Clinical practice of acupuncture techniques in the perioperative setting within the context of enhanced recovery after surgery programs: a narrative review

Introduction

Background

The current approach to anesthesia practice is undergoing significant evolution, with growing recognition of non-pharmacological techniques in improving clinical quality. Recently, alternative approaches such as relaxation therapy (1) and holistic health practice have been successfully integrated (2). Among these complementary traditional practices, acupuncture has gained prominence and has been included in many clinical trials, earning clear recognition within the context of enhanced recovery after surgery (ERAS) programs (3-5).

Rationale and knowledge gap

The rise in acupuncture’s popularity in Western countries dates back to the 1970s after its first application for postoperative pain relief (6). Positive outcomes garnered widespread attention and sparked further exploration and studies on the efficacy of acupuncture, particularly in the context of surgical analgesia. While skepticism about its effectiveness persisted in Western countries, in 1979, the WHO recognized the potential benefits of acupuncture (7).

Many of the symptoms that can be treated by acupuncture are of great interest in anesthesia practice.

Objective

The aim of this narrative review is to synthesize recent evidence on the role of acupuncture in the perioperative period, providing guidance for anesthesiologists interested in integrating this practice into their clinical routine.

We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-24-37/rc).

Methods

PubMed and Scopus databases were searched for studies in English language, mainly meta-analysis and systematic or narrative reviews, comparing the effect of acupuncture with sham or control in adult patients except pregnant women in the perioperative period, as well as investigating acupuncture suggested mechanisms of action based on animal or human research. The databases were searched for articles published between January 2000 and January 2024, but we included older references, if relevant.

To ensure a comprehensive overview, a synthesis search strategy table has also been provided (Table 1).

Acupuncture techniques

The understanding of acupuncture in the context of traditional Chinese medicine evolves around the philosophical concept of Yin and Yang, two opposite but interconnected forces, governing the universe and human events.

The balance of Yin and Yang facilitates the flow of “Qi”, the vital force forming part of any living entity, both on the spiritual and physical level.

In terms of the human body, health is believed to be achieved when there is Yin-Yang and Qi balance of the so-called functional entities: the five fundamental substances, the Zang-fu organs, the blood (xiě) that nourishes all parts and tissues of the body, and the meridians (Jing-Luo) through which Qi flows, and that together are responsible of the five cardinal functions that maintain health within the body. Yin and Yang are in harmonious balance, while illness or discomfort arises when there is disruption in this equilibrium (8). Eleven Zang-fu organs produce and regulate Qi within the body: each Zang-fu organ has a Yin-Yang pair and follows a cyclical pattern of five stages.

It is conceivable that meridians might be a functional, but not an anatomical concept that includes a summation of multiple physiological functions, including the nervous, circulatory, endocrine and immune systems (9).

By targeting some of the 361 acupuncture points along these meridians, acupuncture aims to restore the flow of Qi and therefore a person’s overall health and wellbeing. Acupuncture, originally limited to the use of fine needles, has evolved to include various forms of stimulation, such as electric acupuncture (EA), transcutaneous electrical acupoint stimulation (TEAS), laser acupuncture, microsystem acupuncture that targets specific areas such as the ear, face, hand or scalp, believed to correspond to the entire body, and acupressure, usually with fingers or hands (10).

Gentle, needle-free techniques, comprise the shonishin, that through the use of small metal tools, brushes, or tapping instruments, stimulate specific pathways on the child’s body to address a wide variety of conditions such as digestive or respiratory problems, sleep disturbances and behavioral disorders (11).

The exact mechanisms of action of acupuncture remain to be fully elucidated but various theories including neurotransmitter modulation, neurohormonal and anti-inflammatory effects as well as nervous system modulation have been proposed based on empirical evidence and research findings (12-20) (Table 2).

The WHO’s list of a series of symptoms, conditions, and diseases effectively treated with acupuncture based on controlled trials, can be used as a guide for promoting its appropriate use in countries where acupuncture is not widely practiced (Table 3).

Role of acupuncture in the perioperative period

“Acupuncture anesthesia” evolved in China since the 1950’s when sole acupuncture analgesia at the bilateral LI4 (Hegu, on the dorsum of the hand, between the 1st and 2nd metacarpal bones) acupoint was performed during tonsillectomy (21). The technique was then in vogue for a time in the 1970s until more practitioners realized that despite acupuncture itself was not able to provide adequate anesthesia during surgery, nevertheless, it could reduce the demand for anesthetics with positive effects on perioperative homeostasis (22-26).

