostomy-
Related Complications. Nutrients [Internet]. 2022 Aug 20;14(16):3431. Available from: 
https://www.mdpi.com/2072-6643/14/16/3431 
20. 
Gumuskaya O, Cavdar I, Beyoglu CA. Prevention of post-operative nausea and vomiting with 
honey as a pre-operative oral carbohydrate: A randomised controlled pilot trial. J Perioper 
Nurs [Internet]. 2022 Sep 1;35(3):e21–32. Available from: 
https://search.informit.org/doi/10.3316/informit.721369814231869 
21. 
Sudiyatmo, Rivai M, Puar N, Lipoeto N. Effects of Preoperative Honey Drink on Gastric 
Content, Perioperative Discomfort and Insulin Resistance in Patients Undergoing Open 
Colorectal Surgery a Randomized, Controlled Trial. Br J Med Med Res [Internet]. 2016 Jan 
10;14(7):1–8. Available from: https://journaljammr.com/index.php/JAMMR/article/view/726 
22. 
Rahimi VB, Shirazinia R, Fereydouni N, Zamani P, Darroudi S, Sahebkar AH, et al. 
Comparison of honey and dextrose solution on post-operative peritoneal adhesion in rat model. 
Biomed Pharmacother [Internet]. 2017 Aug;92:849–55. Available from: 
https://linkinghub.elsevier.com/retrieve/pii/S0753332217318127 
23. 
Aznan MI, Khan OH, Unar AO, Tuan Sharif SE, Khan AH, Syed Abd. Aziz SH, et al. Effect 
of Tualang honey on the anastomotic wound healing in large bowel anastomosis in rats-A 
randomized controlled trial. BMC Complement Altern Med [Internet]. 2016;16(1):28. 
Available from: https://doi.org/10.1186/s12906-016-1003-6 
24. 
Ergul E, Ergul S. The effect of honey on the intestinal anastomotic wound healing in rats with 
obstructive jaundice. Bratisl Lek List. 2010;111(5):265.  
25. 
Gollu A, Kismet K, Kilicoglu B, Erel S, Gonultas MA, Sunay AE, et al. Effect of honey on 
intestinal morphology, intraabdominal adhesions and anastomotic healing. Phyther Res 
[Internet]. 2008 Sep 11;22(9):1243–7. Available from: 
https://onlinelibrary.wiley.com/doi/10.1002/ptr.2457 
26. 
Behera BK, Misra S, Tripathy BB. Systematic review and meta-analysis of safety and efficacy 
of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery 
[ERAS] in children after bowel anastomosis surgery. J Pediatr Surg [Internet]. 2022 Aug 1 
[cited 2022 Oct 24];57(8):1473–9. Available from: 
https://pubmed.ncbi.nlm.nih.gov/34417055/ 
27. 
Peng Y, Xiao D, Xiao S, Yang L, Shi H, He Q, et al. Early enteral feeding versus traditional 
feeding in neonatal congenital gastrointestinal malformation undergoing intestinal 
anastomosis: A randomized multicenter controlled trial of an enhanced recovery after surgery 
(ERAS) component. J Pediatr Surg [Internet]. 2021 Sep 1 [cited 2022 Nov 2];56(9):1479–84. 
Available from: https://pubmed.ncbi.nlm.nih.gov/33838898/ 

10 
 
28. 
Park SH, Choi MS. Meta-Analysis of the Effect of Gum Chewing After Gynecologic Surgery. 
J Obstet Gynecol Neonatal Nurs. 2018 May 1;47(3):362–70.  
29. 
Canzan F, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E. The effect of early oral 
postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: 
Protocol for a systematic review and meta-analysis. Meyer A, editor. PLoS One [Internet]. 
2022 Aug 18;17(8):e0273085. Available from: 
https://dx.plos.org/10.1371/journal.pone.0273085 
30. 
Madan S, Sureshkumar S, Anandhi A, Gurushankari B, Keerthi AR, Palanivel C, et al. 
Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care  in 
Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial. J 
Gastrointest Surg  Off J Soc Surg  Aliment Tract. 2023 Nov;27(11):2667–75.  
31. 
Ng ZQ, Levitt M, Platell C. The feasibility and safety of early ileostomy reversal: a systematic 
review and meta-analysis. ANZ J Surg. 2020 Sep;90(9):1580–7.  
32. 
Davis BR, Valente MA, Goldberg JE, Lightner AL, Feingold DL, Paquette IM, et al. The 
American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy 
Surgery. Dis Colon Rectum [Internet]. 2022;65(10). Available from: 
https://journals.lww.com/dcrjournal/fulltext/2022/10000/the_american_society_of_colon_and_
rectal_surgeons.5.aspx 
33. 
Chapman SJ, Thorpe G, Vallance AE, Harji DP, Lee MJ, Fearnhead NS, et al. Systematic 
review of definitions and outcome measures for return of bowel function after gastrointestinal 
surgery. BJS Open [Internet]. 2019 Feb 1;3(1):1–10. Available from: 
https://doi.org/10.1002/bjs5.102 
34. 
Climent M, Frago R, Cornellà N, Serrano M, Kreisler E, Biondo S. Prognostic factors for 
complications after loop ileostomy reversal. Tech Coloproctol [Internet]. 2022 Jan;26(1):45–
52. Available from: http://10.0.3.239/s10151-021-02538-0 
35. 
Aktaş A, Kayaalp C, Ateş M, Dirican A. Risk factors for postoperative ileus following loop 
ileostomy closure. Turkish J Surg. 2020 Dec;36(4):333–9.  
36. 
Andrew BY, Habib AS, Taicher BM. The Association of Guideline-Directed Prophylaxis with 
Postoperative Nausea and Vomiting in Pediatric Patients: A Single-Center, Retrospective 
Cohort Study. Anesth Analg [Internet]. 9900; Available from: 
https://journals.lww.com/anesthesia-
analgesia/fulltext/9900/the_association_of_guideline_directed_prophylaxis.590.aspx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

