Abstract
Background:
Acupuncture therapy is gaining prevalence in the perioperative treatment of postoperative nausea and vomiting (PONV). Furthermore, PONV prophylaxis is recommended by enhanced recovery after surgery (ERAS) guidelines. The study investigated the efficacy of acupuncture in reducing PONV in patients undergoing colorectal surgery with the ERAS program.
Methods:
We conducted a case-control study in patients, who underwent colorectal surgery between January 2022 and March 2024. All of them were enrolled in the ERAS program and they were divided into two study groups: Group 1, was composed of patients who received acupuncture as additional PONV prophylaxis. Group 2, were patients who received only pharmacologic PONV prophylaxis. Patients were matched based on gender, American Society of Anesthesia Physical Status (ASA-PS) score, surgical approach, and age (±5 years).
Results:
Forty-four patients in each study group were enrolled. No differences in terms of surgical approach and duration of surgery were observed (respectively, P = 0.53, 0.96). Furthermore, no significant differences between the groups regarding postoperative pain (post-anesthesia care unit admission and at 24 hours after surgery, respectively, P = 0.67, 0,82), opioid consumption as rescue (P = 0.80), and length of stay (P = 0.33) were observed. Group 1 experienced a lower incidence of vomiting (P < 0.03).
Discussion:
Current literature reports very low quality and inconclusive results on the efficacy of acupoint stimulation in addition to antiemetic drugs. The study shows that acupuncture as an additional prophylaxis therapy effectively reduces vomiting incidence in patients undergoing colorectal surgery with the ERAS program. This result may implement the use of acupuncture therapy into perioperative care practice.
Keywords: Colorectal surgery, PONV, traditional Chinese medicine
Background
Traditional Chinese medicine (TCM) has been used in various surgical settings demonstrating efficacy in mitigating pain and improving outcomes related to postoperative nausea and vomiting (PONV).[1] According to TCM, acupoints are the specific parts of the meridians where qi and blood gather, and come in and out of the body surface and may be influenced by acupuncture.[2] In particular, acupuncture therapy is experiencing increasing adoption for both the prevention and perioperative treatment of PONV. This is particularly pertinent given that PONV can precipitate adverse sequelae such as dehydration, electrolyte imbalance, delayed discharge, and patient discomfort, with reported incidences reaching up to 80% in high-risk populations in the absence of antiemetic prophylaxis.[3] The vomiting effect could be particularly relevant in enhanced recovery after surgery (ERAS) colorectal procedures, which provide early postoperative oral intake and mobilization.[4] However, the application of acupuncture in the ERAS context still has some problems, such as a lack of overall consideration and insufficient standardization.[1,4] Therefore, we tested the role of acupuncture therapy in reducing PONV in patients undergoing colorectal surgery with the ERAS program.
Methods
The authors confirm that the study was conducted following the ethical principles of the Declaration of Helsinki. In addition, informed consent has been obtained from the participants involved in the case-control study. Patients who underwent colorectal surgery with the ERAS program between January 2022 and March 2024 in our hospital were considered.[3] Patients were divided into two groups:
Group 1, composed of patients who received acupuncture as additional PONV prophylaxis therapy, and Group 2, (control), composed of patients, who did not receive TCM (acupuncture) but only pharmacological PONV prophylaxis.
The control group was enrolled using a matching scheme 1:1. For each patient of group 1, one control patient matched for gender, American Society of Anesthesia Physical Status (ASA-PS) score, type of surgery, and age (using a ±5 years criterion) was selected. Incomplete clinical data were considered as exclusion criteria. In both study groups ERAS program was applied according to the hospital protocol.[5] In all patients, the use of antiemetic drugs (5-HT3 receptor antagonists, corticosteroids, butyrophenones), based on overall risk as guided by the Apfel score for multimodal PONV prophylaxis, was administered.[3] In group 1, in addition to the acupuncture point (PC6), stimulation of other acupoints (SP4, ST36, CV12, Yintang, CV17, Ht 7) was also performed immediately before surgery. Postoperatively, since PACU admission of the patients, the stimulation of acupuncture points (shen men, tranquillizer point, sympathetic, stomach, esophageal sphincter, and vomit reflex) is achieved by semipermanent needles and patients were encouraged to self-stimulation. This practice was also affected in the ward up to 48 hours after surgery. Exclusion criteria included incomplete clinical data (e.g., age, type of surgery, ASA-PS score, medications administered, clinical parameters recorded every 6 hours postoperatively), patients with ASA score 4, emergency surgeries, patients that refuse the procedure, those with psychiatric or neurological conditions (e.g., dementia) that impair basic functional autonomy, and patients who required postoperative intensive care admission. Postoperative complications were classified according to the Clavier-Dindo classification.[6] During the period of the study, the anesthetic technique was chosen by the anesthesiologist on the day of surgery and included either total intravenous anesthesia (TIVA) or balanced anesthesia. All patients in both groups were admitted to the post-operative care unit (PACU), where early mobilization and oral intake were started.[7]
Statistical analysis
Data were expressed as mean ± standard deviation for parametric variables and as counts (percentage) for categorical variables. Comparison between the two groups was performed using Student’s t-test for continuous parametric variables and the Mann-Whitney U test for non-parametric variables. The Pearson’s chi-square test or the exact Fisher test was used when appropriate for categorical variables; a P-value of < 0.05 was considered for statistical significance. All tests were two-tailed. All analyses were conducted using SPSS (Statistical Package for the Social Sciences), version 24.0 (SPSS Inc, Chicago, IL).
