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Acupuncture and moxibustion for incomplete adhesive intestinal obstruction: A randomized controlled trial
World Journal of Acupuncture – Moxibustion 29 (2019) 174–178
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Research
Acupuncture and moxibustion for incomplete adhesive intestinal obstruction: A randomized controlled trial Lihua ZHANG () a,∗, Shu ZHANG () b, Pengjing YAN () a, Zhiguo ZHANG ( ) c, Suchun XIE () d a Rehabilitation Department, Cangzhou Hospital of Integrated Chinese and Western Medicine, Cangzhou 061000, Hebei, China ( , 061000, ) b Chinese Medical Clinic, Cangzhou Central Hospital, Cangzhou 061000, Hebei, China (, 061000, ) c Center of Preventive Treatment for Disease, Cangzhou Hospital of Integrated Chinese and Western Medicine, Cangzhou 061001, Hebei, China ( , 061001, ) d Acupuncture–Moxibustion and Physiotherapy Department, Xingtai People, s Hospital, Xingtai 054001, Hebei, China (, 054001, )
a r t i c l e
i n f o
Article history: Accepted 13 May 2019 Available online 29 August 2019 Keywords: Acupuncture Moxibustion Incomplete adhesive intestinal obstruction Randomized controlled trial (RCT)
a b s t r a c t Objective: To investigate the clinical efficacy of acupuncture and moxibustion for incomplete adhesive intestinal obstruction. Methods: A total of 100 patients with incomplete adhesive intestinal obstruction were randomly divided into an observation group and a control group, and there were 50 patients in each group. The control group was treated with routine western medicine treatment, while the observation group was treated with acupuncture and moxibustion therapy on the foundation of the routine western medicine treat¯ ¯ ¯ ˘ı (ST36), Shàngjùxu¯ a˘ n (CV12), Tiansh u¯ (ST25), Zúsanl ment of the control group. Zhongw ¯ ( TE6), Dàchángshu¯ ( BL 25), and Xia˘ ochángshu¯ (BL27) were taken (ST37), Zh¯ıgou when acupuncture was performed. Moxibustion was performed with moxibustion box on abdomen after acupuncture. The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery, surgery conversion rate and clinical efficacy were observed in the two groups. Results: The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in the observation group were all shorter than those of the control group. There were statistically significant differences between the two groups (all P < 0.01). The surgery conversion rate of the observation group was lower than that of the control group, there was statistically significant difference between the two groups (P < 0.01). The clinical efficacy of the observation group was superior to that of the control group, the difference between the two groups was statistically significant (P < 0.05). Conclusions: Acupuncture and moxibustion therapy on the foundation of the routine western medicine treatment, which can reduce the surgical conversion rate and cut down the time of treatment, was superior to routine western medicine treatment on the clinical efficacy of incomplete adhesive intestinal obstruction. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
In recent years, with the mounting number of abdominal surgery, the incidence of adhesive intestinal obstruction has been increasing and occupies an increasing proportion which was about 30–60% in acute intestinal obstruction [1]. Many methods are tried to prevent adhesion in modern clinic, such as peritoneal lavage with hypertonic saline, various anticoagulants and prevention of fibrin deposition, however, none of them has achieved ideal efficacy. At present, there is no specific therapeutic method in the
∗
Corresponding author. E-mail address: [email protected] (L. ZHANG).
prevention and treatment of adhesive intestinal obstruction, while conservative treatments are applied in clinic such as continuous gastrointestinal decompression, maintaining the balance of liquid and electrolyte, parenteral nutrition support and anti-infection, etc. Moreover, the efficacy of conservative treatments is not ideal, and sometimes surgical operation is required again, which means another possibility of adhesion. Thus, it is necessary and significant to explore a therapy which is safe and effective, feasible and simple, noninvasive and less pain. In recent years, acupuncture and moxibustion on the foundation of routine western medicine treatment has been applied to incomplete adhesive intestinal obstruction in the Rehabilitation Department, Cangzhou Hospital of
https://doi.org/10.1016/j.wjam.2019.08.011 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
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Table 1 Comparison of general information between the two groups of patients with incomplete adhesive intestinal obstruction (Mean±SD). Groups
Observation group Control group
Cases
49 50
Gender (cases)
Age (years)
Male
Female
Minimum
Maximum
Mean
Minimum
Course of disease (h) Maximum
Mean
Abdominal surgery
Cause of disease (cases) Gastrointestinal inflammation
Unknown
23 20
26 30
25 31
79 76
54.78 ± 10.11 51.98 ± 8.46
10 12
46 54
27.27 ± 8.43 29.90 ± 7.26
35 31
12 16
2 3
Integrated Chinese and Western Medicine, now it is reported as follows. Clinical data General information A total of 100 patients with incomplete adhesive intestinal obstruction who had been treated in surgical, respiratory and digestive department wards of Cangzhou Hospital of Integrated Chinese and Western Medicine from January 2015 to December 2018 were selected. The patients were randomly divided into an observation group and a control group by computer, and the ratio of the two groups was 1:1. SPSS16.0 software was utilized to make a random coding scheme, the random coding table was arranged in the order of selected cases, and random allocation concealment was adopted. One case of the observation group did not complete the trial due to intolerance of acupuncture therapy. There were no statistically significant differences between the two groups on general information such as gender, age, course of disease, and cause of disease, so it was comparable of the two groups (all P > 0.05, see Table 1). Ethical approval was obtained from Cangzhou Hospital of Integrated Chinese and Western Medicine, and the approval number of ethical committee was: sop/003/01.0.
