Randomized Clinical Trial Comparing Efficacy of Simo Decoction and Acupuncture or Chewing Gum Alone on Postoperative Ileus in Patients With Hepatocellular Carcinoma After Hepatectomy

Abstract

To compare the efficacy of simo decoction (SMD) combined with acupuncture at the tsusanli acupoint or chewing gum alone for treating postoperative ileus in patients with hepatocellular carcinoma (HCC) after hepatectomy.
In postoperative ileus, a frequent complication following hepatectomy, bowel function recovery is delayed, which increases length of hospital stay. Studies suggest that chewing gum may reduce postoperative ileus; SMD and acupuncture at the tsusanli acupoint have long been used in China to promote bowel movement.
Patients with primary HCC undergoing hepatectomy between January 2015 and August 2015 were randomized to receive SMD and acupuncture (n = 55) or chewing gum (n = 53) or no intervention (n = 54) starting on postoperative day 1 and continuing for 6 consecutive days or until flatus. Primary endpoints were occurrence of postoperative ileus and length of hospital stay; secondary endpoints were surgical complications.
Groups treated with SMD and acupuncture or with chewing gum experienced significantly shorter time to first peristalsis, flatus, and defecation than the no-intervention group (all P < 0.05). Hospital stay was significantly shorter in the combined SMD and acupuncture group (mean 14.0 d, SD 4.9) than in the no-intervention group (mean 16.5 d, SD 6.8; P = 0.014), while length of stay was similar between the chewing gum group (mean 14.7, SD 6.2) and the no-intervention group (P = 0.147). Incidence of grades I and II complications was slightly lower in both intervention groups than in the no-intervention group.
The combination of SMD and acupuncture may reduce incidence of postoperative ileus and shorten hospital stay in HCC patients after hepatectomy. Chewing gum may also reduce incidence of ileus but does not appear to affect hospital stay. (Clinicaltrials.gov registration number: NCT02438436.)

