Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023).

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

Effect of perioperative acupoint electrical stimulation on macrophages in mice under operative stress.

The strong perioperative stress response caused by surgical anesthesia can significantly suppress immune function, and the body is in a state of immunosuppression for 3 to 4 days after surgery, which leads to an increase in the probability of postoperative infection. Traditional Chinese medicine believes that acupuncture points can "reconcile yin and yang", promote the recovery of immune function, and help reduce the incidence of postoperative infection. Macrophages are an important type of immune cells that participate in the body's innate immunity. They have powerful phagocytosis and clearance functions. They can be polarized into M1 and M2 types under the regulation of the body, and play different roles in fighting microbial infections. Among them, the M1 type can participate in the elimination of pathogens. In this study, we will investigate the perioperative acupoint electrical stimulation to alleviate the immunosuppressive state of surgical stress mice, clarify the regulation of perioperative acupoint electrical stimulation on glucocorticoids and the relationship between NF-κB molecules and macrophage polarization.The key molecules of related pathways were verified by glucocorticoid receptor inhibitors, and it was found that electrical stimulation of acupoints during the perioperative period can affect the polarization of macrophages in surgically stressed mice to the M1 type by reducing the level of glucocorticoids and promoting the expression of NF κB molecules. Further reveal the partial mechanism of electroacupuncture regulating the anti-inflammatory and pro-inflammatory processes of macrophages in the immune response.

Perioperative transcutaneous electrical acupoint stimulation (pTEAS) in pain management in major spinal surgery patients.

BACKGROUND: Lumbar disc herniation is seen in 5-15% of patients with lumbar back pain and is the most common spine disorder demanding surgical correction. Spinal surgery is one of the most effective management for these patients. However, current surgical techniques still present complications such as chronic pain in 10-40% of all patients who underwent lumbar surgery, which has a significant impact on patients' quality of life. Research studies have shown that transcutaneous electrical acupoint stimulation (TEAS) may reduce the cumulative dosage of intraoperative anesthetics as well as postoperative pain medications in these patients. OBJECTIVE: To investigate the effect of pTEAS on pain management and clinical outcome in major spinal surgery patients. METHODS: We conducted a prospective, randomized, double-blind study to verify the effect of pTEAS in improving pain management and clinical outcome after major spinal surgery. Patients (n = 90) who underwent posterior lumbar fusion surgery were randomized into two groups: pTEAS, (n = 45) and Control (n = 45). The pTEAS group received stimulation on acupoints Zusanli (ST.36), Sanyinjiao (SP.6), Taichong (LR.3), and Neiguan (PC.6). The Control group received the same electrode placement but with no electrical output. Postoperative pain scores, intraoperative outcome, perioperative hemodynamics, postoperative nausea and vomiting (PONV), and dizziness were recorded. RESULTS: Intraoperative outcomes of pTEAS group compared with Control: consumption of remifentanil was significantly lower (P < 0.05); heart rate was significantly lower at the end of the operation and after tracheal extubation (P < 0.05); and there was lesser blood loss (P < 0.05). Postoperative outcomes: lower pain visual analogue scale (VAS) score during the first two days after surgery (P < 0.05); and a significantly lower rate of PONV (on postoperative Day-5) and dizziness (on postoperative Day-1 and Day-5) (P < 0.05). CONCLUSION: pTEAS could manage pain effectively and improve clinical outcomes. It could be used as a complementary technique for short-term pain management, especially in patients undergoing major surgeries. TRIAL REGISTRATION: ChiCTR1800014634, retrospectively registered on 25/01/2018. http://medresman.org/uc/projectsh/projectedit.aspx?proj=183.

Prophylactic hyperthermic intraperitoneal chemotherapy may benefit the long-term survival of patients after radical gastric cancer surgery.