Fig. 1. Patient with incomplete adhesive intestinal obstruction treated with acupuncture and moxibustion in observation group (the lid was being covered when the therapy was performing).
compression, enema for promoting defecation, fluid infusion, parenteral nutrition support, inhibiting gastric acid, anti-infection, and maintaining electrolyte and acid-base balance in the body, etc. Observation group
Diagnostic criteria It was referred to the diagnostic criteria of Surgery [2]. 1 Clinical manifestations: abdominal pain, abdominal distension, nausea and vomiting, with no anus exhaust and defecation. 2 Examination: abdominal tenderness at different degree and mild muscle tension, no peritoneal irritation sign, tympany to percussion, the sound of air passing through water and hyperactive bowel sound could be auscultated. 3 Gas–liquid level or flatulence and intestinal loop were showed in plain abdominal radiograph of standing position. Inclusion criteria Patients that met the above diagnostic criteria, and they were less than 80 years old, sought medical advice within 72 h when the disease occurred, were able to tolerate acupuncture therapy, and signed the informed consent form. Exclusion criteria Patients with complete intestinal obstruction; strangulated intestinal obstruction; accompanied with severe heart, liver and kidney dysfunction; accompanied with serious complications, such as severe intestinal and pulmonary infections, even respiratory failure. Treatment methods Control group Patients were hospitalized with routine western medicine treatment including fasting and water deprivation, gastrointestinal de-
Patients were treated with acupuncture and moxibustion on the foundation of the routine western medicine treatment of the control group. ¯ ¯ a˘ n ( CV12), Tiansh u¯ ( ST25), Acupoints seletion: Zhongw ¯ ˘ı ( ST36), Shàngjùxu¯ ( ST37), Zh¯ıgou ¯ ( TE6), Zúsanl Dàchángshu¯ ( BL 25), and Xia˘ ochángshu¯ ( BL27). Disposable acupuncture needle were produced by Suzhou Dongbang Medical Apparatus Co., Ltd. (0.30 mm × 75 mm acupuncture needles were adopted at abdominal acupoints, and 0.30 mm × 50 mm needles were adopted at the acupoints of four limbs and back-Shu points). Acupuncture therapy: firstly, the patient lay in prone position, and acupuncture needles were inserted at BL25 and BL27, and the needles were withdrawn after 1 min of needling at each acupoint. Secondly, the patient lay in supine position, and the acupuncture needles were inserted at the acupoints of four limbs, and later the acupuncture needles were inserted at abdominal acupoints. Lifting, thrusting, and twirling, and even reinforcing-reducing were performed at each acupoint for 30 s, and the manipulation was performed once per 10 min, and 30 min for needle retention. Moxibustion: after needling, a cubic moxibustion box was utilized. The cubic moxibustion box was 32 cm (length) × 23 cm (width) × 18 cm (height) (see Fig. 1). There was a steel wire mesh in the box which was 7.5 cm away from the bottom of the box, and the steel wire mesh was fixed in the inner wall of the box and was parallel to the horizontal plane. Three moxa sticks were placed on the wire mesh, and the moxa sticks were evenly distributed and parallel to the minor axis of the moxibustion box. The length of moxa stick was about 5 cm. There were grooves in the mesh to fix the moxa sticks, and prevent moxa sticks from rolling. There were air inlets on the side wall of the moxibustion box. The end of the
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3 moxa sticks were lit simultaneously, then the cubic moxibustion box was placed on the patient’s abdomen with the lid covering. The patient’s navel was taken as the center when the cubic moxa box was placed. The major axis of the moxibustion box was parallel to the horizontal plane of the navel. Acupuncture and moxibustion were performed simultaneously, and the moxibustion box was over the needles (the needles would not be pressed, since the wire mesh was 7.5 cm away from the patient’s skin). The cubic moxibustion box was kept for 30 min and the moxa sticks were burned out. Then the cubic moxibustion box and needles were removed. Both the groups were treated once a day for 5 days. Observation of curative effect Observation indicators (1) The primary efficacy indicators: the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery. (2) The secondary efficacy indicators: cases of surgery conversion. Operation indications: if the conservative treatment was ineffective or the illness was aggravated in 72 h, the patients would be converted to treat with surgery. Criteria of curative effect Curative effects were assessed according to the Diagnostic and Efficacy Standards for Traditional Chinese Medicine Diseases [3]. Cured: the clinical symptoms and signs disappeared, the anus exhaust and defecation became normal, and the examination of plain abdominal radiograph test in standing position showed that there were no inflatable dilatation in intestinal tube, the gas–liquid level disappeared, and the symptoms did not recur after restoring normal diet. Effective: the clinical symptoms and signs were relieved obviously, the examination of plain abdominal radiograph test in standing position showed that inflatable dilatation in intestinal tube was alleviated significantly, and the gas–liquid level was reduced significantly. Ineffective: the clinical symptoms and signs were not alleviated obviously, no anus exhaust and defecation, the examination of plain abdominal radiograph test in standing position showed that inflatable dilatation of intestinal tube was not alleviated obviously, and the gas–liquid level was not reduced obviously. The above observation indicators were collected specially once a day by chief residents of the department in which patient was admitted during the treatment, and curative effects were assessed after the treatment. Statistical analysis SPSS16.0 statistic software was applied for statistical analysis. The measurement data were expressed by mean ± standard deviation (Mean±SD), paired sample t-test was used for intra-group comparison, independent sample t-test was used for inter-group comparison, and chi-square test was used for count data, the difference was statistically significant when P < 0.05. Results Comparisons of the primary efficacy indicators between the two groups of patients with incomplete adhesive intestinal obstruction The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in observation group were all shorter than those of the control group, and the differences between the two groups were statistically significant (all P < 0.01, see Table 2).
