Effectiveness of acupuncture in postoperative ileus: a ... · postoperative pain, nausea, vomiting, delay in resum-ing enteral nutrition, and prolonged hospitalization. Other postoperative

TOPIC

JTCM |www. journaltcm. com June 15, 2016 |Volume 36 | Issue 3 |

Online Submissions: http://www.journaltcm.com J Tradit Chin Med 2016 June 15; 36(3): [email protected] ISSN 0255-2922

SYSTEMATIC REVIEW

Effectiveness of acupuncture in postoperative ileus: a systematic re-view and Meta-analysis

Cheong Kah Bik, Zhang Jiping, Huang Yongaa

Cheong Kah Bik, School of Traditional Chinese Medicine,Southern Medical University, Guangzhou 510515, ChinaZhang Jiping, Huang Yong, School of Traditional ChineseMedicine, Southern Medical University, Guangzhou 510515,ChinaSupported by The Committee of Development and Reform,Guangdong Province, [2009] 431, the 3rd-stage "211 proj-ect" key subject construction project of Guangdong Prov-ince, Integrative Chinese and Western Medicine for the treat-ment of difficult and complicated diseasesCorrespondence to: Prof. Huang Yong, School of Tradition-al Chinese Medicine, Southern Medical University, Guang-zhou 510515, China. [email protected]: +86-20-61648771; +86-20-61648254Accepted: July 6, 2015

AbstractOBJECTIVE: To conduct a systematic review andMeta-analysis of the effectiveness of acupunctureand common acupoint selection for postoperativeileus (POI).

METHODS: Randomized controlled trials (RCTs)comparing acupuncture and non-acupuncturetreatment were identified from the databasesPubMed, Cochrane, EBSCO (Academic Source Pre-mier and MEDLINE), Ovid (including Evidence-Based Medicine Reviews), China National Knowl-edge Infrastructure, and Wanfang Data. The datafrom eligible studies were extracted and a Me-ta-analysis performed using a fixed-effects model.Results were expressed as relative risk (RR) for di-chotomous data, and 95% CI (confidence intervals)were calculated. Each trial was evaluated using theCONSORT (Consolidated Standards of Reporting Tri-als) and STRICTA (STandards for Reporting Interven-tions in Controlled Trials of Acupuncture) guide-

lines. The quality of the study was assessed usingthe Grading of Recommendations, Assessment, De-velopment and Evaluation (GRADE) approach.

RESULTS: Of the 69 studies screened, eight RCTswere included for review. Among these, four RCTs(with a total of 123 patients in the interventiongroups and 124 patients in the control groups) metthe criteria for Meta-analysis. The Meta-analysis re-sults indicated that acupuncture combined withusual care showed a significantly higher total effec-tive rate than the control condition (usual care) (RR1.09, 95% CI 1.01, 1.18; P = 0.02). Zusanli (ST 36) andShangjuxu (ST 37) were the most common acu-points selected. However, the quality of the studieswas generally low, as they did not emphasize theuse of blinding.

CONCLUSION: The results suggested that acupunc-ture might be effective in improving POI; however,a definite conclusion could not be drawn becauseof the low quality of trials. Further large-scale,high-quality randomized clinical trials are neededto validate these findings and to develop a stan-dardized method of treatment. We hope that thepresent results will lead to improved research, re-sulting in better patient care worldwide.

© 2016 JTCM. All rights reserved.

Key words: Gastrointestinal diseases; Postopera-tive complications; Ileus; Acupuncture; Point ST 36(Zusanli); Point ST 37 (Shangjuxu); Review; Me-ta-analysis

INTRODUCTIONPostoperative ileus (POI), also known as postoperative

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Cheong KB et al. / Systematic Review

June 15, 2016 |Volume 36 | Issue 3 |


functional gastrointestinal disorder or enteroplegia, is afrequent condition after surgery. Ileus is the absence ofintestinal peristalsis without mechanical obstruction.1

POI refers to the time post-surgery before coordinatedelectromotor bowel function resumes.1 It is generallydefined as transient inhibition of normal gastrointesti-nal motility and typically lasts 3-5 days post-surgery.2

POI can selectively affect the stomach, small intestine,or colon; each type is characterized by differentmechanisms and clinical presentations and is manageddifferently.1

The small bowel normally resumes activity severalhours post-surgery, the stomach 24-48 h post-surgery,and the colon 3-5 days post-surgery.1 After abdominalsurgery, multiple reasons may cause functional gastroin-testinal disorders, which disturb the recovery of the pa-tients and it usually takes 2-4 days to heal.3 POI thatpersists longer than this can be considered pathologicand is sometimes called paralytic ileus.1

The clinical consequences of POI include worsenedpostoperative pain, nausea, vomiting, delay in resum-ing enteral nutrition, and prolonged hospitalization.Other postoperative complications include decon-ditioning, malnutrition, increased risk of nosocomialinfections, and pulmonary complications.2 Prolongedhospital stays increase the risk of hospital-acquired in-fections, deep vein thrombosis, and other conditions.1

