Effects of Transcutaneous Electrical Acupoint Stimulation on Postoperative Recovery in Patients Undergoing Endoscopic Submucosal Dissection: A Prospective, Randomized Clinical Trial

Effects of Transcutaneous Electrical Acupoint Stimulation on Postoperative Recovery in Patients Undergoing Endoscopic Submucosal Dissection: A Prospective, Randomized Clinical Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Transcutaneous Electrical Acupoint Stimulation on Postoperative Recovery in Patients Undergoing Endoscopic Submucosal Dissection: A Prospective, Randomized Clinical Trial Xu-ming Liu, Yu-xuan Qi, Jian-yong Zheng, Xin-lu Chang, Wen-wen Hao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4062875/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Postoperative abdominal pain is one of the most common minor adverse events of endoscopic submucosal dissection (ESD) surgery which is a well-established treatment for early gastrointestinal neoplasms. Transcutaneous electrical acupoint stimulation (TEAS) is a potential treatment option for reducing postoperative pain and improving gastrointestinal function. This study aims to assess the efficacy of TEAS for postoperative pain and gastrointestinal function recovery in patients after ESD surgery for early gastric and esophageal neoplasms. Methods: A total of 129 patients undergoing ESD surgery were randomized into the TEAS group or the sham group and were stratified by the surgical type (i.e., gastric or esophageal ESD surgery). Patients in the TEAS group were treated bilaterally at the Acupoint Hegu (L14), Neiguan (PC6), Zusanli (ST36), and Shangjuxu (ST37). Patients in the sham group were treated at sham acupoints. The TEAS and sham stimulations are both given from 30 min before surgery to the end of the surgery. Postoperative pain was measured by a visual analog scale. T-tests, Mann-Whitney U test, chi-square test, Fisher's test, and univariate and multivariate logistic regression analysis were used to analyze the data of this study. Results: Compared with the sham group, the pain levels of the TEAS group improved from 5 min after surgery to 1 hour after surgery (P＜0.05). The incidence of moderate to severe pain, postoperative nausea and vomiting, and cases needing morphine were significantly lower in the TEAS group (P＜0.05). There was no statistically significant difference between the two groups in the postoperative recovery of gastrointestinal function. Conclusion: Pretreating with TEAS could effectively improve the early postoperative pain of patients, reduce the incidence of moderate to severe pain, decrease the application of morphine after surgery, and reduce the occurrence of postoperative nausea and vomiting. Trial registration: Chinese Clinical Trial Registry, ChiCTR2100052837. (06/11/2021) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Background Endoscopic submucosal dissection (ESD) surgery is a well-established minimally invasive treatment for early gastrointestinal neoplasms that has considerable advantages regarding high rate of en bloc removal, large and complete resection, and low risk of recurrence and fast recovery after surgery [1,2] . Since ESD surgery has been a widespread treatment with expanded indications, perioperative major complications such as bleeding, perforation, and stenosis have been increasingly reported [2-4] . Postoperative abdominal pain, which is one of the most common ESD-related minor adverse events, has been complaint by patients undergoing ESD surgery [5] . It is reported that 44.9%-62.8% of patients suffer moderate to severe pain after EDS surgery, especially in the early postoperative period (within 1-4h after surgery) [6-8] . Postoperative pain not only has a direct negative impact on patient satisfaction but also prolongs hospitalization time and increases hospitalization costs [8,9] . However, postoperative pain treatment after ESD surgery is always underestimated and ignored by anesthesiologists and endoscopists, partly due to the emphasis on enhanced recovery after surgery (ERAS) protocol on earlier discharge and earlier mobilization [9] . At present, there are no unified strategies on how to alleviate postoperative pain and promote gastrointestinal function recovery for patients undergoing gastroesophageal ESD surgery. In clinical practice, anesthesiologists and clinicians are usually unwilling to use painkillers, such as opioids, because they are concerned that these drugs may mask some postoperative complications of ESD, such as perforation, bleeding, etc [10,11] . Some studies have found that intravenous injection of dexamethasone or lidocaine, or local infusion of bupivacaine and triamcinolone acetonide, can help alleviate abdominal pain after ESD surgery while reducing intraoperative opioid consumption and decrease patient physical activity [12-14] . Our previous study also found that intraoperative dexmedetomidine could significantly relieve post-ESD pain and reduce the dosage of morphine used after ESD surgery [15] . However, we also found that some patients still experienced abdominal distension, gastrointestinal dysfunction, or other discomfort. Inflammatory reactions and burns caused by operational stimuli are essential in the development of postoperative pain after ESD surgery. Electroacupuncture, or Transcutaneous electrical acupoint stimulation (TEAS), a potential treatment option for postoperative pain, nausea, and vomiting [16,17] , was recently found that inflammation can be reduced via activating the vagal-adrenal pathway [18] . Similarly, we reported that TEAS improved gastrointestinal function recovery in patients, reduced postoperative pain after abdominal surgery, and decreased the concentration of brain-gut peptide substance P [16] . In recent years, some systematic reviews have reported the promising effects of electroacupuncture or TEAS for postoperative pain treatment after surgery [19-21] , but the benefits of TEAS for patients after gastric ESD remain unclear, especially in the current medical practice that adopts ERAS protocol and emphasizes comfortable healthcare. We therefore conducted this prospective, randomized clinical trial to assess the efficacy of TEAS for postoperative pain and gastrointestinal function recovery in patients after ESD surgery for early gastric and esophageal neoplasms. 2. Methods 2.1 Trial Design and Study Population This study was a single-center, prospective, randomized, sham-controlled clinical trial conducted at Beijing Friendship Hospital affiliated to Capital Medical University in China. It was approved by the Bioethics Committee of Beijing Friendship Hospital, Capital Medical University (No. 2021-P2-315-01) and registered in the China Clinical Trials Registry (No.ChiCTR2100052837), and the first format of this study protocol is 10/10/2021/V1.0. It followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The study protocol for this trial has been published in BMC Complement Med Ther [22] . All participants signed the informed consent form after being recruited by the anesthesiologist at the preoperative visit. This study was performed from December 2021 to March 2023. A total of 275 patients undergoing elective gastric and esophageal endoscopic submucosal dissection were assessed for eligibility, and 129 patients were enrolled by study staff. The inclusion criteria were 18-75 years old, American Society of Anesthesiologists (ASA) Physical Status of I-III, 18 ≤ BMI ≤ 30 [body mass index = weight (kg)/height (m) 2 ], and undergoing gastric and esophageal ESD. They will be excluded from the trial if they have the following conditions: ① With surgical incision or scar on the meridian of the acupoints of Hegu (L14), Neiguan (PC6), Shangjvxu (ST37), and Zusanli (ST36); ② Local skin infection at the acupoints above; ③ There is nerve injury on the upper or lower limbs; ④ The patient participated in other clinical trials within the last 4 weeks; ⑤ The patient does not understand the Visual Analogue Scale (VAS) score and Numeric Rating Scale (NRS) score or the patient is unable to perform the scoring; ⑥ Fitted with a pacemaker; ⑦ Pregnancy, in labor, or with a positive urine pregnancy test; ⑧ Preoperative pain, ongoing use of central analgesic medications, and addiction or dependence on opioids; ⑨ Severe central nervous system disease or psychiatric disorders; ⑩ Considered unsuitable for participation. 2.2 Randomization and Blinding Randomization was performed using computer-generated random numbers with a block size of 4, the allocation was sealed in an opaque envelope. Subjects were randomly assigned to the sham group or the TEAS group with a ratio of 1:1 by the anesthesiologist. As a single-blind trial, only the anesthesiologist and acupuncturist who was in charge of the TEAS stimulation were aware of the grouping, the patients, surgeons, and physicians responsible for follow-up were unaware. 