ZHANG Kun (張琨), YU Qiquan (俞杞泉), BAO Qi (包祺), GUO Wentao (郭文韜), SHOU Weizhen (壽偉臻)Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China

Abstract

Keywords: Acupuncture Therapy; Acupuncture Analgesia; Acupoint Application; Pain, Postoperative; Thoracoscope; Lung Neoplasms

Lung cancer is the most prevalent cancer worldwide and is the leading cause of cancer death, accounting for about 18%[1].Surgery is currently the main treatment for early-stage lung cancer, and thoracoscopic radical lung cancer surgery (TRLCS) is the predominant surgery pattern[2-3].Despite advantages like minimal wounds,less bleeding, and sooner recovery, thoracoscopic surgery still causes a high incidence of intensive postoperative chest wound pain.Patient-controlled intravenous analgesia (PCIA) and analgesic injections are commonly used to manage postoperative pain but have certain limitations[4].Acupuncture analgesia has a long history originating from the meridian and acupuncture theories of traditional Chinese medicine(TCM), and the analgesic effect is achieved by puncturing points selected according to pattern identification.Acupuncture analgesia has been used to treat various postoperative pains.Research demonstrates that acupuncture has significant preoperative sedative effects and postoperative analgesic effects.Thus, it can reduce the consumption of anesthetics and anesthetic-related nausea and vomiting to improve surgical outcomes[5].This study added acupuncture and point application to analgesics to observe the effect on the pain after TRLCS, with the purpose of seeking a more effective treatment regime for this condition.

1 Clinical Materials

1.1 Inclusion criteria

Underwent TRLCS, aged between 16 and 80 years;willing to receive acupuncture and point application after TRLCS; PCIA was used after the thoracoscopic surgery; agreed and signed the informed consent form.

1.2 Exclusion criteria

Took oral analgesics for other forms of pain after the surgery; severe dysfunction of the heart, liver, or kidney was present after the thoracoscopic surgery; needle shock; point application allergy; peripheral neuropathies.

1.3 Statistical methods

The data were analyzed using SPSS 26.0.Normally distributed measurement data were expressed as mean ± standard deviationand checked by t-test;those not conforming to normal distribution were described using median (lower quartile, upper quartile)[M (QL, QU)] and checked by the rank-sum test.Enumeration data were expressed as cases or rates and processed by the Chi-square test.Repeated measurement data [e.g., visual analog scale (VAS) score]that satisfied normal distribution and the assumption of spherical symmetry were analyzed by the two-way repeated measurement analysis of variance; those not meeting normal distribution were checked using Scheirer-Ray-Hare test, and those not meeting the assumption of spherical symmetry were checked by the Greenhouse-Geisser correction.P＜0.05 indicated statistical significance.

1.4 General data

This study was approved by the Ethics Committee of Longhua Hospital, Shanghai University of Traditional Chinese Medicine (Approval No.2019LCSY073).We generated numbers using SPSS version 26.0 for random grouping.With these numbers, 120 patients undergoing TRLCS under general anesthesia were divided into a treatment group and a control group, with 60 cases in each group.There was no statistical significance in comparing the data of gender and age between the two groups (P＞0.05), suggesting the comparability (Table 1).

Group n Age/year M (QL, QU)Gender/case Male Female Treatment 60 57.0 (32.7, 63.1) 28 32 Control 60 60.0 (32.3, 62.8) 26 34

2 Treatment Methods

PCIA, consisting of 1.0 mg fentanyl (State Food and Drug Administration Approval No.H42022076, Yichang Humanwell Pharmaceutical Co., Ltd., China) and 0.5 g tramadol (State Food and Drug Administration Approval No.H20051867, Henan Huali Pharmaceutical Co., Ltd.,China) resolved in 100 mL normal saline was offered to both groups.The initial dosage was set at 1 mL/h, and the self-controlled dosage was 2 mL/time with a lockout of 15 min.PCIA started from the end of the surgery till 48 h later.

2.1 Treatment group

Patients in the treatment group received acupuncture and point application besides PCIA.

