Electroacupuncture Analgesia in Mafor Abdominal and Pelvic Surgery:

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in
Analgesia
Electroacupuncture
MaforAbdominal
andPelvicSurgery:
A Randomised
Study
oI SaienlificAcupuncturc
Thissludy '"\,aspresentedat the ICMART2nd World ConS;ress
held in Lotldotl in May l986
And morerecently,
research
intothe
methods46,731.
Summaty
to providing
have tenalea! physioiogy
of pain hirsgonesome\a,'ay
Proponentsaf aaupunclureanacsthesia
involvecl
of the mechanisms
to lt:ctkon it as a rcplacementfor conventional a possibleexplanation
(EA)
Electroacupuncture
anaesthe.sla.This randantised,controlled trial in acupunctufeanalSesia.
p
a
t
i
e
n
t
s
anacsthesia
is tholrght
involving 250 canccr
u n d e r B o i n g combinedwith non-narcolic
per opcratively.
The air.s
lhe to providegood analBesia
abclominalor pelvic surgcry,hasaimed to assess
as the sole analgesic,bLt oi oLrrstudy\,/efeI
use ol eleclroacupuncLure
whetherEA cou d be uscd as tne sore
\vitllin a standardanaesthetic.lt v,as found that l- lo assess
duringmajor abdominal
componentof analgesia
while there was littl-. dit'ferenccbetween the peF
and peLvc surgery
opentive requirementIor anaesthcticdrugs,all the
n o n a c u p u t i c t L t r eB r o u p r e q L l i r e d f e n t a n y l , ii. lo show if patientswho receivedlessmedication
morequicky
comparedto oDly 5lo oi the electroacupunctLtre recovered
(P<0.001).
the analgesic
eflicacyof transcutancous
group
Tine to sponlaneousrespiratiotl i/1.to assess
(P<0.02)and extubation(P<0.001)innediatcly
electricalneIvestimulation(TENS)clurinBlhe 5
post-operative
dayspost opcratively was reduceclin the acupuncturc
8raup.
Transcuta
neouselectricaI nerve stin uIaIi on (TENS) Patientsand methods
was used far post operative pain r,.lief in the The day beforesurgerythe patientswere examtned
who explainedthe natureoi the
a c u p u n c l u r eE ; r o u p ,w h i l e t h e c o n t r o l g r o u p by the anaesthetisl
were
receivednotl-narcaticanalgesics,There was no studyand obtainedinfofmedconsent.Patients
the
that shouldEAproveto be ineffective,
siEnificantdiilerence in the numbersof patienls reassured
aould be adopted.
' otnpl.,,ntng nl pa,n. but the tFquitcmont !.t
standard
m e t h o do f a n a l g e s iw
a so tau8htallthe patientshow and
atlditional analgesiawas /esswhen IENS was uie.l Thc anaesthetist
(P<A.01).There was no differencein the period of whento usea TENSrnachine.
post operative i/eu-sai nreasuredby the return of
lnclusioncriteria:
n o r m a l b o w e l s o u n d s .H o w e v c r t h e r e t u r n t a
Cancerpatients
normal self caring wassignificantlyimptoved in the
and/orpelvicsufgery
Abdomina
acupunctureBraup (P<0.A2).Bath ptactically and
available
lnformed
consent
econonically this is prabablythe most important
b e n e f i ci aI a s p e c l o f e l c c t r a a c u p u n c t u r e Exclusioncriteria:
proximalto
Infection
or radiotherapy
denonstratedby this study.
points
acupuncture
Key words
A ler8ies(spccialpremedicatior])
Posl aperative analEesia,
Acupuncturc anaesthesia,
< 14 yearsold
Randomisetlcontrolled tr;al, T ENS.
emcrgencles
Surgical
Pacemakers
lntroduction
post-operative
therapy
of intensive
Anticipation
is widely
The analgesie
c f f i c a c yo f a c u p u n c t u r e
lnformedconsentnot avaiable.
kno\,n. In the sixtiesdoctorsthrouBholrt
Chinawere
t
o
u
s
e
a
c
u
p
u
n
c
t
u
r
e
f
o
r
a
n
a
e
s t h e s i (a5 ) , Alterinforr.edconsenthad beenoblained,patjcnts
tauBhl
f o l l o w i n g t h e p r e c e p t sd i c t a t e d b y t h e C r e a t wereenteredinto the studyand randomlyallocated,
envelopes,
into two Eroups.The
P r o l e t a r i aC
n u l t u r a lR e v o l u t i o nw, i t h a c l a r . n e c l usingpre-prepared
using
received
standafd
anaesthesia
ol
contfol
rate
around
90L
The
exchan8e
effective
of
f7).