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been proven to improve the survival rate of gastric cancer and reduce peritoneal recurrence. We aimed to evaluate the effectiveness and safety of prophylactic HIPEC after radical gastric cancer surgery in this study. Researchers searched for studies published in PubMed, Embase, Web of science, Scopus, Cochrane, Clinical key databases and Microsoft Academic databases to identify studies that examine the impact of prophylactic HIPEC on the survival, recurrence and adverse events of patients undergoing radical gastric cancer surgery. RevMan 5.3 was used to analyze the results and risk of bias. The PROSERO registration number is CRD42021262016. This meta-analysis included 22 studies with a total of 2097 patients, 12 of which are RCTs. The results showed that the 1-, 3- and 5-year overall survival rate was significantly favorable to HIPEC (OR 5.10, 2.07, 1.96 respectively). Compared with the control group, the overall recurrence rate and peritoneal recurrence rate of the HIPEC group were significantly lower (OR 0.41, 0.24 respectively). Significantly favorable to the control group in terms of renal dysfunction and pulmonary dysfunction complications (OR 2.44, 6.03 respectively). Regarding the causes of death due to postoperative recurrence: liver recurrence, lymph node and local recurrence and peritoneal recurrence, the overall effect is not significantly different (OR 0.81, 1.19, 0.37 respectively). 1-, 3- and 5-year overall survival follow-up may be incremented by the prophylactic HIPEC, and which reduce the overall recurrence rate and peritoneal recurrence rate. HIPEC may have high-risk of pulmonary dysfunction and renal dysfunction complications. No difference has been found in the deaths due to recurrence after surgery.

Inhibiting ATG5 mediated autophagy to regulate endoplasmic reticulum stress and CD4+ T lymphocyte differentiation: Mechanisms of acupuncture's effects on asthma.

OBJECTIVE: Asthma is characterized by airway hyperresponsiveness(AHR), inflammation and remodeling. Autophagy and endoplasmic reticulum stress(ERS) are dysregulated in asthma, and ATG5 has attracted wide attentions a representative gene of autophagy. Previous evidence shows that acupuncture may treat asthma by regulating the immune environment.However,the precise mechanism involved in acupuncture's effects on asthma is unclear. Thus, we investigated the inner-relationships of acupuncture and ATG5-mediated autophagy, ERS and CD4+ T lymphocyte differentiation in asthma. METHODS: Ovalbumin (OVA)-sensitized and challenged ATG5+/- and ATG5-/-mice with asthma were treated by acupuncture at Dazhui(GV14),Feishu(BL13) and Zusanli(ST36),and sacrificed the next day.Then blood and bronchoalveolar lavage fluid (BALF)samples were collected to determine inflammatory cell counts and cytokine levels. Lung tissue samples were obtained for histological examination, and the spleen was harvested for flow cytometry. RESULTS: Compared with the untreated group, acupuncture decreased BALF inflammatory cell counts and AHR in OVA-induced mice.Acupuncture decreased autophagy-related protein and mRNA (ATG5,Beclin-1,p62 and LC3B)amounts and ERS-related protein (p-PERK, p-IRE-1,Grp78, and ATF6)levels as well as autophagosome formation in lung tissue, concomitant with increased IFN-γ and decreased IL-4, IL-17 and TGF-ß amounts in BALF.Consistently, the imbalance of CD4+ T lymphocyte subsets(Th1/Th2 and Treg/Th17) was also corrected by acupuncture.Meanwhile, AHR and inflammation were decreased in ATG5-/- mice compared with ATG+/-animals,without affecting the therapeutic effect of acupuncture. CONCLUSION: Acupuncture reduces airway inflammation and AHR in asthma by inhibiting ATG5-mediated autophagy to regulate endoplasmic reticulum stress and CD4+T lymphocyte differentiation.

[Effects of ligustrazine injection on IL-2, IL-10, and IFN-gamma in patients undergoing spinal operation after autologous blood transfusion].