2.3 Intervention Both TEAS and sham stimulation were performed by a licensed acupuncturist with more than 3 years of practice. Patients in both groups received the intervention from 30 minutes before surgery until the end of surgery. Patients in the TEAS group were treated bilaterally at the Hegu (L14), Neiguan (PC6), Zusanli (ST36), and Shangjuxu (ST37) (The detail of the location of acupoints were in the Figure 1. The location of acupoints. A. The location of L14, PC6. L14 is Hegu acupoint; PC6 is Neiguan acupoint. B. The location of ST36, ST37. ST36 is Zusanli acupoint; ST37 is Shangjvxu acupoint.). Self-adhesive electrodes with wires were attached to the location of these 4 acupoints and connected to the HANS acupoint nerve stimulator (HANS-200A, Nanjing Jisheng Medical Technology Co., Ltd., China), setting the current frequency to 2/100Hz (the wave width at 2 Hz was 0.6 ms, and at 100 Hz was 0.2ms), alternating frequency for 3s, and stimulation intensity to the patient's maximum tolerance level. Figure 1. The location of acupoints. A. The location of L14, PC6. L14 is Hegu acupoint; PC6 is Neiguan acupoint. B. The location of ST36, ST37. ST36 is Zusanli acupoint; ST37 is Shangjvxu acupoin In the sham group, two of the sham points were located at 7 cun above and 1 cun outside Shenmen (HT7), and 7 cun above and 1 cun outside HT7. The other two sham points were at 9 cun and 12 cun above Kunlun (BL60) (Figure 2. The location of sham points. A. The location of sham points 1 and 2. HT7 is Shenmen acupoint. B. The location of sham points 3 and 4. BL60 is Kunlun acupoint.). Self-adhesive electrodes were glued to these points, but no electrical stimulation was given from the HANS stimulator. Figure 2 . The location of sham points. A. The location of sham points 1 and 2. HT7 is Shenmen acupoint. B. The location of sham points 3 and 4. BL60 is Kunlun acupoint. 2.4 Anesthesia procedures On the day before surgery, all enrolled patients signed informed consent and received relevant education on the implementation and follow-up of this study. Electrocardiogram, blood pressure, pulse oxygen saturation, and bispectral (BIS) were monitored before anesthesia. TEAS and sham stimulation were conducted by the experienced acupuncturist 30 minutes before the surgery. Midazolam 0.03mg/kg, remifentanil 1-2μg/kg, etomidate 0.1-0.2mg/kg and rocuronium 0.6-0.8mg/kg were used before intubation. Anesthesia was maintained with a total intravenous infusion of propofol (4-6mg/kg/h), remifentanil (0.05-0.2µg/kg/min), and rocuronium (one-third of the induced dose every 40min). Anesthetic depth was controlled by the adjustment of intravenous propofol to maintain a bispectral index of 45-55 during the procedure. Tramadol 50mg was applied for analgesia 30 minutes before the end of ESD surgery. At the end of the surgery, the patient was extubated and transferred to the post-anesthesia care unit (PACU) in routine. The Visual Analogue Scale (VAS) was used to assess the patient’s pain level. If the VAS score≥4 points or the patient requested analgesia during the follow-up, morphine 1mg was administered intravenously. The Numerical Rating Scale (NRS) was used to evaluate the degree of nausea. If NRS≥7 or vomiting occurred, a serotonin 3 receptor antagonist was given. The concomitant medication during the trial period from the start of surgery to 2 days after the end was recorded. 2.5 Outcomes The primary outcome was a visual analog scale (VAS) score at different time points which were 5 minutes, 10 minutes, 20 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 18 hours, 24 hours, 48 hours postoperatively. The scale was 0-10 cm, 1-3 cm for mild pain, 4-6 cm for moderate pain, and 7-10 cm for severe pain. Secondary outcomes included the incidence of post-ESD VAS≥4 and the consumption of morphine during follow-up, gastrointestinal function recovery time, the incidence of postoperative complications, and patient satisfaction. These outcomes were recorded by an anesthesiologist specializing in follow-up. For recovery of gastrointestinal function, we mainly recorded the time of first flatus, defecation, drink, and solid food intake. The main recorded postoperative complications were hypertension, hypotension, tachycardia, bradycardia, nausea and vomiting [measured with the 0-10 cm numeric rating scale (NRS)], gastrointestinal perforation or bleeding, reoperation, and fever. Postoperative adverse events will also be recorded by the follow-up anesthesiologist, and in the event of a malignant event such as bleeding >500 ml, the trial will be immediately terminated and reported to the Principal Investigator and a review board will be established. 2.6 Statistical Analysis The sample size was calculated based on the outcomes of our pre-trial. In the pre-trial, we observed that patients always felt no pain or tolerated pain completely within half an hour after extubation. It was only at approximately 1 hour postoperatively that patients felt obvious pain. Therefore, we applied the VAS score at 1 hour postoperatively to calculate the sample size: it was 0.86±1.14 (mean±SD) in the TEAS group and 1.68±1.46 (mean±SD) in the sham group. Setting an α of 0.05, a β of 0.1, and a power of 0.9, plus a 10% dropout rate, we calculated that a total of 120 cases were needed using PASS 11.0. 60 cases per group were required. All data were described and analyzed using SPSS. Continuous variables were reported as mean±SD or median (IQR), where normally distributed data were analyzed for differences between groups by t-test, and skewed data were by Mann-Whitney U test. Categorical variables were reported as the number of cases (percentages) and intergroup differences were analyzed by chi-square test or Fisher's test. A P value less than 0.05 indicates a statistically significant difference. Perioperative factors were analyzed using univariate and multivariate logistic regression analysis, and the resulting odds ratio (OR) values, 95% confidence intervals (95%CI), and P values were provided. The potential influencing factors included in this trial were derived from previous investigations [7,8] . 3. Results 3.1 Trial Flow From July 2021 to August 2022, a total of 275 patients took part in this trial. Among them, 11 patients did not meet the inclusion criteria, 3 had ASA grades more than III, 125 had taken part in earlier research, 2 had pacemakers placed, and 5 had opted out of the trial. As a result, 129 patients were randomized to the TEAS group and the sham group. One patient from the TEAS group and one from the sham group were converted to laparotomy due to further pathological infiltration of lesions and were eliminated from the study. Two patients from the TEAS group and one from the sham group dropped out due to postoperative bleeding. Three patients from the TEAS group and one from the sham group asked to withdraw their informed consent and withdrew from the trial. Finally, a total of 120 patients completed the entire research. There were 58 patients in the TEAS group and 62 patients in the sham group. An explanatory flowchart is depicted in Figure 3. Except for the fact that more patients in the sham group had a history of cerebral infarction than in the TEAS group (P=0.032), there were no statistically significant differences in the baseline characteristics of the patients across groups. The baseline characteristics of 120 patients are provided in Table 1. Figure 3. Flowchart of this trial Table 1 ． Demographic Data and Clinicopathological Characteristics of Patients Variables TEAS Group (n=58) Sham Group (n=62) P value Age (years) 62 ± 9 61 ± 9 0.497 Height (cm) 168 ± 8 167 ± 8 0.774 Weight (kg) 69 ± 11 68 ± 10 0.892 BMI (kg/m2) 24.4 ± 2.9 24.2 ± 2.5 0.660 Sex (male/female, cases) 38/20 44/18 0.521 Type of surgery (gastric/esophageal, cases) 29/29 33/29 0.724 Lesion location ( a cases) Gastric cardia 10 9 0.901 Gastric body 7 10 Gastric antrum 10 14 Gastric angle 3 5 Upper esophagus 2 3 Median esophagus 22 20 Lower esophagus 7 12 Histopathology ( a cases) Benign tumor 7 13 0.664 Dysplasia 14 14 Adenoma 25 25 Carcinoma 15 21 Length of the major axis of the tumor≥3cm ( b cases) 31 29 0.223 Multiple lesions (cases [%]) 3 (5.17) 10 (16.13) 0.054 Smoking history (cases) 27/31 32/30 0.579 History of alcohol intake (cases) 31/27 33/29 0.981 Previous surgical history (cases [%]) 38 (65.52) 50 (80.65) 0.061 ASA (cases [%]) I 9 (15.52) 14 (22.58) 0.529 II 40 (68.97) 37 (59.68) III 9 (15.52) 11 (17.74) Comorbidities (cases [%]) Hypertension 29 (50) 33 (53.23) 0.724 Diabetes 11 (18.97) 11 (17.74) 0.863 Coronary disease 5 (8.62%) 8 (12.90) 0.451 Hyperlipidemia 22 (37.93) 20 (29.41) 0.515 Cerebral infarction 3 (5.17) 11 (17.74) 0.032 a: Some patients have multiple lesions; b: For patients with multiple lesions, as long as one lesion is greater than 3cm, it is recorded. TEAS Group: transcutaneous electrical acupoint stimulation group; SD: standard deviation. Values are present as number of patients (%), median (IQR) or mean ±SD. 3.2 Primary Endpoints: Visual Analogue Scale Scores The VAS scores at different postoperative time points are represented in Figure 4. Compared with the sham group, the pain levels of the TEAS group improved from 5 min after surgery to 1 hour after surgery (P＜0.05). While no statistical difference was detected between the two groups at other postoperative time points (Table 2). We defined VAS ≥4 as moderate to severe pain. We found that the incidence of moderate to severe pain in the TEAS group was 37.9%, whereas in the sham group was 64.5%, P =0.004 (Table 3). This difference was much more significant in esophageal ESD surgery, the incidence was 44.8% (the TEAS Group) vs 86.2% (the sham Group). Figure 4. The Boxplot of VAS at different postoperative time points. Table 2. Postoperative Pain Score at Different Time ( mean (IQR), VAS ) VAS pain score TEAS Group (n=58) Sham Group (n=62) P value 5min post-OP 0 (0,0) 0 (0,2) 0.000 10min post-OP 0 (0,2) 2 (0,4) 0.009 20min post-OP 1 (0,2) 3 (0,4) 0.001 30min post-OP 2 (0,3) 3 (0,4) 0.011 1h post-OP 2 (0.8,2) 3 (1.8,4) 0.000 2h post-OP 2 (0,3) 2 (1.8,3) 0.073 4h post-OP 2 (0.8,3) 2 (1,3) 0.293 6h post-OP 1 (0,2) 2 (0,3) 0.520 18h post-OP 1 (0,2) 1 (0,2) 0.948 24h post-OP 1 (0,1.3) 1 (0,2) 0.843 48h post-OP 0 (0,1) 0 (0,1) 0.635 VAS, visual analog scale; OP operation. Table 3. The Incidence of Moderate to Severe Pain (VAS ≥ 4) (cases / %) Incidence (cases/[%]) TEAS Group (n=58) Sham Group (n=62) Sum up Gastric surgery (n=62) 9 (31.03%) 15 (45.45%) 24 (38.71%) Esophageal surgery (n=58) 13 (44.83%) 25 (86.21%) 38 (65.52%) Sum up 22 (37.93%) 40 (64.52%) 62 (51.67%) P value 0.004 3.3 Secondary Endpoints: Postoperative Recovery of Gastrointestinal Function and Postoperative Adverse Events There was no