Indeed, a new concept of “acupuncture-drug balanced anesthesia” arose (27), and acupuncture has been increasingly integrated with conventional anesthesia to enhance patient outcomes in the so-called “acupuncture-assisted anesthesia” (AAA) or combined acupuncture-medicine anesthesia (CAMA) (22).

At present, perioperative acupuncture medicine refers to the use of acupuncture techniques for the optimization of preoperative, intraoperative and postoperative phases (28). Growing evidence confirmed that acupuncture applied to surgical patients could relieve anxiety, reduce the need of anesthetics, favor respiratory and hemodynamic stability, as well as improve postoperative intestinal function recovery, pain management and shorten the length of hospital stay, with potential benefits in the context of ERAS programs. However, various degrees of bias susceptibility, methodological issues and high heterogeneity among study protocols, were pointed out from authors of the majority of recent meta-analyses as critical aspects that weaken the quality of certainty related to the effectiveness of any considered therapeutic intervention.

Premedication

Preoperative anxiety is a frequent psychological condition that can negatively affect the perioperative experience and may worsen perioperative outcomes (29,30).

Currently, various pharmacological and non-pharmacological interventions are available and among them, acupuncture and auricular stimulation (AS), which includes auricular acupuncture and comparable techniques such as EA and acupressure, have been demonstrated to be helpful in treatment of preoperative anxiety, possibly due to the induced release of modulators such as β-endorphin, serotonin and substance P (31). The increased sense of relaxation induced by acupuncture could also improve the pain response and alleviate postoperative nausea and vomiting (PONV), with beneficial effects both before and after surgery. In this context, the PC6 (Neiguan, on the inner forearm, three finger-widths away from the wrist), EX-HN3 (Yintang, at the midpoint between the inner edges of the eyebrows, HT7 (Shenmen, at the wrist crease, on the radial side of the flexor carpi ulnaris tendon, between the ulna and the pisiform bones) and the relaxation auricular point in the superior lateral wall of the triangular fossa, are amongst the most studied and effective acupoints (32,33).

In several meta-analyses, these techniques resulted superior to sham and no control conditions and comparable to conventional benzodiazepines, with patients reporting lower scores in several different but validated anxiety scales (33-36). Quality of evidence assessed according to GRADE (Grading of Recommendations Assessment, Development and Evaluation) guidelines ranged from very low to moderate.

Hypnotic and analgesic drugs sparing effect

Following earliest finding that EA could reduce the requirements of inhaled anesthetics in dogs (37), the effect of acupuncture on the demand for volatile anesthetics and hypnotics has been widely investigated and in 2015, a meta-analysis, quantitatively showed that acupuncture-assisted general anesthesia (GA) could reduce the intraoperative dosage of propofol (38). Subsequent literature further supported this finding, particularly during thyroid, abdominal and anorectal surgeries (39) while a recent network meta-analysis deeply investigated the comparative effects of different acupuncture-assisted GA techniques (40).

Among these techniques, traditional acupuncture exhibited the most significant impact, although both EA and TEAS were either effective. Despite the quality of evidence being rated as low to moderate based on the GRADE methodology, EA- and TEAS-assisted GA not only reduced the required dosages of propofol but also showed a reduction in the dosage of remifentanil compared to conventional GA. EA, in particular, demonstrated a higher benefit in this regard.

The mechanism behind these effects is believed to involve the secretion of endogenous opioid peptides in the spinal cord, with the frequency of electrical stimulation playing a pivotal role in inducing central antinociception (33).

Analgesic effect

Opioids are often necessary for the induction and maintenance of anesthesia. Inadequate pain management, especially in the postoperative period, has profound short- and long-term effects, can impair immune system function, decrease mobility with increased risk of cardiovascular and respiratory complications, and can favor transition to chronic pain and prolonged or misused narcotic consumption (41-45). Among nonpharmacological approaches, acupuncture may be an effective complementary intervention for postoperative pain, by reducing or postponing the required doses of analgesics.

Mechanism of acupuncture analgesia is not entirely clear, although a growing body of scientific knowledge supported by animal models and functional imaging, suggests that it could be the result of a plurality of integrative processes, acting at peripheral, spinal and supraspinal levels (15).

Those may include the gate control theory of pain proposed by Melzack in 1965 (12), according to which stimulation by the acupuncture needle activates the inhibitory brainstem system and therefore blocks pain signals; anti-inflammatory effects; the release of endogenous opioids such as beta-endorphins; stimulation of spinal descending antinociceptive pathways through release of inhibitory neurotransmitters such as norepinephrine and serotonin; modulation of the hypothalamic-limbic system subserving pain association, and a placebo effect.