The mean length of hospital stay for patients with POIis 9.3 days; for patients without POI is 5.3 days.1 Theeconomic burden of the disorder is considerable.1

Neural and chemical factors may cause POI. Impor-tant risk factors are a sympathetic-parasympathetic im-balance, chemical mediators (e.g., nitric oxide), vasoac-tive intestinal peptide, substance P, calcitonin gene-re-lated peptide, endogenous opioids, inflammation, andnarcotic analgesics.1 Opiates delay colonic transit inpostoperative patients.1 Nonsteroidal anti-inflammato-ry drugs such as ketorolac (Toradol) possess anti-in-flammatory and opiate-sparing properties, but cancause bleeding, renal insufficiency, and gastritis.1

Strategies for POI prevention and management includesurgical techniques, supportive care, patient-initiatedactivities, and pharmacologic interventions.1 Epiduralanesthesia shortens ileus and reduces the need for nar-cotics.1 Thoracic epidural analgesia effectively blockssympathetic pathways, hastens the return of bowelfunction by 1-2 days, and reduces the need for opiatescompared with systemic opioids alone.1

Laparoscopic surgery is less traumatic than open sur-gery and results in a less vigorous systemic inflammato-ry response, as measured by interleukin-1, -6, and C-re-active protein circulating levels.1 The length of stay andthe duration of POI are also shorter.1 Prokinetic agentshave been evaluated with mainly disappointing results.2

Metoclopramide failed to improve postoperative bowelmotility in several randomized trials.2 Cisaprideshowed promise in some prospective trials but waswithdrawn from the US market because of cardiovascu-

lar side effects.2 Erythromycin was ineffective in short-ening POI in two prospective trials.2 Domperidone hasnot been evaluated in a postoperative setting and is notcurrently available in the United States of America.2

Laxatives are a potential agent in the management ofPOI but larger, randomized trials need to be per-formed before their routine use in postoperative care.2

A recent small study showed that cyclooxygenase(COX)-2-selective inhibitors are effective in reducing il-eus and may decrease the risk of bleeding associatedwith nonselective COX inhibitors.2 However, a stan-dardized treatment with minimal side effects stillawaits further trials.2

Acupuncture is widely accepted in China as well asthroughout the world as an effective treatment optionfor the management of postoperative nausea and vomit-ing, and various functional gastrointestinal disorders.4-6

However, its role in treating POI is less clear and datafrom the Chinese and Western literature are scarce.4

Acupoint injection, auricular acupressure, abdominalacupuncture, electroacupuncture, and catgut embed-ment have been used to treat gastrointestinal disor-ders.7 Common acupoints selected include single acu-points of Zusanli (ST 36) and Tianshu (ST 25); thelower confluent acupoints of bilateral Zusanli (ST 36),Shangjuxu (ST 37), Xiajuxu (ST 39), and Yan-glingquan (GB 34); the distant acupoints of bilateralHegu (LI 4), Zusanli (ST 36), Shangjuxu (ST 37),Xiajuxu (ST 39); and combinations of near and distantacupoints, such as Zhongwan (CV 12), Tianshu (ST25), Guanyuan (CV 4), Qihai (CV 6), Zhigou (TE 6),Zusanli (ST 36), and Shangjuxu (ST 37) and such asZhongwan (CV 12), Tianshu (ST 25), Zusanli (ST36), Yinlingquan (SP 9) and Pishu (BL 20). Othermethodologies used for these problems are warm nee-dle therapy, acupuncture combined with oral Chineseherbs, and acupuncture combined with topical Chi-nese medicine.7

In view of the potential value of acupuncture treat-ment for POI, this study was carried out to evaluate itsefficacy and to examine common acupoint(s) selection,manipulation techniques, side effects, and its effects onthe use of rescue anti-emetics.

MATERIALS AND METHODSThe study registration number was PROSPEROCRD42013005485.

Database search strategyThe following search terms for Chinese and English ar-ticles were used:1# To locate articles on POI: "postoperative" OR "ile-us" OR "functional gastrointestinal disorder" OR "gas-trointestinal dysfunction" OR "gastrointestinal disor-der" OR "gastrointestinal motility" OR "gastrointesti-nal function" OR "enteroplegia" OR "enteroparalysis"OR "intestinal paralysis" OR "paralytic ileus"

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2# To locate articles containing acupuncture interven-tions: "acupuncture" OR "acupoints" OR "moxibus-tion" OR "electro-acupuncture" OR "electro-acupointstimulation" OR "transcutaneous electric nerve stimu-lation" OR "electrical acustimulation" OR "electroacu-stimulation" OR "acupressure" OR "auricular acupunc-ture" OR "auricular acupressure" OR "warm needletherapy" OR "catgut embedment" OR "sticking thera-py"3# 1# AND 2#The following databases were used: PubMed, Co-chrane Controlled Trials Register (CCTR), EBSCO(Academic Source Premier [ASP] and MEDLINE), Ov-id (Ovid Technologies, Lippincott Williams & Wilkins[LWW] and EBM Reviews), China National Knowl-edge Infrastructure (CNKI), and Wanfang Data.Supplementary searches were performed using the web-sites http://www.google.cn and http://www.clinicaltri-als.gov to search for articles not accessible from the da-tabases via the university library website. Any uncer-tainties were clarified by contacting the respective corre-sponding authors of the studies.