statistically significant difference between the two groups in the postoperative recovery of gastrointestinal function (P＞0.05, Table 4. The details of postoperative adverse events are summarized in Table 5. The incidence of postoperative nausea and vomiting (PONV) and cases needing morphine in the TEAS group were significantly lower than in the sham group (PONV: 6.9% vs. 22.6%, P =0.016; cases needing morphine: 32.7% vs. 64.5%, P ＜0.001). No differences in other postoperative adverse events were found between the two groups ( P ＞0.05, Table 5). Table 4. Postoperative Recovery of Gastrointestinal Function ( mean (IQR), h ) Variables TEAS Group (n=58) Sham Group (n=62) P value Time to first flatus 11 (6,22) 14 (7,21) 0.738 Time to first defecation 68 (37, 91) 54 (24, 91) 0.318 Time to first drinking 69 (48, 75) 68 (50, 76) 0.766 Time to first eating solid food 73 (63, 87) 75 (69, 92) 0.350 Table 5. The Incidence of Postoperative Adverse Events Variable ( Cases/[%] ) TEAS Group (n=58) Sham Group (n=62) P value PONV 4 (6.89) 14 (22.58) 0.016 Cases needing morphine 19 (32.76) 40 (64.52) ＜0.001 Giving acid-inhibitory drugs after surgery 56 (96.55) 61 (98.39) 0.953 Shivering 1 (1.72) 3 (4.84) 0.619 Hypertension 2 (3.45) 5 (8.06) 0.441 Hypotension 0 (0) 3 (4.84) 0.245 Tachycardia 1 (1.72) 2 (3.23) 1.000 Bradycardia 2 (3.45) 8 (12.90) 0.123 Gastrointestinal perforation or bleeding 2 (3.45) 3 (4.84) 1.000 Reoperation 1 (1.72) 3 (4.84) 0.619 Fever 4 (6.90) 2 (3.23) 0.428 PONV: postoperative nausea and vomiting. 3.4 Associations Between Factors and Pain Scores According to the results (Table 3), there were 62 (51.7%) cases experienced moderate to severe pain. All perioperative factors that may cause VAS scores ≥ 4 were analyzed with univariate logistic regression analysis (Table 6). The results showed that TEAS treatment ( P =0.004), the type of surgery ( P =0.003), and tumor location ( P ＜0.05) were potential contributing factors associated with VAS scores ≥ 4. Therefore, we performed multivariate logistic regression analysis for all factors with P ＜0.1 (Figure 5. Forest plot of Multivariate logistic regression analysis of risk factors for moderate to severe pain). Figure Forest plot showed that TEAS treatment was a protective factor associated with reduced incidence of VAS scores ≥ 4 (OR=0.227; 95% CI: 0.100 to 0.512; P ＜0.001). In addition, the type of surgery was also a protective factor: patients undergoing gastric ESD surgery had a much lower incidence of VAS scores ≥ 4 than patients undergoing esophageal ESD surgery (OR=0.287; 95% CI: 0.133 to 0.621; P = 0.002) Figure 5. Forest plot of Multivariate logistic regression analysis of risk factors for moderate to severe pain Table 6. Results of univariate logistic regression analysis of risk factors for moderate to severe pain Variable OR 95%CI P value Age 1.013 (0.971-1.057) 0.547 BMI 0.961 (0.841-1.098) 0.561 Sex 0.910 (0.417-1.987) 0.814 TEAS treatment 0.336 (0.160-0.707) 0.004 Type of surgery 0.350 (0.173-0.707) 0.003 Tumor location Gastric cardia 1 Gastric body 0.178 (0.043-0.736) 0.017 Gastric antrum 0.121 (0.026-0.559) 0.007 Gastric angle 0.226 (0.058-0.883) 0.032 Upper esophagus 0.267 (0.045-1.567) 0.144 Median esophagus 0.178 (0.022-1.454) 0.107 Lower esophagus 0.480 (0.135-1.711) 0.258 Tumor histology Benign tumor 1 Dysplasia 0.346 (0.109-1.103) 0.073 Adenoma 0.629 (0.221-1.792) 0.386 Carcinoma 0.236 (0.093-0.595) 0.002 Length of the major axis of the tumor≥3cm (case) 0.950 (0.436-2.069) 0.898 Multiple lesions (case [%]) 0.608 (0.156-2.359) 0.472 Smoking history 2.404 (0.601-9.622) 0.215 History of alcohol intake 0.514 (0.137-1.927) 0.323 Previous surgical history 1.601 (0.489-5.238) 0.437 ASA I 1 II 0.579 (0.170-1.977) 0.383 III 0.932 (0.346-2.509) 0.888 Comorbidities Hypertension 0.818 (0.388-1.726) 0.599 Diabetes 0.846 (0.333-2.151) 0.726 Coronary disease 0.279 (0.072-1.072) 0.063 Hyperlipidemia 0.799 (0.374-1.710) 0.564 Cerebral infarction 1.457 (0.471-4.510) 0.513 Induction dose of remifentanil 1.114 (0.941-1.319) 0.209 Dose of anesthetic maintenance drugs Propofol 1.002 (0.994-1.010) 0.846 Remifentanil 1.001 (0.998-1.004) 0.511 Duration of surgery 0.999 (0.928-1.075) 0.977 Duration of anesthesia 0.978 (0.906-1.055) 0.557 OR: odds ratio; CI: confidence interval; TEAS: Transcutaneous electrical acupoint stimulation. 3.5 Patient Satisfaction A scale with a maximum score of 10 was utilized to evaluate patient satisfaction after ESD surgery. In TEAS and sham groups, the mean ranks of patient satisfaction scores were 73.0 and 48.8, respectively. In comparison with the sham group, patient satisfaction in the TEAS group was considerably higher ( P ＜0.001). 4. Discussion In this study, our data suggested that in patients undergoing gastroesophageal ESD surgery under general anesthesia, pretreating with TEAS could effectively improve the early postoperative pain of patients, reduce the incidence of moderate to severe pain, and decrease the application of morphine after surgery. In addition, the results showed that the type of surgery was a risk factor for postoperative pain. Patients undergoing gastric ESD surgery had a much lower incidence of VAS scores ≥ 4 than patients undergoing esophageal ESD. Moreover, this treatment could reduce the occurrence of PONV, and correspondingly achieve higher patient satisfaction. ESD, an unusual endoscopic technique, has been reported to be completely effective for early gastroesophageal cancer with higher en bloc and has a histologically complete resection rate and lower local recurrence. As its apparently minimally invasive nature, post-ESD pain is often neglected by physicians. However, based on recently published data, the incidence of moderate to severe pain induced by ESD was as high as 44.9% to 62.8% [6-8] . The same conclusion was obtained in Kim’s study [23] . In our research, we found that the incidence of moderate to severe pain in the sham group was 64.5%. It was further demonstrated that the rate of post-ESD pain is high enough for physicians to pay more attention and make active pain management. However, at present, there is no unified measure of how to carry out good postoperative analgesia for patients undergoing gastroesophageal ESD. Fortunately, our study found that TEAS can effectively alleviate post-ESD pain. In this regard, several recently published investigations confirmed that TEAS can provide powerful protection against postoperative pain for a variety of procedures, like laparoscopy surgery [24] , gastric and colorectal surgery [16] as well as pediatric orthopedic surgery [25] . More importantly, we also found that pretreating with TEAS was a protective factor associated with reduced incidence of moderate to severe pain according to logistic regression analysis. All this evidence paved TEAS as an attractively therapeutic avenue for post-ESD pain. Based on published data, post-ESD pain is more severe in the early postoperative period (within 1-4h after surgery) [6-8] . In fact, this was also confirmed in our preliminary experiment [22] . In line with these results, we emphatically followed up the VAS scores of patients in the early postoperative period. Moreover, we appropriately extended the visit to 48 hours after surgery. Further investigation showed that TEAS could improve post-ESD pain at 5 min, 10 min, 20 min, 30 min, and 1 h after surgery. No statistical difference was detected at other postoperative time points. In addition, a recently published retrospective study confirmed that gender, operation duration, and lesion site were clear factors affecting postoperative pain in ESD [8] . Strikingly, our study revealed that patients undergoing gastric ESD surgery had a much lower incidence of medium-to-severe pain than esophageal ESD surgery. This may be due to the different mechanisms of pain transmission in different organs. Moreover, we cannot rule out the possibility that increased peristalsis at the esophageal site and frequent contractions may also lead to aggravated postoperative pain after ESD. In this study, peri-operative TEAS treatment decreased the cases of PONV, this result is similar to our previous study in gastrointestinal surgery [16] . As known, LI4, PC6, ST36, and ST37 are the most commonly used acupoints for regulating the intestines and stomach, channeling the channels and collaterals. It was well documented that stimulating these acupoints could improve intestinal motility, and regulate endocrine function, which helps reduce PONV [26] . However, the data from this study failed to confirm that TEAS improved gastrointestinal function in patients after gastroesophageal ESD. This result is inconsistent with another study by our research team [16] . In this regard, we consider that ESD is a minimally invasive surgery in nature, it has little interference with gastrointestinal function, so it has almost no impact on the exhaust function of patients. What is more, the eating and drinking time of patients after ESD surgery is basically carried out according to the doctor’s advice, the time of all patients is therefore relatively fixed. There are several limitations to this study. First, TEAS was performed only during the operation, and there was no continuous intervention after surgery. Although, in our previous observation, we found that the postoperative pain of most patients was concentrated in the early postoperative period. Hence, TEAS was not administered after patients returned to the ward. However, we still cannot rule out that this may be related to the lack of difference in pain 1h after ESD between the TEAS group and the sham group. Second, this study could not measure some analgesic substances such as endorphins, or some injury-related factors such as interleukin-6 to quantitatively compare the postoperative pain response between the two groups. It is also about our cost budget. 