The acupuncture treatment was performed at 4 time points after the thoracoscopic surgery (4, 24, 48, and 72 h) at bilateral Zulinqi (GB41), Qiuxu (GB40), and Taichong (LR3) points with disposable acupuncture needles of 0.25 mm in diameter and 40 mm in length(Suzhou Medical Appliance Factory, China).The patient took a supine position.The points were all perpendicularly punctured, but the depth varied:0.8-1.0 Cun at Zulinqi (GB41), 0.5-1.0 Cun at Qiuxu(GB40), and 0.5-0.8 Cun at Taichong (LR3).Reducing manipulation was applied for Zulinqi (GB41) and Qiuxu(GB40); the patient inhaled when the needle was inserted, and the needle was then lightly pressed and heavily lifted for 5 min.Reinforcing manipulation was used for Taichong (LR3); the patient exhaled when the needle was inserted, and the needle was then heavily pressed and lightly lifted for 5 min.It took 30 min to finish needle manipulation for the three pairs of points.

Patients received point applications (Tianjin Health Co., Ltd., China) at the above points starting from 1 h after acupuncture, lasting 6 h each time.

2.2 Control group

Patients in the control group only received PCIA without other interventions.

3 Treatment Efficacy

3.1 Observation items

3.1.1 VAS score

After the surgery, all patients were followed up by a particular person for 72 h.The chest wound pain was assessed using the VAS score at 4, 24, 48, and 72 h after the operation (the postoperative 4 h VAS was estimated before acupuncture, and the 24, 48, and 72 h VAS scores were assessed after acupuncture).The VAS was measured in millimeters and scored 0-100 points; 0 meant painless, and 100 meant the most unbearable pain.Patients were asked to mark their pain intensity on the visual scale.The detailed criteria were: 0 points,painless; ≤30 points, mild and bearable pain; ＞30 and≤60 points, moderate pain that might affect sleep and require clinical management; ＞60 and ≤100 points,intensive pain.

3.1.2 Peripheral blood 5-hydroxytryptamine (5-HT)content

Before and at the four points after the surgery, 5 mL peripheral blood was collected from each patient to detect the 5-HT content using human 5-HT kits (Cat.No.ARD10686, Guangzhou Ao Rui Da Biology, China).

3.1.3 Additional analgesic consumption

The additional consumption of opioid analgesics in both groups was kept a record.

3.2 Therapeutic efficacy criteria

We adopted the Nimodipine method to calculate the VAS improvement rate, which was taken to evaluate the general analgesic effect[6].

VAS improvement rate = (VAS score before treatment - VAS score after treatment) ÷ VAS score before treatment × 100%.

Recovered: VAS improvement rate ≥95%.

Markedly effective: VAS improvement rate ≥70% but＜95%.

Effective: VAS improvement rate ≥30% but ＜70%.Invalid: VAS improvement rate ＜30%.

3.3 Results

3.3.1 Comparison of the analgesic efffect

The total effective rate was 93.3% in the treatment group versus 78.3% in the control group; the betweengroup difference was statistically significant (P＜0.05).The details are shown in Table 2.

3.3.2 Comparison of the VAS score at each point of time

Before treatment, there was no significant difference in the VAS score between the two groups (P＞0.05).After treatment, both groups showed decreases in the VAS score (P＜0.05).The interaction effect between time and group was significant (P＜0.05).The change in VAS score varied between the two groups at each point of time (P＜0.05); the VAS score was markedly lower in the treatment group than in the control group.Table 3 and Figure 1 present more details.

Figure 1 Changes in the estimated marginal means of VAS over time

Group n Recovered Markedly effective Effective Invalid Total effective rate/%Treatment 60 8 12 36 4 93.31)Control 60 5 8 34 13 78.3

3.3.3 Comparison of the 5-HT content

The peripheral blood 5-HT content dropped significantly after treatment in the two groups (P＜0.05),and the content was notably smaller in the treatment group than in the control group (P＜0.05).The details are shown in Table 4.

Group n Before treatment After treatment Treatment 60 336.81±67.54 216.28±43.611)2)Control 60 319.56±63.63 249.67±46.491)

3.3.4 Comparison of the additional analgesic consumption in PCIA

The postoperative additional analgesic consumption in PCIA was markedly smaller in the treatment group than in the control group (P＜0.05).Table 5 shows more details.