Comparison of the cases of surgery conversion between the two groups of patients with incomplete adhesive intestinal obstruction The surgery conversion rate of observation group was 2.00%, while control group was 10.00%, the rate of observation group was lower than that of the control group, the difference between the two groups was statistically significant (P < 0.01), see Table 3. Comparison of clinical efficacy between the two groups of patients with incomplete adhesive intestinal obstruction The clinical efficacy rate of observation group was higher than that of the control group, and the difference was statistically significant (P < 0.05), and there was no significant difference in the total effective rate between the two groups, see Table 4. Discussions Incomplete intestinal obstruction refers to a group of syndromes that intestinal contents accumulate in the intestine and cannot be eliminated smoothly due to intestinal wall nerve, smooth muscle dysfunction or contractile muscle weakness cause by various reasons. The main pathophysiological changes are intestines become dilated, intestinal wall become thin, and then intestinal wall circulatory disturbance, loss of body fluid and electrolytes, infection and toxicemia appeared. If the treatment was delayed, shock and death would even occur. Its main manifestations are abdominal pain, abdominal distension, no anal exhaust and defecation. What is more, nausea, vomiting, aversion to cold with fever and other symptoms would appear in some patients. At present, the main clinical routine treatments are conservative, such as continuous fasting and gastrointestinal decompression, blind enema and enema therapy, correction of electrolyte and acid-base balance disorders, and anti-infection, etc., and severe patients would be treated with surgical treatment. There is no disease named intestinal obstruction in traditional Chinese medicine. Intestinal obstruction belongs to the category of intestinal knot and anuria and vomiting according to the clinical symptoms. The location of the disease is large intestine, and the pathomechanism is “pain causes by obstruction”. It is believed that the disease of six fu organs should be applied with the method of unobstructed and descending according to the principle of traditional Chinese medicine. At present, it is common to combine traditional Chinese medicine treatment with the routine western medicine treatment together, which includes acupuncture and moxibustion therapy [4,5], enema with Chinese medication [6,7], Chinese medication for external application [8], Chinese medicine rubbing [9], and the combination of various methods. When it comes to the mechanism of acupuncture and moxibustion of intestinal obstruction, it has been showed from the study [10] that the recovery of gastrointestinal motility of postoperative rats with incomplete intestinal obstruction could be promoted by adjusting nitric oxide synthetase (NOS) content in intestinal tissue with acupuncture. Acupuncture could improve the intestinal propulsion rate and accelerate intestinal movement in rats with incomplete intestinal obstruction. It has been showed in clinical studies that acupuncture had characteristics of alleviating stress and promoting rehabilitation, and could accelerate the recovery of gastrointestinal motility [11], prevent and treat nausea and vomiting, alleviate abdominal pain after operation. Based on the routine treatment of western medicine, this study combined with acupuncture and moxibustion to treat patients with incomplete adhesive intestinal obstruction. The results showed that the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in observation group were all lower than those of the control group.
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Table 2. Comparisons of the primary efficacy indicators between the two groups of patients with incomplete adhesive intestinal obstruction (Mean±SD, h). Groups
Cases
Time of abdominal pain relief
Time of the first anal exhausting
Time of the first defecation
Observation group Control group
49 50
25.57 ± 3.87a 28.58 ± 3.29
39.55 ± 3.51a 42.36 ± 2.93
62.77 ± 4.20a 66.22 ± 4.85
a
Time of intestines sound recovery 29.85 ± 3.30a 33.10 ± 3.95
Compared with the same items of the control group, P < 0.01.
Table 3 Comparison of the cases of surgery conversion between the two groups of patients with incomplete adhesive intestinal obstruction. Groups
Cases
Surgery conversion cases
Observation group Control group
49 50
1 5
a
Surgery conversion rate (%) 2.00a 10.00
Compared with the control group, P < 0.01.
Table 4 Comparison of the clinical efficacy between the two groups of patients with incomplete adhesive intestinal obstruction (cases). Groups
Cases
Cured
Effective
Ineffective
Cure rate (%)
Total effective rate (%)
Observation group Control group
49 50
31 21
18 29
0 0
63.30a 42.00
100.00 100.00
a
Compared with the control group, P < 0.05.
The surgery conversion rate was lower than that of the control group. The clinical efficacy was higher than that of the control group. This method had obvious advantages as follows. Firstly, it was rigorous and standardized in acupoints selection and formulation. The therapeutic efficacy of acupuncture and moxibustion was achieved by adjusting acupoints, meridians and collaterals, and viscera and bowels. There was a saying in the eight volume of Huangfu Mi’s Zhe¯ njiu˘ Jia˘ y˘ı Classic ( The Systematic Classic of Acupuncture and Moxibustion) in Jin Dynasty that is “ST 36 was always taken to treat distention of the five viscera and six bowels, since ST36 was the key acupoint to treat distension”. Thus, the specificity of the acupoint was one of the reasons that ST36 was selected. It was showed from the modern study [12] that there were benign regulatory effects on the intestinal motility in postoperative rats with intestinal obstruction by increasing the number of interstitial cells of small intestine muscular layer and inhibiting the expression of inflammatory factor cox-2 when applying electroacupuncture at ST36. Tian et al. [13] found that applying electroacupuncture at ST 36 could reduce the degree of cecum thickening and cecum contracture deformation, reduce intestinal adhesion area, alleviate inflammatory reaction, decrease hyperplasia of type I collagenous fiber and alleviate the adhesion degree of abdominal cavity in postoperative rats. Li et al. [14] have confirmed from clinical studies that ST36 could regulate gastrointestinal function (relaxation or contraction) bidirectionally, and also enhance ¯ the body’s resistance and leukocyte phagocytosis ability. Zh¯ıgou ( TE6) belongs to the hand-Shaoyang meridian, was the meridian qi exuberance parts of sanjiao, the key acupoint for treating various diseases caused by inhibited qi mechanism [4,15,16], and good at regulating all kinds of qi. Medical practitioners of successive dynasties also believed that TE 6 belongs to Yang and could stimulate yang qi of sanjiao. Therefore, TE6 is taken to promote sanjiao based on meridians and collaterals. It is showed from the study that needling at TE 6 could promote intestinal motility and improve intestinal transit function of patients [17]. There is a saying that “he-sea points can treat the diseases of internal fu organ”. Therefore, the lower he-sea points of stomach, large intestine and small intestine including ST36, ST37 and Xiàjùxu¯ (ST39) were selected. In addition, the three acupoints (ST36, ST37 and ST39) are also belong to the foot-yangming meridian of stomach,