5. Conclusion Data from this study showed that pretreating with TEAS could effectively improve the early postoperative pain of patients, and reduce the incidence of moderate to severe pain. Considering that there is no unified consensus and effective method for post-ESD pain, our study may provide a feasible strategy for relieving it. Abbreviations ESD endoscopic submucosal dissection ERAS enhanced recovery after surgery TEAS CONSORT ASA BMI VAS NRS BIS PACU SD IQR OR CI PONV transcutaneous electrical acupoint stimulation Consolidated Standards of Reporting Trials American Society of Anesthesiologists body mass index Visual Analogue Scale Numeric Rating Scale bispectral post-anesthesia care unit standard deviation interquartile range odds ratio confidence interval postoperative nausea and vomiting Declarations Ethics approval and consent to participate This trial was approved by the Ethics Committee of Beijing Friendship Hospital affiliated to Capital Medical University (Approval number: 2021-P2-315-01). Each patient signed an informed consent form when recruited. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by Beijing Municipal Administration of Traditional Chinese Medicine (No. BJZYQN-2023-22), and the Capital’s Funds for Health Improvement and Research, PR China (Grant No. CFH 2022-2-20210). Authors' contributions An LX and Li WJ are the chief investigators who are responsible for quality control of the topic selection, design, trial overseeing, and paper revision. They contributed equally to this article and are co-corresponding authors of this trial. Liu XM and Qi YX recruited participants, analyzed the data, improved the study protocol, and drafted this manuscript. They contributed equally to this work and should be considered as co-first authors. Zheng JY, Chang XL, Hao WW, and Du Y worked for data collection and performed anesthesia and intervention. Acknowledgements The authors would like to express sincere thanks to the gastroenterologists and all patients for their understanding and support of this trial. References Maple JT, Abu Dayyeh BK, Chauhan SS, et al. Endoscopic submucosal dissection. Gastrointest Endosc. 2015;81(6):1311-1325. Liu Q, Ding L, Qiu X, Meng F. Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis. Int J Surg. 2020;73:28-41. Misumi Y, Nonaka K. Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection. J Clin Med. 2021;10(11). Hayashi T, Kudo SE, Miyachi H, et al. Management and risk factor of stenosis after endoscopic submucosal dissection for colorectal neoplasms. Gastrointest Endosc. 2017;86(2):358-369. Toyonaga T, Man-i M, East JE, et al. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc. 2013;27(3):1000-1008. Choi HS, Kim KO, Chun HJ, et al. The efficacy of transdermal fentanyl for pain relief after endoscopic submucosal dissection: a prospective, randomised controlled trial. Dig Liver Dis. 2012;44(11):925-929. Kim SY, Jung SW, Choe JW, et al. Predictive Factors for Pain After Endoscopic Resection of Gastric Tumors. Dig Dis Sci. 2016;61(12):3560-3564. Kim JW, Jang JY, Park YM, Shim JJ, Chang YW. Clinicopathological characteristics of patients with pain after endoscopic submucosal dissection for gastric epithelial neoplasm. Surg Endosc. 2019;33(3):794-801. Li D, Jensen CC. Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols. Clin Colon Rectal Surg. 2019; 32(2): 138-144. Uozumi T, Abe S, Makiguchi ME, Nonaka S, Suzuki H, Yoshinaga S, Saito Y. Complications of endoscopic resection in the upper gastrointestinal tract. Clin Endosc. 2023; 56(4): 409-422. Tanabe S, Ishido K, Matsumoto T, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a multicenter collaborative study. Gastric Cancer. 2017; 20(Suppl 1): 45–52. Pyo JH, Lee H, Min YW, Min BH, Lee JH, Rhee PL, et al. A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm. Gut Liver. 2016; 10(4): 549-55. Kim B, Lee H, Chung H, Park JC, Shin SK, Lee SK, et al. The efficacy of topical bupivacaine and triamcinolone acetonide injection in the relief of pain after endoscopic submucosal dissection for gastric neoplasia: a randomized double-blind, placebo-controlled trial. Surg Endosc. 2015; 29(3): 714-22. Kim JE, Choi JB, Koo BN, Jeong HW, Lee BH, Kim SY. Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study. Medicine (Baltimore). 2016; 95(18): e3593. Luo X, Chen P, Chang X, Li Y, Wan L, Xue F, An L. Intraoperative Dexmedetomidine Decreases Postoperative Pain after Gastric Endoscopic Submucosal Dissection: A Prospective Randomized Controlled Trial. J Clin Med. 2023;12(5):1816. Li WJ, Gao C, An LX, Ji YW, Xue FS, Du Y. Perioperative transcutane‐ous electrical acupoint stimulation for improving postoperative gastrointestinal function: a randomized controlled trial. J Integr Med. 2021;19(3):211–8. Wang Y, Yang JW, Yan SY, Lu Y, Han JG, Pei W, Zhao JJ, Li ZK, Zhou H, Yang NN, Wang LQ, Yang YC, Liu CZ. Electroacupuncture vs Sham Electroacupuncture in the Treatment of Postoperative Ileus After Laparoscopic Surgery for Colorectal Cancer: A Multicenter, Randomized Clinical Trial. JAMA Surg. 2023;158(1):20-27. Liu S, Wang Z, Su Y, et al. Aneuroanatomical basis for electroacupuncture to drive the vagal-adrenal axis. Nature . 2021;598(7882):641-645. Shah S, Godhardt L, Spofford C. Acupuncture and Postoperative Pain Reduction. Curr Pain Headache Rep. 2022; 26(6):453-458. Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, Lee FP, Lin JG, Chen C. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016; 11(3): e0150367. Wang D, Shi H, Yang Z, Liu W, Qi L, Dong C, Si G, Guo Q. Efficacy and Safety of Transcutaneous Electrical Acupoint Stimulation for Postoperative Pain: A Meta-Analysis of Randomized Controlled Trials. Pain Res Manag. 2022; 2022: 7570533. Chang XL, Liu XM, An LX, Zheng JY, Zhang K. Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial. BMC Complement Med Ther. 2023; 23(1): 253. Jung DH, Youn YH, Kim JH, Park H. Factors influencing development of pain after gastric endoscopic submucosal dissection: a randomized controlled trial. Endoscopy. 2015; 47(12): 1119-1123. Meng D, Mao Y, Song QM, Yan CC, Zhao QY, Yang M, Xiang G, Song Y. Efficacy and Safety of Transcutaneous Electrical Acupoint Stimulation (TEAS) for Postoperative Pain in Laparoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2022; 2022: 9922879. Li Y, Ma Y, Guo W, Ge W, Cheng Y, Jin C, Guo H. Effect of transcutaneous electrical acupoint stimulation on postoperative pain in pediatric orthopedic surgery with the enhanced recovery after surgery protocol: a prospective, randomized controlled trial. Anaesth Crit Care Pain Med. 2023; 42(6): 101273. Hou L, Xu L, Shi Y, Gu F. Effect of electric acupoint stimulation on gastrointestinal hormones and motility among geriatric postoperative patients with gastrointestinal tumors. J Tradit Chin Med. 2016; 36(4): 450–45 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4062875","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293735575,"identity":"2431558e-c1a7-41fb-9759-da768be5ccec","order_by":0,"name":"Xu-ming Liu","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu-ming","middleName":"","lastName":"Liu","suffix":""},{"id":293735576,"identity":"bae0d0dc-9d78-4088-839f-f7810caa0023","order_by":1,"name":"Yu-xuan Qi","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu-xuan","middleName":"","lastName":"Qi","suffix":""},{"id":293735577,"identity":"168b1f29-0c42-4f64-b8a5-a56df5686211","order_by":2,"name":"Jian-yong Zheng","email":"","orcid":"","institution":"Perking University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jian-yong","middleName":"","lastName":"Zheng","suffix":""},{"id":293735578,"identity":"54e41918-d3cb-4ce1-8ddb-0f349bb81893","order_by":3,"name":"Xin-lu Chang","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xin-lu","middleName":"","lastName":"Chang","suffix":""},{"id":293735580,"identity":"07414a26-6689-4396-b300-f622a05f8e7c","order_by":4,"name":"Wen-wen Hao","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen-wen","middleName":"","lastName":"Hao","suffix":""},{"id":293735582,"identity":"66da9ed0-a34c-4d8b-9248-f1153c030825","order_by":5,"name":"Yi Du","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Du","suffix":""},{"id":293735584,"identity":"04d1602d-839b-4e5e-be2a-235880744370","order_by":6,"name":"Wen-jing Li","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen-jing","middleName":"","lastName":"Li","suffix":""},{"id":293735585,"identity":"236f49b8-e27f-421c-b900-ea6111fcf23b","order_by":7,"name":"Li-xin An","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFAC5oYDDAYMcmzsjY0PEipqiNHCCNZizMdz+LDBgzPHiNMCIhPnSaSlST5sYSasgX92Y+NhnoI7xmwMOWYViQ1sDPzt3Ql4tUjcOdhwcIbBMzk2hjNmNxJ3yDBInDm7Ab81NxIbDnwwOGzMxtgD1HKGjcFAIhe/FnmQlgSDw4ltzDxmBUCSsBYDqC2JbWxsaQxEaTEEagH6BegwHubDEglnjvEQ9IvcjeTDn3n+HJaTn/+w8eOPiho5/vZeAt5HBzykKR8Fo2AUjIJRgBUAALD7Ttaj9/WFAAAAAElFTkSuQmCC","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":true,"prefix":"","firstName":"Li-xin","middleName":"","lastName":"An","suffix":""}],"badges":[],"createdAt":"2024-03-10 07:45:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4062875/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4062875/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55510621,"identity":"c1c6b718-327c-497b-838f-121b822b7500","added_by":"auto","created_at":"2024-04-29 12:29:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2341178,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe location of acupoints. A. The location of L14, PC6. L14 is Hegu acupoint; PC6 is Neiguan acupoint. B. The location of ST36, ST37. ST36 is Zusanli acupoint; ST37 is Shangjvxu acupoin\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.Thelocationofacupoints.A.ThelocationofL14PC6.L14isHeguacupointPC6isNeiguanacupoint.B.ThelocationofST36ST37.ST36isZusanliacupointST37isShangjvxuacupoint..