Highlight
– A large multicenter randomized trial reported that electroacupuncture (EA) significantly shortened time to first flatus and first defecation and reduced incidence of prolonged postoperative ileus (POI) after laparoscopic gastrectomy for gastric cancer.
– EA showed clinically meaningful reductions versus both sham acupuncture (SA) and standard care without serious adverse events, suggesting a low‑risk adjunct to Enhanced Recovery After Surgery (ERAS) pathways.
– Key next steps include mechanistic biomarker studies, international validation, head‑to‑head comparisons with prokinetics and multimodal analgesia strategies, and standardization of EA protocols for implementation.
Background: POI and the unmet need
Postoperative ileus (POI) is a common, resource‑intensive complication after abdominal surgery, characterized by delayed gastrointestinal transit, intolerance of oral intake, abdominal distension, and delayed mobilization and discharge. POI increases length of stay (LOS), opioid exposure, and healthcare costs and worsens patient experience. Current ERAS pathways emphasize early feeding, multimodal analgesia to limit opioids, early mobilization, and selective use of pharmacologic prokinetics, but efficacious, safe, nonpharmacologic options to accelerate return of bowel function remain limited.
Study design
The multicenter randomized trial by Pei et al. (summarized by Bao and colleagues) enrolled patients undergoing laparoscopic gastrectomy for gastric cancer across multiple Chinese centers. The full analysis set included 578 participants. Participants were randomized to electroacupuncture (EA), sham acupuncture (SA), or standard care. EA targeted traditional acupoints often implicated in gastrointestinal regulation (for example Zusanli [ST36] and Tianshu [ST25]) using electrical stimulation. The trial employed blinded methodology where feasible and used objective endpoints: time to first flatus and time to first defecation, plus incidence of prolonged POI and safety monitoring.
Key findings
EA produced statistically and clinically significant improvements in postoperative gastrointestinal recovery compared with both SA and standard care.
Primary and key secondary endpoints
– Time to first flatus: EA versus SA difference = -12.96 hours (95% CI, -19.17 to -6.75; P < .001); EA versus standard care difference = -24.46 hours (95% CI, -30.61 to -18.30; P < .001).
– Time to first defecation: EA versus SA difference = -15.41 hours (95% CI, -27.73 to -3.09; P = .007); EA versus standard care difference = -24.66 hours (95% CI, -36.76 to -12.55; P < .001).
– Incidence of prolonged POI: EA versus SA group difference = -0.41 (95% CI, -0.66 to -0.16; P < .001); EA versus standard care group difference = -0.56 (95% CI, -0.82 to -0.31; P < .001).
Safety
No severe adverse events attributable to acupuncture or EA were reported in the trial, consistent with the favorable safety profile of acupuncture delivered by trained practitioners in perioperative settings.
Interpretation and clinical significance
The magnitudes of change—reductions measured in half‑day to one‑day ranges for GI recovery—are likely clinically meaningful in the immediate postoperative period. Earlier flatus and defecation can enable earlier oral intake and mobilization, reduce discomfort, and may shorten LOS when integrated with other ERAS elements. The use of a sham acupuncture control strengthens causal inference versus non‑specific care effects, and the multicenter design improves internal validity.
Mechanistic plausibility
Electroacupuncture plausibly modulates gastrointestinal recovery through convergent pathways recognized by both Traditional Chinese Medicine (TCM) and contemporary biomedical science:
- Autonomic modulation: EA at specific somatic acupoints may increase parasympathetic (vagal) tone and reduce sympathetic overactivity. Vagal stimulation triggers the cholinergic anti‑inflammatory pathway, dampening systemic and local inflammation that contributes to enteric dysmotility.
- Neuroimmune effects: Preclinical studies link peripheral somatic stimulation to reduced proinflammatory cytokines (including interleukin‑6) and to modulation of splenic neural circuits; such immunomodulation can shorten the inflammatory milieu that impairs enteric neural function after surgery.
- Enteric nervous system and motility: EA can influence gastrointestinal smooth muscle activity through central and enteric neural circuits, enhancing coordinated peristalsis.
- Microbiome and gut‑brain axis hypotheses: Though speculative, EA could indirectly influence microbial composition or barrier function via changes in motility and immune signaling; this remains an area for prospective exploration.