which could stimulate the stomach meridian qi and promote normal peristalsis of gastrointestinal tract then eliminate abdominal distention, stagnation and accumulations so that could achieve the goal of promoting patients’ rehabilitation [18]. What is more, the function of dredging meridians and collaterals would be strengthened when the three acupoints (ST 36, ST 37 and ST 39) are cou¯ pled with TE6. Then, CV 12, ST 25, Guanyuán (CV4) are the front-mu point of stomach, large intestine and small intestine. Gastrointestinal function is regulated by the level of zang-fu organs when acupuncture points are matched with front-mu points. The three acupoints (CV 12, ST 25, and CV 4) are taken together with BL25 and BL 27. Li et al. [19] have found that abnormal ultrastructure in intestinal mucosal epithelial cells of rats could be improved, and the defensive barrier function in intestinal mucosal of rats could be enhanced, when the ST36 and ST25 of rats were stimulated by acupuncture. The apoptosis of colon epithelial cells could be reduced, and the expression levels of glialcellline-derived neurotrophic factor (GDNF) mRNA could be increased when BL25 was stimulated [20]. Moreover, it has been showed from another study that there are such neurons in spinal ganglion which have bifurcated peripheral processes that could respectively govern the small intestine and BL27, and the small intestine and CV4. Both direct nerve pathways of BL 27 and CV4 were formed with small intestine through spinal ganglion, which could explain some neurological mechanism on clinical application of BL27 and CV4 in enteropathy treatment [21]. Secondly, “some diseases cannot be treated with acupuncture, apply moxibustion instead”, the combination of acupuncture and moxibustion have complementary advantages. Shénquè (CV8) is taken as the center of moxibustion acupoint selection. The moxibustion acupoints covere many acupoints such as conception vessel, the stomach meridian and the spleen meridian, etc. around the navel. Moxibustion could make the abdominal meridian qi promoted and unobstructed, and restore the function of qi transformation of sanjiao by encouraging and promoting yang qi, assisting yang and moving qi, and fortifying the spleen and removing dampness [22]. It has been showed from the study that moxibustion could significantly reduce the levels of serum C-reaction protein (CRP), Tumor Necrosis Factor-α (TNFα ), and interleukin-6(IL-6), and could significantly alleviate the clinical symptoms of early postoperative inflammatory intestinal
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obstruction [23]. The recovery of gastrointestinal function after operation could be accelerated, the occurrence of complications after operation could be reduced, various syndromes caused by intestinal dysfunction could be eliminated or alleviated, when performed moxibustion at acupoints such as ST 25 [24]. Thirdly, it could save therapy time since acupuncture and moxibustion were carried out simultaneously. Using cubic moxibustion box is easy to standardize the operation, could strictly control the quantity of moxibustion, and have powerful operability and high thermal efficiency. Because of abdominal distending pain, patients with intestinal obstruction could not tolerate longer treatment time, and acupuncture and moxibustion are carried out simultaneously which could greatly reduce the treatment time and guarantee the dose of treatment. This study chose the moxibustion box to carry on moxibustion, and could form a specification control for the moxibustion on the moxibustion dose, the distance and the treatment time. The moxibustion dose and the moxibustion distance are summarized from many years’ practice and exploration of our department, and this method shows a good repeatability. The cubic moxibustion box is a relatively closed device so heat would not be lost easily that thermal efficiency is high. The moxa sticks were 7.5 cm away from the patient’s skin, therefor, burning pain would not accrue. What is more, multiple moxa sticks were used simultaneously, which ensured a sufficient moxibustion dose and made heat well-distributed and lasting. Previous studies mostly applied suspended moxibustion which consumed a lot of manpower. Besides, suspended moxibustion is difficult to control the dose and distance of moxibustion, and therefore, it is difficult to achieve standardization that would easily lead to treatment bias. In summary, on the foundation of routine western medicine treatment in clinical efficacy of incomplete adhesive intestinal obstruction treatment, combined with acupuncture and moxibustion could reduce the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery, improve the cured rate, let some patients avoid being treated with surgery, reduce the surgical conversion rate, and it has advantages in clinical promotion. References [1] Sun Y, Xie JL. Progress of integrative medicine therapy on adhesive intestinal obstruction. Chin J Surg Integr Tradit West Med 2017;23(2):215–17. [2] Chen XP. Surgery. Beijing: People’s Med Publishing House; 2005. p. 588–93. [3] State Administration of Traditional Chinese Medicine. Traditional Chinese medicine industry standards of the People’s Republic of China diagnostic and efficacy standards for traditional Chinese medicine diseases. Nanjing: Nanjing Univ Press; 1994. p. 24–5. [4] Wen Q, Chen WW, Li J, Zhao Y, Li N, Wang CW. Adhesive ileus treated by elec¯ ( TE 6) and Zúsanl ¯ ˘ı ( ST36): a randomized troacupuncture at Zh¯ıgou controlled study. Chin Acupunct Moxibustion 2012;32(11):961–5.
