Naturopathic Treatment and Complementary Medicine in Surgical Practice
A systematic review
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Background: Many patients in Germany use naturopathic treatments and complementary medicine. Surveys have shown that many also use them as a concomitant treatment to surgery.
Methods: Multiple databases were systematically searched for systematic reviews, controlled trials, and experimental studies concerning the use of naturopathic treatments and complementary medicine in the management of typical postoperative problems (PROSPERO CRD42018095330).
Results: Of the 387 publications identified by the search, 76 fulfilled the inclusion criteria. In patients with abnormal gastrointestinal activity, acupuncture can improve motility, ease the passing of flatus, and lead to earlier defecation. Acupuncture and acupressure can reduce postoperative nausea and vomiting, as well as pain. Moreover, aromatherapy and music therapy seem to reduce pain, stress and anxiety and to improve sleep. Further studies are needed to determine whether phytotherapeutic treatments are effective for the improvement of gastrointestinal function or the reduction of stress. It also remains unclear whether surgical patients can benefit from the methods of mind body medicine.
Conclusion: Certain naturopathic treatments and complementary medical methods may be useful in postoperative care and deserve more intensive study. In the publications consulted for this review, no serious side effects were reported.
Complementary medicine (CM) and naturopathic treatments (NT) are relevant topics for clinically active physicians. Many patients either would like to have advice about CM/NT or are already using them on their own for mostly harmless and self-limiting diseases (1). Indeed, more than 50% of cancer patients report using CM/NT. This not only affects primary care physicians, but also oncologists, radiotherapists, anesthesiologists, palliative care physicians, and surgeons (1). Nonetheless, little-to-no efforts seem to have been made at integrating CM/NT into everyday surgical routines. Surgeons are confronted not only with the needs of cancer patients but also with those of non-cancer patients undergoing surgery, as up to 30% of patients in this group also report using CM/NT (2, 3). Furthermore, although up to 60% of patients who undergo surgery would like complementary medical advice, almost none of them discuss this with the treating surgeon (3). This is a critical point, as self-medication with herbal supplements can lead to interactions with other drugs and cause risks, such as interference with blood clotting. This article therefore aims to give an overview of possible supportive CM/NT approaches in surgery while at the same time addressing their risks.
After evaluation of typical postoperative problems by the authors, a systematic literature review was conducted via Medline, Web of Science, and the Cochrane Library. Randomized controlled trials (RCTs) and experimental human studies, as well as systematic reviews, were included. Detailed information on the methodology is presented in the eMethods section and in the eBox. This review was prospectively registered in PROSPERO (CRD42018095330).
A total of 387 references were identified, of which 76 were suitable for evaluation after checking the inclusion and exclusion criteria (eFigure).
Improvement of gastrointestinal function
Three systematic reviews (two of high quality) were identified that reported the use of acupuncture and acupressure for impaired gastrointestinal function following surgery (Table 1, eTable 1). All three reviews concluded that the stimulation of acupuncture points can improve motility and lead to both shorter time to first flatus and earlier defecation after surgery. A further eleven systematic reviews (three of high quality, and five of moderate quality) focused on treating postoperative nausea and vomiting through acupuncture and acupressure. Of these, nine reviews reported a positive effect (Table 1, eTable 1).
Table 2 and eTable 2 indicate the effectiveness of aromatherapy with various substances at the onset of, and during courses of, nausea and vomiting. A total of nine studies were evaluated, including seven RCTs (of which only one was of good quality) and one systematic review (of high quality). Four RCTs showed that aromatherapy can significantly improve nausea and vomiting. The systematic review, however, showed only low evidence for the use of aromatherapy for reducing nausea and vomiting, with poor overall study quality (e1).
Possible uses of phytotherapy for antiemesis are listed in Table 3 and eTable 3. Currently, studies on treatments of surgical patients have only tested the effects of ginger. We did not find any results for other substances that could have a positive effect on gastrointestinal function, such as artichokes or black pepper. The mechanism of action of ginger has now been elucidated. Similar to the mechanisms of the setron group antiemetics, it seems to be based on the influence of the ingredients gingerol and shogaol on the 5-HT3 receptors (4). Although the twelve RCTs examined here were mostly of high methodological quality (with only two of poor methodological quality), the results from them were inhomogeneous (Table 3, eTable 3). In fact, some studies even showed an increase of nausea and vomiting during therapy with ginger. Possible side effects of taking ginger are heartburn and upper abdominal discomfort. Traditionally, ginger is used once nausea has started. As none of the studies examined the effects of a symptom-bound therapy, it still remains unclear whether ginger in this case could have a positive effect.
