The high incidence of pain after anal surgery is due to the physiological structure and pathological status of the anus. At present, the use of painkillers cannot provide satisfactory pain relief, which makes complementary therapy important. This paper proposes acupoint needle-embedding combined with ironing therapy to relieve postoperative pain.
Acupoint needle-embedding combined with ironing therapy is a non-drug treatment method to release postoperative pain after anal surgery. The practice is guided by traditional Chinese medicine (TCM) syndrome differentiation theory and employs acupoint stimulation and heat to alleviate pain. Although prior research has shown that these are dependable methods for pain relief, the combined effect of the two techniques has not been described. In our research, we found that compared to using diclofenac sodium enteric-coated capsules alone, adding acupoint needle-embedding combined with ironing therapy was more effective for reducing pain levels at different stages after hemorrhoid surgery. Although this technique is efficient and commonly used in clinics, due to its invasive practice, acupoint needle embedding still carries risks relating to hospital-acquired infections and broken needles. Ironing therapy, on the other hand, can result in burns and connective tissue injuries. Therefore, there is an urgent need to develop a standardized protocol for medical staff. Our protocol refines the traditional techniques and provides detailed instructions on patient preparation, operation techniques, and postoperative care to ensure the therapy is carried out safely and efficiently. By standardizing this therapy, this technique is expected to become an important complementary therapy for postoperative pain relief in hemorrhoids, which will significantly improve patients 'life quality after anal surgery.
Postoperative pain is one of the most common complications in anorectal surgery. Among these conditions, pain caused by hemorrhoid surgery is particularly prevalent1. Generally speaking, postoperative pain may be caused by anxiety after surgery2, improper surgical methods3, obstruction of blood and lymph flow4, surgical wound infection, and spasm of the internal anal sphincter5. In most cases, postoperative pain is a normal physiological response, but excessive or persistent pain causes discomfort to the patients, aggravates psychological pressure, and, thus, hinders recovery6.
For mild pain, non-steroid anti-inflammatory drugs (NSAIDs), calcium channel blockers, and surface anesthetics can fulfill the treatment requirements7,8. For severe pain, morphine and tramadol seem to be an appropriate selection9. However, analgesics are associated with poor pain relief effects in anorectal surgery, and the risks of gastrointestinal bleeding or gastric ulcers caused by NSAIDs make clinicians hesitant to prescribe them10,11. Furthermore, the addictiveness of opioids can have a huge impact on the patients' living standards12. Optimizing the surgical procedure to prevent postoperative pain, such as by including lateral internal anal sphincterotomy, has been criticized due to its risk of anal incontinence13.
Acupoint needle embedding is a branch of acupuncture treatment, and its analgesic effect has been recognized for a long time. Ashi acupoint has a good analgesic effect, but its practice is limited because of the anus' physiological function and anatomical structure, as directly stimulating the anus only increases the pain for the patients14. In recent years, stimulation on other acupoints to release pain has been reported15,16. Wang et al.17 achieved significant pain relief effects after hemorrhoid surgery by stimulating acupoints such as Changqiang (DU1), Chengshan (BL57), and Erbai (EX-UE2) with pestle needles. A more comprehensive study found that in the sham acupuncture group, pain relief was lower at 5 h, 7 h, and 8 h after treatment than in the acupuncture stimulation group18. Meanwhile, according to several meta-analyses, stimulation of acupoints can reduce postoperative pain with a better therapeutic effect than NSAIDs19,20. In TCM theory, stimulating acupoints can reduce the anxiety state of patients. In addition, it can promote local blood circulation to accelerate the resolution of inflammation and tissue repair17. A study has reported that acupuncture can also promote the release of endogenous analgesic substances, such as enkephalins and endorphins, to block the transmission of pain signals in nerve cells21. Acupuncture treatment is not only effective in relieving postoperative pain in hemorrhoids, but it has also been reported to be effective in relieving musculoskeletal pain22, back pain23, and primary dysmenorrhea24. Summarizing the previous clinical trials, we believe that acupuncture point stimulation is effective for pain relief after hemorrhoid surgery.