Full text

Randomized Clinical Trial Comparing Efficacy of Simo
Decoction and Acupuncture or Chewing Gum Alone on
Postoperative Ileus in Patients With Hepatocellular
Carcinoma After Hepatectomy
Xue-Mei You, MD, Xin-Shao Mo, MD, Liang Ma, MD, Jian-Hong Zhong, MD, Hong-Gui Qin, MD,
Zhan Lu, MD, Bang-De Xiang, MD, Fei-Xiang Wu, MD, Xin-Hua Zhao, BD, Juan Tang, BD,
Yong-Hui Pang, BD, Jie Chen, MD, and Le-Qun Li, MD
Abstract: To compare the efficacy of simo decoction (SMD) com-
bined with acupuncture at the tsusanli acupoint or chewing gum alone
for treating postoperative ileus in patients with hepatocellular carcinoma
(HCC) after hepatectomy.
In postoperative ileus, a frequent complication following hepatect-
omy, bowel function recovery is delayed, which increases length of
hospital stay. Studies suggest that chewing gum may reduce post-
operative ileus; SMD and acupuncture at the tsusanli acupoint have
long been used in China to promote bowel movement.
Patients with primary HCC undergoing hepatectomy between Jan-
uary 2015 and August 2015 were randomized to receive SMD and
acupuncture (n ¼55) or chewing gum (n ¼53) or no intervention
(n ¼54) starting on postoperative day 1 and continuing for 6 consecu-
tive days or until flatus. Primary endpoints were occurrence of post-
operative ileus and length of hospital stay; secondary endpoints were
surgical complications.
Groups treated with SMD and acupuncture or with chewing gum
experienced significantly shorter time to first peristalsis, flatus, and
defecation than the no-intervention group (all P<0.05). Hospital stay
was significantly shorter in the combined SMD and acupuncture group
(mean 14.0 d, SD 4.9) than in the no-intervention group (mean 16.5 d,
SD 6.8; P¼0.014), while length of stay was similar between the
chewing gum group (mean 14.7, SD 6.2) and the no-intervention group
(P¼0.147). Incidence of grades I and II complications was slightly
lower in both intervention groups than in the no-intervention group.
The combination of SMD and acupuncture may reduce incidence of
postoperative ileus and shorten hospital stay in HCC patients after
hepatectomy. Chewing gum may also reduce incidence of ileus but does
not appear to affect hospital stay. (Clinicaltrials.gov registration num-
ber: NCT02438436.)
(Medicine 94(45):e1968)
Abbreviations: HCC = hepatocellular carcinoma, SMD = simo
decoction.
INTRODUCTION
Hepatectomy is widely used to treat patients with hepato-
cellular carcinoma (HCC), even those with intermediate
and advanced disease.
1,2
Despite its well-demonstrated clinical
safety and efficacy in many patients, it is associated with
postoperative morbidity and mortality.
2,3
One complication
after hepatectomy is delayed resumption of gastrointestinal
function, known as postoperative ileus. This can decrease
patient comfort and increase morbidity and mortality, prolong-
ing hospital stay, and raising healthcare costs.
4,5
While post-
operative ileus usually resolves within approximately 3 days, it
can last longer in some cases as a condition termed post-
operative paralytic ileus.
6
Postoperative use of opioid-based
analgesics can increase incidence of postoperative ileus.
7,8
No drugs or interventions to prevent or treat postoperative
ileus have been approved by the China Drug Administration or
the US Food and Drug Administration. Studies suggest that
postoperative oral administration of simo decoction (SMD)
9
and acupuncture
10
can accelerate the return of gastrointestinal
function following several types of surgery. Several studies also
show that chewing gum, a new and simple modality, can
accelerate complication-free recovery of gastrointestinal func-
tion following gastrointestinal surgery
5,11
and obstetrical–
gynecological surgery.
12,13
This raises the question whether
postoperative SMD, acupuncture, or chewing gum can reduce
risk of postoperative ileus following hepatectomy.
To examine this question, we conducted a randomized
controlled trial to compare incidence of postoperative ileus
and length of hospital stay in HCC patients who received
SMD and acupuncture, chewing gum or no intervention follow-
ing hepatectomy.
Editor: Johannes Mayr.
Received: September 14, 2015; revised: October 8, 2015; accepted:
October 10, 2015.
From the Hepatobiliary Surgery Department, Affiliated Tumor Hospital of
Guangxi Medical University (XMY, XSM, LM, JHZ, HGQ, ZL, BDX,
FXW, YHP, JT, XHZ, JC, LQL); and Guangxi Liver Cancer Diagnosis and
Treatment Engineering and Technology Research Center, Nanning, PR
China (XMY, LM, JHZ, BDX, FXW, YHP, JT, XHZ, JC, LQL).
Correspondence: Jian-Hong Zhong, Hepatobiliary Surgery Department,
Affiliated Tumor Hospital of Guangxi Medical University, He Di Rd.
#71, Nanning 530021, PR China (e-mail: zhongjianhong66@163.com).
Correspondence: Le-Qun Li, Hepatobiliary Surgery Department,
Affiliated Tumor Hospital of Guangxi Medical University, He Di Rd.
#71, Nanning 530021, PR China (e-mail: xitongpingjia@163.com).
Xue-Mei You, Xin-Shao Mo, and Liang Ma contributedequally to this work.
This work was supported by the National Science and Technology Major
Special Project of the Ministry of Science and Technology of China
(2012ZX10002010001009), the National Natural Science Foundation of
China (81260331, 81160262, 81560460), the Guangxi University of
Science and Technology Research Projects (KY2015LX056), the Self-
Raised Scientific Research Fund of the Ministry of Health of Guangxi
Province (GZPT1240, GZZC15-34, Z2015621, Z2014241), the Inno-
vation Project of Guangxi Graduate Education (YCBZ2015030), and the
Guangxi Science and Technology Development Projects (14124003-4).
The authors have no conflicts of interest to disclose.
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution-NonCommercial-NoDerivatives License 4.0, where it is
permissible to download, share and reproduce the work in any medium,
provided it is properly cited. The work cannot be changed in any way or
used commercially.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000001968
Medicine®
OBSERVATIONAL STUDY
Medicine Volume 94, Number 45, November 2015 www.md-journal.com |1

