Improving surgical outcomes with perioperative acupuncture

Photo Cred: Thirdman/Pexels

By Bill Reddy, LAc, DiplAc

Surgical interventions can be viewed as controlled car accidents, depending on what tissues and structures are involved.  Both entail somatic and visceral trauma, and result in acute pain from tissue and nerve inflammation and irritation. Opioids are commonly used to manage postoperative pain, but there are several side effects that patients prefer to avoid, including constipation, dizziness, urinary retention, and pruritis. Although acupuncture is well known for its analgesic effects, it can also be used to safely reduce preoperative anxiety as well as post-surgical ileus and nausea/vomiting.  It’s not unusual to use acupuncture analgesia during surgical procedures in China, including open heart surgery, which reduces the amount of anesthesia medications, but we’re only going to cover the benefits of acupuncture treatment before and after surgery.

Let’s begin with preoperative applications. Up to 80 percent of adults experience preoperative anxiety, especially before high-risk procedures. Studies demonstrate that acupuncture is at least effective as benzodiazepines in treating preoperative anxiety without the sedative effects of the drugs. In a 2001 study, researchers enrolled 175 patients scheduled for major abdominal surgery and randomly assigned them to a group with an epidural catheter in combination with real or sham acupuncture.  “Sham” acupuncture, or placebo acupuncture, is where the researchers insert needles in non-acupuncture points, or use a prop that simulates a needle taped in place without penetrating the skin. The patients who received real acupuncture required 50 percent less morphine and reported significantly less post-op pain as well as 20 to 30 percent lower rates of vomiting and nausea. The researchers also measured plasma concentrations of cortisol and adrenalin in addition to biomarkers for stress which were all lower in the acupuncture group. 

Regarding post-surgical interventions, a meta-analysis published in September 2021 evaluated acupuncture treatment after total knee replacement surgery.  The authors found that acupuncture had a statistically significant impact on pain relief and use of analgesic medications in postoperative patients. The studies, involving a total of 891 participants, included ear acupressure, ear acupuncture, needle acupuncture and electroacupuncture. Similar positive results were found in patients undergoing arthroscopic shoulder surgery, where the patients also reported improved sleep quality compared with the control group.  

Interestingly, electroacupuncture analgesia is mediated by different opioid peptides depending on the frequency used. Low level laser acupuncture can also be applied with promising results without the skin being penetrated. In a study of 82 patients undergoing total knee replacement surgeries, researchers split them into two groups, one that received laser acupuncture and the other receiving the same treatment procedure without laser energy output. Not surprisingly, those who received the real laser acupuncture treatment had reduced post-op pain and morphine consumption within the first 72 hours after surgery (including reduced morphine-induced nausea and vomiting) in addition to exhibiting less pain interference with general activities, walking, and working. 

Perioperative acupuncture has been shown to improve the recovery of bowel peristaltic function and reduce the time to first bowel movement and flatus in colorectal surgeries.  One of the issues related to acupuncture treatment during surgery is access to the proper acupuncture points (there are 361 to choose from both front and back).  If the patient is supine, accessing segmental paravertebral points is out of the question, however two common points used to reduce pain in abdominal surgery are Hegu (LI 4 on the hand) and Zusanli (ST 36 on the lower leg), so proper choices can be made for optimal treatment and analgesic outcomes.

Despite the significant number of high-quality randomized controlled trials related to the use of perioperative acupuncture, it has yet to be adopted into mainstream surgical protocols. In 2008, a study was performed at a Norwegian hospital using acupuncture to reduce the incidence of nausea and vomiting in pediatric tonsillectomies and/or adenoidectomies. The research team found that the acupuncture intervention didn’t delay the surgical procedure or require any additional anesthesia time, and that the children experienced a reduction in vomiting and retching from 66 percent to 47 percent.  Even though the evidence was positive, the hospital didn’t introduce acupuncture as standard care.  A concerted effort by the acupuncture community to bridge the gap from test tube to treatment table is necessary for safe and effective analgesia to be applied perioperatively.

References

Han, J. (1984). High and low frequency electroacupuncture analgesia are mediated by different opioid peptides. Pain. Retrieved from: https://journals.lww.com/pain/Citation/1984/01001/High_and_low_frequency_electroacupuncture.543.aspx

Huang, C.H., Yeh, M.L., Chen, F.P., and Wu, D. (2022) Low-level laser acupuncture reduces postoperative pain and morphine consumption in older patients with total knee arthroplasty: A randomized placebo-controlled trial. Journal of Integrative Medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/35459599/

Karst, M., Winterhalter, M., Münte, S., et al. (2007) Auricular acupuncture for dental anxiety: a randomized controlled trial. Anesthesia & Analgesia. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/17242083/

Ko, H.F., Chen, C.H., Dong, K.R., and Wu, H.C. (2021) Effects of Acupuncture on Postoperative Pain After Total Knee Replacement: Systematic Literature Review and Meta-Analysis. Pain Med. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/34152398/

Kotani, N., Hashimoto, H., Sato, Y., et al. (2001) Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/11506105/

Norheim, A.J., Liodden, I., and Howley, M. (2010) Implementation of acupuncture and acupressure under surgical procedures in children: a pilot study. Acupuncture in Medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/20458123/

Lewis, G.B.H. and Litt, M. (1987) An alternative approach to premedication: comparing diazepam with auriculotherapy and a relaxation method. American Journal of Acupuncture. Retrieved from: https://www.mdpi.com/2305-6320/7/12/73

Ward, U. and Nilsson, U.G. (2012) Acupuncture for postoperative pain in day surgery patients undergoing arthroscopic shoulder surgery. Clinical Nursing Research. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22843248/

Zemła, A.J., Nowicka-Sauer, K., Jarmoszewicz, K., Wera, K., Batkiewicz, S., and Pietrzykowska, M. (2019) Measures of preoperative anxiety. Anaesthesiology Intensive Therapy. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31280554/

Zhang, Z. et al. (2014) Electroacupuncture at Zusanli accelerates the recovery of gastrointestinal motility after colorectal surgery: a randomised controlled trial. Acupuncture in Medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/24739815/

Zhou, J., Chi, H., Cheng, T.O., Chen, T.Y., Wu, Y.Y., and Zhou, W.X., et al. (2011)   Acupuncture anesthesia for open heart surgery in contemporary China. International Journal of Cardiology. Retrieved from: https://www.sciencedirect.com/science/article/abs/pii/S0167527311003494