Contribution of mast cells in acupuncture analgesia is nowadays clearer and more thought to play a pivotal role. Acupoints have been revealed to be particularly enriched of connective tissue and of mast cells (46). Heat or mechanical stimulation could activate the cell with subsequent degranulation and release of numerous biological substances that will rapidly interact with neighboring nerves, blood vessels, and muscles, forming an active neural-endocrine-immune network (47).

Activation of the central nervous system is mostly mediated by µ-/δ- and κ-receptors, it may vary in health and in pain conditions and, in case of electrical stimulations, it could elicit secretion of different endogenous opioid peptides depending on the applied frequency. Under physiologic conditions, both in rats and humans, EA at low-frequency (2 Hz) would exert an antinociceptive effect eliciting the release of enkephalin and β-endorphin which are highly selective for µ- and δ-receptors, while EA at high frequency (100 Hz) would induce the release of dynorphin, primarily acting on κ-receptors. On the contrary, in murine models in pathological conditions, κ-receptors seem not to be involved in EA analgesia (9).

Hemodynamics

Several studies have demonstrated the synergistic effects of acupuncture, attributed to its analgesic (48) and neuroendocrine properties (48), which influence hemodynamics with both anti-hypotensive (49) and anti-hypertensive effects (50). These findings suggest that acupuncture can help mitigate the physiological stress response triggered by surgery and anesthesia (51,52) (Figure 1).

Figure 1 Auricolotherapy plastic ball (white arrows) applied for controlled hypotension in the perioperative period.

In case of EA, this autonomic modulation might be expressed differently according to the frequency of stimulation: low frequency could favor a hypotensive effect and high frequency, anti-hypotensive effects (22).

Physiology studies highlighted that EA performed before surgery elicited inhibition of the premotor sympathetic area in the rostral ventrolateral medulla and an increase of parasympathetic activity in areas such as the nucleus raphe pallidus, the arcuate nucleus of the hypothalamus, and the ventrolateral periaqueductal grey (53,54).

By stimulating the vagus nerve, acupuncture anesthesia facilitates vasodilation, decreases peripheral circulation resistance and modulates the renin-angiotensin-aldosterone system (55,56). This modulation reduces the expression of substances like epinephrine, norepinephrine and renin, thereby preventing excessive increase of the heart rate and blood pressure (57).

Despite the quality of studies investigating those aspects was rated as low, combining acupuncture anesthesia with cervical plexus block anesthesia (CPBA) during thyroid surgery has shown promising results. While CPBA typically enhances sympathetic nerve activity, acupuncture at specific points like LI4 (Hegu) and PC6 (Neiguan) has been found to reduce intraoperative heart rate, blood pressure, and the incidence of postoperative adverse reactions (58).

Moreover, research suggests that acupuncture may offer myocardial protection and improve myocardial anti-ischemic hypoxia ability by reducing oxidative damage, inhibiting myocardial cell apoptosis, promoting myocardial cell recovery, and enhancing cardiac function (59,60).

Role of acupuncture in the postoperative period

Postoperative delirium (POD)

POD is a relatively common and serious neurological complication possibly due to neuroinflammation and alterations in neurotransmitters (61,62), characterized by acute and fluctuating impairment in attention and awareness, most prevalent in older and frail patients, those with existing neurocognitive disorders, and patients undergoing complex or emergency surgeries.

Whenever possible, in high-risk populations, risk of delirium should be assessed and multicomponent interventions, implemented: multimodal opioid-sparing analgesia, depth of anesthesia monitoring, sleep therapy (63) and postoperative dexamethasone are frequently-adopted POD risk reducing interventions.

A recent meta-analysis of 12 studies investigated the effectiveness of TEAS in reducing the incidence of POD in elderly patients undergoing orthopedic, thoracic and digestive surgery. Despite the certainty of evidence of most of the included studies being rated at a high or unclear risk of bias, the meta-analysis findings suggested that TEAS could be beneficial in reducing the incidence of POD, except in digestive surgery.

However, of note, only one study involving digestive surgery assessed this outcome. The dilatational wave mostly at 2/100 Hz and 2/30 Hz, and continuous wave at 2 Hz were commonly adopted irrespective of the type of surgery, while the most commonly used acupoints were PC6 (Neiguan), LI4 (Hegu), GV20 (Baihui, at the top of the head, in line with the tips of the ears), and ST36 (Zusanli, at the tibialis anterior muscle four finger breadths below the kneecap and one finger breadth lateral from the anterior crest of the tibia) (64). Due to their anti-inflammatory, neuroprotective and analgesic properties, their stimulation might reduce the incidence of POD by attenuating the extent of postoperative pain and improving sleep quality (65,66).