Selection criteriaStudies that met the following criteria were included:randomized controlled clinical trials; studies involvingpatients undergoing surgery regardless of age, gender,ethnicity, type of surgery, or anesthesia; studies involv-ing patients fulfilling the POI diagnostic criteria; allstudies that involved the use of acupuncture; and fulltext articles in English or Chinese from 1986 to 30June, 2013. As the number of potential studies meet-ing the criteria was so small, all relevant dissertationsand publications which fulfilled our criteria were in-cluded.

Outcome measuresThe primary outcome was to evaluate the efficacy ofacupuncture for the treatment of POI and to evaluatethe acupoint(s) selection(s).The treatment outcomes were defined as follows:Cured/Fully recovered: Post-intervention abdominalpain and bloating disappeared, passing flatus and bow-el activity normal, normal appetite, no nausea andvomiting, no fever.Markedly effective: Resumption of passing flatus, ab-dominal pain and bloating disappeared, occasionalslight nausea appeared, able to consume food and liq-uid.Effective/Improved: Resumption of passing flatus,slight abdominal bloating or no abdominal pain, occa-sional slight nausea and vomiting.Ineffective: No significant improvement in symptomsafter intervention.The secondary outcome was to evaluate the acupunc-ture manipulation techniques, side effects, and effectson the use of rescue anti-emetics. The exclusion criteriawere as follows: non-randomized trials; non-clinical tri-

als; studies involving patients with other coexistingacute or chronic illness; studies involving patients whohad taken medication before surgery; articles not inEnglish or Chinese; duplicate articles; and articles withincomplete data or analysis.

Data collection and analysisArticles were evaluated independently by two authors.Relevant, complete articles were sorted and cross-exam-ined. Any discrepancies were discussed or further evalu-ated by the third author. Data were collected using MSExcel 2010 (Microsoft Corporation, Washington,USA), and included journal title, author(s), publica-tion year, type of randomization, type and duration ofanesthesia and surgery, type of intervention, samplesize, age and gender of participants, timing and tech-nique of intervention, needle retention, depth of inser-tion, duration of intervention, follow-up, any side ef-fects, use of rescue anti-emetics, results, and conclusions.Trials satisfying the inclusion criteria were included forinitial analysis. Trials whose protocols significantly var-ied from others were excluded (Figure 1). Data were di-vided into subgroup according to type of intervention.The control groups of the studies selected were treatedwith the usual care and/or medication.A Meta-analysis was performed using a fixed-effectsmodel with RevMan (version 5.2, The Cochrane Col-laboration). Analysis was presented as RR (relative risk)for dichotomous data and 95% CI (confidence inter-vals) with P < 0.05 as the significance level. Heteroge-neity of the data was assessed using I 2 values. I 2 valuesof 25%, 50%, and 75% represent low, moderate, andhigh heterogeneity, respectively. A funnel plot was pro-duced to check for bias (outcome level). If the heteroge-neity test yielded values of P < 0.1 or I 2 > 50, a sensitiv-ity analysis was carried out; any outliers were examinedas potential causes of heterogeneity.All trials were evaluated according to the CONSORT(Consolidated Standards of Reporting Trials)8 andSTRICTA (STandards for Reporting Interventions inControlled Trials of Acupuncture)9 guidelines. Thequality of each study was assessed using the Grading ofRecommendations, Assessment, Development and Eval-uation (GRADE) approach10 with the GRADE profiler(version 3.6, GRADE Working Group) according to:(a) the risk of bias/study limitations (study level), in-consistency, indirectness, imprecision, and publicationbias (evidence for downgrading the quality of evidence);(b) magnitude of the effect, influence of residual plausi-ble confounding, and dose-response gradient (evidencefor upgrading the quality of evidence).The quality of each study was graded as high, moder-ate, low, or very low.10

RESULTSOf the 69 studies screened, eight randomized con-trolled trials (RCTs)11-18 were included for review and

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among these, four studies (247 participants)11-14 met thecriteria for Meta-analysis (Table 1).