Ironing therapy is one of the most widely used treatment methods throughout human history. It involves using heat to penetrate the skin and accelerate blood flow, promote tissue metabolism, and regulate sensory nerves to reduce pain25. Furthermore, heat can also relieve the contraction of the muscles26. Massage techniques can be added to this treatment to increase the effect of pain relief. A previous clinical trial demonstrated that massage on the suprapubic and sacral regions could relieve pain in the perineal region27. It works by blocking pain signals from reaching the central nervous system while increasing sympathetic nerve activity and reducing the pain caused by negative emotions28,29.
The operating procedures included in the protocol increased the safety of the operation, shortened the hospitalization days, reduced the level of postoperative pain, and decreased the incidence of urinary retention and anal edema. Acupoint needle-embedding combined with ironing treatment is a characteristic traditional Chinese medical method for postoperative pain from hemorrhoids and is recommended for healthy adults with no contraindications. It is expected to become an important complementary treatment for patients with postoperative pain.
A brief graphical flow of the protocol is shown in Figure 1. The protocol was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Hospital of Chengdu University of Traditional Chinese Medicine (code: 470000013, 4300000011). The data were obtained with the informed consent of the patients. The patients voluntarily signed informed consent prior to the study. The inclusion criteria were as follows: the ability to follow the doctor's advice; signing the consent form; diagnosis of hemorrhoids; excision of hemorrhoids with Milligan-Morgan surgery (M-M surgery). The exclusion criteria were as follows: patients with serious organ diseases; patients with anxiety, depression, or other mental disorders; patients with drug allergies; patients who could not cooperate.
1. Instrument preparation
2. Doctor-patient preparation
3. Operation steps
Statistical analysis
Collect and analyze the data using SPSS 22.0. In this work, normally distributed continuous variables were expressed as mean ± standard (SD), and comparisons between two groups were made using the Student's t-test. Continuous variables with skewed distributions were described using the median and 25% and 75% interquartile range, M (QL, QU), and comparisons between groups were performed using the Mann-Whitney U-test. Dichotomous variables were tested using the Chi-square test. Values of p < 0.05 were considered statistically significant.
Results
A total of 60 patients who underwent M-M surgery in the Hospital of Chengdu University of Traditional Chinese Medicine from August 2022 to September 2022 were selected as the research subjects, and they were divided into a treatment group and a control group based on the patient preferences, with 30 cases in each group. The control group received oral administration of diclofenac sodium enteric-coated capsules; the treatment group received oral administration of diclofenac sodium enteric-coated capsules and acupoint needle-embedding combined with ironing therapy. Diclofenac sodium enteric-coated capsules were administered every 12 h during hospitalization in both groups. Needle-embedding combined with ironing therapy was simultaneously implemented at every observation node, which strictly followed the same operation flow, steps, and frequency in the protocol.
There were 18 males and 12 females in the control group, with an average age of 47.17 years ± 2.09 years, an average BMI of 24.89 kg/m2 ± 0.77 kg/m2, and a preoperative visual pain score (VAS) of 1.83 ± 0.20. There were 14 males and 16 females in the observation group, with an average age of 44.97 years ± 2.26 years, a BMI of 24.89 kg/m2 ± 0.77 kg/m2, and a preoperative VAS score of 2.01 ± 0.21. There was no statistical difference in the baseline data between the two groups (p > 0.05).