PONV

PONV is a prevalent complaint after surgical anesthesia and since the National Institutes of Health Consensus Development Conference report in 1998 suggested acupuncture as appropriate for PONV (67), effectiveness of different techniques was investigated in several surgical settings in the adult and pediatric population (68-71).

Several large studies investigated the protective role of acupuncture techniques (72,73). PC6 (Neiguan) wrist acupuncture point is one of the most commonly used acupoint for PONV prophylaxis and treatment since it is believed to have an impact on gastric acid secretion and on the modulation of endogenous neurotransmitters involved in the neuroendocrine system (74,75).

Nausea seems to be easier to prevent than to treat in the postoperative period (76), and the use of synergistic acupuncture techniques should be preferable. Nevertheless, evolving research suggests that stimulation of a standard “PONV point” across different surgeries may not be effective. Therefore, the selection of acupoints should be tailored to the surgical site and their relationship with both analgesic and antiemetic properties (77). Amelioration of emesis may possibly be synergistic with reduced opioids requirements induced by acupuncture analgesic effects as well as consequence of direct modulation of the chemoreceptor trigger zone via autonomic reflexes (76).

Postoperative pain control

In the context of a multimodal and opioid sparing approach to relieve acute or persistent postoperative pain according to ERAS philosophy, acupuncture showed promising advantages as a complementary and relatively safe alternative to opioid analgesia (6,78) which though remaining the most effective method for postoperative pain, may bear potential serious adverse events. Growing body of evidence is arising on the role of different acupuncture techniques in specific surgeries such as after thoracic, abdominal or orthopedic surgery (41,79-81).

Results from systematic reviews and meta-analysis suggest that acupuncture or related techniques significantly reduced pain and opioids consumption on the first postoperative day, with more favorable outcomes when conventional acupuncture and TEAS compared to EA were applied as adjuvant therapy (82,83). Entity of cumulative reduction in opioids consumption yielded to statistically significant results in both studies, but clinical impact of those results varied. The meta-analysis by Sun (82) included 15 studies, whereas the meta-analysis by Wu (83) included 11 studies, and both encompassed a wide variety of acupuncture interventions applied to different types of surgery, either pre- and/or postoperatively. Sun reported a weighted mean difference of −8.33 mg [95% confidence interval (CI): −11.06, −5.61] at 24 hours for acupuncture compared to control (corresponding to a morphine sparing effect of 23%) while standardized mean difference (SMD) for opioids usage reported by Wu was −0.72 mg (95% CI: −1.21, −0.22).

Impaired intestinal function

Postoperative ileus is a common, mostly transient, gastrointestinal dysmotility dysfunction following abdominal surgery, characterized by abdominal distension, pain, constipation, nausea, vomiting and inability to tolerate an oral diet. It can represent a risk factor for dehydration, electrolyte imbalance or sepsis and would delay hospital discharge.

The pathophysiology involves surgical trauma, inflammation, opioid use, and complex interactions among autonomic, endocrine, and immune responses (84).

Traditional postoperative management of ileus mainly includes nasogastric tubes, parenteral nutrition, early mobilization, opioid-sparing anesthesia and 5HT₄R agonists, anti-flatulence drugs or prokinetics, as well as complementary therapies like intraoperative or postoperative acupuncture.

Studies, including systematic reviews, have suggested with very low-to-moderate quality of evidence that acupuncture might offer modest yet beneficial effects in improving postoperative symptoms (85-88), potentially aiding in the recovery of patients after colorectal cancer resection (23,89,90).

Acupuncture may offer both direct and indirect benefits (91). Direct benefits may stem from its ability to reduce local inflammation in the intestinal musculature and activate the parasympathetic efferent pathway, thus enhancing gastric emptying and colonic transit (92).

On the other hand, indirect benefits could arise from acupuncture’s ability to alleviate pain, thereby reducing the need for opioid medications and potentially lowering the incidence of PONV.

Although more than 20 acupoints were selected as beneficial depending on the study protocol, ST36 (Zusanli) and ST37 (Shangjuxu, one handbreadth below the tibial tuberosity and one finger’s width lateral to the anterior crest of the tibia), both in the stomach meridian, were among the most commonly selected acupoints.