Risk of biasAssessment was based on descriptions of sequence gen-eration for randomization, allocation concealment,blinding, incomplete outcome data, and other bias.One study14 reported the generation of random se-quences and allocation concealment (low risk of bias).No studies reported blinding of participants, person-nel, or outcome assessors. All studies11-14 were assessedas having a low risk of bias associated with incompleteoutcome data. One study reported drop-out.11 No stud-ies used intention-to-treat analysis. All trials reportedbaseline comparisons of age and gender.11-14 One study12

compared pre- and post-treatment electrogastroentero-gram frequency and amplitude and one study13 com-pared pre- and post-treatment motilin and vasoactiveintestinal peptide levels; these two studies were as-signed as low risk for other bias (Figure 2A, 2B).

Response rate to acupunctureAll trials classified the acupuncture effect according tofour levels of improvement: three trials11,12,14 classifiedthe effect as "recovered," "markedly effective," "im-proved," and "ineffective"; one trial13 classified the ef-fect as "recovered," "markedly effective," "effective,"and "ineffective." Treatment outcomes were based on

clinical symptoms,11-14 color Doppler ultrasound,11-13

and leucocyte count14 according to the 200011-12 and200214 internationally recognized Rome Ⅱ criteria.For overall analysis, we transformed these outcomes in-to dichotomous data by grouping together "recovered,""markedly effective," "improved," and "effective" intothe category "total effective."

Acupuncture + usual care versus control (usual care)The proportion of "total effective" outcomes for thefour pooled trials was 95.93% (118/123) for (acupunc-ture + usual care) and 87.90% (109/124) for the con-trol. The pooled RR was 1.09 (95% CI 1.01, 1.18),P = 0.02. Acupuncture combined with usual careshowed a significantly higher total effective rate thanthe control condition (Figure 3). The results showedlow to moderate heterogeneity, P > 0.1 and I 2 < 50 andthe funnel plot indicated no bias (Figure 4).

Type of interventionAll four studies11-14 involved the use of manual acupunc-ture. One of the studies applied a fast-track treatmentprogramme.14

Acupoint(s) selectionZusanli (ST 36) and Shangjuxu (ST 37) were the mostcommon acupoints selected.11-14 In addition, some stud-ies used Xiajuxu (ST 39),11-13 Yanglingquan (GB 34),11

Neiguan (PC 6),14 and Gongsun (SP 4).14

Database search:CNKI (n = 67)

WanfangData (n=57)PubMed (n = 2)

Ovid (n = 0)EBSCO (n = 1)Cochrane (n = 1)

Supplementary search:www.google.cn (n = 40)

www.clinicaltrials.gov (n = 2)

Records after duplicates removed(n = 69)

Records screened(n = 69)

Records excluded:non randomized study

(n = 32)

Full-text articlesassessed for eligibility

(n = 37)

Full-text articles excluded:1. Data presentation not

met protocol criteria(n = 28); 2. Studies

with data error (n = 1)Studies included inqualitative synthesis

(n = 8)

Studies included inquantitative synthesis

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Figure 1 PRISMA 2009 Flow diagram for data collection and analysis.n: total number.

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Manipulation techniqueA study of cholelithotomy performed single finger in-sertion bilaterally with reinforcing-reducing for 20 s us-ing 0.30 mm × 40 mm filiform needles. The needlewas left in for 20-30 min and manipulated once at5-10 min intervals; treatment was done once daily, to-tally 2 treatment.11 Two studies on appendectomy per-

formed rapid insertion with lift-thrust and twirl rota-tion techniques, reinforcing-reducing bilaterally for 30 s,followed by needle retention for 20 min; the needlewas manipulated once at 10 min intervals with 0.30 mm× 40 mm filiform needles within 8 h post-surgery.12,13

Another study on colorectal carcinoma resection per-formed acupuncture at 24 h after surgery. Lift-thrust,twirl rotation techniques were used, with rapid inser-tion followed by slow penetration to a depth of 0.8inch at Neiguan (PC 6) and Gongsun (SP 4) using 32#x 1 inch filiform needles and to a depth of 1-1.5 inchat Shangjuxu (ST 37) and Zusanli (ST 36) using32# x 1.5 inch filiform needles. Needles were left in for30 min, and treatment was performed once daily for5 days.14

Side effects and use of rescue anti-emeticsThree studies11-13 reported no side effects. One study14

did not mention whether there were any side effects.None reported the use of anti-emetics.

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel(performance bias)

Blinding of outcome assessors (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

Kou

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Wang

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Random sequence generation (selection bias)Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)Blinding of outcome assessors (detection bias)

Incomplete outcome data (attrition bias)Selective reporting (reporting bias)

Other bias

Low risk of bias Unclear risk of bias High risk of bias0% 25% 50% 75% 100%

Figure 2 Risk of bias for the 4 included studiesA: risk of bias graph for the 4 included studies; B: risk of bias summary for the 4 included studies.

A

B

Figure 3 Efficacy of response rate to (acupuncture + usual care) vs control (usual care)CI: confidence intervals; df: degrees of freedom; M-H: Mantel-Haenszel test.

