Acupoint Needle-Embedding Combined with Ironing Therapy for Postoperative Pain After Anal Surgery

Summary

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.

Abstract

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.

Introduction

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 requirements^7,8. 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 them^10,11. 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 reported^15,16. 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 NSAIDs^19,20. 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 emotions^28,29.

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.

Protocol

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

1. Disinfect all the tools with iodophor cotton swabs, followed by sterile cotton swabs, and then hand sanitizer. No special treatment is needed to disinfect sterile tweezers. Use disposable sterile press needles with dimensions of 0.25 mm x 1.3 mm.
2. Ensure that the pulverizer can accommodate more than 200 g of the medicine. Maintain the speed between 25,000-30,000 rpm. Choose a gauze bag with at least a length and width of 10 cm x 8 cm and a treatment towel with a length and width of 50 cm x 40 cm.
3. Select a microwave oven with a rated power of 600-900 W and the capacity for the heat to reach between 80-90 °C in medium or high mode.
4. Obtain the following ironing medicine for acute pain: Fructus foeniculi 70 g, Fructus aurantii 20 g, Rhizoma curcumae longae 20 g, and Rhizoma corydalis 20 g. Obtain the following ironing medicine for chronic pain: Rhizoma chuanxiong 20 g, Fructus foeniculi 70 g, Radix paeoniae alba 20 g, and Rhizoma curcumae longae 20 g.
5. Obtain a thermometer that is capable of measuring in the range of 10-110 °C and allows for multiple measurements.

2. Doctor-patient preparation

1. Before the operation, perform a patient assessment. Evaluate the skin condition in advance. Do not perform the operation when the skin is damaged, infected, or suffering from other skin diseases.
2. Evaluate all the equipment. Check all the medical consumables if they are within the usage time, and check the press needles to ensure they are not bent, broken, or have burrs or barbs, etc.
3. Disinfection
   1. Use pre-sterilized operating instruments in the operation. Ensure they are all disposable medical consumables and are not sterilized in advance.
   2. Carry out operator disinfection by using hand sanitizer to perform the seven-step handwashing method³⁰.
   3. Carry out disinfection of the acupoint needle-embedding site using an iodophor cotton swab; perform spiral disinfection of the operation area from the center to the outside. Ensure the diameter of the disinfection site is larger than 3 cm, and let the disinfectant stay for about 1 min until all the iodophor has been volatilized.
      NOTE: Generally, one disinfectant is enough. If the local area is seriously polluted, three disinfections are required. Prepare the ironing site using warm water to remove the residual dirt on the skin. Additional disinfection is not required.
4. Prepare the ironing site after needle-embedding; do not perform this simultaneously.

3. Operation steps

1. Needle-embedding
   1. Carry out acupoint selection (international code). Locate three acupoints, including Erbai (EX-UE2), Chengshan (BL57), Sanyinjiao (SP6; see Figure 2) before the operation. Perform acupoint location selection as done in previous studies in the literature^16,31.
   2. Use sterilized tweezers to grip the edge of the press needle with the left hand, and aim the needle at the selected acupoint.
   3. After positioning the needle, press the needle's tail (bottom side) with the right thumb within 1 s.
   4. After inserting the needle, use the right thumb to gently rotate the needle 20-25 times clockwise at 40-50 times/min. Then, rotate the needle 20-25 times counterclockwise at the same speed. The operation should last 60-90 s.
      CAUTION: When massaging, the patient may have acid reflux, numbness, swelling, or pain. The practitioner should always ask how the patient feels; if they complain about an obvious pain or discomfort, the practitioner should reduce the strength of the massage or stop imminently.
   5. Fix the needle with tape, and keep it at the acupoint. During the stagnation, press the tail of the needle with up and down floating pressure; the amplitude fluctuates at 1-2 cm, the frequency should range between 40-50 times/min, and each massage lasts 3 min. Perform two sessions per day for 2 weeks, once in the morning and once in the evening.
   6. Change the needles every 48 h.
2. Needle removal
   1. After performing the seven-step hand disinfection process, remove the tape. Use tweezers to separate the base of the needle from the skin gently. When it is completely peeled off from the area, use tweezers to pull it out gently.
   2. When the operation is done, use an iodophor cotton swab to disinfect the broken skin. Use a sterile cotton swab to press and achieve hemostasis if the broken skin is bleeding.
   3. After completing the operation, perform the seven-step hand-washing method again for disinfection.
3. Management of acupuncture complications
   1. If the needle is broken and the end is still inside the skin, clamp it out with tweezers.
   2. If the broken end of the needle is flat or slightly depressed within the skin, use the thumb and index finger of the left hand to squeeze the skin vertically downward so that the broken needle will be exposed outside the body, and then remove the needle with tweezers.
   3. If the broken needle is too deep, locate it under the X-ray, and remove it by surgery.
      NOTE: For needlestick injuries or fainting during acupuncture, please see another protocol³².
4. Ironing
   1. Refer to step 2.3.3 to disinfect the operation site, and make sure that the patient's urine is emptied before the operation.
   2. Operation sites include Qihai (CV29), Tianshu (ST25), and Changqiang (DU1)^16,33 (see Figure 2).
   3. According to the characteristics of pain, crush the drug at a room temperature of 10-30 °C and a humidity of 40%-70% for 3 min using a pulverizer at a speed of 25,000-30,000 rpm. After pulverization, pack 130 g of the drug into a gauze bag, and soak in 10-30 °C water until it is fully saturated (about 60-80 s).
   4. Put the gauze bag in a microwave oven, and heat it for 2 min at 90-110 °C. After the temperature drops to 40-45 °C, wrap the medicated gauze bag firmly with a treatment towel.
   5. Place both hands on both sides of the top of the gauze bag, straighten both elbows, lean forward slightly, and press down slowly with the help of part of the body weight. The skin of the abdomen should sink by about 3-5 cm, and on the Changqiang acupoint, 2-3 cm is enough. Hold for 3-5 s, let the heat slowly penetrate the skin and subcutaneous tissue, and then release slowly. Repeat the procedure 60 times.
   6. Massage with the ironing medicine bag clockwise 60 times and counterclockwise 60 times. Each spiral massage lasts 1-2 s; repeat the whole procedure three times.
      NOTE: For RN6 and ST25, the above methods can be applied with no differences. However, it is worth noting that DU1 is close to the anus, so excessive intensity of the operation may aggravate the patient's discomfort. Therefore, the operator can halve the massage time, and the temperature of the drug should be maintained at 35-40 °C. In order to protect patient privacy, operations can be carried out with clothing in DU1.
   7. After the operation is completed, cover the operation part, and keep it warm. Perform the procedure twice per day, once in the morning and once in the evening, and reuse the ironing medicine bag up to four times. The treatment lasts for 2 weeks.
5. Scald management
   1. For the treatment of burns, prevention is more important than operation. Strictly follow the above protocol, and do not extend the operation time or increase the operation intensity without authorization.
   2. If the burns occur that are limited below a deep partial degree burn, quickly rinse the scalded area with flowing cold water (5-15 °C is preferred) for 30 min. Then, disinfect the damaged spot with iodophor swabs, cover it with gauze, and fix it with medical tape. If the damaged area is large, use antibiotic ointment.
      NOTE: At the injury site, do not perform the treatment until the lesions have fully recovered. Puncturing of the blisters should not be done.
   3. If the scald reaches a deep partial degree, please consult with the burn department immediately.

Results

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-squar...

Discussion

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 used^37,38,39. However, the advantages of M-M surgery, such as the high cure rate, low price, and simple opera...

Materials

Name	Company	Catalog Number	Comments
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