Patients after hemorrhoid surgery often face different degrees of wound pain. We routinely manage the patients' diet, operative area care (keeping the anus dry and hygienic), and emotional well-being. The administration of diclofenac sodium enteric-coated capsules is one of the common treatment measures to relieve postoperative pain of hemorrhoids, and it has a high therapeutic efficiency compared to the external application of surface anesthetics (lidocaine)34. We found that compared with the use of diclofenac sodium enteric-coated capsules alone, patients treated with acupoint needle-embedding combined with ironing had lower VAS scores after the first defecation (5[4,6] vs. 4[3,4], p < 0.001; see Figure 3A). To observe the treatment effect at different time points, we also recorded the VAS scores on the fifth day after surgery and the discharge day. The results showed that on the fifth day after surgery and discharge day, patients with TCM treatment were in less pain than the control group (4[3,5] vs. 2[1,2], p < 0.001; 2[2,3] vs. 1[0,1], p < 0.001; see Figure 3B,C). We also noticed that the treatment group showed a greater decrease in VAS scores between the first defecation and the fifth day after surgery (p < 0.001; see Figure 3D). Pain is one of the main causes of postoperative urinary retention, and nearly 60% (n = 30) of patients in the control group had urinary retention during hospitalization compared to 26.7% (n = 30) in the treatment group, with significant statistical differences (p = 0.009). In addition, the incidence of postoperative anal edema was 33.3% (n = 10) in the treatment group and 63.3% (n = 19) in the control group (p = 0.02). The statistics also revealed that compared with the treatment group, the hospitalization days were shorter in the control group (6[5,6] days vs. 7[6,8] days, p < 0.001).
Figure 1: A graphical flowchart of the protocol. The flowchart describes all the steps performed to carry out the protocol. Please click here to view a larger version of this figure.
Figure 2: Diagram of the distribution of acupoints. The red points indicate the needle-embedding acupoints, and the blue points indicate the ironing therapy acupoints. (A) Erbai (EX-UE2): 4 cun (8 cm35) above the wrist crease of the forearm, on both sides of the flexor carpi radialis tendon, two acupoints in one limb. (B) Chenshan (BL57): Below the belly of the gastrocnemius muscle when stretching the leg and lifting the heel. (C) Sanyinjiao (SP6): Posterior to the mesial border of the tibia, and 3 cun (7 cm35) above the tip of the medial malleolus. (D) Qihai (CV29): On the anterior midline, 1.5 cun (3 cm35) below the umbilicus. (E) Tianshu (ST25): On the same level as the umbilicus, and 2 cun (4.5 cm35) lateral to the anterior midline. (F) Changqiang (DU1): Below the coccyx, at the midpoint between the end of the coccyx and the anus. Cun is a special unit of measurement in TCM theory; it is generally equal to the distance between the distal interphalangeal joint and the proximal interphalangeal joint of the index finger, and according to the literature, 1 cun is about 2.0-2.2 cm in length35,36. Please click here to view a larger version of this figure.
Figure 3: VAS scores at different stages after surgery. (A) VAS score after the first defecation; (B): VAS score on the fifth day after the operation. (C) VAS score on discharge day. (D) VAS score difference between the first defecation and the fifth day; a positive value means the pain is relieved, and a negative value means the pain increased. Please click here to view a larger version of this figure.
Surgical procedures for hemorrhoids have developed rapidly. In addition to the traditional M-M surgery, procedures such as rubber band ligation (RBL), the procedure for prolapse and hemorrhoids (PPH), tissue-selecting therapy stapler (TST), hemorrhoidal artery ligation, and infrared photocoagulation have also been widely used37,38,39. However, the advantages of M-M surgery, such as the high cure rate, low price, and simple operation, make it still one of the most commonly used procedures today40. As one of the most sensitive organs, a slight injury in the anus will bring discomfort to patients41. Relieving postoperative pain remains a major complication of anorectal surgery.
Acupoint needle-embedding and ironing treatments have been utilized as a vital component of TCM for thousands of years. Due to its excellent pain relief advantages, it has received continuous attention in recent years. Research has shown that 59%–90% of patients claim acupuncture is helpful in pain relief42, and multiple randomized controlled trial studies and meta-analysis articles have also proven that compared with non-acupuncture groups, acupuncture treatment has a significant effect in relieving acute and chronic pain43,44,45. During acupuncture treatment, stimulation signals are transmitted to the brain, leading to changes in pain-related cytokines and neurotransmitters46. Otherwise, ironing therapy has been found to promote the reduction of edema and accelerate the reflow of blood and lymph25. Combining traditional Chinese medicine and massage techniques makes it more effective.