Group n Additional consumption/mL Treatment 60 14.27±1.481)Control 60 18.12±1.56

4 Discussion

In recent years, as thoracoscopic surgery develops,the thoracic incision has become smaller and smaller.Some studies hold that the surgical wound causes much less pain in video-assisted thoracoscopic surgery than in the traditional open thoracotomy, and the postsurgical recovery time and hospital stay are shorter[7-9].Controversially, some scholars believe that thoracoscopic surgeries do not reduce the surgery wound pain but cause longer time and larger bleeding volume during the operation because of the increased technical difficulty compared with the traditional open thoracotomy[10]; in addition, the lenses compress intercostal nerves harder in thoracoscopic surgeries[11-12].The pain after thoracoscopic surgeries is usually acute,in the forms of stabbing pain, pulling pain, and cutting pain, and mostly happens within 72 h after the surgery.The pertinent investigation finds that the incidence of acute incision pain after thoracic surgeries is 80%-96%[13].The acute incision pain after the thoracoscopic surgery has become a significant issue as it prevents patients from coughing, causing difficulties in expectoration and increasing the risk of postsurgical pulmonary infections, which causes a severe negative impact on the patient’s sleep and mental health,extends the postsurgical recovery time, and hampers the quality of life[14].

To date, Western medications are predominantly used for postsurgical analgesia.Despite the definite analgesic effect, medications may cause various adverse effects, and the most common ones include dizziness,nausea, vomiting, decreased blood pressure, and constipation[15].TCM has numerous approaches for killing pain, of which acupuncture analgesia ranks the top and has been extensively applied in the perioperative period[16].Acupuncture analgesia can regulate and unblock meridians and collaterals,circulate Qi and blood, and harmonize Yin and Yang,which enables the pain-killing effect[17].Hence, the combination of acupuncture and PCIA has expanded the postsurgical analgesic pattern; it not only relieves the incision pain after the thoracoscopic surgery but also reduces the consumption of analgesics and thus can avoid or reduce medication-induced adverse reactions.

We previously studied the effect of acupuncture at points like Hegu (LI4), Neiguan (PC6), and Zusanli (ST36)in relieving pain after thoracic surgeries[18].The points were selected mainly based on experiences but not pattern differentiation of meridians, which may be the factor causing poor clinical efficacy in some patients.Therefore, we optimized the current clinical trial by integrating pattern differentiation of meridians.The two TRLCS incisions are located on the lateral side of the chest.That is why the pain after the thoracoscopic surgery occurs around the route of Gallbladder Meridian on the side of the chest.According to Ling Shu(Miraculous Pivot)[19], Gallbladder Meridian disorders can be treated with points of Gallbladder and Liver Meridians.Here, we specifically applied reducing manipulations at two Gallbladder Meridian points and reinforcing manipulations at one Liver Meridian point.Clinical practice discovers that Qi-blood stagnation around incisions after thoracic surgeries is usually located on the route of the Gallbladder Meridian, and Qi-blood deficiency occurs in the Liver Meridian which is exteriorly-interiorly related to the Gallbladder Meridian.Therefore, Qi-blood stagnation can be eliminated by reinforcing Liver Meridian points and reducing Gallbladder Meridian points.Based on the relevant study[20]and the clinical practice of our study group, this trial treated the pain after the thoracic surgery mainly with the Yuan-primary and Shu-stream points of the Gallbladder Meridian and the Shustream point of the Liver Meridian, i.e.Zulinqi (GB41),Qiuxu (GB40), and Taichong (LR3).Specifically,reinforcing manipulations were performed at Taichong(LR3) first, followed by reducing manipulations at Zulinqi (GV41) and Qiuxu (GB40), and point application was conducted between two acupuncture sessions.

The results showed a more significant decrease in the VAS score and a higher total effective rate in the treatment group than in the control group (P＜0.05), as well as a more notable reduction in the 5-HT content and smaller additional analgesic consumption (P＜0.05).These all suggest lower postsurgical pain intensity in the treatment group.

In summary, the additional use of acupuncture and point application based on PCIA can reduce the incision pain after TRLCS, lessen the additional consumption of opioid analgesics in the PCIA to reduce the opioidscaused adverse reactions, enhance the patient’s postsurgical quality of life, and accelerate recovery.This offers a new treatment method for patients with postoperative pain after TRLCS and provides novel ideas for the prevalent enhanced recovery after surgery research[21].

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was supported by the Health Industry Clinical Research Youth Project of Shanghai Municipal Health Commission (上海市衛(wèi)生健康委員會衛(wèi)生行業(yè)臨床研究青年項目, No.20194Y0503).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 20 September 2022/Accepted: 1 February 2023