SE (log［RR］)0.00

0.05

0.10

0.15

0.200.01 0.1 1 10 100

RR

Figure 4 Funnel plot for (acupuncture + usual care) vs con-trol (usual care)

276



Quality evaluationIn relation to the CONSORT criteria, three studies(75%) reported baseline data, one study (25%) report-ed sequence generation for randomization, and onestudy (25%) reported allocation concealment. No stud-ies reported details of blinding (Figure 5A).In relation to the STRICTA criteria, two studies(50% ) reported the style of acupuncture used, threestudies (75%) reported acupoint locations (as unilater-al or bilateral), one study (25%) reported depth of nee-dle insertion, four studies (100% ) reported the re-sponse sought, four studies (100% ) reported needlestimulation, four studies (100%) reported duration ofneedle retention, and four studies (100%) reported theneedle type (Figure 5B).In relation to the GRADE criteria, all four studiesshowed low quality of evidence (Table 1). Blinding wasnot applied and precision was not reported in the out-comes.

DISCUSSIONRisk of biasBlinding is a challenge for acupuncture practice. Manypatients have some experience with acupuncture or re-alize that "deqi" is necessary. However, blinding of as-sessors and statisticians is feasible and should be adopt-ed in future studies.

Response rate to acupunctureThere is a lack of standardization in the measurementof acupuncture outcomes. A standard scale is stronglyrecommended. The use of total scores would better re-flect symptom severities.

Type of interventionThe total effective rate for manual acupuncture com-bined with usual care was significantly higher than forusual care alone. One study applied acupuncture withusual care in a fast-track surgery programme.14 The re-sults were more effective than usual care alone.14 Earlyrecovery of gastrointestinal function is important in

colorectal surgery and is an important item infast-track surgery.14

POI is a common complication of abdominal surgery.11

The longer the duration of gastrointestinal dysfunc-tion, the more the accumulation of gas and luminal flu-id and the less the likelihood of recovery. Gastrointesti-nal dysfunction can even cause adhesions, intestinal ob-struction, anastomotic hernia, and other serious com-plications. The earlier gastrointestinal function is recov-ered, the earlier the patient is able to consume food,which is beneficial for full recovery.12,13

The use of drugs to stimulate gastrointestinal motilitynot only fails to treat the root of the disease, but in-creases the burden of the gastrointestinal tract. Acu-puncture balances the disharmony of blood, Qi, andthe functions of the internal organs without additionalburden. It can effectively promote the recovery of gas-trointestinal function.12,13 In a study conducted by Wu(2008),19 acupuncture was given simultaneously withenteral nutrition support. The results showed that acu-puncture could effectively relieve abdominal pain,bloating, nausea, vomiting, diarrhea, and other gastro-intestinal disorder symptoms, and could facilitate theadministration of enteral nutrition, speed up post-sur-gery early energy intake, and promote patients' recovery.Chinese medicine practitioners believe that Yin andYang deficiency are the main causes of poor Qi, Qi stag-nation, blood stasis, internal organ Qi transportationdisorders, and disharmony of Qi within the Stomachand Spleen in abdominal surgery. Acupuncture regu-lates the smooth transport of Qi within the Stomachand the Small and Large intestines.11

Acupoint(s) selectionAcupoints frequently used were Zusanli (ST 36) andShangjuxu (ST 37),11-14 which are located along theStomach meridian of Foot-Yangming. Zusanli (ST 36)is the lower He-Sea point of the Stomach. It plays atwo-way role in regulating gastrointestinal movement.Acupuncture during gastric relaxation strengthens itscontraction; acupuncture during gastric contraction in-creases relaxation and relieves pyloric spasm.13 Acu-

Style of acupunctureAcupoint locations (unilateral or bilateral)

Depth of needle insertionResponse sought

Needle stimulationDuration of needle retention

Needle type0 1 2 3 4

Number of important items reported

Baseline data

Sequence generation for randomizationAllocation concealment

Details of blinding0 1 2 3 4

Figure 5 Evaluation of quality using CONSORT and STRICTA for the 4 included studiesA: evaluation with CONSORT; B: evaluation with STRICTA.

A

B

277




puncture at Zusanli (ST 36) also regulates gastric secre-tion; increases low gastric acid levels, pepsin, and lipaseactivity; promotes increase of opsonin levels and thephagocytic index; and enhances body immunity.13

Shangjuxu (ST 37) is the lower He-Sea point of theLarge Intestine and point of the Sea of Blood. Acu-puncture at this acupoint improves bowel activity, ab-dominal pain, diarrhea, constipation, appendicitis, andother gastrointestinal disorders.14 Acupuncture at bothZusanli (ST 36) and Shangjuxu (ST 37) regulates gas-trointestinal Qi, harmonizes the Stomach, alleviatespain, smoothes the qi of the intestinal organs, and elim-inates bloating.14