METHODS
The protocol for this trial was approved by the Medical
Ethics Committee of the Affiliated Tumor Hospital of Guangxi
Medical University, and was designed in accordance with the
Declaration of Helsinki. The trial was registered at Clinical-
trials.gov (NCT02438436). Data were collected, analyzed, and
reported according to the Consolidated Standards of Reporting
Trials (CONSORT) statement.
Patients
Patients older than 18 years who underwent open hepa-
tectomy at 1 of the 2 Hepatobiliary Surgery Departments of the
Affiliated Tumor Hospital of Guangxi Medical University
(Nanning, China) were eligible to participate in the study.
Diagnosis of HCC was based on 2 types of clinical imaging,
together with a serum level of a-fetoprotein higher than
400 ng/mL; diagnosis was confirmed by histopathological
examination of surgical samples. Patients were excluded if they
had a history of exploratory laparotomy, laparoscopic surgery,
inflammatory bowel disease, abdominal radiation, or substance
abuse; if they had psychological or social conditions that might
interfere with their participation in the study; if they were
allergic to mint; or if they required intensive care more than
24 hours postoperatively or a nasogastric tube beyond the first
postoperative morning.
Randomization
The study information was explained to all enrolled
patients. After written informed consent was obtained, patients
were assigned randomly to groups that would receive SMD
combined with acupuncture or chewing gum or no intervention.
Randomization was performed the day before hepatectomy
using TenAlea software (http://nl.tenalea.net). The fundamen-
tally different characteristics of SMD or chewing gum meant
that no blinding was used after randomization. Patients were
informed that the ability of SMD, acupuncture, or chewing gum
to promote recovery of gastrointestinal function after hepatect-
omy was not known, and that none of these measures was
expected to cause obvious side effects.
Interventions
The same surgical team performed all hepatectomies using
general anesthesia, the same evidence-based protocol of peri-
operative management and standardized postoperative care
plans.
3,14,15
An abdominal cavity drainage tube was placed in
each patient. The nasogastric drainage tube was removed on the
first postoperative morning. Enteral or nasogastric feeding was
not provided until after passage of first flatus. All patients were
mobilized as soon as possible in the postoperative period.
Additional opioid or nonsteroidal analgesia was prescribed
for pain when required and their use carefully documented.
Then nursing ward staff administered the following interven-
tions to the randomized groups, recording their actions in
patient records.
One group of patients received oral SMD decoction (Han-
sen Co., Ltd, Yiyang, Hunan Province, China, 10mL/dose) 3
times per day beginning on the first day after hepatectomy. They
also received bilateral injections of vitamin B1 (50 mg 2) at
the tsusanli acupoint 1 time per day after the skin was swabbed
with 75% alcohol. This intervention was performed for a total of
6 consecutive days or until flatus.
Another group of patients was instructed to chew commer-
cially available sugarless chewing gum (Extra & Reg, Wm.
Wrigley Jr. Co., Ltd, Shanghai, China) 3 times daily starting on
postoperative day 1. They were instructed to chew the piece of
gum for 30 minutes. This intervention was performed for a total
of 6 consecutive days or until flatus.
A third group did not receive any postoperative interven-
tion, including SMD, acupuncture, chewing gum, or adjuvant
drugs that might influence recovery of bowel function.
Outcomes
Primary endpoints were time to first flatus and time to
defecation, which were recorded daily by nursing staff. Sec-
ondary endpoints were length of hospital stay and postoperative
complications such as fever, pneumonia, wound infection, and
bleeding. Length of hospital stay was defined as the number of
days from hepatectomy to discharge. Criteria for hospital dis-
charge included stability of vital signs with no fever, achieve-
ment of flatus or defecation, ability to tolerate solid food
without vomiting, control of postoperative pain, absence of
other postoperative complications, and ability to function at
home independently or with the home care provided. Post-
operative complications were classified and graded according to
the Clavien– Dindo scheme.
16
Sample Size Calculation
Sample size calculation was based on our previous retro-
spective study
17
performed in patients with HCC after hepa-
tectomy. Mean time to first flatus was assumed to be 73 and
51 hours between SMD combined with acupuncture and no-
intervention group. The minimum detectable difference was 22.
Assuming that the common standard deviation is 24 hours, the
sample size was calculated to be a total of 171 participants
applying statistical power of 90% at a 2-sided significance level
of 5%. We recruited an additional 10 subjects to offset potential
attrition.
Statistical Analysis
SPSS 19.0 (IBM, USA) was used for all statistical
analyses, with the threshold of significance defined as a two-
tailed P<0.05. Data for continuous variables were expressed as
median (range), while data for categorical variables were
expressed as number (percentage). Intergroup differences
in continuous variables were assessed for significance using
Student ttest (if data were normally distributed) or the Mann –
Whitney Utest (if data were skewed). Intergroup differences in
categorical data were assessed using the x
2
test or Fisher exact
tests (2-tailed), as appropriate. Length of hospital stay was
calculated using Kaplan–Meier analysis and compared between
groups using the log-rank test.
RESULTS
Patient Characteristics
From January 1, 2015 to August 31, 2015, 245 patients
with HCC were assessed for eligibility. Of these, 43 were
excluded because they did not meet the inclusion criteria, 16
refused to participate, 3 were unwilling to receive SMD and 2
were unwilling to receive chewing gum. The remaining 181
patients were randomly assigned to receive SMD with acu-
puncture (n ¼62), chewing gum (n ¼60), or no intervention
(n ¼59). After randomization, 7 patients diagnosed with cho-
langiocellular carcinoma were excluded. Another 5 patients
were excluded because they had a prolonged stay in the
intensive care unit and so could not receive SMD or chewing
You et al Medicine Volume 94, Number 45, November 2015
2|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.