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/1af23f859018a7325aa11fe0.jpg"},{"id":55510623,"identity":"71f9a1e2-6542-4e4b-a069-7d4799bf310b","added_by":"auto","created_at":"2024-04-29 12:29:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":205369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe location of sham points. A. The location of sham points 1 and 2. HT7 is Shenmen acupoint. B. The location of sham points 3 and 4. BL60 is Kunlun acupoint.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig2.Thelocationofshampoints.A.Thelocationofshampoints1and2.HT7isShenmenacupoint.B.Thelocationofshampoints3and4.BL60isKunlunacupoint..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/b8ac10c6938e7721bc42189c.jpg"},{"id":55511688,"identity":"7e09e13d-7ab3-4750-9ae4-ae5aede24fa3","added_by":"auto","created_at":"2024-04-29 12:37:55","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":310402,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of this trial\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig3.Flowchartofthistrial.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/aca86b3219c8af61fbf05db6.jpg"},{"id":55510625,"identity":"9712c906-112b-4fc8-a81e-d5b0d04fecef","added_by":"auto","created_at":"2024-04-29 12:29:55","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":177928,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Boxplot of VAS at different postoperative time points.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig4.TheBoxplotofVASatdifferentpostoperativetimepoints..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/6b5e707b90ecd3c16c6e1bbb.jpg"},{"id":55510624,"identity":"39d0519a-1400-4d35-942d-4b0f496d109e","added_by":"auto","created_at":"2024-04-29 12:29:55","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1135551,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of Multivariate logistic regression analysis of risk factors for moderate to severe pain\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig5.ForestplotofMultivariatelogisticregressionanalysisofriskfactorsformoderatetoseverepain.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/b32aa479a9d66921b0f33859.jpg"},{"id":71410332,"identity":"ce4737ca-e39a-4466-be17-74f335099457","added_by":"auto","created_at":"2024-12-14 13:01:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5434357,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4062875/v1/ac3220f5-e0d6-4f31-90ef-073f7023ce4e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Transcutaneous Electrical Acupoint Stimulation on Postoperative Recovery in Patients Undergoing Endoscopic Submucosal Dissection: A Prospective, Randomized Clinical Trial","fulltext":[{"header":"1. Background","content":"\u003cp\u003eEndoscopic submucosal dissection (ESD) surgery is a well-established minimally invasive treatment for early gastrointestinal neoplasms that has considerable advantages regarding high rate of en bloc removal, large and complete resection, and low risk of recurrence and fast recovery after surgery\u0026nbsp;\u003csup\u003e[1,2]\u003c/sup\u003e. Since ESD surgery has been a widespread treatment with expanded indications, perioperative major complications such as bleeding, perforation, and stenosis have been increasingly reported\u0026nbsp;\u003csup\u003e[2-4]\u003c/sup\u003e. Postoperative abdominal pain, which is one of the most common ESD-related minor adverse events, has been complaint by patients undergoing ESD surgery\u0026nbsp;\u003csup\u003e[5]\u003c/sup\u003e. It is reported that 44.9%-62.8% of patients suffer moderate to severe pain after EDS surgery, especially in the early postoperative period (within 1-4h after surgery)\u0026nbsp;\u003csup\u003e[6-8]\u003c/sup\u003e. Postoperative pain not only has a direct negative impact on patient satisfaction but also prolongs hospitalization time and increases hospitalization costs\u0026nbsp;\u003csup\u003e[8,9]\u003c/sup\u003e. However, postoperative pain treatment after ESD surgery is always underestimated and ignored by anesthesiologists and endoscopists, partly due to the emphasis on enhanced recovery after surgery (ERAS) protocol on earlier discharge and earlier mobilization\u0026nbsp;\u003csup\u003e[9]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAt present, there are no unified strategies on how to alleviate postoperative pain and promote gastrointestinal function recovery for patients undergoing gastroesophageal ESD surgery. In clinical practice, anesthesiologists and clinicians are usually unwilling to use painkillers, such as opioids, because they are concerned that these drugs may mask some postoperative complications of ESD, such as perforation, bleeding, etc\u0026nbsp;\u003csup\u003e[10,11]\u003c/sup\u003e. Some studies have found that intravenous injection of dexamethasone or lidocaine, or local infusion of bupivacaine and triamcinolone acetonide, can help alleviate abdominal pain after ESD surgery while reducing intraoperative opioid consumption and decrease patient physical activity\u0026nbsp;\u003csup\u003e[12-14]\u003c/sup\u003e. Our previous study also found that intraoperative dexmedetomidine could significantly relieve post-ESD pain and reduce the dosage of morphine used after ESD surgery\u0026nbsp;\u003csup\u003e[15]\u003c/sup\u003e. However, we also found that some patients still experienced abdominal distension, gastrointestinal dysfunction, or other discomfort.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Inflammatory reactions and burns caused by operational stimuli are essential in the development of postoperative pain after ESD surgery. Electroacupuncture, or Transcutaneous electrical acupoint stimulation (TEAS), a potential treatment option for postoperative pain, nausea, and vomiting \u003csup\u003e[16,17]\u003c/sup\u003e, was recently found that inflammation can be reduced via activating the vagal-adrenal pathway \u003csup\u003e[18]\u003c/sup\u003e. Similarly, we reported that TEAS improved gastrointestinal function recovery in patients, reduced postoperative pain after abdominal surgery, and decreased the concentration of brain-gut peptide substance P \u003csup\u003e[16]\u003c/sup\u003e. In recent years, some systematic reviews have reported the promising effects of electroacupuncture or TEAS for postoperative pain treatment after surgery \u003csup\u003e[19-21]\u003c/sup\u003e, but the benefits of TEAS for patients after gastric ESD remain unclear, especially in the current medical practice that adopts ERAS protocol and emphasizes comfortable healthcare. We therefore conducted this prospective, randomized clinical trial to assess the efficacy of TEAS for postoperative pain and gastrointestinal function recovery in patients after ESD surgery for early gastric and esophageal neoplasms.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1 Trial Design and Study Population\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a single-center, prospective, randomized, sham-controlled clinical trial conducted at Beijing Friendship Hospital affiliated to Capital Medical University in China. It was approved by the Bioethics Committee of Beijing Friendship Hospital, Capital Medical University (No. 2021-P2-315-01) and registered in the China Clinical Trials Registry (No.ChiCTR2100052837), and the first format of this study protocol is 10/10/2021/V1.0. It followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The study protocol for this trial has been published in BMC Complement Med Ther \u003csup\u003e[22]\u003c/sup\u003e. All participants signed the informed consent form after being recruited by the anesthesiologist at the preoperative visit.\u003c/p\u003e\n\u003cp\u003eThis study was performed from December 2021 to March 2023. A total of 275 patients undergoing elective\u0026nbsp;gastric and esophageal\u0026nbsp;endoscopic submucosal dissection were assessed for eligibility, and 129 patients were enrolled by study staff. The inclusion criteria were 18-75 years old, American Society of Anesthesiologists (ASA) Physical Status of I-III, 18 \u0026le; BMI \u0026le; 30 [body mass index = weight (kg)/height (m)\u003csup\u003e2\u003c/sup\u003e], and undergoing\u0026nbsp;gastric and esophageal ESD.\u0026nbsp;They will be excluded from the trial if they have the following conditions:\u0026nbsp;①\u0026nbsp;With surgical incision or scar on the meridian of the acupoints of Hegu (L14), Neiguan (PC6), Shangjvxu (ST37), and Zusanli (ST36);\u0026nbsp;②\u0026nbsp;Local skin infection at the acupoints above;\u0026nbsp;③\u0026nbsp;There is nerve injury on the upper or lower limbs;\u0026nbsp;④\u0026nbsp;The patient participated in other clinical trials within the last 4 weeks;\u0026nbsp;⑤\u0026nbsp;The patient does not understand the Visual Analogue Scale (VAS) score and Numeric Rating Scale (NRS) score or the patient is unable to perform the scoring;\u0026nbsp;⑥\u0026nbsp;Fitted with a pacemaker;\u0026nbsp;⑦\u0026nbsp;Pregnancy, in labor, or with a positive urine pregnancy test;\u0026nbsp;⑧\u0026nbsp;Preoperative pain, ongoing use of central analgesic medications, and addiction or dependence on opioids;\u0026nbsp;⑨\u0026nbsp;Severe central nervous system disease or psychiatric disorders;\u0026nbsp;⑩\u0026nbsp;Considered unsuitable for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2 Randomization and Blinding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRandomization was performed using computer-generated random numbers with a block size of 4, the allocation was sealed in an opaque envelope. Subjects were randomly assigned to the sham group or the TEAS group with a ratio of 1:1 by the anesthesiologist. As a single-blind trial, only the anesthesiologist and acupuncturist who was in charge of the TEAS stimulation were aware of the grouping, the patients, surgeons, and physicians responsible for follow-up were unaware.