OBJECTIVE: To study the regulatory effect of Ligustrazine Injection (LI) on the cellular immune function in patients undergoing autologous blood transfusion (ABT). METHODS: Enrolled were 60 patients scheduled for receiving selective lumbar surgery at the Department of Spinal Orthopedics, First Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine during October 2009 to June 2010. They were equally randomized into two groups, the trial group and the control group. LI was given to patients in the trial group by intravenous dripping at the dose of 2 mg/kg 30 min before autologous blood collection. The LI (at the final concentration of 0.005%) was added in the heparin saline solution and the washing saline for recycle blood. No LI was given to patients in the control group. They received the same treatment of the trial group. The operation time, the amount of blood loss and blood transfusion were recorded. Patients' venous blood samples were collected for determining cytokines including interleukin-2 (IL-2), interleukin-10 (IL-10), interferon-gamma (IFN-gamma) by ELISA and calculating IL-2/IL-10 ratio before surgery (T1), 1 h (T2), 1 day (T3), and 5 days (T4) after ABT. RESULTS: There was no statistical difference in the amount of blood loss and blood transfusion, the levels of IL-2, IL-10, IFN-gamma, or IL-2/IL-10 at T1 between the two groups (P>0.05). Compared with T1 of the same group, the level of IL-2 decreased at T(2-4), IL-10 increased and IL-2/IL-10 decreased at T(2-3) in the two groups. The level of IFN-gamma decreased at T(2-4), IL-2/IL-10 increased at T4, the level of IL-10 decreased at T4 in the control group (P<0.05, P<0.01). The level of IL-10 decreased at T4 in the trial group with statistical difference (P<0.05, P<0.01). Compared with the control group, the level of IL-2, IFN-gamma, and IL-2/IL-10 at T(2-4) were obviously higher in the trial group. But the IL-10 level was lower in the trial group than in the control group at T(2-4) (P<0.05, P<0.01). CONCLUSION: The application of LI in ABT had regulatory effects on the balance of cytokines.

[Effects of electroacupuncture assistant general anesthesia on postoperative cognitive dysfunction of aged patients].

OBJECTIVE: To observe the effects of electroacupuncture (EA) assistant general anesthesia on postoperative cognitive dysfunction (POCD) of aged patients. METHODS: One hundred and twenty senile American Society of Anesthesiology (ASA) grade I - III patients (more than 65 years old) with non-cardiac surgery were randomly assigned to two groups, Group A and Group B, 60 cases in each group. Patients in Group A received general anesthesia, while those in Group B received EA assistant general anesthesia. Patients in Group B received EA at Baihui (DU20), Hegu (LI4), Neiguan (PC6), Zusanli (ST36) 30 min before anesthesia induction to the end of operation. Anesthesia was induced by etomidate 0.2 - 0.3 mg/kg, fentanyl 3-5 microg/kg, cisatracurium 0.15 mg/kg in the two groups. Anesthesia maintenance was provided by sevoflurane and continuous pumping of remifentanil. Tramadol 50 mg was given 30 min before ending the operation. The scores of mini-mental state examination (MMSE), nausea and vomiting were recorded in the two groups one day before anesthesia, the 2nd, 4th, and 6th day after operation. The occurrence of postoperative cognitive dysfunction (POCD) on day 2, 4, and 6 was compared. RESULTS: The occurrence of POCD on day 2 and 4 was obviously lower in Group B than in Group A at the same time period (40.0% vs 66.7%, 13.3% vs 43.3%), showing statistical difference (P < 0.05). There was no significant difference in the pre-anesthesia scores of MMSE between the two groups. The scores of MMSE on the 2nd and the 4th day were higher in Group B than in Group A (21.3 +/- 3.9 vs 18.3 +/- 3.8, 26.4 +/- 2.9 vs 22.9 +/- 3.9, P < 0.05). Compared with one day before anesthesia in the same group, the scores of MMSE were significantly different on the 2nd and the 4th day (Group A: 18.3 +/- 3.8, 22.9 +/- 3.9 vs 27.9 +/- 2.1; Group B: 21.3 +/- 3.9 vs 27.5 +/- 2.5; P < 0.05). The occurrence of post-aesthesia nausea and vomiting was lower in Group B (23.3%, 14/60) than in Group A (46.7%, 28/60) with statistical difference (P < 0.05). CONCLUSION: EA assistant general anesthesia could reduce the occurrence of POCD in aged patients.