In a study of acupuncture following cholelithotomy,11

Xiajuxu (ST 39) and Yanglingquan (GB 34) were usedin addition to Zusanli (ST 36) and Shangjuxu (ST 37).Xiajuxu (ST 39) is the lower He-Sea point of the SmallIntestine and point of the Sea of Blood and is locatedalong the Stomach meridian of Foot-Yangming. Acu-puncture at Shangjuxu (ST 37) and Xiajuxu (ST 39)regulates the Qi of the Large and Small intestines, re-spectively.3,11 Yanglingquan (GB 34) is the lowerHe-Sea point of the Gall Bladder and is located alongthe Gall Bladder meridian of Foot-Shaoyang. Acupunc-ture at Yanglingquan (GB 34) disperses stagnant Liverqi, promotes bile flow, smoothes the flow of Gallblad-der Qi, and prevents regurgitation.11,20 Integrated appli-cation of the above points activates the flow of qi andblood, regulates gastrointestinal functions, induces ca-tharsis in the Liver and Gallbladder, promotes intesti-nal peristalsis, and improves abdominal bloating.3,11

Acupuncture at the lower He-Sea points shortens thehealing process3 and recovery period11 of post-choleli-thotomy gastrointestinal function.Two studies on appendectomy performed manual acu-puncture on bilateral Zusanli (ST 36), Shangjuxu (ST37), and Xiajuxu (ST 39).12,13 A study of colorectal car-cinoma resection selected Neiguan (PC 6) and Gong-sun (SP 4) in addition to Zusanli (ST 36) andShangjuxu (ST 37).14 Neiguan (PC 6) is located alongthe Pericardium meridian of Hand-Jueyin; it is fre-quently used to treat vomiting and has a good pain re-lief function.14 Acupuncture at Neiguan (PC 6) adjustsgastrointestinal function, inhibits gastric acid secretion,and regulates intestinal motility.14 Gongsun (SP 4) is lo-cated along the Spleen meridian of Foot-Taiyin. It regu-lates, and has a special relationship with, the Stomachand Intestine and lowers inverse Qi.14 Neiguan (PC 6)and Gongsun (SP 4) are two of the eight confluent acu-points connecting the eight extra channels. Gongsun(SP 4), the master point of the Chong Mai vessel, toni-fies the Spleen and promotes Yang. Coupled with Nei-guan (PC 6), it helps to regulate the Qi of the middleJiao. Modern research indicates that the coupling ofthese two acupoints can have synergistic effects.21 Theycan transmit information through the nervous systemto adjust the Stomach and other viscera.21 Neiguan (PC6) coupled with Zusanli (ST 36) tonifies the Spleen,

harmonizes the Stomach, regulates Qi, and alleviatespain.14 Different acupoints may be chosen based on thetype of surgery.

Manipulation techniqueTechniques used included lift thrust,12-14 twirl rotation,12-14 or reinforcing-reducing,11-13 for 20 s11 or 30 s;12-13rapidinsertion12-13 or rapid insertion followed by slow penetra-tion to the depth of 0.8-1.5 inch;14 and needle reten-tion for 20 min11-13 or 30 min.11,14 Three studies report-ed the use of bilateral acupoints.11-13

Shi Xuemin has devised some new acupuncture defini-tions and quantitative manipulation techniques. Oneof these is the direction of applied force as an impor-tant factor that determines reinforcing-reducing. Hehas also suggested that the reinforcing-reducing effectof twirling rotating is directly related to the appliedforce; that the best duration of reinforcing-reducingmanipulation of a twirling rotating needle is 1-3 minfor each point; and that the best interval between twoacupuncture sessions is 3-6 h, making acupuncture thera-py more standardized, reproducible, and controllable.22

It is still unclear whether bilateral acupuncture produc-es a better effect than unilateral acupuncture. The num-ber of treatments needed might be related to the typeof acupuncture and intervention combination. Larg-er-scale trials are needed to draw firmer conclusions.

Side effects and use of rescue anti-emeticsOverall, there were no major adverse events. The stud-ies we examined did not report the use of anti-emetics.Thus, the effect of acupuncture on these medicationscould not be evaluated.

Quality evaluationAlthough high-quality evidence does not necessarilyimply strong recommendations, and strong recommen-dations can arise from low quality evidence,10 futurestudies should follow the standard guidelines to im-prove the quality of evidence.

LimitationsBecause of the lack of studies using the same type of in-tervention(s), it was difficult to form subgroups for Me-ta-analysis. Therefore, we could not evaluate the effica-cy of interventions other than manual acupuncture,the efficacy of different types of combination interven-tions, and the efficacy of acupuncture or combinationintervention versus anti-emetics. Another limitationwas that practitioners may vary on their judgments ofthe extent of recovery. The resulting bias could be re-duced with larger sample sizes.Although the database search included articles world-wide, the articles that met the inclusion criteria weremainly from mainland China. The small sample sizewas also a potential limitation of this study.

