Three Acupuncture Methods for Postoperative Pain in Mixed Hemorrhoids: A Systematic Review and Network Meta-Analysis

Mixed hemorrhoids are one of the most common anorectal conditions, and although surgery is the most effective treatment for definitive removal, postoperative pain represents one of the main complications these patients face after the procedure. This pain arises from the rich innervation of the region below the dentate line, which makes the painful response highly sensitive, in addition to the release of inflammatory mediators after surgery and the constant stimulation of the surgical wound by activities such as defecation and dressing changes, resulting in persistent spasm of the anal sphincter muscle.

Traditionally, postoperative pain management in hemorrhoid surgery has been carried out primarily with analgesic medications. However, these medications require multiple doses over short periods, which can cause adverse effects on the gastrointestinal and central nervous systems. Patients frequently experience dizziness, nausea, vomiting, dry mouth, and skin itching, and the high cost of medications increases the economic burden. This has created an urgent clinical need for nonpharmacological approaches that can effectively relieve patients' pain and improve their quality of life while keeping the adverse effects of medications to a minimum.

This study aimed to compare the clinical efficacy of three different acupuncture methods in the treatment of postoperative pain after mixed hemorrhoid surgery: auricular application with seeds, application of medications at acupoints, and catgut thread embedding at acupoints. The researchers conducted a systematic review and network meta-analysis, searching for evidence in eight major medical databases, including PubMed, Embase, Cochrane Library, Web of Science, and Chinese databases such as CNKI, Wanfang, VIP, and CBM, from database inception through October 2021. The search was conducted by combining specific terms related to the three acupuncture methods and postoperative pain in mixed hemorrhoids.

After a rigorous literature screening process, 47 randomized controlled trials involving 5,121 patients were included. The analysis examined several important clinical outcomes: total efficacy rate, pain scores, pain grade, complications, and adverse reactions. The network meta-analysis allowed not only direct comparisons between treatments but also indirect comparisons across an evidence network, providing a hierarchical ranking of treatments based on their efficacy.

The results revealed significant findings on the relative efficacy of the three acupuncture methods. In terms of overall efficacy, both auricular application and catgut thread embedding at acupoints demonstrated significant superiority compared with conventional analgesics. When compared with conventional treatment, auricular application showed an odds ratio of 3.66, indicating considerably superior efficacy. Cumulative ranking analysis showed that application of medications at acupoints obtained the best overall ranking, with a 73.6% probability of being the most effective treatment, followed by auricular application at 68.7%, catgut thread embedding at 64.6%, and the combination of auricular application with point application at 63.4%.

Regarding pain score reduction, all three acupuncture methods demonstrated superior efficacy compared with both analgesics and conventional treatment. Particularly noteworthy was that the combination of auricular application with point application showed the greatest efficacy in pain reduction, with a 99.5% probability of being the best treatment. Point application alone maintained the second position with a 73.5% probability. The study also demonstrated that the analgesic effects of acupuncture methods were lasting and stable, maintaining superior efficacy at 24, 48, and 72 hours after the intervention, with the 72-hour efficacy being particularly pronounced.

For patients and healthcare providers, these results have important clinical implications. First, acupuncture methods offer safe and effective alternatives to traditional analgesics, with significantly fewer adverse effects. The study showed that catgut thread embedding at acupoints was the most effective in reducing adverse reactions, followed by the combination of auricular application with point application. Second, these methods can be easily integrated into standard postoperative care protocols, offering patients personalized treatment options based on their specific preferences and conditions.

Third, acupuncture techniques can reduce dependence on analgesic medications, potentially decreasing the risk of medication-related side effects and reducing healthcare costs.

The acupuncture methods studied offer several practical advantages over traditional acupuncture. They avoid the pain caused by multiple needle insertions, reduce the workload of medical staff, and compensate for the short duration of the curative effect of conventional acupuncture. More importantly, there is no need to change needles daily, which improves patient adherence and promotes clinical application at the primary care level. These methods are classified as complementary or alternative green therapy, aligning with the growing preference for more natural treatment approaches.

The study has some important limitations that should be considered. The methodological quality of the included studies was variable, with many failing to mention adequate methods of allocation concealment. Due to the specific nature of acupuncture therapy, most studies did not implement blinding, which may have produced implementation bias. In addition, the specific details of acupuncture protocols were not uniformly reported, including traditional Chinese medicine pattern identification, treatment frequency, and duration.

For combined therapies, fewer clinical studies were available, representing an area for future research. Future studies should follow more rigorous reporting standards, such as the CONSORT and STRICTA guidelines, to improve the quality of evidence.

In conclusion, current evidence suggests that acupuncture methods, particularly application of medications at acupoints, offer superior benefits in the treatment of postoperative pain after mixed hemorrhoid surgery compared with conventional analgesics and standard treatment. These methods demonstrate improved overall efficacy, significant reduction in pain scores, and relief of pain levels while maintaining favorable safety profiles. The lasting nature of the analgesic effects, particularly evident at 72 hours postoperatively, suggests that acupuncture treatments provide sustained pain relief. For healthcare providers, these findings support the integration of acupuncture methods into postoper