[Comparison of effects of acupuncture-assisted anesthesia with different acupoint combination in gynecologic laparoscopy operation].

OBJECTIVE: To explore the best acupoint combination of acupuncture-assisted anesthesia in gynecologic laparoscopy operation. METHODS: Ninety patients, with American Society of Anesthesiologists (ASA) physical status I - II, and scheduled for elective gynecologic laparoscopy operation, were randomly divided into 3 groups, 30 cases in each group. Group I received only general anesthesia, group II and group III received general anesthesia after Han's acupoint nerve stimulator (HANS) administered for 30 min, bilateral Zusanli (ST 36) and Sanyinjiao (SP 6) were selected for group II, and bilateral Hegu (LI 4) and Taichong (LR 3) were selected for group III. During operation, the concentration of Seveflurine was adjusted to maintain NTS at D1-D2. The change of ETsev value was recorded, the heart rate (HR) and blood pressure (BP) were observed, and the time from the end of operation to extubation, awake time were recorded adverse events such as restlessness, shivering, postoperative pain, nausea and vomiting, cases of respiratory depression, the analepsia quality, the time of first anus exhaust, the awaking of patient in operation and satisfactory of patients after surgery were recorded so as to evaluate the effect of acupuncture anesthesia. RESULTS: Compared with group I, the ETsev in group II was decreased 35% (P < 0.05), group ifi was decreased 25% (P < 0.05), with a significant difference between group II and group III (P < 0.05). BP and HR had more stability in group II and group III, the best in group II. As for the time from the end of operation to extubation and the time from the end of operation to open the eye on command, group I was the longest (all P < 0.05), group III was longer, group II was the shortest. The score of restlessness, postoperative pain, vomiting and in analepsia were the highest in group I (all P < 0.05), higher in group III and the lowest in group II. Consciousness score was lowest in group I (P < 0.05). As for the satisfactory of patient after operation, it was higher in group II and group IIII (both P < 0.05 ) than group I. The time of first anus exhaust in group II and group III were significantly shorter than that in group I (both P < 0.05). CONCLUSION: Han's acupoint nerve stimulator has a certain adjuvant action for general anesthesia and analgesia and acupuncture point combination with both Zusanli (ST 36)and Sanyinjiao (SP 6) have the best effect in gynecologic laparoscopy operation. It can decrease the dosage of anaesthetic, has a stable effect on HR and BP during the surgery and has a better quality of analepsia.

[Effect of ligustrazine on T-lymphocyte immunity in patients undergoing autologous blood transfusion].

OBJECTIVE: To evaluate the protective effect of ligustrazine on T-lymphocyte immunity of patients undergoing autologous blood transfusion (ABT). METHODS: Forty American Society of Anesthesiologist (ASA) I - II patients scheduled for receiving selective lumbar surgery, with pre-operational anticipatory blood loss > 400 mL and without any diseases of blood or endocrinal system were enrolled. They were equally randomized into two groups, the trial group and the control group. Ligustrazine was given to patients in the trial group by intravenous dripping at the dose of 2 mg/kg, 30 min before auto-blood collection, also by mixed in the washing saline and heparinized saline solution to make the final concentration of ligustrazine 0.005%. No ligustrazine was given to patients in the control group. The amount of blood loss and autotransfused were measured and recorded; and patients' venous blood samples for T-lymphocyte subsets (CD3, CD4, CD8) determination and CD4/CD8 ratio calculation were collected at different time points, i. e. before surgery (T0) and at 1 h (T1), 1st day (T2) and 5th day (T3) after ABT. RESULTS: CD3 decreased obviously at T1 and T2 in both groups (P < 0.05 or P < 0.01), while at T3, it restored to baseline in the trial group, but remained at the low level in the control group (P < 0.05). Moreover, levels of CD3 at T1-T3 were lower in the control group than those in the trial group respectively (P < 0.05 or P < 0.01). CD4 decreased obviously at T1 (P < 0.01) in both groups, it recovered at T2 in the trial group, but the recovering in the control group was T3, so comparison of CD4 level between groups showed significant difference at T1 and T2 (P < 0.05 or P < 0.01). As for CD4/CD8 ratio, it decreased obviously at T2 and T3 in the control group (P < 0.05), but unchanged in the trial group, showing statistical difference between groups (P < 0.05). CONCLUSION: Ligustrazine had definite protective effect on T-lymphocyte immunity in patients undergoing ABT, which was presented by the milder inhibition and quicker recovery of immunity.