However, traditional acupoint needle-embedding and ironing techniques cannot satisfy the treatment of postoperative pain in hemorrhoids. Based on the previous techniques, the protocol standardizes and refines the operation and elaborates on detailed methods for three acupoints for needle-embedding and three acupoints for ironing. Adjustments have been made to the acupuncture massage time, acupuncture technique, ironing temperature, and ironing techniques in this protocol. In general, the intensity of stimulation was reduced. In needle-embedding treatment, one of the most basic and essential points is to ensure the accurate positioning of acupoints. In press needle massage, the protocol should be strictly followed to reduce the incidence of broken or stalled needles. Likewise, as this represents a relatively invasive operation, it is necessary to avoid large blood vessels and major nerves to avoid adverse events of acupuncture. At the same time, temperature measurements must be carried out before the ironing. During the treatment process, the massage techniques, such as the strength, depth, and frequency, should be closely monitored.
In our clinical trial, we discovered that patients who underwent acupoint needle-embedding and ironing treatments had significantly lower VAS scores on their first defecation, the fifth day after surgery, and the discharge day (p < 0.001). The usage of this method also shortened the hospitalization days (p < 0.001) and reduced the incidence of postoperative urinary retention (p = 0.009) and anal edema (p = 0.02). These results are consistent with previous studies, providing evidence that this treatment can effectively alleviate postoperative pain and enhance patients’ postoperative quality of life.
Although this operation is performed under professional supervision, burns and needlestick injuries are still one of the main points that should be taken care of. In the meantime, the operation is not applicable to special populations (pregnant women, pediatric patients) or patients in special states (surgical inappropriateness, extreme hunger, overfeeding, mental stress, or needle sickness). In previous studies, laboratory or auxiliary tests have not been perfected, so there is an urgent need to elaborate on the microscopic mechanisms through these indicators.
The authors have nothing to disclose.
This research was supported by the Hospital Foundation of Hospital of Chengdu University of Traditional Chinese Medicine (Y2023016) and the Second Postgraduate Research Innovation Practice Project of the School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine (LCYJSKT2023-35) and Sichuan Provincial Administration of Traditional Chinese Medicine General Program (2023MS005).
diclofenac sodium enteric-coated capsules | Temmler Ireland Co., Ltd., Kerry, Ireland | H20170098 | |
fructus aurantii | Traditional Chinese Medicine Co., Ltd., Sichuan, China | 220209 | |
fructus foeniculi | Traditional Chinese Medicine Co., Ltd., Sichuan, China | 220210 | |
gauze bag | Anhui Meijianan Household Products Co., Ltd, Anhui, China | M921 | |
hand sanitizer | Suolang Medical Disinfectants Co., Ltd., Zhejiang, China | 200561121Q | |
iodophor cotton swabs | Jiabeier Medical Technology Co., Ltd., Zhejiang, China | 20162140536 | |
microwave oven | Galanz Group Co., Ltd., Guangdong, China | P70D20L-ED(W0) | |
press needle | Suzhou Acupuncture Supplies Co., Ltd. Zhejiang, China | 20162200591 | |
pulverizer | Zhaofenger Industry and Trade Co., Ltd., Hunan, China | J80031 | |
radix paeoniae alba | Guoqiang Pharmaceutical Co., Ltd., Sichuan, China | 220601 | |
rhizoma chuanxiong | Yuankang Pharmaceutical Co., Ltd., Sichuan, China | 220603 | |
rhizoma corydalis | Xinhehua Pharmaceutical Co., Ltd., Sichuan, China | 2206071 | |
rhizoma curcumae longae | Traditional Chinese Medicine Co., Ltd., Sichuan, China | 220216 | |
sterile cotton swabs | Zhongxin Sanitary Materials Co., Ltd., Sichuan, China | 20180021 | |
sterile tweezers | Weigao Grope Medical Polymer Co., Ltd., Shandong, China | 20182640148 | |
thermometer | Beierkang Medical Devices Co., Ltd., Guangdong, China | 20162200505 | |
treatment towel | Sichuan Hualikang Medical Technology Co., Ltd, Sichuan, China | 2111901 |