In an Italian placebo-controlled RCT (n = 60) of good methodological quality according to Jadad-Score (eMethods), administration of 3.5 g of psyllium husk after rectal resection (STARR) resulted in significantly less obstruction one week after surgery (obstructed defecation syndrome score according to Longo [ODS]: 6.25 ± 3.55 versus 11.94 ± 4.99, p<0.01; Cleveland clinic constipation score [CCS]: 6.59 ± 2.65 versus 15.10 ± 3.33, p<0.01) and less incontinence (Wexner incontinence score, difference in scores from baseline: 0.5 versus 2.70, p<0.01) (e2). This benefit was also evident in the follow-up after six months (constipation: ODS, 3.40 ± 5.26 versus 4.97 ± 4.21, p<0.05; CCS, 5.00 ± 3.82 versus 6.63 ± 3.68, p<0.01; incontinence, –0.17 versus 1.33, p<0.01). Another controlled study of 38 patients after ileostomy (which was however of poor quality, according to its Jadad score) showed that the group of patients who ate 7 g of psyllium husk each day (n = 20) had a significantly lower ileostomy output after 90 days (–322 mL) than those in the control group (n = 18) (–95 mL; p<0.0001) (e3).
Postoperative wound infection and anastomotic insufficiency
Already in ancient Egypt, infected wounds were treated with fat and honey (5). However, only very few, small studies have addressed acute treatment of surgical wounds, as shown in an overview of the current study situation in Table 4 and eTable 4. The current data situation is heterogeneous and not convincing overall. Many other plant extracts are used worldwide in traditional medical practices for wound healing (6). However, as efficacy has so far only been investigated in isolated cases and in preclinical wound healing models, it can not be adequately assessed clinically.
Wound healing and and healing of colorectal anastomosis seem to be influenced by the composition of the gut microbiome (7, 8). Controlled studies have shown clear indications in humans that the intestinal microbiome changes postoperatively (9); in particular, levels of lactobacilli and bifidobacteria appear to decrease. A 2013 meta-analysis (13 RCTs, 962 patients) of moderate quality found that probiotics significantly reduced the rate of septic complications after general surgery (10). However, the optimal composition and dosage of probiotics remains to be determined. Furthermore, the extent to which the intestinal microbiome is causally involved in postoperative complications in humans is still not clear.
Studies on CAM for postoperative pain have been most frequently carried out for acupuncture and acupressure. The results are listed in Table 1 and eTable 1. Six of the ten systematic reviews reported a reduced perception of pain or a reduced need for analgesics in patients treated with acupuncture or acupressure. Two further reviews stated that they could not comment on the effectiveness of acupuncture treatment due to a small sample size or inhomogeneous data.
Aromatherapy seems to offer another option for pain relief. The results of recent studies are shown in Table 2 and eTable 2. Eight studies were identified (including seven RCTs). Due to the lack of blinding in these studies, their methodological quality is predominantly rated as poor by the Jadad scoring system (see eMethods). But it must be emphasized that it is difficult to blind a study on aromatherapy. Five of the eight studies reported significant improvement after aromatherapy. The aroma was mostly lavender. In principle, aromatherapy offers a number of advantages: it is inexpensive, available without prescription, has no risk of addiction, has a low side-effect profile (after allergies have been excluded), and can be independently used and modulated by the patient depending on the application system.
Whether music therapy can have pain-reducing effects was examined in two systematic reviews, which were of good and moderate quality. Both reviews reported a reduction in pain perception (Table 5, eTable 5).
A further study, which was however non-controlled and of poor methodological quality, examined an extensive, multimodal, and holistic approach to reducing pain that consisted of multiple preoperative interviews and a combination of several of the therapies mentioned above (11). Even though the study found a significant reduction in pain (of –1.19 points, on a scale of 1 to 10, p<0.001), it is not very meaningful for everyday clinical practice due to methodological shortcomings and a questionable feasibility (as it carries high financial and time expenses).
Sleep disturbances, stress-related symptoms, and postoperative recovery
Depending on the type and extent of surgery, surgical interventions lead to a stress reaction that can become an independent problem in a post-aggression catabolic metabolism (12, 13). A simple and cost-effective way to reduce sympathicotonia and thus reduce sleep onset latency is to apply heat to the extremities (14, 15). Phytotherapeutically, lavender, valerian, and hops (humulus) are used in restlessness and sleep disturbances, although none of the preparations have been validly analyzed for treating surgical patients. At present there are only two RCTs of good quality that have addressed the effectiveness of valerian in surgical patients (Table 3, eTable 3). In the first study, a preoperative dose of valerian was tested for reducing anxiety in patients about to undergo wisdom tooth surgery. In the second study, the effect of valerian on the development of cognitive dysfunction after cardiac surgery was examined (Table 3, eTable 3). In both studies, valerian was found to have a positive effect. The efficacy of finished preparations containing lavender, valerian, or hops for sleep disturbances can not be determined due to lack of studies.