[Effects of electroacupuncture anesthesia of different frequencies on stress reaction in thyroid surgery].

OBJECTIVE: To probe into the optimal frequency of electroacupuncture for the access to the best anesthesia. METHODS: Sixty cases of optional thyroid surgery were randomly divided into group A, group B and group C, 20 cases in each group. In group A, 2 Hz/100 Hz disperse-dense wave was selected in stimulation. In group B, 2 Hz/15 Hz disperse-dense wave was selected. Group C was the control group without electric stimulation applied. Hegu (LI 4) and Neiguan (PC 6) were stimulated bilaterally. Cervical plexus block was produced after 15 min acupuncture. The concentration changes in plasma cortisone (COR) and beta-endorphin (beta-EP) were compared among 4 time-points, named before anesthesia (T1), before skin incision after induction (T2), thyroid traction in surgery (T3) and the end of surgery (T4). RESULTS: Group B achieved the highest significant rate of analgesia (50.0%, 10/20) and that in group C was the lowest (10.0%, 2/20). COR content was the highest at T2 in group A and that was the lowest at T3 in group B. At the end of surgery, COR content was up the maximum in 3 groups, but still COR content was the lowest in group B in comparison. The plasma beta-EP content decreased apparently at T3 and T4 in group B as compared with the value before (both P < 0.05). CONCLUSION: In electroacupuncture-assisted anesthesia, 2 Hz/15 Hz disperse-dense wave achieves the optimal anesthesia compared with 2 Hz/100 Hz disperse-dense wave, and moreover inhibits stress reaction induced by anesthesia surgery.

[Effect of shenfu injection on the stability of circulation during induction of general anesthesia for aged people].

OBJECTIVE: To observe the intervention of Shenfu Injection (SFI) on the hemodynamics and circulatory function during induction of general anesthesia for aged people, in order to optimize the medication of anesthesia inductive phase in aged people. METHODS: Sixty aged patients scheduled to receive general anesthesia were equally randomized into 2 groups, the SFI group and the control group. SFI via intravenous drip (1 mL/kg diluted with 5 mL/kg saline) was administered to the SFI group 15 min before anesthesia induction and to the control group, normal saline was administered instead. Then the induction and intubation were implemented. The systolic blood pressure (SBP), diastolic pressure (DBP), heart rate (HR), central venous pressure (CVP), pulse saturation oxygen (SpO2), and the ST segment of ECG were observed at the different time points of induction, i.e. at the time of entry into the operating room (T1), ending the medication (T2), before the induction (T3), showing the lowest SBP in induction (T4), before and after intubation (T5 and T5). The dose and frequency of atropine and ephedrine applied in the inductive phase were observed as well. RESULTS: As compared with the baseline values measured at T1, CVP elevated at T2, T3, and T6 (P < 0.05), SBP and DBP descended at T4, T5, T6 in both groups; HR accelerated at T2, T3, and T6 in the control group; and HR at T4, T5 and T6 in both groups were significantly different (P < 0.05 or P < 0.01). Inter-group comparisons showed significant difference between groups in CVP at T2 (P < 0.05); so did SBP, DBP and HR at T4, T5 and T6 (P < 0.05 or P < 0.01). CONCLUSION: Application of SFI in the inductive phase of general anesthesia in aged people could evidently reduce the fluctuation of hemodynamics to prevent the occurrence of myocardial ischemia and improve it definitely.