[5] Shi SH, Wang C, Zhang RP, Fang Y, Xiao YY. Retrospective study on incomplete intestinal obstruction treated with the adjuvant therapy of acupuncture and moxibustion. Chin Acupunct Moxibustion 2018;38(7):707–10. [6] Wang M, Ding J, Rong BH, Xu ZG, Zhou YK. Effect of Qingchang mixture enema on plasma Motilin and IL-6 in adhesive intestinal obstruction. Chin J Surg Integr Tradit West Med 2018;24(1):7–10. [7] Liu WJ. Clinical observation of traditional Chinese medicine retention enema in treatment of adhesive intestinal obstruction. J N Pharm 2018;15(8):5–6. [8] Wang W, Xu MQ, Wang H, Ge Y, Rui J. Effect of umbilical compress of Rhubarb and Glauber salt powder in the treatment of adhesive intestinal obstruction. J Nanjing Univ Tradit Chin Med 2018;34(2):140–2. [9] Ji J, Ye YQ. Application of traditional Chinese medicine rubbing manipulation combined with intestinal function rehabilitation training to patients with incomplete intestinal obstruction. Nurs Integr Tradit Chin West Med 2018;24(9):73–6. [10] Zheng F, Li P, Meng FZ, Zhao JS. Effect of acupuncture on the expression of NOS in gastrointestinal tissues after abdominal operation in rats. Shanghai J Acupunct Moxibustion 2015;34(9):888–91. [11] Stott A. Examining the efficacy of stimulating the PC6 wrist acupuncture point for preventing postoperative nausea and vomiting: a Cochrane review summary. Int J Nurs Stud 2016;64:139–41. [12] Fang JF, Du JY, Wang W, Li JJ, Shao XM, Fang JQ. Advances in the modern studies of acupuncture treatment of postoperative ileus. Shanghai J Acupunct Moxibustion 2016;35(3):257–61. ¯ ˘ı [13] Tian YJ, Wang L, Geng SJ, Bao CM, Jin F, Hu S. Electroacupuncturingat Zúsanl ( ST 36) attenuates abdominal adhesions in rats: an experimental study. Infect Inflam Repair 2008(3):153–6. [14] Li G, Wu ZY, Li HR, Lu DG. Clinical observation on adhesive intestinal obstruction treated with integrative medicine therapy. Chin J Mod Drug Appl 2008(3):153–6. ¯ ( [15] Wang XC. Clinical observation on intractable hiccup treated with Zh¯ıgou TE 6). Chin J Urban Rural Enterp Hygiene 2018;33(07):148–9. [16] Yang YQ. The Lin Guohua’s therapeutic experience on shingles treated mainly ¯ ( TE 6). Hunan J Tradit Chin Med 2013;29(10):28–9. with Zh¯ıgou [17] Zhang WS, Zong L, Gu K. Clinical observation of ordinary acupuncture plus ¯ ( TE 6) and Zhaohai (KI6) for constipation due to yin deficiency in Zh¯ıgou parkinson’s disease. Shanghai J Acupunct Moxibustion 2018;37(2):165–9. [18] Li Y, Zhang XX, Li WH, Zhou SP. Observation of postoperative inflammatory ¯ ileus treated with Jiawèi Xia˘ ochéngqì decoction ( supplemented minor purgative decoction) coupled with acupuncture and moxibustion therapy. Chin J Tradit Med Sci Technol 2013;20(6):651–2. [19] Li H, Wu JW, Chen SJ, Liu JW, Zhang JW. Effects of acupuncture on the altrastructure of intestinal mucosa in rats with adhesive intestinal obstruction injury. Liaoning J Tradit Chin Med 2008(7):1094–6. [20] Zhang W, Li Y, Liu LS, Luo LF, Zheng QH. Effects of electroacupuncture back-shu and front-mu points on the GDNF-mRNA, RAI mRNA expression in colonic tissue for mice of functional constipation. Chin J Basic Med Tradit Chin Med 2016;22(11):1522–5. [21] Tong CG, Yi HQ, Gu SZ, Xiang XR. A study on connection between back-shu and front-mu points of small intestine and specificity of small intestine with fluorescent double-labeling method. J Nanjing Univ Tradit Chin Med 2003;19(1):41–3. [22] Zhang L. Clinical observation of medicine-separated moxibustion shenque eight-array points for the treatment of postoperative inflammatory intestinal obstruction. J Sichuan Tradit Chin Med 2018;36(2):180–2. [23] Li Y, Zhang L. Clinical observation of medicine-separated moxibustion for the treatment of early postoperative inflammatory intestinal obstruction. Chin J Surg Integr Tradit West Med 2018;24(2):212–14. [24] Hong YL. Effect of moxibustion combined with hot ironing on recovery of gastrointestinal function after abdominal operation. J N Chin Med 2016;48(4):67–9.
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Research
Acupuncture and moxibustion for incomplete adhesive intestinal obstruction: A randomized controlled trial Lihua ZHANG () a,∗, Shu ZHANG () b, Pengjing YAN () a, Zhiguo ZHANG ( ) c, Suchun XIE () d a Rehabilitation Department, Cangzhou Hospital of Integrated Chinese and Western Medicine, Cangzhou 061000, Hebei, China ( , 061000, ) b Chinese Medical Clinic, Cangzhou Central Hospital, Cangzhou 061000, Hebei, China (, 061000, ) c Center of Preventive Treatment for Disease, Cangzhou Hospital of Integrated Chinese and Western Medicine, Cangzhou 061001, Hebei, China ( , 061001, ) d Acupuncture–Moxibustion and Physiotherapy Department, Xingtai People, s Hospital, Xingtai 054001, Hebei, China (, 054001, )
a r t i c l e
i n f o
Article history: Accepted 13 May 2019 Available online 29 August 2019 Keywords: Acupuncture Moxibustion Incomplete adhesive intestinal obstruction Randomized controlled trial (RCT)
a b s t r a c t Objective: To investigate the clinical efficacy of acupuncture and moxibustion for incomplete adhesive intestinal obstruction. Methods: A total of 100 patients with incomplete adhesive intestinal obstruction were randomly divided into an observation group and a control group, and there were 50 patients in each group. The control group was treated with routine western medicine treatment, while the observation group was treated with acupuncture and moxibustion therapy on the foundation of the routine western medicine treat¯ ¯ ¯ ˘ı (ST36), Shàngjùxu¯ a˘ n (CV12), Tiansh u¯ (ST25), Zúsanl ment of the control group. Zhongw ¯ ( TE6), Dàchángshu¯ ( BL 25), and Xia˘ ochángshu¯ (BL27) were taken (ST37), Zh¯ıgou when acupuncture was performed. Moxibustion was performed with moxibustion box on abdomen after acupuncture. The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery, surgery conversion rate and clinical efficacy were observed in the two groups. Results: The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in the observation group were all shorter than those of the control group. There were statistically significant differences between the two groups (all P < 0.01). The surgery conversion rate of the observation group was lower than that of the control group, there was statistically significant difference between the two groups (P < 0.01). The clinical efficacy of the observation group was superior to that of the control group, the difference between the two groups was statistically significant (P < 0.05). Conclusions: Acupuncture and moxibustion therapy on the foundation of the routine western medicine treatment, which can reduce the surgical conversion rate and cut down the time of treatment, was superior to routine western medicine treatment on the clinical efficacy of incomplete adhesive intestinal obstruction. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
In recent years, with the mounting number of abdominal surgery, the incidence of adhesive intestinal obstruction has been increasing and occupies an increasing proportion which was about 30–60% in acute intestinal obstruction [1]. Many methods are tried to prevent adhesion in modern clinic, such as peritoneal lavage with hypertonic saline, various anticoagulants and prevention of fibrin deposition, however, none of them has achieved ideal efficacy. At present, there is no specific therapeutic method in the
∗
Corresponding author. E-mail address: [email protected] (L. ZHANG).