13 
 
Consent Form 
 
<COMPARISON OF THE EFFECT OF CHEWING GUM AND HONEY ON POSTOPERATIVE RECOVERY AND 
COMPLICATIONS IN ILEOSTOMY REVERSAL= 
 
You are asked to participate in a research study conducted by Dr. Shahroze Wajid under supervision of Dr. Bahzad Akram 
Khan (Assistant Professor, West Surgical Ward, Mayo Hospital, Lahore), from the West Surgical Ward at Mayo Hospital affiliated 
with King Edward Medical University (KEMU). The Institutional Review Board (IRB) of KEMU has reviewed this project. IRB is 
an independent hospital committee that safeguards the welfare and rights of human research participants. Your participation in this 
study is entirely voluntary. Please read the information below and ask questions about anything you do not understand, before 
deciding whether or not to participate. 
You are being asked to take part in this study because you had undergone an ileostomy formation surgery and have now 
presented to the hospital to undergo stoma reversal surgery.  The purpose of this study is to compare the effect of chewing gum and 
honey on postoperative recovery and complications in ileostomy reversal. About 100 people will take part in this study. You will 
be randomly allocated to a group upon consent to this study and will be asked to start oral intake either chewing gum or honey 1 
day after your stoma reversal procedure. Starting from 1 day after the surgery, depending on your allocated group, you will be either 
be asked to chew gum for 5 minutes every 4 hours or to eat one half tablespoon of natural honey every 4 hours. Your postoperative 
recovery and complication parameters will be assessed and documented every 8 hours. Relevant questions and investigations 
including history taking, clinical examination and blood sampling to confirm the presence of complications will be carried out 
accordingly. The total length of time for your participation in the study will be up to a maximum of 5 days or earlier if you are 
discharged from the ward upon consultant orders. 
Any foreseeable risks or discomforts from undergoing the surgery could include postoperative bloating, pain, nausea, 
vomiting, change in bowel habits, delayed recovery after surgery or reoperation (in case of intraabdominal infection or anastomotic 
leakage). These risks or discomforts may or may not be related to or caused by the use of chewing gum or honey and may entirely 
be due to postsurgical complications. The potential benefits of the study intervention can be improved postoperative recovery after 
surgery, decreased likelihood of postoperative complications, early return of bowel function and early discharge. Any information 
that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only 
with your permission or as required by law. Confidentiality will be maintained by means of restricting your data to only the relevant 
medical professionals involved in this study. The case report forms containing your data will be safely kept in the research record 
in the custody of the principal investigator and will not be shared to any irrelevant person without your informed consent. You will 
not receive any payment to participate in this study. 
You can choose whether or not to be in this study. If you volunteer to be in this study, you may withdraw at any time 
without consequences of any kind or loss of benefits to which you are otherwise entitled.  We will tell you about new information 
that may affect your health, welfare, or willingness to stay in this study. The investigator may withdraw you from this research if 
circumstances arise which warrant doing so. If you have any questions or concerns about this research, please contact the principal 
investigator, Dr. Shahroze Wajid, Email: shahrozewajid@gmail.com, Contact Number: +923054480616.  The Institutional Review 
Board of KEMU has reviewed this project. If you have any concerns or questions about your rights in this study as a research 
subject, you should contact the Secretary, Institutional Review Board, KEMU. 
I understand the procedures described above. My questions have been answered to my satisfaction, and I agree to participate 
in this study. I have been given a copy of this form. 
 
Name of the participant: ___________________________________ Patient I.D: ________________________ 
 
 
Name of the witness: _____________________________________ Witness I.D: ________________________ 
 
 
Signature of the participant: ______________________ Signature of the witness:________________________  
 
 
Name and signature of the person obtaining consent: _______________________________________________