SroLrp
peFoperatively
and
non-narcolic
medicine
narcotic
analSesia
Eastern
and
Western
knowledgebetween
Patientsin the sludy
f e s u l t e di n d o c t o r sc o m b i n i n ga n d a d a p t i n Bb o t h analgeslcspost-operatively.
group
EA
during
the
opefationand TENS
received
w
i
t
h
a
v
i
e
w
t
o
i
r
n
p
r
o
v
i
n
S
e
x
i
s
t
i
n
g
approaches
A..upun.tLrc i n M e.li c i ne
t0
M a y 1 9 9 7V a l l 5 N o . 1
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At the end of the operationin the StudySroup
patients,two sterile,conductingelectrodeswere
placedeitherside of the scar and connectedto a
controlgroup studygroup
p r e - s e tT E N Sm a c h i n e( N e u r o D o 4 m e d t r o n i c ,
PeFoperative
Narcotic
EA
USA).We madeno pharmacological
reversal
of the
Postoperative
Non nafcoiic TENS
competitive muscle relaxant (pancuronium),so
patientswere transferredto the recoveryward and
post-operatively
flable /).
e x t u b a t e dw h e n c l i n i c a l r e v e r s a l i, n c l u d i n g
l n b o t h g r o u p s p a t i e n t s r e c e i v e dt h e s a m e spontaneous
respirationwith a minute volume ot
premedication
t hourpriorto surgery:
morethan100m1kg', wasevident.
Flunitrazepam3 x 10" mg kB',
Postoperatively,patientsin both groups were
Atropinesulphate0.25
to 0.75m9
givennon narcoticanalSesics
as required,and were
(according
to weight).
interviewed by a data managerover 5 days. PostIn C'oup | , aldeqrhe,.a
\^ac ndu(ed usinB:
o p e r a t i v ea s s e s s m e nwta s m a d e f o r : q u a l i t y o f
DroperidolO.3mBkg'
i m m e d i a t e r e c o v e r y , d o s e r e q u i r e m e n t so f
Thiopentone sm9 kgr
patientcomfortand self assessment
analgesics,
of
Pancuroniumbromide 8 x 10'mg kg'
pain,end of postoperativeileus,and achievement
Fentanyl
5 x 10'mg kB'
of independence.
Afterintubationpatients
wereventilated
with a 10ml
A minimum of 125 subjectsin each group was
kg mixtureof oxySenand nitrousoxide(FiO,= 0.4) c o n s i d e r e dn e c e s s a r yt o s h o w a s t a t i s t i c a l l y
per minute.
at a rateo{ 12 to 15 insufflations
s i g n i f i c a n dt e c r e a s ef r o m B 0 % t o 6 0 % o f p a i n
ln the StudyBroup,30 minutespriorto induction, experienced
posi-operatively,
with a probabilityof 5%.
B s t a i n l e s ss t e e l , s t e r i l e a c u p u n c t u r en e e d l e s
(diameter
0.4mm,length40mm)were insertedto a Resurls
depthof 5 to 1omm, bilaterallyin the following4 D u r i n g t h e p e r i o d f r o m N o v e m b e r1 9 8 3 t o
acupuncture poinls (Table2): Eat Shenmen,PC.6, December1985,250 cancerpatientswere entered
SP6and C8.39 (2.).
into the study.