prevention and treatment of adhesive intestinal obstruction, while conservative treatments are applied in clinic such as continuous gastrointestinal decompression, maintaining the balance of liquid and electrolyte, parenteral nutrition support and anti-infection, etc. Moreover, the efficacy of conservative treatments is not ideal, and sometimes surgical operation is required again, which means another possibility of adhesion. Thus, it is necessary and significant to explore a therapy which is safe and effective, feasible and simple, noninvasive and less pain. In recent years, acupuncture and moxibustion on the foundation of routine western medicine treatment has been applied to incomplete adhesive intestinal obstruction in the Rehabilitation Department, Cangzhou Hospital of
https://doi.org/10.1016/j.wjam.2019.08.011 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
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Table 1 Comparison of general information between the two groups of patients with incomplete adhesive intestinal obstruction (Mean±SD). Groups
Observation group Control group
Cases
49 50
Gender (cases)
Age (years)
Male
Female
Minimum
Maximum
Mean
Minimum
Course of disease (h) Maximum
Mean
Abdominal surgery
Cause of disease (cases) Gastrointestinal inflammation
Unknown
23 20
26 30
25 31
79 76
54.78 ± 10.11 51.98 ± 8.46
10 12
46 54
27.27 ± 8.43 29.90 ± 7.26
35 31
12 16
2 3
Integrated Chinese and Western Medicine, now it is reported as follows. Clinical data General information A total of 100 patients with incomplete adhesive intestinal obstruction who had been treated in surgical, respiratory and digestive department wards of Cangzhou Hospital of Integrated Chinese and Western Medicine from January 2015 to December 2018 were selected. The patients were randomly divided into an observation group and a control group by computer, and the ratio of the two groups was 1:1. SPSS16.0 software was utilized to make a random coding scheme, the random coding table was arranged in the order of selected cases, and random allocation concealment was adopted. One case of the observation group did not complete the trial due to intolerance of acupuncture therapy. There were no statistically significant differences between the two groups on general information such as gender, age, course of disease, and cause of disease, so it was comparable of the two groups (all P > 0.05, see Table 1). Ethical approval was obtained from Cangzhou Hospital of Integrated Chinese and Western Medicine, and the approval number of ethical committee was: sop/003/01.0.
Fig. 1. Patient with incomplete adhesive intestinal obstruction treated with acupuncture and moxibustion in observation group (the lid was being covered when the therapy was performing).
compression, enema for promoting defecation, fluid infusion, parenteral nutrition support, inhibiting gastric acid, anti-infection, and maintaining electrolyte and acid-base balance in the body, etc. Observation group
Diagnostic criteria It was referred to the diagnostic criteria of Surgery [2]. 1 Clinical manifestations: abdominal pain, abdominal distension, nausea and vomiting, with no anus exhaust and defecation. 2 Examination: abdominal tenderness at different degree and mild muscle tension, no peritoneal irritation sign, tympany to percussion, the sound of air passing through water and hyperactive bowel sound could be auscultated. 3 Gas–liquid level or flatulence and intestinal loop were showed in plain abdominal radiograph of standing position. Inclusion criteria Patients that met the above diagnostic criteria, and they were less than 80 years old, sought medical advice within 72 h when the disease occurred, were able to tolerate acupuncture therapy, and signed the informed consent form. Exclusion criteria Patients with complete intestinal obstruction; strangulated intestinal obstruction; accompanied with severe heart, liver and kidney dysfunction; accompanied with serious complications, such as severe intestinal and pulmonary infections, even respiratory failure. Treatment methods Control group Patients were hospitalized with routine western medicine treatment including fasting and water deprivation, gastrointestinal de-
Patients were treated with acupuncture and moxibustion on the foundation of the routine western medicine treatment of the control group. ¯ ¯ a˘ n ( CV12), Tiansh u¯ ( ST25), Acupoints seletion: Zhongw ¯ ˘ı ( ST36), Shàngjùxu¯ ( ST37), Zh¯ıgou ¯ ( TE6), Zúsanl Dàchángshu¯ ( BL 25), and Xia˘ ochángshu¯ ( BL27). Disposable acupuncture needle were produced by Suzhou Dongbang Medical Apparatus Co., Ltd. (0.30 mm × 75 mm acupuncture needles were adopted at abdominal acupoints, and 0.30 mm × 50 mm needles were adopted at the acupoints of four limbs and back-Shu points). Acupuncture therapy: firstly, the patient lay in prone position, and acupuncture needles were inserted at BL25 and BL27, and the needles were withdrawn after 1 min of needling at each acupoint. Secondly, the patient lay in supine position, and the acupuncture needles were inserted at the acupoints of four limbs, and later the acupuncture needles were inserted at abdominal acupoints. Lifting, thrusting, and twirling, and even reinforcing-reducing were performed at each acupoint for 30 s, and the manipulation was performed once per 10 min, and 30 min for needle retention. Moxibustion: after needling, a cubic moxibustion box was utilized. The cubic moxibustion box was 32 cm (length) × 23 cm (width) × 18 cm (height) (see Fig. 1). There was a steel wire mesh in the box which was 7.5 cm away from the bottom of the box, and the steel wire mesh was fixed in the inner wall of the box and was parallel to the horizontal plane. Three moxa sticks were placed on the wire mesh, and the moxa sticks were evenly distributed and parallel to the minor axis of the moxibustion box. The length of moxa stick was about 5 cm. There were grooves in the mesh to fix the moxa sticks, and prevent moxa sticks from rolling. There were air inlets on the side wall of the moxibustion box. The end of the
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3 moxa sticks were lit simultaneously, then the cubic moxibustion box was placed on the patient’s abdomen with the lid covering. The patient’s navel was taken as the center when the cubic moxa box was placed. The major axis of the moxibustion box was parallel to the horizontal plane of the navel. Acupuncture and moxibustion were performed simultaneously, and the moxibustion box was over the needles (the needles would not be pressed, since the wire mesh was 7.5 cm away from the patient’s skin). The cubic moxibustion box was kept for 30 min and the moxa sticks were burned out. Then the cubic moxibustion box and needles were removed. Both the groups were treated once a day for 5 days. Observation of curative effect Observation indicators (1) The primary efficacy indicators: the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery. (2) The secondary efficacy indicators: cases of surgery conversion. Operation indications: if the conservative treatment was ineffective or the illness was aggravated in 72 h, the patients would be converted to treat with surgery. Criteria of curative effect Curative effects were assessed according to the Diagnostic and Efficacy Standards for Traditional Chinese Medicine Diseases [3]. Cured: the clinical symptoms and signs disappeared, the anus exhaust and defecation became normal, and the examination of plain abdominal radiograph test in standing position showed that there were no inflatable dilatation in intestinal tube, the gas–liquid level disappeared, and the symptoms did not recur after restoring normal diet. Effective: the clinical symptoms and signs were relieved obviously, the examination of plain abdominal radiograph test in standing position showed that inflatable dilatation in intestinal tube was alleviated significantly, and the gas–liquid level was reduced significantly. Ineffective: the clinical symptoms and signs were not alleviated obviously, no anus exhaust and defecation, the examination of plain abdominal radiograph test in standing position showed that inflatable dilatation of intestinal tube was not alleviated obviously, and the gas–liquid level was not reduced obviously. The above observation indicators were collected specially once a day by chief residents of the department in which patient was admitted during the treatment, and curative effects were assessed after the treatment. Statistical analysis SPSS16.0 statistic software was applied for statistical analysis. The measurement data were expressed by mean ± standard deviation (Mean±SD), paired sample t-test was used for intra-group comparison, independent sample t-test was used for inter-group comparison, and chi-square test was used for count data, the difference was statistically significant when P < 0.05. Results Comparisons of the primary efficacy indicators between the two groups of patients with incomplete adhesive intestinal obstruction The time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in observation group were all shorter than those of the control group, and the differences between the two groups were statistically significant (all P < 0.01, see Table 2).
