Bowel dysfunction following abdominal surgery is common and usually temporary, lasting no more than 3 d; however, if patients are unable to tolerate an oral diet, pass flatus, or have a bowel movement by postoperative day 4, they are considered to have prolonged postoperative ileus (PPOI). PPOI is uncomfortable for patients and potentially dangerous. The collection of gas and secretions related to PPOI causes pain and discomfort with bloating, distention, and often emesis[1
]. Delayed gastric emptying also increases the risk of aspiration in patients during the early postoperative period. Patients with PPOI cannot be discharged from the hospital until the ileus has resolved. Few published studies have estimated the cost of PPOI, but expenses related to longer hospital stays, nursing care, laboratory/diagnostic testing, and interventional treatments are likely to be considerable.
Current treatment for postoperative ileus in China is primarily supportive and includes nasogastric suction, intravenous fluids, parenteral nutrition, and gradual ambulation with simple exercises. However, a variety of preventive interventions[2-6
] for PPOI, such as preoperative carbohydrate loading, wrapping patients in warm blankets in the operating room, chewing gum, and rocking in a rocking chair postoperatively to stimulate gastrointestinal function, have been mentioned in the literature. Further research is needed, however, to evaluate the efficacy of these approaches. Two studies published by Sculati and colleagues have concluded that a preoperative bran-enriched diet (lasting 8-10 d) may help prevent PPOI[7,8
], but this is often not practical for patients undergoing gastrointestinal surgery.
Although prevention and treatment of PPOI with various pharmacologic agents has been explored for several years, success has been limited[9-17
]. Alternatives to systemic opioid analgesia, such as thoracic epidural analgesia[18
] and non-opioid analgesics such as ketorolac tromethamine[10,11
], have been shown to shorten the duration of PPOI when compared with opioids, but non-opioid analgesia does not adequately control pain in all patients[10,11
]. The combined use of a local anesthetic for chemical sympathectomy and sparing amounts of narcotic for improved pain control has been proposed, but there is no clear guidance as to which combination best promotes bowel motility while maintaining adequate pain control[17
A 2008 Cochrane review of the use of prokinetic agents in PPOI has concluded that there was no evidence to support the use of erythromycin, and insufficient evidence for cisapride, cholecystokinin-like drugs such as cerulein, and dopamine antagonists such as metoclopramide, propranolol and vasopressin[19
]. Neostigmine rapidly decompresses the colon and has shown some potential in PPOI; however, side effects such as bradycardia, bronchospasm, and increased risk of anastomotic dehiscence are of major concern[17,20
]. Lubiprostone, a bicyclic fatty acid that acts as a chloride channel opener and thereby increases intestinal water secretion, has been shown to be effective in constipation[21
] and is currently being investigated in PPOI[16
Narcotic receptor antagonists represent another major class of drugs studied in the treatment of PPOI. Naloxone, for example, is limited by its central nervous system effects and potential to reverse analgesia[17
]. Methylnaltrexone, a quaternary derivative of naltrexone that does not cross the blood-brain barrier, has shown some efficacy in opioid-induced constipation[22,23
], but preliminary results from two trials in PPOI showed no benefit over placebo[24
]. In May 2008, alvimopan, a selective mu-receptor antagonist, was the first drug to receive United States Food and Drug Administration (FDA) approval specifically for the treatment of PPOI after showing benefit in several phase III trials[25,26
]. However, there are concerns about the cost-benefit ratio of this drug, given that it shows only a modest reduction in hospital stay (7-15 h) and costs nearly $1000/treatment cycle[27,28
Some research has suggested that traditional Chinese herbal medicines can also help bowel motility[29,30
]. For example, saussura cappa
and the formula Liu Jun Zi Tang
have been associated with improved stomach and intestinal emptying time and increased plasma motilin levels[29,31
]. Although herbal medicine shows some benefit for gastrointestinal motility, abdominal surgery patients generally cannot have anything by mouth during the perioperative period.
Acupuncture has been used in China for thousands of years to treat a variety of gastrointestinal problems[32
]. The advantages of acupuncture are that it is a cost-effective, minimally invasive procedure with a very low incidence of side effects. Although prior studies have investigated the effects of acupuncture on gastrointestinal motility in humans[33
], few randomized clinical trials have been published. Controlled animal studies supported by plausible physiological and laboratory evidence have, however, shown that acupuncture has positive effects on gastric and intestinal motility[34-38
]. Although the exact mechanisms are not fully understood, one hypothesis is that acupuncture may help regulate the gastrointestinal tract via
the autonomic nervous system. Several animal studies have revealed that the effect of acupuncture on gastrointestinal function is mediated through sympathetic and parasympathetic efferent pathways[39,40
To the best of our knowledge, only one study[41
] has evaluated the efficacy of acupuncture in preventing PPOI after abdominal surgery. However, in that trial, the incidence of PPOI assessed at postoperative day 4 after ileostomy/colostomy closure was too small to show significance between the treatment and control groups. Therefore, in the current prospective, randomized study, we investigated whether acupuncture could prevent PPOI after invasive colon cancer surgery. Bowel motility was determined by time to first flatus, time to first bowel movement, and by electrogastroenterography (EGEG), a device that detects electrical signals from the abdomen. Secondary objectives were to compare postsurgical quality of life (QOL) between the treatment and control groups in terms of pain, nausea, insomnia, abdominal distension/fullness, and sense of well-being.