Studies not included in the meta-analysisThe four studies15-18 that were excluded involved colon

278



cancer surgery,15 intestinal surgery,16 and abdominal sur-gery.17,18The techniques used included manual acupunc-ture,15 manual and electroacupuncture,16 electroacu-puncture with usual care,17 and acupuncture, elec-troacupuncture combined with oral Chinese medicine(Table 2).18 As techniques used among the studies werenot uniform, an attempt to categorize them into thesame subgroup would have increased heterogeneityand affected the validity of the results.Not all of these trials generated random sequences.One trial reported allocation concealment (low risk ofbias).18 None reported blinding of participants, person-nel, or outcome assessors. All studies15-18 were assessedas low risk of bias associated with incomplete outcomedata. One study reported drop-out.18 No studies usedintention-to-treat analysis. Three trials16-18 reported base-line comparisons of age and gender. Three studies15,17,18

reported comparison of total clinical symptom scoresfor pre- and post-treatment and were assessed as lowrisk (Figure 6A and 6B).One trial classified acupuncture effects according tofour levels of improvement: "recovered," "markedly ef-fective," "effective," and "ineffective."16 Three studiesclassified the outcome according to the effect index:[(total scores pre-treatment total scores post-treatment)/total scores pre-treatment] × 100% . One study15 de-fined the treatment outcome as "markedly effective"(effect index > 76% ), "effective" (51%-75% ), "im-proved" (26%-50%), and "ineffective" (< 25%). Twostudies17-18 defined the treatment outcome as "recov-ered" (effect index ≥ 95% ), "markedly effective"(70% ≤ n < 95%), "effective" (30% ≤ n < 70%), and"ineffective" (n < 30%); where n = effect index. Evalua-tions were based on clinical symptoms.15-18 In thesestudies, the total effective rate was higher in the inter-vention group than in the control group.15-18

Frequently used acupoints were Zusanli (ST 36),15-18

Shangjuxu (ST 37),16,17,18 and Xiajuxu (ST 39).16,17,18 Twostudies reported the use of bilateral acupoints.16,17 Sideeffects were not reported for all studies. No trials re-ported the use of anti-emetics. Acupoint(s) selectionmight vary according to different combination of inter-ventions. The use of combined interventions might im-prove efficacy and reduce the need for anti-emetics(thus reducing their side effects). However, more RCTsare needed to verify this.In relation to the CONSORT criteria, two studies(50% ) reported baseline data, no studies reported se-quence generation for randomization, one study (25%)reported allocation concealment, and no studies report-ed details of blinding (Figure 7A).In relation to the STRICTA criteria, one study (25%)reported the style of acupuncture used, two studies(50%) reported acupoint locations, two studies (50%)reported the depth of needle insertion, four studies(100% ) reported the response sought, four studies(100% ) reported needle stimulation, four studies(100%) reported the duration of needle retention, and

three studies (75%) reported needle type (Figure 7B).In relation to the GRADE criteria, all studies showedlow quality of evidence (Table 2). Blinding was not ap-plied and precision was not reported for all outcomes.

Other types of interventionsInterventions such as acupoint injection, auricular acu-pressure, and catgut embedment might be useful thera-pies. However, there were no RCTs using these inter-ventions that fulfilled the inclusion criteria for reviewand Meta-analysis.

ConclusionAcupuncture treatment might be beneficial for POI.We could not draw any firm conclusions regarding itsefficacy because of the low quality of trials. Furtherlarge-scale, high-quality RCTs are needed to validatethe indications reported here and to develop a standard-ized method of treatment.Zusanli (ST 36) and Shangjuxu (ST 37) were the mostcommon acupoints used. The techniques used includ-ed lift thrust, twirl rotation, reinforcing-reducing, rap-id insertion, and rapid insertion followed by slow pene-tration;needle retentionwasbetween20minand30 min.Generally, no major adverse events occurred. Rescueanti-emetics did not seem to be an important part ofmanagement in these studies.More rigorous trials are needed to evaluate the efficacyof different types of acupuncture and combination in-terventions. Although these trials were mainly carriedout in mainland China, acupuncture intervention forPOI is worth further investigation, as it is a potentiallyeffective therapy that could be used worldwide. Wehope that the results of this systematic review and Me-ta-analysis will prompt further research that leads tobetter patient care for POI patients both in China andworldwide.

REFERENCES1 Johnson MD, Walsh RM. Current therapies to shorten

postoperative ileus. Cleve Clin J Med 2009; 76 (11):641-648.

2 Behm B, Stollman N. A special article. Postoperative ile-us. Pract gastroenterol 2002; 13-24. Available from URL:http://www.practicalgastro.com/pdf/December02/Behm-Article.pdf 02 Dec 2002; 13-24.

3 Kou XR, Sun LM, Gua N, Li P. Clinical observation onacupuncture treating functional gastrointestinal disorderafter gallstone surgery. J Acupunct Tuina Sci 2011; 9(3):182-184.