These mechanisms align conceptually with the “inflammatory reflex” that links neural circuits to immune responses and are biologically plausible bridges between TCM concepts (eg, unblocking qi) and measurable physiological effects. Independent mechanistic biomarker data (eg, serial CRP, IL‑6, heart rate variability, or neuroimaging) would strengthen causal chains.
Positioning EA within ERAS and alternatives
ERAS programs already focus on minimizing opioid exposure and encouraging early oral intake and mobilization. EA could be complementary in several ways:
- Opioid‑sparing potential: If EA reduces pain and opioid consumption, this would further support its inclusion in multimodal analgesia protocols and indirectly reduce opioid‑induced bowel dysfunction.
- Alternative or adjunct to prokinetics: Pharmacologic prokinetics (where used) have modest benefit and are associated with side effects and cost; head‑to‑head comparisons or combinatorial trials of EA versus agents such as 5‑HT4 agonists would clarify relative and additive value.
- Feasibility: EA requires trained personnel and equipment; implementing standardized protocols within surgical pathways will need logistical planning, credentialing, and cost analyses.
Study limitations and considerations
While robust, several limitations temper immediate broad adoption:
- Geographic and population generalizability: The trial population was predominantly from Chinese centers; reproducibility in diverse settings, surgical practices, and ethnic groups should be confirmed.
- Sham acupuncture challenges: SA controls vary in design and may not be physiologically inert; however, the EA versus SA difference observed supports a specific EA effect beyond placebo alone.
- Long‑term outcomes missing: The trial focused on early GI recovery; data on LOS, readmission, longer‑term GI function, quality of life, and cost are needed to inform health‑system decisions.
- Protocol standardization: Details such as timing, frequency, intensity of EA stimulation, and the exact acupoint regimen will matter for reproducibility and scale‑up; consolidated reporting (eg, STRICTA standards) is essential.
Research and implementation priorities
To translate these results into practice with confidence, several steps are recommended:
- International, multicenter replication trials that include Western surgical pathways and diverse patient populations.
- Mechanistic substudies embedded in RCTs measuring autonomic function (heart rate variability), inflammatory biomarkers (CRP, IL‑6, TNF‑α), opioid consumption, and microbiome sampling to build causal chains.
- Comparative effectiveness trials versus and combined with prokinetics, and trials specifically measuring hospital LOS, readmissions, health‑related quality of life, and cost‑effectiveness.
- Standardization and training: develop consensus EA protocols (acupoints, stimulation parameters, timing) and credentialing pathways for perioperative providers to ensure consistent delivery.
- Health services research to assess workflow integration, patient acceptance, and reimbursement models.
Expert commentary
The trial provides strong, pragmatic evidence that EA can accelerate short‑term gastrointestinal recovery after major upper GI surgery with a favorable safety profile. For clinicians and ERAS teams, the most actionable near‑term role is as an adjunctive, low‑risk modality to be evaluated locally in pilot implementation projects, especially where trained practitioners are available. For guideline panels, the evidence warrants consideration but probably not yet universal recommendation until external validation and cost‑effectiveness data are available.
Conclusion
The multicenter randomized trial summarized here demonstrates that electroacupuncture can meaningfully shorten the duration of POI after laparoscopic gastrectomy, with robust differences versus both sham and standard care and no serious safety signals. EA represents a credible bridge between TCM practice and Western perioperative medicine with biologically plausible mechanisms. Integration into ERAS pathways should proceed cautiously, supported by replication trials, mechanistic biomarkers, and implementation research to define optimal protocols and to ensure broad generalizability.
Funding and trial registration
Funding sources and trial registration details should be consulted in the original trial report by Pei et al. and the accompanying commentary (Bao H, Jian J, Sun X) for full disclosure.
References
1. Bao H, Jian J, Sun X. Electroacupuncture in Postoperative Ileus: Bridging Traditional Chinese and Western Medicine for Enhanced Recovery. Gastroenterology. 2025 Oct 28:S0016-5085(25)05973-6. doi: 10.1053/j.gastro.2025.07.046. Epub ahead of print. PMID: 41148086.
2. Tracey KJ. The inflammatory reflex. Nature. 2002;420:853–859. (Foundational review on neural control of inflammation.)