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3 Intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth TEAS and sham stimulation were performed by a licensed acupuncturist with more than 3 years of practice. Patients in both groups received the intervention from 30 minutes before surgery until the end of surgery.\u003c/p\u003e\n\u003cp\u003ePatients in the TEAS group were treated bilaterally at the Hegu (L14), Neiguan (PC6), Zusanli (ST36), and Shangjuxu (ST37) (The detail of the location of acupoints were in the Figure 1. The location of acupoints. A. The location of L14, PC6. L14 is Hegu acupoint; PC6 is Neiguan acupoint. B. The location of ST36, ST37. ST36 is Zusanli acupoint; ST37 is Shangjvxu acupoint.). Self-adhesive electrodes with wires were attached to the location of these 4 acupoints and connected to the HANS acupoint nerve stimulator (HANS-200A, Nanjing Jisheng Medical Technology Co., Ltd., China), setting the current frequency to 2/100Hz (the wave width at 2 Hz was 0.6 ms, and at 100 Hz was 0.2ms), alternating frequency for 3s, and stimulation intensity to the patient\u0026apos;s maximum tolerance level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1. The location of acupoints. A. The location of L14, PC6. L14 is Hegu acupoint; PC6 is Neiguan acupoint. B. The location of ST36, ST37. ST36 is Zusanli acupoint; ST37 is Shangjvxu acupoin\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the sham group, two of the sham points were located at 7 cun above and 1 cun outside Shenmen (HT7), and 7 cun above and 1 cun outside HT7. The other two sham points were at 9 cun and 12 cun above Kunlun (BL60) (Figure 2. The location of sham points. A. The location of sham points 1 and 2. HT7 is Shenmen acupoint. B. The location of sham points 3 and 4. BL60 is Kunlun acupoint.). Self-adhesive electrodes were glued to these points, but no electrical stimulation was given from the HANS stimulator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;The location of sham points. A. The location of sham points 1 and 2. HT7 is Shenmen acupoint. B. The location of sham points 3 and 4. BL60 is Kunlun acupoint.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4 Anesthesia procedures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the day before surgery, all enrolled patients signed informed consent and received relevant education on the implementation and follow-up of this study.\u0026nbsp;Electrocardiogram, blood pressure, pulse oxygen saturation, and bispectral\u0026nbsp;(BIS) were monitored before anesthesia. TEAS and sham stimulation were conducted by the experienced acupuncturist 30 minutes before the surgery. Midazolam 0.03mg/kg, remifentanil 1-2\u0026mu;g/kg, etomidate 0.1-0.2mg/kg and rocuronium 0.6-0.8mg/kg were used before intubation. Anesthesia was maintained with a total intravenous infusion of propofol (4-6mg/kg/h), remifentanil (0.05-0.2\u0026micro;g/kg/min),\u0026nbsp;and rocuronium (one-third of the induced dose every 40min). Anesthetic depth was controlled by the adjustment of intravenous propofol to maintain a bispectral index of 45-55 during the procedure. Tramadol 50mg was applied for analgesia 30 minutes before the end of ESD surgery.\u0026nbsp;At the end of the surgery, the\u0026nbsp;patient\u0026nbsp;was extubated and\u0026nbsp;transferred to the post-anesthesia care unit (PACU) in routine.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; The Visual Analogue Scale (VAS) was used to assess the patient\u0026rsquo;s pain level. If the VAS score\u0026ge;4 points or the patient requested analgesia during the follow-up, morphine 1mg was administered intravenously.\u0026nbsp;The Numerical Rating Scale (NRS) was used to evaluate the degree of nausea.\u0026nbsp;If NRS\u0026ge;7 or vomiting occurred, a serotonin 3 receptor antagonist was given.\u0026nbsp;The\u0026nbsp;concomitant medication during the trial period from the start of surgery to 2 days after the end was recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.5 Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was a visual analog scale (VAS) score at different time points which were 5 minutes, 10 minutes, 20 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 18 hours, 24 hours, 48 hours postoperatively. The scale was 0-10 cm, 1-3 cm for mild pain, 4-6 cm for moderate pain, and 7-10 cm for severe pain. Secondary outcomes included the incidence of post-ESD VAS\u0026ge;4 and the consumption of morphine during follow-up,\u0026nbsp;gastrointestinal function recovery time,\u0026nbsp;the incidence of postoperative complications, and patient satisfaction. These outcomes were recorded by an anesthesiologist specializing in follow-up.\u003c/p\u003e\n\u003cp\u003eFor recovery of gastrointestinal function, we mainly recorded the time of first flatus, defecation, drink, and solid food intake. The main recorded postoperative complications were hypertension, hypotension, tachycardia, bradycardia, nausea and vomiting [measured with the 0-10 cm numeric rating scale (NRS)], gastrointestinal perforation or bleeding, reoperation, and fever. Postoperative adverse events will also be recorded by the follow-up anesthesiologist, and in the event of a malignant event such as bleeding \u0026gt;500 ml, the trial will be immediately terminated and reported to the Principal Investigator and a review board will be established.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.6 Statistical Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated based on the outcomes of our pre-trial. In the pre-trial, we observed that patients always felt no pain or tolerated pain completely within half an hour after extubation. It was only at approximately 1 hour postoperatively that patients felt obvious pain. Therefore, we applied the VAS score at 1 hour postoperatively to calculate the sample size: it was 0.86\u0026plusmn;1.14 (mean\u0026plusmn;SD) in the TEAS group and 1.68\u0026plusmn;1.46 (mean\u0026plusmn;SD) in the sham group. Setting an \u0026alpha; of 0.05, a \u0026beta; of 0.1, and a power of 0.9, plus a 10% dropout rate, we calculated that a total of 120 cases were needed using PASS 11.0. 60 cases per group were required.\u003c/p\u003e\n\u003cp\u003eAll data were described and analyzed using SPSS. Continuous variables were reported as mean\u0026plusmn;SD or median (IQR), where normally distributed data were analyzed for differences between groups by t-test, and skewed data were by Mann-Whitney U test. Categorical variables were reported as the number of cases (percentages) and intergroup differences were analyzed by chi-square test or Fisher\u0026apos;s test. A P value less than 0.05 indicates a statistically significant difference. Perioperative factors were analyzed using univariate and multivariate logistic regression analysis, and the resulting odds ratio (OR) values, 95% confidence intervals (95%CI), and P values were provided. The potential influencing factors included in this trial were derived from previous investigations\u0026nbsp;\u003csup\u003e[7,8]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.1 Trial Flow\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom July 2021 to August 2022, a total of 275 patients took part in this trial. Among them, 11 patients did not meet the inclusion criteria, 3 had ASA grades more than III, 125 had taken part in earlier research, 2 had pacemakers placed, and 5 had opted out of the trial. As a result, 129 patients were randomized to the TEAS group and the sham group. One patient from the TEAS group and one from the sham group were converted to laparotomy due to further pathological infiltration of lesions and were eliminated from the study. Two patients from the TEAS group and one from the sham group dropped out due to postoperative bleeding. Three patients from the TEAS group and one from the sham group asked to withdraw their informed consent and withdrew from the trial. Finally, a total of 120 patients completed the entire research. There were 58 patients in the TEAS group and 62 patients in the sham group. An explanatory flowchart is depicted in Figure 3. Except for the fact that more patients in the sham group had a history of cerebral infarction than in the TEAS group (P=0.032), there were no statistically significant differences in the baseline characteristics of the patients across groups. The baseline characteristics of 120 patients are provided in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3. Flowchart of this trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e．