acupuncture decreases post-op ileus

 An interesting recently published Chinese study found that electroacupuncture decreased postoperative ileus after laparoscopic surgery for colorectal cancer, decreasing time to several important patient outcome measures (see acupuncture for postop surgery JAMAsurg2022 in dropbox, or doi:10.1001/jamasurg.2022.5674)

 

Details:

-- 248 patients randomized in 4 tertiary hospitals in China to acupuncture vs sham acupuncture treatment after laparoscopic surgery for colorectal cancer, from 2020-2021

    -- patients were all adults who were getting first time laparoscopic resection of colorectal cancer with a primary anastomosis

-- mean age 60, 62% male, BMI 24, current smoker 25%, diabetes 14%,

-- operation: left hemicolectomy 23%, right hemicolectomy 23%, rectal resection 41%, sigmoid resection 14%

-- tumor stage: 0-1 in 10%, II in 50%, III in 36%, and IV in 5% (85% of the tumors were moderately differentiated)

-- duration of surgery 3.0 hours, intraoperative blood loss 50 ml

-- patients received either electroacupuncture (EA) versus sham electroacupuncture (SA) by a licensed acupuncturist with 5 to 12 years of acupuncture education and at least 3 years of clinical training. Patients received 30-minute acupuncture sessions once a day for 4 consecutive days after surgery

    -- the EA group had acupuncture at 4 documented acupoints with a real electrical current titrated to trigger slight vibration of the needle handles; the SA group had minimally invasive acupuncture at 4 non-acupoints, electrodes were attached but without electric current

-- all patients were similarly treated by the Enhanced Recovery After Surgery (ERAS) protocol, see below

 

-- primary outcome: time to first defecation

-- secondary outcome: patient-reported outcome measures, length of postoperative hospital stay, readmission rate within 30 days, and incidence of postoperative complications and adverse events

 

Results:

-- median time to first defecation, in hours, with inter-quartile range (IQR) in parentheses:

    -- EA group: 76.4 (IQR 67.6-96.8)

    -- SA group: 90.0 (IQR 73.6-100.3)

        -- mean difference -8.76 hours (confidence intervals -15.80 to -1.73), p=0.003

-- secondary outcomes, comparing EA versus SA groups:

    -- time to first flatus (with bowel sounds): median 44.3 (IQR 37.0-58.2) hours versus 58.9 (IQR 48.2-67.4) hours, p<0.001

    -- tolerability of semiliquid diet: median 105.8 (IQR 87.0-120.3) hours versus 116.5 (IQR 92.0-137.0) hours, p=0.01

    -- tolerability of solid food: median 181.8 (IQR 149.5- 211.4) hours versus 190.3 (IQR 165.0- 228.5) hours, p=0.01

 

-- prolonged postoperative ileus:

    -- EA group: 13 of 125 patients (10%)

    -- SA group: 25 of 123 patients (20%), risk ratio 0.51 (0.27 0.95), p=0.03

 

-- the other secondary outcomes did not have statistically significant differences, and also no difference in median time to first ambulation, mean length of postop hospital stay, readmission within 30 days, or based on those patients who guessed correctly that they received real acupuncture (patients pretrial expectations of electroacupuncture benefit in the SA group were actually lower than in the EA group)

 

-- serious adverse events: zero  

 

Commentary: 

-- there was an important international consensus document on optimal perioperative care for colorectal surgery, referred to as Enhanced Recovery After Surgery (ERAS), which outlined the evidence in detail for interventions that would likely facilitate postoperative recovery (see surgery consensus for enhanced recovery ArchSurg2009 in dropbox, or Arch Surg. 2009;144(10):961-969).

 

-- this current study provided pretty strong evidence that electroacupuncture was associated with impressive shortening of many of the main problems in post-op recovery and preventing prolonged post-op ileus, when the acupuncture was applied to appropriate acupuncture sites with electrical stimulation to achieve slight vibration.

-- one possible mechanism for electroacupuncture is that it seems to reduce local intestinal musculature inflammation in those who have post-operative ileus (and post-op ileus is associated with an inflammatory response from the surgical trauma/gut manipulation). Another study by these authors found this anti-inflammatory effect was mediated through excitation of the vagal nerve

 

-- there have been several studies that have documented benefit from electroacupuncture for many different types of surgery including pancreatectomy or gastrectomy. The benefit in this study was less impressive, perhaps for a few reasons:

    -- this study implemented the full set of ERAS, not so in some of the other studies. So the intervention of electroacupuncture benefit may be diminished by having some of the other beneficial aspects implemented. For example, other studies have found that acupuncture decreased nausea and vomiting. In this study with ERAS, there was no difference, suggesting that the ERAS protocol may have benefitted this important outcome; and there were similar findings with post-op pain or abdominal distension (both also had no difference in the above study)

    --there might be a small benefit to having needles put superficially in the SA group; and there could be a nocebo effect in those in the EA group (since those in the EA group had lower expectation that  the acupuncture would work); both of these possibilities would diminish the difference between groups

-- as an aside, another recent article documenting benefit from acupuncture: men having moderate to severe chronic prostatitis/chronic pelvic pain syndrome had significant benefit of 20 sessions of acupuncture vs sham acupuncture. and this benefit was durable when assessed 24 weeks after treatment (see  acupuncture helps chronic prostatitis chronic pelvic pain in men AIM2021 in dropbox, or doi:10.7326/M21-1814)

 

Limitations:

-- electroacupuncture requires specialized training (and in this study, 5-12 years of study and 3 of clinical practice). And it might be hard to find sufficient well-trained acupuncturists in other countries to replicate this study (it is easier to just give a pill, but that has its own issues, and of course those pesky issues of acupuncture coverage by insurances). Of note, this study in China was multicenter, which suggests that the results are translatable to other locations having acupuncturists with similar backgrounds/skills

-- given that there was a difference in electrical stimulation in the EA versus SA groups, and the EA group of patients may have felt some “slight vibration”, it is conceivable that there was a placebo effect here which was not acknowledged by patients. however, it was notable that there was no difference between the groups in which patients perceived that they had actual acupuncture, and those in the EA group had a lower expectation of benefit.

-- all of these patients had laparoscopic surgery for colon cancer.  ??generalizable to open surgery  ??generalizable to other conditions or surgeries. their outcomes were specific to post-op ileus and its sequelae

-- as mentioned above, sham acupuncture can possibly be associated with physiologic changes. so sham acupuncture is not necessarily a true "placebo"

 

So, one important goal in hospitalized patients, whether surgical or medical, is to minimize hospital stay. Longer hospital stays are associated with higher risks of nosocomial infections, delirium/disorientation (especially in older adults), stress on the patient and family, deconditioning (which happens remarkably quickly in geriatric patients, within a few days) etc. So, though electroacupuncture should be tested in other sites, it appears to be a safe and effective way to improve post-op outcomes, at least for those receiving laparoscopic abdominal surgery that is likely to create an ileus. And there does not seem to be any downside....

geoff

 

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