The data of 233 patients(r=113 Controlgroup;
Iable2
l1=120Studygroup)were statistically
analysed(12
POINTS
USEDfOR ACUPUNCTURE
ANALGESIA
'2)
patientsfrom the pilot study were withdrawn:2
whose randomisedenvelopeswere lost, 2 for whom
Shernen ear pointr inferiorcornerofbifurcationpoinrof
surgerywas cancelled,and 1 who was randomised
t!vice).The two groupswere statisticallymatcheclas
(AUM
NetSurn(PC.6):2 acupunctureunitsof measurement
regardssex, age,weiSht, height and type of surgery
METHODOf ANALCESIA
or cun) abovewrist, betlveentendonsof palmarislongus
a n df e x o rc a l p ir a d i a l i s
sa,yinliao (sP6):3 AUM abovetip of medial malleolus
post€riorto tibial border
Xuanzhon9(C8.39):3 AUM abovelateralmalleolus
b€tlveenposteror borderoffibula and tendonsof
peroneuslons!s and brevis
Table3
PATIENTCHARACIERISTICS
These needles were connected to an
(DSM | 500, MCM Laboratories,
electrostimulator
Paris)deliveringa biphasiccurrentat a frequencyof
40H2,raisingthe intensityuntilthe subjectreported
a sensation
oftinSling(mean5mA).After30 m'nutes
was inducedin an
of electrostimulation,
anaesthesia
identicalmannerto the Control group, using the
samedrugsat the samedosage,but without using
fenfanyl. Patientswere also ventilated rn the same
way as those in the Control Broup.lmmediatelyafter
i n d u c t i o no f a n a e s t h e s i tah e e l e c t r o s t i m u l a t o r
curent was increasedto 15mA and the frequency
was modulated.
DufinB surgefy,the anaestheticrequirementswere
assessed
in both groupsfollowingthe sameclinical
c f i t e r i a : b l o o d p r e s s u r ea n d p u l s e r a t e w e r e
monitoredevery smin. Fentanyl,in boih groups,
was injected to patients as requiredi per-operative
a s s e s s m e nw
t a s m a d e o f e a c h p a i i e n t ' sd o s e
requirementsof anaestheticdrugsand of /entanyl.
May 1997 Vol 15 Na.1
11
Femalepatients(%)
Averageage
Averaseweisht (kd
Averageheight(cm)
Pelvicsursery(%)
A b d o m i n a l s u r s e(r%
y)
ControlSroup Studygroup
(n=113)
(n=120)
ago/,
a6Y.
49
47
62
61
164
162
88Y"
88Y"
12Yo
12Yo
TableI
TYPEOf SURGERY
conirol group studygroup
(n=113)
(n=120)
Hynercctomy
Totalhysterectomy
Totalhysterectomy
with pelvic
& aortic lymphadenectomy
32
11
24
10
30
41
3
2
t
5
4
l
17
20
aortic lymphadenectomy
Acupuncture in Meclicine
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(Iables 3 and ,+). Thefe was no differencebet\'veen SroupusinBthe TENSmachinefrom day 1 to day 5
8170,79"/",70'/,,,51"tr,,
18f".
the two gfoupsin the anaesthetic
dosefequifernentswererespectively
( r e l a t e dt o b o d y w e i g h t a n d d u r a t i o no f s u r g e r y ) Therewas no statistical
dilference
betwcefrurr r\\,1)
( T a b l e5 ) . A ) l t h e p a t i e n t si n t h e C o n t r o lg r o u p grolrpsin thosepatieftswho conrplainedol paini
patientsin the StudyBrouprequiredlcss
fequiredierfaryl, whereasonly 7 out of the 120 cofversel!,,
(P<0.01)
patientsin the Studygroup neededit, and that at analgesia
flable/.1.
' . u d l " " r , * r ^ r . o b . " , p d r ' , | , e - a '^ \ o r ) . - '
very row oosaSes,
from post-operative
ileus:the Controlgroup had a
meanof 3.2 days,the SLudygfoup a mcan of 3.3,
P E R . O P T R A T IDVRI U CR E Q U I R T M E N T S
but patientsin the Studygroup becarncsellcaring
Control group StudyBroup P
s o o n e r( P < 0 . 0 2 )d; L r r i n gt h e f i r s l : l d a y s2 0 ' 1 ,o f
(n=ll3)
(n=120)
patlentsin the Controlgroupand 12% in the Study
t r L r r . n i ooi i n , t s e r y( m n )
1,16
I52
NS
grouphad achievedtheirindependence.