Comparison of the cases of surgery conversion between the two groups of patients with incomplete adhesive intestinal obstruction The surgery conversion rate of observation group was 2.00%, while control group was 10.00%, the rate of observation group was lower than that of the control group, the difference between the two groups was statistically significant (P < 0.01), see Table 3. Comparison of clinical efficacy between the two groups of patients with incomplete adhesive intestinal obstruction The clinical efficacy rate of observation group was higher than that of the control group, and the difference was statistically significant (P < 0.05), and there was no significant difference in the total effective rate between the two groups, see Table 4. Discussions Incomplete intestinal obstruction refers to a group of syndromes that intestinal contents accumulate in the intestine and cannot be eliminated smoothly due to intestinal wall nerve, smooth muscle dysfunction or contractile muscle weakness cause by various reasons. The main pathophysiological changes are intestines become dilated, intestinal wall become thin, and then intestinal wall circulatory disturbance, loss of body fluid and electrolytes, infection and toxicemia appeared. If the treatment was delayed, shock and death would even occur. Its main manifestations are abdominal pain, abdominal distension, no anal exhaust and defecation. What is more, nausea, vomiting, aversion to cold with fever and other symptoms would appear in some patients. At present, the main clinical routine treatments are conservative, such as continuous fasting and gastrointestinal decompression, blind enema and enema therapy, correction of electrolyte and acid-base balance disorders, and anti-infection, etc., and severe patients would be treated with surgical treatment. There is no disease named intestinal obstruction in traditional Chinese medicine. Intestinal obstruction belongs to the category of intestinal knot and anuria and vomiting according to the clinical symptoms. The location of the disease is large intestine, and the pathomechanism is “pain causes by obstruction”. It is believed that the disease of six fu organs should be applied with the method of unobstructed and descending according to the principle of traditional Chinese medicine. At present, it is common to combine traditional Chinese medicine treatment with the routine western medicine treatment together, which includes acupuncture and moxibustion therapy [4,5], enema with Chinese medication [6,7], Chinese medication for external application [8], Chinese medicine rubbing [9], and the combination of various methods. When it comes to the mechanism of acupuncture and moxibustion of intestinal obstruction, it has been showed from the study [10] that the recovery of gastrointestinal motility of postoperative rats with incomplete intestinal obstruction could be promoted by adjusting nitric oxide synthetase (NOS) content in intestinal tissue with acupuncture. Acupuncture could improve the intestinal propulsion rate and accelerate intestinal movement in rats with incomplete intestinal obstruction. It has been showed in clinical studies that acupuncture had characteristics of alleviating stress and promoting rehabilitation, and could accelerate the recovery of gastrointestinal motility [11], prevent and treat nausea and vomiting, alleviate abdominal pain after operation. Based on the routine treatment of western medicine, this study combined with acupuncture and moxibustion to treat patients with incomplete adhesive intestinal obstruction. The results showed that the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery in observation group were all lower than those of the control group.
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Table 2. Comparisons of the primary efficacy indicators between the two groups of patients with incomplete adhesive intestinal obstruction (Mean±SD, h). Groups
Cases
Time of abdominal pain relief
Time of the first anal exhausting
Time of the first defecation
Observation group Control group
49 50
25.57 ± 3.87a 28.58 ± 3.29
39.55 ± 3.51a 42.36 ± 2.93
62.77 ± 4.20a 66.22 ± 4.85
a
Time of intestines sound recovery 29.85 ± 3.30a 33.10 ± 3.95
Compared with the same items of the control group, P < 0.01.
Table 3 Comparison of the cases of surgery conversion between the two groups of patients with incomplete adhesive intestinal obstruction. Groups
Cases
Surgery conversion cases
Observation group Control group
49 50
1 5
a
Surgery conversion rate (%) 2.00a 10.00
Compared with the control group, P < 0.01.
Table 4 Comparison of the clinical efficacy between the two groups of patients with incomplete adhesive intestinal obstruction (cases). Groups
Cases
Cured
Effective
Ineffective
Cure rate (%)
Total effective rate (%)
Observation group Control group
49 50
31 21
18 29
0 0
63.30a 42.00
100.00 100.00
a
Compared with the control group, P < 0.05.