Results
In the study 44 patients for each group were enrolled. The descriptive characteristics and the postoperative data of the two study groups are shown in Table 1. In both groups, two patients (4,5%) were ASA 1, 34 (77%) ASA 2, 8 (18,1%) ASA 3, while 18 (40,9%) patients underwent the right hemicolectomy, 14 (31,8%) the left hemicolectomy, and 12 (27,2%) anterior resections of rectum. In both Groups, no significant difference in adherence to all perioperative items was recorded with an incidence greater than 80%. Specifically, 100% adherence was registered for thromboprophylaxis, preoperative maltodextrin intake, and clear liquid consumption up to two hours before surgery. Furthermore, there were no significant differences between the groups regarding the number of regional analgesia techniques performed before general anesthesia (11 [22%] in Group 1 vs. 10 [20%] in Group 2; P = 0.80). Details concerning incidence of PONV, postoperative pain, opioid consumption and length of stay are summarized in Table 1.
Table 1.
Demographic characteristics, surgical procedures, and postoperative outcome data
| Group 1 (n=44) | Group 2 (n=44) | P | |
|---|---|---|---|
| Age (aa±ds) | 67.7±10.5 | 69.0±10.5 | 0.57 |
| BMI (value±ds) | 26.8±8.0 | 25.4±4.4 | 0.28 |
| Duration of surgery (min) | 210.9±65.8 | 211.6±69.2 | 0.96 |
| Surgical approach n° (%) | 0.53 | ||
| laparoscopic | 41 (93%) | 42 (95.5%) | |
| laparotomic | 5 (11%) | 2 (4.5%) | |
| Reintervention n° (%) | 5 (11%) | 3 (6.8%) | 0.46 |
| LOS (days±ds) | 6.9±7.0 | 5.8±3.1 | 0.33 |
| NRS±ds | |||
| 12 hours | 0.8±1.0 | 0.7±1.0 | 0.67 |
| 24 hours | 1.0±0.8 | 1.2±1.0 | 0.82 |
| Opioids consumption as rescue n° (%) | 10 (22.7%) | 11 (25%) | 0.80 |
| PONV n° (%) | |||
| Drug prophylaxys (according Apfel score) | 44 (100%) | 44 (100%) | --- |
| Nausea | 15 (34.1%) | 20 (45.45%) | 0.27 |
| Vomit | 7 (15.9%) | 16 (36.3%) | 0.03* |
Data are expressed as mean±standard deviation or number (percentage). Normally distributed data were compared by Student’s t-test. Categorical variables were compared using the χ2 test. *P<0.05. Ds: standard deviation, BMI: body mass index, LOS: length of stay, NRS: Numeric Rating Scale, PONV: postoperative nausea and vomiting
Discussion
The case-control study shows that the application of TCM with acupuncture therapy as additional prophylaxis therapy effectively reduces vomiting incidence in patients undergoing colorectal surgery with the ERAS program. Although current literature reports numerous studies regarding the use of TCM in the perioperative period, the evidence on the efficacy of acupoint stimulation in addition to antiemetic drugs compared to antiemetic drugs alone was of very low quality and inconclusive.[8] Furthermore, the mechanism of TCM in treating PONV is still unclear and may be related to the imbalance of gastrointestinal hormone secretion.[9,10] Indeed, acupuncture therapy could have a good effect on regulating motilin and serum gastrin levels, or through its influence on the vagus nerve.[11] Notably, in the study, the lower vomit incidence did not impact the postoperative ERAS elements, as well as early oral intake or mobilization in terms of better adherence. Although this may be explained considering the relative size of the sample, this issue remains to be clarified. However, postoperative vomiting represents an important cause of patient discomfort.[3,11] In this context, patient perioperative course perception represents an important aim in the modern approach to surgery. As things stand today, any healthcare system can no longer disregard the patient’s perceived quality of hospitalization.[12] In this sense, the result of the study as well as the application of acupuncture in the perioperative period go in this modern vision. However, there is still a need to assess the benefits of various acupoints in addition to PC6 and of electrical acupoint stimulation, also with wearable devices.[13]
Nonetheless, the study presents certain limitations, including its retrospective, single-center design, and the enrolment procedures typical of case-control studies.
In conclusion, although more robust studies are needed, the application of acupuncture in patients undergoing colorectal surgery with an ERAS program reduces postoperative vomiting. The study results may represent a small step toward integrating acupuncture into perioperative care practice.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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