B - " e d i n (gl )
. A.7
Averaed
e o s er e q u i r e m e n(txs] 0 - n i e k e
Barbtlrare fthropen?onel
61
Nelrol€pti. f.rroperLlolt
).7
Mu5. e re axantlprr.urortur,
I
Patientsrequirng ierranyl (%) 100%
NS = Non rArlt.arr
0!
NS
in )
Discussiot
Most oi lhe works discussing
the clinicalanalgesic
e f f i c a c yo f E A i o r s L r r g e ray r e d e s c r i p t i v ea, n d
1 )t . t h c
t h e f e f o r eo f i m i t e dv a l u e( 1 , 1 , 1 , 6 , 1 O , 1O
fecentstudieswhich have been carried out, icv,/
havebeen randomised(3,8,15)aft thc resultsare
The anaesthetics
wefe Bivenby 11 anaesthetists,u n c o n v i n c i n gT.h i s t r i a l w a s r a n d o ms e d a n d
differencebetween
one of whom anaesthetised
53% of the patients. showeda statistically
siBnificanl
T h e r ew a s n o s i g n i f i c a ndt i f f e r e n c eb e t w e e nh i s the two groupsin doserequiremenl
ol opiates,whj e
(of eithergroup)and that p a t i e n t sr e q u i r e dt h e s a n l ed o s eo l n o n n a l c o t i c
anaesthetic
management
anaestnet
c oru85.
of the others.
One can arguethat this stlrdywas nol b ind and
P e r i o p e r a t i v e l yp a t i e n t si n t h e S t u d y g r o u p
of both
f e c o v e r e ds p o n t a n e o urse s p i r a t i o (nP < 0 . 0 2 a) n d that this might haveaftectedthe responses
were extubated(P<0.u01)more quickly (Table6). p a t i e n t sa n d p h y s i c i a n sl .- 1 o w e v etrh, i s w o r k
most oi \{,honl
Patientsin the Studygroup recoveredspontaneous invo ved l1 diiferentafaesthetists,
to acupunctufeand who clid
r e s p i r a t i oan m e a no [ l 9 m i n e a r l i e rt h a nC o r ] t r o l were fot accustomed
p a t i e n t s( 7 4 . 1 %o f p a t i e n t si n S t u d ya n d 5 5 " 1 i, n not realy bellevethat this methodof anaesthetisin8
Control had recoveredby 30r.in alter slrr€iery). p a t i e l l t sw a s e l l i c i e n t .C o m p a r i s o fb e t w e e n
showedno differencein the dose.rf
P a t i e n t si n i h e S t u d yg r o u pw e r e e x l u b a t e da l a afaesthetists
n r e a no f 3 6 m i n e a r l i e rt h a n t h o s ei n t h e C o n t r o l drugsadministered.lt is, anyway,very difficultto
g r o u p( 5 7 . 5 %o f p a t i e n t si n S i u d ya n d 2 7 . 4 % i n usea doubleblind methodin the assessment
of the
protocol
FA.
In
our
\a,'e
could
have
usecl
were
effectol
Control
extubated
by 60mina{tersurrgery).
patients
acupunclure
versus
slandard
acupuncture,
but
Post-operatively,
226
out of the 233 had a sham
previous
stLrdies
have
sho\,n
that
sham
and
standard
f
o
l
l
o
w
u
p
;
r
e
r
n
a
i
n
d
e
r
2
:
c o r n p l e t e5 d a y s
of the
wefe effectivein about50% and 65%
deceased(Controland Study),3 were retLrrned
to acupLrncture
(
2
r
e
c
o
v
e
r
y
w
a
r
d
1
1
the
S t u d y , C o n t r o l ) , w a s respectively
l9)-Thus,the numberof patientsin the
(Study)
siBnificance
woLrld
discharged
on day 4
and 1 escapedon day 3 trial neededto achievestatistical
(Study).The percentages
patients
larger.
of
in the Study havebeensubstantially
Thecornbination
of Chineseafd Westemmedrcrne
more
research,
fesultingin a better
hasencouraged
IMMEDIATEPOST.OPERATIVE
RECOVIRY(RETATED
TO
p
o
s
s
t
h
e
i
bl e m e c h a n i s m s
u n d e r s t a n d i n oSf
SURGERY
TIME)
(
7
.