gum. Four patients discontinued the study and three received the
incorrect intervention, so these 7 were excluded from the final
analysis. In the end, 162 patients completed the study, compris-
ing 55 in the SMD with acupuncture group, 53 in the chewing
gum group, and 54 in the control group (Fig. 1).
Patients in all 3 groups had similar hepatectomy charac-
teristics, including major or minor hepatectomy, mean duration
of surgery and blood loss (Table 1). No intervention-related
adverse events more severe than grade I were recorded in any
of the groups, based on the Common Terminology Criteria for
Adverse Events 3.0.
18
Postoperative Ileus
Time to first peristalsis, first flatus, and first defecation was
significantly shorter in the 2 intervention groups than in the no-
intervention group (all P<0.05). All 3 time intervals were
slightly shorter in the groups receiving SMD with acupuncture
than in the group receiving chewing gum (all P>0.05)
(Table 2).
Length of Hospital Stay
Hospital stay lasted a mean of 14.0 d (SD 4.9, median 13)
for patients receiving SMD with acupuncture, 14.7 d (SD 6.2,
median 13) for patients receiving chewing gum, and 16.5 (SD
6.8, median 15) for no-intervention controls (Table 2). Kaplan –
Meier analysis showed that length of stay was significantly
shorter for SMD with acupuncture than for no intervention
(P¼0.014) (Fig. 2). In contrast, length of stay was slightly
shorter for the group receiving SMD with acupuncture than the
group receiving chewing gum (P¼0.295), and it was slightly
shorter for the group receiving chewing gum than for the group
receiving no intervention (P¼0.147).
Complications
The frequency of complications was significantly higher in
the no-intervention group than in the groups receiving SMD
with acupuncture or receiving chewing gum (P<0.001). Most
complications were grade I or II and included wound pain,
abdominal distension, fever, and hydrothorax. One patient in the
chewing gum group required second surgery because of liver
bleeding. One patient in the SMD with acupuncture group and
1 patient in the no-intervention group died within 30 d after
hepatectomy because of liver failure (Table 3).
DISCUSSION
Although most hepatectomies do not involve gastrointes-
tinal surgery, transient impairment of gastrointestinal motility
known as postoperative ileus occurs in a substantial proportion
of patients. This increases healthcare costs and resource util-
ization.
19
Various strategies have been developed to reduce the
incidence of postoperative ileus, including fast-track care,
minimally invasive surgery, and epidural anesthesia, but none
of these methods is entirely satisfactory.
20
Our results suggest
that the combination of SMD and acupuncture may reduce
incidence of postoperative ileus and shorten hospital stay in
HCC patients after hepatectomy. Chewing gum may also reduce
incidence of ileus but does not appear to significantly affect
hospital stay.
Assessed for eligibility n=245
Excluded n=64
Did not meet inclusion criteria n=43
Withdrew consent n=16
Other reason n=5
Randomized n=181
Allocated to SMD+acupun n=62
Received intervention n=57
Excluded after surgery n=3
Inability to take SMD n=2
Lost to follow-up n=0
Discontinued intervention n=2
Analyzed n=55
Lost to follow-up n=0
Discontinued intervention n=2
Allocated to chewing gum n=60
Received intervention n=55
Excluded after surgery n=2
Inability to chew gum n=3
Allocated to no intervention n=59
Received no intervention n=57
Excluded after surgery n=2
Lost to follow-up n=0
Received SMD n=3
Analyzed n=53 Analyzed n=54
FIGURE 1. CONSORT diagram for the study. SMD þacupun, simo decoction with acupuncture.
Medicine Volume 94, Number 45, November 2015 SMD or Chewing Gum on POI
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |3