\u003c/strong\u003e\u003cstrong\u003eDemographic Data and Clinicopathological Characteristics of Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSham Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e62\u0026nbsp;\u0026plusmn;\u0026nbsp;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e61\u0026nbsp;\u0026plusmn;\u0026nbsp;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.497\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e168\u0026nbsp;\u0026plusmn;\u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e167\u0026nbsp;\u0026plusmn;\u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e69\u0026nbsp;\u0026plusmn;\u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e68\u0026nbsp;\u0026plusmn;\u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eBMI (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e24.4\u0026nbsp;\u0026plusmn;\u0026nbsp;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e24.2\u0026nbsp;\u0026plusmn;\u0026nbsp;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.660\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eSex (male/female, cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e38/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e44/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eType of surgery (gastric/esophageal, cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e29/29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e33/29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eLesion location (\u003csup\u003ea\u0026nbsp;\u003c/sup\u003ecases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric cardia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\" rowspan=\"7\"\u003e\n \u003cp\u003e0.901\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric antrum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric angle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Upper esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Median esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lower esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eHistopathology (\u003csup\u003ea\u0026nbsp;\u003c/sup\u003ecases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Benign tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.664\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Adenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eLength of the major axis of the tumor\u0026ge;3cm (\u003csup\u003eb\u003c/sup\u003ecases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.223\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eMultiple lesions (cases [%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e3 (5.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e10 (16.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eSmoking history (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e27/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e32/30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eHistory of alcohol intake (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e31/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e33/29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003ePrevious surgical history (cases [%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e38 (65.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e50 (80.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eASA (cases [%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e9 (15.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e14 (22.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e40 (68.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e37 (59.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.19847328244275%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e9 (15.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.900763358778626%\"\u003e\n \u003cp\u003e11 (17.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003eComorbidities (cases [%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e29 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e33 (53.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e11 (18.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e11 (17.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.863\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Coronary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e5 (8.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e8 (12.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hyperlipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e22 (37.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e20 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.63013698630137%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e3 (5.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.54794520547945%\"\u003e\n \u003cp\u003e11 (17.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.273972602739725%\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003ea: Some patients have multiple lesions;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eb: For patients with multiple lesions, as long as one lesion is greater than 3cm, it is recorded.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTEAS Group: transcutaneous electrical acupoint stimulation group; SD: standard deviation.\u003c/p\u003e\n \u003cp\u003eValues are present as number of patients (%), median (IQR) or mean\u0026nbsp;\u0026plusmn;SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.2 Primary\u0026nbsp;Endpoints: Visual Analogue Scale Scores\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe VAS scores at different postoperative time points are represented in Figure 4. Compared with the sham group, the pain levels of the TEAS group improved from 5 min after surgery to 1 hour after surgery (P＜0.05). While no statistical difference was detected between the two groups at other postoperative time points (Table 2). We defined VAS \u0026ge;4 as moderate to severe pain. We found that the incidence of moderate to severe pain in the TEAS group was 37.9%, whereas in the sham group was 64.5%, \u003cem\u003eP\u003c/em\u003e=0.004 (Table 3). This difference was much more significant in esophageal ESD surgery, the incidence was 44.8% (the TEAS Group) vs 86.2% (the sham Group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 4. The Boxplot of VAS at different postoperative time points.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Postoperative Pain Score at Different Time ( mean (IQR), VAS )\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"575\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS pain score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSham Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e5min post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e0 (0,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e0 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e10min post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e0 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e2 (0,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.009\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e20min post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e1 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e3 (0,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.001\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e30min post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e2 (0,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e3 (0,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.011\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e1h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e2 (0.8,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e3 (1.8,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e2h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e2 (0,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e2 (1.8,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.073\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e4h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e2 (0.8,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e2 (1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.293\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e6h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e1 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e2 (0,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.520\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e18h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e1 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e1 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.948\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e24h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e1 (0,1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e1 (0,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.843\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91304347826087%\"\u003e\n \u003cp\u003e48h post-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.565217391304348%\"\u003e\n \u003cp\u003e0 (0,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.565217391304348%\"\u003e\n \u003cp\u003e0 (0,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.956521739130435%\"\u003e\n \u003cp\u003e0.635\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eVAS,\u003c/strong\u003e visual analog scale; \u003cstrong\u003eOP\u0026nbsp;\u003c/strong\u003eoperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. The Incidence of Moderate to Severe Pain (VAS \u0026ge; 4) (cases / %)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.92929292929293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncidence (cases/[%])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSham Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSum up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.92929292929293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastric surgery (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e9 (31.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e15 (45.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e24 (38.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.92929292929293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEsophageal surgery (n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e13 (44.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e25 (86.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e38 (65.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.92929292929293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSum up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e22 (37.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e40 (64.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e62 (51.