1
4
)
.
E
A
P
h
y
s
i
c
) a r sd i f f e r i n t h e i r
underlying
role
EA
Lrutthere
opinionas to the
oi
dufinSsufgery,
Controlgroup Studygroup P
(n=| 3)
(n=120)
M
o
s
t Easlern
a r e t w o m a i f s c h o o l so f t h o u g h t .
lo
replace
doctorsand some ELrropeans
try
opiate
Time to spontanco!srcsprat on
( n r i np e r m i n o f s l r S e r y l
0.38
0.21 <0.02
with acupuncturealone l/21. On
and anaesthesia
E x r l b a ot n t i m c { m i np € f m i n ) 0 . 6 , 1
0 . 1 2 < 0 . 0 0 1 t h e o t h e f h a n d , i n o u r i r i a l , w e p r o p o s e dl h a t
a c u p u n c t u r ei n d u c e d a n a l : l e s i aw a s I L r s ta
componentof anaesthesia,
and so \,vecombinedthe
two techniques,
for the comfoftof the patientand oi
POST-OPIRAftV[8[NIHT
t h e m e d i c a lt e a m . T h e e l e c t r o s t i r n L r l a t oi ol n
pointsenabledus
selecied,traditionalacupuncture
Controlgroup Studygroup P
g
i
v
e
to
a n e f f e c t i v ea n a l g e s i aT.h e l o w i n t e n s i t y
(n=l l)
(n=120)
c
u
r
r
e
n
t
sw
, j t h m o d u l a t e df r e q u e n c ya r e t h o u S h t
P a t i e n lcso m p l a i in g o l p a i n
Ul%
75%
NS
bolh to stimulate
thc naturalsecretion
of endofphins
Requirlne.nalgesics
26"i
I8'/, <0.01
(low frequency)
and serotonin(highfrequency),
and
20"1,
Se lcnriig wilhi. -l days
32'A <o.o2
to providesegmentaanalgesia
by activationof the
N.S= Nor s€rili.
t
sprnalgalecontro systcm.
AcDpDncture
in Medicine
69
Ns
Ns
J.l
I
N5
-5% <0.001
1)
M a r 1 9 9 7V o l 1 5 N a . I
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The choiceof pointsusedin this irial was specific
to the type of surgery(lowerabdominaland pelvic)
and may needto be adaptedfor other operations.
N o n e o f t h e d r u g sw e u s e df o r a n a e s t h e s iias
k n o w n t o p o s s e s sa n a l g e s i cp r o p e r t i e sI.n b o t h
g r o u p s ,t h e c o n c e n t r a t i o no f N 2 O p r o v i d e d a
potentiationof the other drugs,with a negligible
analgesic
effectduringmajorsurgery.
E A d u r i n gt h e s u r 8 i c apl e r i o dp r o v i d e da g o o d
analgesia
and allowedus to extubatepatientsin the
StudySroup in half the time requiredfor those in
the Control group, suggestingthat EA affordsa safer
post-operative
periodimmediate
In both groups there were patientswho
pain, but thosein the
complainedof post-operative
At firstsightthis
Studygrouprequiredlessanalgesia.
s e e m sa c o n t r a d i c t i o n ,h o w e v e r w e t h i n k t h e
reduceduseof opiateanalgesia
allowedEApatients
to be rnofe alertand aware,and thus to recallany
painexperienced
rnoreclearly.