Our findings in this randomized controlled trial are con-
sistent with our previous small retrospective study, in which
SMD with acupuncture reduced incidence of postoperative ileus
in HCC patients after hepatectomy.
17
Our observation that
chewing gum reduced the incidence of postoperative ileus is
supported by findings in other randomized trials
11– 13
and meta-
analyses,
4,21
as well as a small prospective case– control study
from South Korea in which HCC patients who chewed gum
after hepatectomy recovered bowel function faster than those
who did not.
22
Thus the available evidence suggests that SMD
combined with acupuncture may be the most promising strategy
for reducing the incidence of postoperative ileus and shortening
the length of hospital stay for HCC patients after hepatectomy.
Incidence of grade I and II postoperative complications was
significantly lower in the group receiving SMD with acupunc-
ture than in the no-intervention group. We did not observe any
adverse events related to SMD, acupuncture, or chewing gum
in the present study, similar to the lack of adverse events in
previous trials.
10,17,21,23
Postoperative ileus may have multiple causes, though
surgically induced intestinal inflammation appears to be the
most frequent one.
24,25
Inflammatory infiltration into the intes-
tinal muscularis can lead to hypomotility along the entire
gastrointestinal tract.
26
Consistent with this, early inhibition
of inflammation reduces the incidence of postoperative
ileus,
27,28
usually by vagus nerve-mediated activation of
the autonomic nervous system.
29,30
This may help explain
TABLE 2. Outcomes of Postoperative Simo Decoction þAcupuncture or Chewing Gum in Patients With Hepatocellular
Carcinoma
Variable
Simo Decoction þ
Acupuncture
(n ¼55)
Chewing
Gum
(n ¼53)
No
Intervention
(n ¼54) P
Time to first peristalsis, h 19.6 (8.5– 46.2) 25.2 (12.0– 52.5) 29.6 (16.5– 69.4) 0.127

, 0.014
y
, 0.035
z
Time to first flatus, h 51.4 (22.5– 82.1) 55.9 (28.4– 110.5) 70.6 (46.8– 127.3) 0.353

, 0.012
y
, 0.013
z
Time to first defecation, d 2.5 (0.8– 4.6) 3.3 (1.5–9.4) 4.7 (4.2– 8.7) 0.158

, 0.003
y
, 0.035
z
Length of postoperative hospital stay, d 13.1 (7.0 – 28.1) 13.2 (6.4– 34.1) 15.3 (7.4– 41.2) 0.295

, 0.014
y
, 0.147
z
Values shown are median (range).

