Study: Acupuncture vs. Metoclopramide in postoperative gastroparesis syndrome

Reference

Sun BM, Luo M, Wu SB, et al. Acupuncture versus metoclopramide in the treatment of postoperative gastroparesis syndrome in patients with abdominal surgery: a randomized controlled study. J Chin integr med. 2010; 8 (7): 641-644.

Design

This is a randomized controlled study with 63 patients of the Eastern Hepatobilialy Hospital of the Second Military Medical University, Shanghai, China, 2004–2007, with postoperative gastroparese syndrome (PGS), which were dealt with with acupuncture or Metoclopramid (Reglan). 32 patients received acupuncture, including 22 men and 10 women. Metoclopramid was administered 31 patients, including 24 men and 7 women. The acupuncture points were CV/RN12 (Zhongwan) and bilateral ST36 (together), which were treated with a mild addition, P6 (Neiguan), which were treated with stimulation, and SP6 (Sanyinjiao), which were treated with reinforcement technology. All 7 needles were left in there for 30 minutes once a day. Metoclopramid was administered 20 mg in three times a day. PGS was confirmed by radiological visualization of Meglumindiatrizoat.

Results were grades of the improvement, evaluated as:

• recovery: no discharge of gastric juice, no nausea or vomiting after removal of the gastric tube and the patient was able to eat half -liquid food;
• Effective: reduced amount of gastric juice, nausea without vomiting, gastric tube available; And
• Ineffective: no decrease in gastric juice volume, still nausea and vomiting, gastric tube still available; PGS was available for 9-10 days + 6–7 days.

At the beginning of the study, the starting age, the volume of stomach and the lack of diabetes between the treatment arms did not differ significantly.

most important knowledge

of the acupuncture patients were recovered as recovered and 3, according to a therapeutic treatment frequency of 6.58 + 4.26. Of the metoclopramide patients, 10 were recovered, 12 as effective and 9 classified as ineffective.

previous research

1. PGS is defined in China 1 based on 7 diagnostic criteria:
2. nausea, vomiting, flatulence and chills after a liquid or semi -liquid diet
3. stagrainage fluid> 600 ml/day for 6 or more days
4. no mechanical gastric care
5. reduced or missing gastrointestinal motility
6. lack of disorders of water, electrolyte and acid-base equilibrium
7. lack of medication that affects the contraction of the gastric muscles
8. lack of diseases that can cause PGS (e.g. type 1 and type 2 diabetes-induced neuropathy)

The chosen acupuncture points are clinically significant for stomach complaints-front MU of the stomach, regulation of the gastrointestinal qi and abdominal expansion on the conception vessel (CV/RN12); to calm Shen (spirit/mood), to calm nausea and vomiting and to regulate Qi (PC6); 3. Yin-meridian screaming in the lower leg for conversion of moisture, spread of Qi, regulation of the abdominal stretch (SP6); And to control the stomach peristalsis at the upper and at the lower end and for the regulation of Qi and blood in weak and poor conditions (ST36). ^{2.3,4 The last three points have been examined in several clinical studies and are often used in clinical practice. The use of CV/RN12 was unique in the current study.}

Two animal studies examined these points and the physiological mechanism. HU et al. (1996) gave large mice 654-2 solution (anisodamine) and showed that the acupuncture of ST36 improved stomach motility, while TFP (trifluoperazine) blocked this reaction. But needles that were held for 25 minutes improved gastric motility. Anisodamine is an anticholinergic, an alpha-1-adrenergic receptor agonist and a tropanalkaloid from the nightshade plants that is used in China to treat circulatory shocks. ^{6 TFP is a schizophrenes, antipsychotic medication with Central antadrenergic, antidopamine and mild anticholinergic effect, which is used in the event of unrest, severe nausea and vomiting, but the risk of late dyskinesia carries. Ouyang et al. In 2002 used PC6 and ST36 to examine the gastric motility in 7 female hunting dogs, which eight electrode pairs were implanted in the stomach erosa and a duodenum cannula to assess the gastric emptying. Points the slow stomach waves in distal stomach normalized on both sides, which increased spike pies in distal stomach, significantly increased vagus activity and significantly reduced the sympathy balance. The improvement of the slow-wave rhythm of the stomach and the antral contractile spike activity accelerated the gastric emptying significantly after 15 minutes ( p <0.02), 45 minutes ( p <0.02) and 90 minutes ( p <0.04). Both animal studies confirmed the effect of acupuncture on gastric emptying and the ability of TFP to block the acupuncture reaction.}