We wereexpectingthat EApatientswould recover
theirbowelsoundsmorequicklythanControlgroup
patientsb
, e c a u s eo p i a t e sa r e k n o w n t o i n h i b i t
peristalsis.ln fact, there was no statisticaldifference
in recovefybetweenthe Sroups.lt may be that postoperativeileus is a local effect relatedto the surBery,
opioidsreleasedfollowinBEA
but the endogenous
opiate
receptorsin the 8ut, and
certainlyact on
has
recorded
as a complication
of
constipation been
Howevet
we
have
no
explanation
acupuncture
f/6).
o f w h y p a t i e n t si n t h e S t u d y g r o u p r e c o v e r e d
a n d b e c a m es e l f c a r i n gm o r e q u i c k l y f o l l o w i n g
s u r g e r yt h a n c o n t r o l s ,b u t b o t h p r a c t i c a l l ya n d
e c o n o m i c a l l yi ,t i s p r o b a b l yt h e r n o s ti m p o r t a n t
aspectof EA in thistrial.
beneficial
Conclusion
T h e r e s u l t so f t h i s i r i a l s u g g e s t h a t i n m a j o r
abdominaland pelvic surgery,EA is an effective
It is a safetechnique,
componentof anaesthesia.
providinga shorterpost operativerecoverytime,
with equailyeffectivepain controlto thosepatients
feceivingopioidanalgesia.
W e t h e r e f o f er e c o m m e n dt h i s c o m b i n a t i o no f
with conventional,non-opiate
electroacupuncture
particularlyin the elderly and those
anaesthesia,
insufficiency.
with respiratory
Pres, BeijinA:11O4,491 523
ForeiSnLanguages
3 . C r a i gj F , H e s t e rJ B ( 1 9 8 6 )T h e u s e o t p e r i o p e r a t i v e
e l e c t r o a c u p u n c t ! ri en p o s to p e r a t i v ep a l n r e l i e f .I n l
Prcceedinss of the 2nd wo.ld Congrcss ol Sclentific
Acquncture, Lo.don: 69
4 . C l e n n i eS m i t hK ( 1 9 8 6 )S t i m u l a t i opnr c d u c e da n a l g e r i lao r
m a j o r j o n l s ! 1 8 e r yi n e l d e r l yp o o r r i s k p a t i e n t s l.n :
Prc.eedings of the 2nd World Congress of Scientific
Acupu ncture, Lordon : 6A
s. Crolpe de rechercheen anesth6se p acupunctlre (1972)
fanesthesiepar acupunctwe. Ann. Anesth.Fnn?. XIll (4).
627-34
6 . H u g u e n a r dP ( 1 9 7 2 )A c u p u n c i u r ea H a n o p o u r a b l a r i o n
d'un nodulethyroidien.Ann. Anesth.Fran9.Xt . (,t).63s-7
t e d i a t o fro r
7 . H a n l S , X i e C X ( 1 9 8 a )D y n o r p h i ni:m p o r t a nm
electroacupunctore
analgeriain the spinalcord ofthe rabbit.
8 . L e f e v r ej e t a l . ( 1 9 a 4 ) E f f e Gd ' u n e 6 l e c t r o s t i m u l a t i o n
acupuncluralesur l'analg€sieper er post op€ratoireau couu
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47(3):317
P Poulain MD, E Pichad Ldand MD
F Montange MD, J Truffa-Bachi MD
Serviced'Anesthesie,InstitutGustave-Roussy
A LaplancheMD, J Bouzy
Departement de Biostatistiques et d' Epi demiologie
Insti tut Custave-Roussy
RueCamilleDesmoulins
91805 Villejuif Cedex, France
) clinicaa
1 . E e i j i n gC h i l d r e nH o s p i t a(l1 9 7 5 A
l n a l y s losf 1 , 4 7 4
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operationsunder ac!p!ncture anaesthesia
ChineseMedicalJaumal. 1(s): 369 74
2. ChengX ed i9a7J Chineseacupunctureand moxibustion.
May 1997 Val 15 Na.1
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Electroacupuncture analgesia in major
abdominal and pelvic surgery: a randomised
study
P Poulain, E Pichard Léandri, A Laplanche, F Montange, J Bouzy and J
Truffa-Bachi
Acupunct Med 1997 15: 10-13
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