Simo decoction þacupuncture versus chewing gum.
y
Simo decoction þacupuncture versus no intervention.
z
Chewing gum versus no intervention.
TABLE 1. Clinicopathological Data of Patients With Hepatocellular Carcinoma Treated With Simo Decoction þAcupuncture,
Chewing Gum, or No Intervention
Variable Simo Decoction þAcupuncture (n ¼55) Chewing Gum (n ¼53) No Intervention (n ¼54) P
Age, y 48 (28– 71) 53 (29– 75) 51 (28– 69) 0.270
Male 45 (82) 46 (87) 44 (81) 0.711
BMI 22.6 (19.3– 28.0) 22.2 (16.3– 29.9) 22.5 (17.3– 30.1) 0.655
Diabetes mellitus 11 (20) 11 (21) 9 (17) 0.848
Smoking 7 (13) 9 (17) 8 (15) 0.824
Alcohol use 25 (45) 20 (38) 19 (35) 0.521
Major hepatectomy 26 (47) 29 (55) 28 (52) 0.840
Surgical time, min 181 (100– 382) 215 (110–424) 192 (100 – 371) 0.427
Blood loss, mL 515 (100–2750) 450 (80– 2550) 525 (50– 3400) 0.317
Opioid analgesia use 21 (38) 23 (43) 32 (59) 0.072
Values shown are median (range) or n (%). BMI ¼body mass index.
FIGURE 2. Kaplan–Meier curves showing length of hospital stay
in the three groups. Significant differences were observed
between the group receiving SMD with acupuncture and the
control group receiving no intervention (P¼0.014), but not
between the group receiving SMD with acupuncture and the
group who chewed gum (P¼0.295), or between the group who
chewed gum and the control group (P¼0.147).
You et al Medicine Volume 94, Number 45, November 2015
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why we observed that gum chewing promoted recovery of
gastrointestinal function: chewing gum not only activates the
cephalic-vagal reflex as a form of sham feeding,
31
but it also
reduces systemic inflammation.
11
Whether SMD, long used in traditional Chinese medicine
to boost gastrointestinal hypomotility, works by a similar
mechanism is unclear. Evidence from animal models suggests
that SMD can reduce serum levels of proinflammatory cyto-
kines and white blood cells.
32,33
That it may also directly
promote gastrointestinal motility is suggested by the obser-
vation that it promotes contraction of antral circular strips by
activating muscarinic M3 receptors.
34
Acupuncture may help
regulate the gastrointestinal tract via the autonomic nervous
system,
35,36
and acupuncture at the tsusanli acupoint, located on
the stomach meridian, is thought to regulate the intestines.
Administering vitamin B1 at acupoints is thought to intensify
and prolong acupoint stimulation synergistically. This may help
explain why we found that SMD with tsusanli acupoint injection
with vitamin B1 promoted gastrointestinal hypomotility to a
greater extent than chewing gum. The ability of tsusanli acu-
point injection to reduce incidence of postoperative ileus has
been demonstrated in numerous studies.
10,23,36
We extend these
findings to the combination of SMD with tsusanli acupoint
injection.
In our population, SMD with acupuncture reduced hospital
stay duration by 2.5 d, which was significant, while chewing
gum reduced it by 1.8 d, which was not significant. It is possible
that the effects of chewing gum would become significant with
a larger sample. These results have several possible expla-
nations. One is that either chewing gum or the combination
of SMD with acupuncture stimulates gastrointestinal motility,
leading to shorter time to first peristalsis, flatus, and defecation.
Such patients will more quickly achieve euphagia without
vomiting and start to ambulate. Another possible explanation
is that the lower incidence of grade I and II postoperative
complications in the 2 intervention groups translated to shorter
hospital stay.
The results of the present study should be interpreted with
caution given several limitations. One is that length of stay
within each group was calculated over patients undergoing
minor and major hepatectomies, which may have confounded
the analysis. Nevertheless the frequencies of hepatectomy type
were similar among the groups. A second limitation is lack of
blinding, which was not feasible because of the nature of the
interventions. A third limitation is that patients within each
group differed in whether they received opioid analgesia,
which may have confounded our analysis. Nevertheless,
the frequencies of these treatments were similar among the
groups.
In conclusion, the present study suggests that acupuncture,
SMD, and chewing gum can be safely administered in a post-
operative setting to HCC patients after hepatectomy. This is
consistent with previous studies.
10,17,21,23,36
Our data also
suggest that gum chewing or the combination of SMD with
acupuncture can prevent postoperative ileus in these patients,
and that at least SMD with acupuncture significantly shortens
hospital stay. Future studies should examine whether chewing
gum or SMD with acupuncture can treat postoperative ileus
after it has already developed.
ACKNOWLEDGMENT
The authors thank A. Chapin Rodrı
´guez, PhD, for his
language editing, which substantially improved the quality of
the article.
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TABLE 3. Clavien – Dindo Classification of Postresection Complications in Patients With Hepatocellular Carcinoma Treated With
Simo Decoction þAcupuncture, Chewing Gum, or No Intervention
Variable
Simo Decoction þ
Acupuncture (n ¼55)
Chewing Gum
(n ¼53)
No Intervention
(n ¼54) P
No complications 21 (38) 18 (34) 2 (4) <0.001

I: deviation from normal postoperative course 19 (35) 23 (43) 31 (57) 0.055

II: complications requiring pharmacological treatment 6 (11) 7 (13) 13 (24) 0.146
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y
Fisher exact test.
Medicine Volume 94, Number 45, November 2015 SMD or Chewing Gum on POI
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |5

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You et al Medicine Volume 94, Number 45, November 2015
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