Urinary retention (UR)

UR characterized by an inability to completely empty the bladder, can arise after spinal cord injury, spinal or regional anesthesia or surgical procedures like joint arthroplasty, hernia repair, anorectal or gynecologic surgeries, with reported incidence rates ranging between 5% and 70% (93-95). Catheterization is generally considered the best treatment option for UR, but it is strongly associated with the risk of urinary tract infections (96).

Although major urological associations such as the European Association of Urology and the American Urological Association have not officially included acupuncture in their treatment guidelines for UR, there has been growing interest and research exploring acupuncture’s potential therapeutic effects in managing this condition (97).

Studies investigating acupuncture for UR have shown promising results indicating potential benefits in alleviating symptoms and reducing residual urine volume when compared to standard nursing care (93,95,96,98-101).

The mechanisms behind these benefits are thought to involve inhibition of apoptosis and facilitation of nerve recovery, which contribute to improved bladder function (98).

Acupuncture points commonly used in treating UR include BL32 (Ciliao in the 2nd posterior sacral foramen), SP6 (Sanyinjiao, above the tip of the medial malleolus), RN3 (Zhongji, below the umbilicus on the mid-line) and RN4 (Guanyuan, on the midline of the abdomen), believed to target the underlying issues related to bladder function and neurological aspects contributing to UR (99).

Moreover, EA combined with moxibustion has been suggested to enhance therapeutic efficacy, particularly in cases of UR resulting from spinal cord injury (100).

Postoperative sore throat (POST)

POST frequently occurs after tracheal intubation and represents one of the most prevalent symptoms reported from patients after GA, second only to PONV (102).

Various medications like dexamethasone (103), benzylamine (104), corticosteroids (105), lidocaine (106), ketamine (107), and magnesium (108) have been explored as effective strategies for preventing or treating POST. In addition to these medications, research has delved into the potential role of acupuncture in reducing its incidence or severity. While data on this topic is limited, a meta-analysis by Jau and colleagues suggests that stimulating specific acupoints might be beneficial, with effects mediated by the anti-inflammatory properties of acupoint stimulation and the activation of neurophysiological pathways involved in pain modulation (109).

Acupuncture direct adverse events

When performed by well-trained practitioners, acupuncture can be considered a safe treatment. The risks associated with acupuncture often involve mild and transient adverse events, even considered as intended reactions, such as bleeding, local reactions at the needling site, vegetative reactions, aggravation of symptoms, and occasional central nervous system-related issues (1–5 out of 100 patients) (110). However, serious adverse events like pneumothorax, strong cardiovascular or vasovagal reactions potentially leading to fall or trauma, though very rare (expected as 1:10,000 patients in a series of acupuncture sessions), necessitate careful consideration and solid medical decision-making by acupuncturists to ensure optimal patient safety. Acupuncturists should be adept at balancing treatment intensity based on individual patient reactions to minimize adverse events. This becomes particularly crucial when considering patients at higher risk of adverse events, such as pregnant women, the elderly, or those with cardiovascular comorbidities. In these cases, acupuncture may offer unique benefits where conventional treatments like analgesics might be limited by side effects or interactions with other medications. Despite the low rate, clear guidelines on how to report acupuncture-related adverse events should be useful (111).

Strengths and limitations of this review

Although a wide literature search was undertaken and we have attempted to organize evidence for the most relevant aspects throughout, this has not the strength of a systematic review.

Nonetheless, we believe it could provide clinicians with a pragmatic resource that highlights the developing role of acupuncture in the perioperative setting.

Conclusions

Over the last decade, application of acupuncture techniques in the perioperative period has attracted great interest and a growing number of related literature has been published (112) promoting acupuncture as a valuable tool in ERAS approach to patients scheduled for surgery. Its use in clinical practice is still sporadic, due to insufficient competence in most providers.

Currently what emerges from systematic reviews and meta-analysis (Table 4) is heterogeneous certainty in effect estimates among studies for all the considered aspects because of too many differences in the design of the included studies, whose quality often raises methodological concerns.

This makes it difficult to draw definitive clinical recommendations claiming for the need for high quality, rigorous, large sample size and multicenter clinical trials.

However, acupuncture has demonstrated effectiveness in treating PONV and other minor anesthesia side effects, as well as in preventing POD, with a degree of evidence comparable to many other common clinical practices. Integrating acupuncture into ERAS programs, which are cornerstone components of perioperative care, could enhance patient outcomes. Nonetheless, the successful integration of acupuncture requires skilled professionals, clear and appropriate indications, and reliable methods to measure its effectiveness.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-24-37/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-37/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-24-37/coif). F.S. serves as an unpaid editorial board member of AME Medical Journal from July 2023 to June 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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