4 Ng SS, Leung WW, Mak TW, et al. Electroacupuncturereduces duration of postoperative ileus after laparoscopicsurgery for colorectal cancer. Gastroenterology 2013; 144(2): 307.e1-313.e1.

5 Ouyang H, Chen JD. Review article: therapeutic roles ofacupuncture in functional gastrointestinal disorders. Ali-ment Pharmacol Ther 2004; 20: 831-841.

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6 Takahashi T. Acupuncture for functional gastrointestinaldisorders. J Gastroenterol 2006; 41: 408-417.

7 Shaera G, Liu ZY. Research progress of the acupuncturetreatment in postoperative functional gastrointestinal dis-orders. Xinjiang Zhong Yi Yao 2011; 29(6): 63-66.

8 Schulz KF, Altman DG, Moher D; CONSORT Group.CONSORT 2010 Statement: updated guidelines for re-porting parallel group randomised trials. Trials 2010; 11:32.

9 MacPherson H, Altman DG, Hammerschlag R, et al. onbehalf of the STRICTA Revision Group. Revised STan-dards for Reporting Interventions in Clinical Trials of Acu-puncture (STRICTA): Extending the CONSORT State-ment. PLoS Med 2010; 7(6): e1000261.

10 Guyatt GH, Oxman AD, Vist GE, et al. For the GRADEWorking Group. GRADE: an emerging consensus on rat-ing quality of evidence and strength of recommendations.BMJ 2008; 336(7650): 924-926.

11 Kou XR, Sun LM, Guo N, Li P. Observations on the ther-

apeutic effect of acupuncture on post-cholelithotomy gas-trointestinal dysfunction. Shanghai Zhen Jiu Za Zhi 2010;29(2): 103-104.

12 Zhang Y, Zhao XF, Li P. The effect of acupuncture onpost-appendectomy electrogastroenterogram. ShaanxiZhong Yi 2011; 32(11): 1526-1527.

13 Zhao XF, Zhang Y, Li P. The effect of acupuncture onpost-appendectomy vasoactive intestinal peptide and plas-ma motilin. Xin Zhong Yi 2010; 42(11): 95-97.

14 Wang HM. The clinical study on gastrointestinal functionrecovery after colorectal carcinoma resection in Fast Trackprogramme using acupuncture. Nanjing: Nanjing ZhongYi Yao Da Xue, 2011: 1-30.

15 Dai ZY, Lin SJ. Acupuncture in the treatment of 30 casespost colorectal surgery gastrointestinal disorder. ShaanxiZhong Yi 2011; 32(2): 210-211.

16 Mu LX, Lv B, Qu Y. Observation of effect of acupunctureand moxibustion therapy in treating enteroplegia after op-eration of intestinal cancer. Zhong Guo Wu Zhen Xue Za

Random sequence generation (selection bias)Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)Blinding of outcome assessors (detection bias)

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Other bias0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

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Dai

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Figure 6 Risk of bias for the 4 excluded studiesA: risk of bias graph for the 4 excluded studies; B: risk of bias summary for the 4 excluded studies.

A

B

Style of acupunctureAcupoint locations (unilateral or bilateral)

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Figure 7 Evaluation of quality using CONSORT and STRICTA for the 4 excluded studiesA: evaluation with CONSORT; B: evaluation with STRICTA.

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Zhi 2011; 11(16): 3817.17 Shi JE. The clinical study on the effect of using elec-

tro-acupuncture on Zusanli, Shangjuxu, Xiajuxu postoper-ative gastrointestinal motility. Guangzhou Zhong Yi YaoDa Xue Master Dissertation 2012; 1-28.

18 Shaera G. Clinical study on Traditional Chinese Medicinecombined with acupuncture for promoting the recovery ofgastrointestinal function in the treatment of postoperativepatients with damp-heat syndrome. Xinjiang Yi Ke DaXue Master Dissertation 2012; 1-50.

19 Wu F. Acupuncture treatment of 62 cases post abdominalsurgery functional gastrointestinal disorders. Zhong Guo

Zhong Xi Yi Jie He Wai Ke Za Zhi 2008; 14(6): 557-558.20 Chen YG, Wang ZY, Wang Y, Wu FX. Guideline for im-

plementation of acupoints selection for clinical disease. 1sted. Shenyang: Liaoning Science and Technology Press,1999: 206.

21 Zhong H, Wu ZL. A survey of the modern research andthe clinical application to the compatibility of the pointsof Neiguan and Gongsun. Beijing Zhong Yi 2004; 23(6):360-362.

22 Bian JL, Zhang CH. Conception and core of academicianShi Xuemin's acupuncture manipulation quantitative arts.Zhong Guo Zhen Jiu 2003; 23(5): 287-289.

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Documents

Effectiveness of acupuncture in postoperative ileus: a ... · postoperative pain, nausea, vomiting, delay in resum-ing enteral nutrition, and prolonged hospitalization. Other postoperative