Acupuncture and acupressure are also used in CM/NT to reduce stress and anxiety as well as to improve sleep. Two systematic reviews (of high and moderate quality) have examined these for surgical patients, and both report reduction in anxiety (Table 1, eTable 1).
Seven studies (including five RCTs) examined the efficacy of aromatherapy in reduction of stress and anxiety related to surgery (Table 2, eTable 2). Four studies showed a positive effect from aromatherapy, although only one study was of good methodological quality. Both studies that addressed improving sleep showed a positive, significant effect; however, both were rated to be of poor quality, as they were non-controlled experimental studies. Overall, it is therefore difficult to make a final assessment. None of the studies shown in Table 2 or eTable 2 reported any impact on physical parameters, such as blood pressure or heart rate (data not shown).
The effectiveness of the therapeutic use of music to reduce anxiety and stress associated with surgery was analyzed in five systematic reviews of predominantly high quality, in both children and adults. Four out of five systematic reviews found a positive effect for this (Table 5, eTable 5). Only one review that assessed the anxiety of children (younger than 7 years of age) prior to anesthesia induction found that treatment with midazolame led to a greater reduction of anxiety than music (e4).
Concepts such as mindfulness-based stress reduction (MBSR) have already been used successfully in the area of oncology, among others (16). This systematic search did not find studies testing MBSR or any other form of mind body medicine (MBM) for surgical patients. MBM serves the biopsychosocial strengthening of personal coping resources, in order to give the patient more autonomy and responsibility in dealing with illness. The success of such strategies has been shown in surgery in recent years. Approaches such as the Fast Track (FT) program or the Enhanced Recovery After Surgery (ERAS) program include elements of modern mind body medicine (17, 18). Patients are taught by the surgeon that they are an “active part” of the recovery process. Through a willingness to mobilize and to early normal food intake, the person concerned can actively contribute to the improvement of his or her state of health (19, 20). The contribution of the psyche to the success of FT and ERAS should be examined in more detail in the future.
Postoperative recovery may also be positively influenced by acupuncture, as reported by Asmussen et al. in two systematic reviews of moderate quality (e5, e6). For both cardiac and neurosurgical patients, they concluded that acupuncture treatment is likely to result in a more rapid recovery (Table 1, eTable 1).
Risks of naturopathic treatment and complementary medicine
None of the research documented any serious side effects for the methods used. The safety of acupuncture in routine medical care has been studied in Germany in more than 300 000 patients, with only 0.8% of the patients experiencing side effects requiring treatment (21).
Herbal preparations can be a safety hazard in everyday clinical practice, as they are often taken by patients without consulting a physician (1, 3). Some substances, such as St. John’s wort, have a significant interaction risk (22, 23). For instance, substances such as cranberry are suspected of increasing the risk of bleeding (24). Although the risk may be very low, perioperative uncertainties persist. Phytotherapeutic drugs should therefore be discontinued prior to major surgery for safety reasons.
CM/NT offer a wide range of possible supportive therapy options. So far, however, only a few measures have been investigated in surgically-treated patients. The use of acupuncture and acupressure has been evaluated in numerous studies for postoperative nausea and vomiting and pain therapy and has been shown to alleviate symptoms. Although recent studies show that ginger can accelerate gastric emptying, they could not establish it as a drug for prophylaxis of postoperative nausea and vomiting. The effectiveness of phytotherapeutics, such as valerian, hops, and lavender, at reducing anxiety and sleep disturbances of surgical patients can still not be determined with certainty from the current study situation. Non-pharmacological procedures, such as music therapy, have been shown by several studies to alleviate restlessness, stress, anxiety, and pain, both preoperatively and postoperatively. Relaxation techniques and mindfulness-based therapies have not been studied for surgical patients. It also remains unclear whether treatment with honey or other plant-based substances has a positive effect on healing of infected wounds. Finally, research on the roles that the gut microbiome plays in helping to prevent postoperative complications, and its modulation by probiotics, is still in its infancy.
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript submitted on 2 January 2018, revised version accepted on 6 September 2018
Translated from the original German by Dr. Veronica A. Raker
Dr. med. Ann-Kathrin Lederer
Institut für Infektionsprävention und Krankenhaushygiene
Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
Breisacher Straße 115b
79106 Freiburg, Germany
For eReferences please refer to:
eMethods, eTables, eFigure, eBox:
Dr. med. Ann-Kathrin Lederer, Prof. Dr. med. Roman Huber
Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg: Dr. sc. hum. Christine Schmucker
Department for General and Visceral Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg: Dr. med. Lampros Kousoulas, Prof. Dr. med. Stefan Fichtner-Feigl
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