Abstract
Background
Patients with severe gastric dysmotility disorder (SGDD) often require parenteral nutrition or jejunostomy feeding. They frequently need long-life gastrostomy drainage tubes for gastric discharge and decompression. Currently few medical options exist for postoperative management. We were recently surprised by the beneficial effect of acupuncture in a case of SGDD, which we present herein.
Case Presentation
The case involved a 68-y-old male who presented with a diagnosis of malignant pancreatic neoplasm for which he had a recent Whipple procedure. He had persistent nausea and vomiting, postoperative abscesses, and high nasogastric tube output. He was assessed to have SGDD, which required discharge on home total parenteral nutrition (TPN) and gastrostomy drainage. Manual acupuncture at the stomach meridian (ST-36) was performed on postdischarge, day 30. His stomach capacity returned to normal, and he eventually returned to a regular diet consistency and volume. His weight and nutritional parameters remained stable and he was weaned off TPN soon after.
Conclusion
Acupuncture of the appropriate stomach meridian may be an important modality for patients with SGDD. This case demonstrates the benefits of considering integrative approach in treatment of gastrointestinal conditions.
Introduction
Pancreatic cancer is one of the leading causes of cancer deaths due to its rapid spread and difficulty in detection at an early stage due to vague symptoms. The Whipple procedure, also called a pancreaticoduodenectomy, is generally the common surgical approach for the removal of the gallbladder, common bile duct, part of the duodenum, part of small intestine, the surrounding lymph nodes, and the head of the pancreas. The remaining stomach, bile duct, and pancreas are then joined to the small intestine so that digestive enzymes can blend with food. The procedure is of high complexity. At the initiation of pancreatic surgery by Dr Whipple in the 1930s, the mortality and morbidity risk was more than 20%. This risk has decreased to less than 5% thanks to advancement of technology. In addition, more patients are candidates for such surgery because age and chronic illnesses are no longer a contraindication to surgical treatment.1
Clinical Findings
This 68-year-old patient presented with a new diagnosis of pancreatic cancer with near organ involvement. He was admitted to the hospital from the surgeon’s office with symptoms of epigastric pain that radiated toward the back, abdominal distention, vomiting, and jaundice. The patient was initially empirically treated with a proton pump inhibitor, showing marginal improvement.
Review of Systems
His main symptoms included inability to tolerate food during the last 3 months, rapid weight loss, nausea and vomiting, early satiety, pain with eating, and slight jaundice. He felt fatigued and had declining physical status.
Medical, Family, and Psychosocial History
No significant medical history was noted. He had been overall healthy, managed a normal body mass index, was married, and was self-employed. He had no history of smoking or alcohol use. The family history was negative for gastrointestinal (GI) malignancy.
Physical Examination
Physical examination showed mild epigastric tenderness and mild jaundice.
Laboratory Tests
Bilirubin and liver enzymes were elevated, blood counts revealed anemia, and hepatitis B and C were negative.
Computed Tomography
Computed tomography revealed a 2.5 cm × 1.9 cm mass in the head section of the pancreas with the obstruction of the bile duct and multiple small low-density lesions scattered throughout the liver.
Diagnosis
Stage IV pancreatic cancer was considered to be resectable.
Therapeutic Intervention
The patient was deemed to be a candidate for surgery and underwent a Whipple procedure during same admission.
Follow-up Outcomes
His postoperative period was remarkable for inability to eat. He was started on clear liquid diet, which he did not tolerate. A nasogastric tube was inserted to decompress the stomach and he was started on peripheral parenteral nutrition and then total (central) parenteral nutrition (TPN).
Intervention Adherence and Tolerability
He tolerated the parenteral nutrition and its volume but the output from a nasogastric tube remained high, resulting in high volume needs, which in turn compromised his breathing status at times.
Adverse and Unanticipated Events
The patient underwent unsuccessful multiple stent placements and dilatations and ultimately received a gastrostomy tube for stomach drainage. After a long hospital stay, he was discharged home with nothing by mouth (NPO) status, on TPN via peripherally inserted central catheter line and gastrostomy for drainage.
Postoperative Period
He had gastric fluid outputs of approximately 2000 mL/d in the hospital, which persisted after discharge. He followed on the outpatient office systematically for close follow up but with no changes in management. Manual acupuncture at the stomach meridian (ST-36) was performed on postdischarge, day 30, per his daughter’s recommendation. The following day, daily gastrostomy drainage declined from 2000 mL to <100 mL. Later that same day, had his first postdischarge bowel movement and began a liquid diet. TPN volume was decreased as he advanced the diet and increased the intake. TPN was stopped a few weeks after the acupuncture treatment.
Discussion
We were surprised by the rapid benefit of acupuncture on this patient’s SGDD. Traditional methods including gastric motility agents and surgery had failed. Evidence exists that acupuncture may involve excitation of the vagus nerve, serotonergic pathways, opioidergic pathways, and spinal or supra-spinal reflexes.2 Acupuncture is used for different diseases of the GI track such as antiemesis, peptic ulcer disease, nonulcer dyspepsia, esophageal disease, pancreatic diseases, acute appendicitis irritable bowel disease, postop GI dysmotility, constipation, irritable bowel syndrome, and diarrhea.3 There are more than 300 acupuncture points and selections points that affect the GI track that are done based on the different practice styles.3 This is a new approach and promising for postoperative care and should be considered in cases such as this one. The strengths and limitations of the study are as follows: The case study was the first one to report on such outcomes. More case studies are needed to assess the efficacy of the method.
Biographies
Eleni Pellazgu, PhDc, MSN, APN, FNP-C, is a nurse practitioner in the Department of Medicine, Morristown Medical Center in Morristown, New Jersey.
Michael M Rothkopf, MD, FACP, is a doctor in the Department of Medicine, Morristown Medical Center.
Footnotes
Author Disclosure Statement
The authors have no ethical considerations to disclose. Informed consent was obtained from the patient. The authors declare no conflicts of interest related to this study.
References
- 1.Tan-Tam C, Segedi M, Chung S. Whipple procedure: Patient selection and special considerations. Open Access Surg. 2016;1(1):51-63. [Google Scholar]
- 2.Kim KH, Kim TH, Choi JY, Kim JI, Lee MS, Choi SM. Acupuncture for symptomatic relief of gastroparesis in a diabetic hemodialysis patient. Acupunct Med. 2010;28(2):101-103. [DOI] [PubMed] [Google Scholar]
- 3.Diehl DL. Acupuncture for gastrointestinal and hepatobiliary disorders. J Altern Complement Med. 1999;5(1):27-45. [DOI] [PubMed] [Google Scholar]