The surgery conversion rate was lower than that of the control group. The clinical efficacy was higher than that of the control group. This method had obvious advantages as follows. Firstly, it was rigorous and standardized in acupoints selection and formulation. The therapeutic efficacy of acupuncture and moxibustion was achieved by adjusting acupoints, meridians and collaterals, and viscera and bowels. There was a saying in the eight volume of Huangfu Mi’s Zhe¯ njiu˘ Jia˘ y˘ı Classic ( The Systematic Classic of Acupuncture and Moxibustion) in Jin Dynasty that is “ST 36 was always taken to treat distention of the five viscera and six bowels, since ST36 was the key acupoint to treat distension”. Thus, the specificity of the acupoint was one of the reasons that ST36 was selected. It was showed from the modern study [12] that there were benign regulatory effects on the intestinal motility in postoperative rats with intestinal obstruction by increasing the number of interstitial cells of small intestine muscular layer and inhibiting the expression of inflammatory factor cox-2 when applying electroacupuncture at ST36. Tian et al. [13] found that applying electroacupuncture at ST 36 could reduce the degree of cecum thickening and cecum contracture deformation, reduce intestinal adhesion area, alleviate inflammatory reaction, decrease hyperplasia of type I collagenous fiber and alleviate the adhesion degree of abdominal cavity in postoperative rats. Li et al. [14] have confirmed from clinical studies that ST36 could regulate gastrointestinal function (relaxation or contraction) bidirectionally, and also enhance ¯ the body’s resistance and leukocyte phagocytosis ability. Zh¯ıgou ( TE6) belongs to the hand-Shaoyang meridian, was the meridian qi exuberance parts of sanjiao, the key acupoint for treating various diseases caused by inhibited qi mechanism [4,15,16], and good at regulating all kinds of qi. Medical practitioners of successive dynasties also believed that TE 6 belongs to Yang and could stimulate yang qi of sanjiao. Therefore, TE6 is taken to promote sanjiao based on meridians and collaterals. It is showed from the study that needling at TE 6 could promote intestinal motility and improve intestinal transit function of patients [17]. There is a saying that “he-sea points can treat the diseases of internal fu organ”. Therefore, the lower he-sea points of stomach, large intestine and small intestine including ST36, ST37 and Xiàjùxu¯ (ST39) were selected. In addition, the three acupoints (ST36, ST37 and ST39) are also belong to the foot-yangming meridian of stomach,
which could stimulate the stomach meridian qi and promote normal peristalsis of gastrointestinal tract then eliminate abdominal distention, stagnation and accumulations so that could achieve the goal of promoting patients’ rehabilitation [18]. What is more, the function of dredging meridians and collaterals would be strengthened when the three acupoints (ST 36, ST 37 and ST 39) are cou¯ pled with TE6. Then, CV 12, ST 25, Guanyuán (CV4) are the front-mu point of stomach, large intestine and small intestine. Gastrointestinal function is regulated by the level of zang-fu organs when acupuncture points are matched with front-mu points. The three acupoints (CV 12, ST 25, and CV 4) are taken together with BL25 and BL 27. Li et al. [19] have found that abnormal ultrastructure in intestinal mucosal epithelial cells of rats could be improved, and the defensive barrier function in intestinal mucosal of rats could be enhanced, when the ST36 and ST25 of rats were stimulated by acupuncture. The apoptosis of colon epithelial cells could be reduced, and the expression levels of glialcellline-derived neurotrophic factor (GDNF) mRNA could be increased when BL25 was stimulated [20]. Moreover, it has been showed from another study that there are such neurons in spinal ganglion which have bifurcated peripheral processes that could respectively govern the small intestine and BL27, and the small intestine and CV4. Both direct nerve pathways of BL 27 and CV4 were formed with small intestine through spinal ganglion, which could explain some neurological mechanism on clinical application of BL27 and CV4 in enteropathy treatment [21]. Secondly, “some diseases cannot be treated with acupuncture, apply moxibustion instead”, the combination of acupuncture and moxibustion have complementary advantages. Shénquè (CV8) is taken as the center of moxibustion acupoint selection. The moxibustion acupoints covere many acupoints such as conception vessel, the stomach meridian and the spleen meridian, etc. around the navel. Moxibustion could make the abdominal meridian qi promoted and unobstructed, and restore the function of qi transformation of sanjiao by encouraging and promoting yang qi, assisting yang and moving qi, and fortifying the spleen and removing dampness [22]. It has been showed from the study that moxibustion could significantly reduce the levels of serum C-reaction protein (CRP), Tumor Necrosis Factor-α (TNFα ), and interleukin-6(IL-6), and could significantly alleviate the clinical symptoms of early postoperative inflammatory intestinal
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obstruction [23]. The recovery of gastrointestinal function after operation could be accelerated, the occurrence of complications after operation could be reduced, various syndromes caused by intestinal dysfunction could be eliminated or alleviated, when performed moxibustion at acupoints such as ST 25 [24]. Thirdly, it could save therapy time since acupuncture and moxibustion were carried out simultaneously. Using cubic moxibustion box is easy to standardize the operation, could strictly control the quantity of moxibustion, and have powerful operability and high thermal efficiency. Because of abdominal distending pain, patients with intestinal obstruction could not tolerate longer treatment time, and acupuncture and moxibustion are carried out simultaneously which could greatly reduce the treatment time and guarantee the dose of treatment. This study chose the moxibustion box to carry on moxibustion, and could form a specification control for the moxibustion on the moxibustion dose, the distance and the treatment time. The moxibustion dose and the moxibustion distance are summarized from many years’ practice and exploration of our department, and this method shows a good repeatability. The cubic moxibustion box is a relatively closed device so heat would not be lost easily that thermal efficiency is high. The moxa sticks were 7.5 cm away from the patient’s skin, therefor, burning pain would not accrue. What is more, multiple moxa sticks were used simultaneously, which ensured a sufficient moxibustion dose and made heat well-distributed and lasting. Previous studies mostly applied suspended moxibustion which consumed a lot of manpower. Besides, suspended moxibustion is difficult to control the dose and distance of moxibustion, and therefore, it is difficult to achieve standardization that would easily lead to treatment bias. In summary, on the foundation of routine western medicine treatment in clinical efficacy of incomplete adhesive intestinal obstruction treatment, combined with acupuncture and moxibustion could reduce the time of abdominal pain relief, the first anal exhausting, the first defecation and intestines sound recovery, improve the cured rate, let some patients avoid being treated with surgery, reduce the surgical conversion rate, and it has advantages in clinical promotion. References [1] Sun Y, Xie JL. Progress of integrative medicine therapy on adhesive intestinal obstruction. Chin J Surg Integr Tradit West Med 2017;23(2):215–17. [2] Chen XP. Surgery. Beijing: People’s Med Publishing House; 2005. p. 588–93. [3] State Administration of Traditional Chinese Medicine. Traditional Chinese medicine industry standards of the People’s Republic of China diagnostic and efficacy standards for traditional Chinese medicine diseases. Nanjing: Nanjing Univ Press; 1994. p. 24–5. [4] Wen Q, Chen WW, Li J, Zhao Y, Li N, Wang CW. Adhesive ileus treated by elec¯ ( TE 6) and Zúsanl ¯ ˘ı ( ST36): a randomized troacupuncture at Zh¯ıgou controlled study. Chin Acupunct Moxibustion 2012;32(11):961–5.
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