Four studies were carried out on people with diabetic gastroparesis. Zhang et al. divided 72 cases of diabetic gastroparesis in the treatment with Motilium 10 mg three times a day 30 minutes before meals or acupuncture. ⁸ The selected points were Li11 (Quchi), Li4 (Hegu), CV12 (ZHongwan), ST36 (Zusanli), ST40 (Fenglong), SP9 (Yinlingquan), SP6 (Sanyinjiao), SP10 (XUEHAI) and SP8 (Diji). for 10 days. The effectiveness rate was 91 % for acupuncture and 77 % for motilium control ( p <0.05). In 2007, Sun and Wang reported over 41 cases of PGS, divided into three groups, which were treated with 1) Warming of the needles with moxibustion (n = 17), 2) acupuncture plus ear acupuncture (n = 12) or 3) routine acupuncture. Therapy was rated 100 % successfully, but the first group required 7.2 + 3.8, the second group 9.8 + 4.6 and the third group 15.2 + 3.8 treatments in order to achieve success in all patients. Therefore, the fewest treatments needed needles with moxibusion heating to be effective. In 2008 Wang et al. Via electrical acupuncture (EA) of ST36 and Li4 or Schein-EA as a control in 19 randomized diabetics with symptoms of a gastroparesis over more than 3 months. ^{10 The treatment that consisted of 4 sessions over 2 weeks improved the stomach emptying at the end of the test and in the 2 weeks that there were significant undesirable events or a significant change in cholesterol and glucose laboratory findings. Zeng and chai compared acupuncture and motilium with diabetic gastroparesis. 11 The needle was carried out at CV12 (Zhongwan), ST36 (together), PC6 (Neiguan) and SP6 (Sanyinjiao) daily for 2 weeks (n = 30). Motilium (10 mg 3 times a day, 30 minutes before meals) was administered for 2 weeks (n = 30). Each group received the treatment for 2 cycles (ie 4 weeks). The effective rate was 93.3 % in the acupuncture group and 73.3 % in the Motilium group ( p <0.05).}

zhang and yan divided 102 cases evenly and randomly into orales omeprazole (dose not specified) or danshen connection ( salvia miltrorrhiza ) in st36 (together) and BL21 (Weishu). Akupunktinjection was effective in 96 % compared to 76 % in omeprazole ( p <0.01) after 2 weeks. The diverse components of the s. Miltrorrhiza connection was not characterized.

pfab et al. (2011) compared the acupuncture of PC6 (Neiguan) with standard medication for promoting mobility (Metoclopramide, Cisaprid and erythromycin) in 30 mechanically ventilated intensive care patients with a gastric residual volume (GRV)> 500 ml for more than 2 days after the operation. ^{13 The success was defined as GRV <200 ml per 24 hours. After 5 days, 80 % of the acupuncture group developed a feed tolerance compared to 60 % of the group of medication. The medication group showed no increase in the feed balance until the 6th day.}

After 5 days, 80 % of the acupuncture group developed a feed tolerance compared to 60 % of the group of medication.

metoclopramide is an anti -metal and gastroprocinetic means to facilitate gastric emptying in gastroparesis. The US Food and Drug Administration has approved it for short-term application (i.e. 4–12 weeks), although it is often used longer in clinical practice. It binds to dopamine-D2 receptors as a receptor assagonist and is a mixed 5-HT3 antagonist and 5-HT4 agonist. The D2 activity contributes to the prevention of nausea and vomiting in the central nervous system, and the 5-HT4 effect can contribute to its antiemetic effect. Its procinetic effect increases the peristaltic tone and the amplitude of the jejunum and duodenum and relaxes the pylorus sphincter and the Bulbus Duodeni. ¹⁴

effects on practice

pgs often occurs after resections of the stomach, the pancreas, the duodenum, the gallbladder and/or liver and affects 2–19 % of the patients. PGS delays the recovery of the patient, the successful removal of the gastric tube and the subsequent oral food intake as well as the discharge from the hospital, which increases health costs, the patient's recovery is slowed down and adequate nutrition is prevented. According to this medium -sized study, acupuncture was more effective than the traditionally prescribed Metoclopramide.

Based on our current knowledge, the use of a bilateral acupuncture of ST36 alone or PC6 alone or in combination with points such as SP6, PC6 or CV/RN12 should be used for the patient in postoperative gastroparesis. All of these points are easy to locate and to be relatively safe or stimulate in other ways. It also seems that a 30-minute storage of the needle is more effective than the 5 minutes usually used in current clinical practice.

restrictions

In the current study, neither the randomization method nor the clinical condition of each subject, which existed before the stomach resection surgery, the exact number of treatment days before the clinical result assessment or the question of whether the reference index system was previously validated were defined. The qualifications and the bias control of those who carry out the treatment and carry out the clinical assessment were not described. Some of these details may have been lost in the translation from Chinese into English. The other essential difference in this study on the clinical practice of traditional acupuncture is that the tongue and pulse diagnosis and other clinical symptoms of the patient do not provide the point position; All patients in the treatment group received acupuncture at the same 7 points. The study carried out in Germany in 2011 used three standard medication and also showed a greater and faster benefit of acupuncture compared to conventional medication, which confirmed the results of the review.