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.92929292929293%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.023569023569024%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.3 Secondary Endpoints: Postoperative Recovery of Gastrointestinal Function and Postoperative Adverse Events\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between the two groups in the postoperative recovery of gastrointestinal function (P＞0.05, Table 4. The details of postoperative adverse events are summarized in Table 5. The incidence of postoperative nausea and vomiting (PONV) and cases needing morphine in the TEAS group were significantly lower than in the sham group (PONV: 6.9% vs. 22.6%, \u003cem\u003eP\u003c/em\u003e=0.016; cases needing morphine: 32.7% vs. 64.5%, \u003cem\u003eP\u003c/em\u003e＜0.001). No differences in other postoperative adverse events were found between the two groups (\u003cem\u003eP\u003c/em\u003e＞0.05, Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Postoperative Recovery of Gastrointestinal Function ( mean (IQR), h )\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91596638655462%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.51260504201681%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSham Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91596638655462%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first flatus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.51260504201681%\"\u003e\n \u003cp\u003e11 (6,22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\"\u003e\n \u003cp\u003e14 (7,21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91596638655462%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first defecation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.51260504201681%\"\u003e\n \u003cp\u003e68 (37, 91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\"\u003e\n \u003cp\u003e54 (24, 91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e0.318\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91596638655462%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first drinking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.51260504201681%\"\u003e\n \u003cp\u003e69 (48, 75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\"\u003e\n \u003cp\u003e68 (50, 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e0.766\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.91596638655462%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first eating solid food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.51260504201681%\"\u003e\n \u003cp\u003e73 (63, 87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\"\u003e\n \u003cp\u003e75 (69, 92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e0.350\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. The Incidence of Postoperative Adverse Events\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"583\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable ( Cases/[%] )\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSham Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePONV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e4 (6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e14 (22.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases needing morphine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e19 (32.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e40 (64.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGiving acid-inhibitory drugs after surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e56 (96.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e61 (98.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.953\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eShivering\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e1 (1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e3 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.619\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e2 (3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e5 (8.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypotension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e3 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTachycardia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e1 (1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e2 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBradycardia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e2 (3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e8 (12.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrointestinal perforation or bleeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e2 (3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e3 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReoperation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e1 (1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e3 (4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.619\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.41095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e4 (6.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e2 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.863013698630137%\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003ePONV: postoperative nausea and vomiting.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.4 Associations Between Factors and Pain Scores\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the results (Table 3), there were 62 (51.7%) cases experienced moderate to severe pain. All perioperative factors that may cause VAS scores \u0026ge; 4 were analyzed with univariate logistic regression analysis (Table 6). The results showed that TEAS treatment (\u003cem\u003eP\u003c/em\u003e=0.004), the type of surgery (\u003cem\u003eP\u003c/em\u003e=0.003), and tumor location (\u003cem\u003eP\u003c/em\u003e＜0.05) were potential contributing factors associated with VAS scores \u0026ge; 4. Therefore, we performed multivariate logistic regression analysis for all factors with \u003cem\u003eP\u003c/em\u003e＜0.1 (Figure 5. Forest plot of Multivariate logistic regression analysis of risk factors for moderate to severe pain). Figure Forest plot showed that TEAS treatment was a protective factor associated with reduced incidence of VAS scores \u0026ge; 4 (OR=0.227; 95% CI: 0.100 to 0.512; \u003cem\u003eP\u003c/em\u003e＜0.001). In addition, the type of surgery was also a protective factor: patients undergoing gastric ESD surgery had a much lower incidence of VAS scores \u0026ge; 4 than patients undergoing esophageal ESD surgery (OR=0.287; 95% CI: 0.133 to 0.621; \u003cem\u003eP\u003c/em\u003e\u003cu\u003e=\u003c/u\u003e0.002)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 5. Forest plot of Multivariate logistic regression analysis of risk factors for moderate to severe pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Results of univariate logistic regression analysis of risk factors for moderate to severe pain\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95%CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.971-1.057)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.547\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.841-1.098)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.561\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.417-1.987)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eTEAS treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.160-0.707)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eType of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.173-0.707)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eTumor location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric cardia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.043-0.736)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric antrum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.026-0.559)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gastric angle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.058-0.883)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Upper esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.045-1.567)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Median esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.022-1.454)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lower esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.135-1.711)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eTumor histology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Benign tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.109-1.103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Adenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.221-1.792)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.093-0.595)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eLength of the major axis of the tumor\u0026ge;3cm (case)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.950\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.436-2.069)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eMultiple lesions (case [%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.156-2.359)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e2.404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.601-9.622)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eHistory of alcohol intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.514\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.137-1.927)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003ePrevious surgical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.601\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.489-5.238)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.437\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.170-1.977)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.346-2.509)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.388-1.726)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.333-2.151)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Coronary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.072-1.072)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hyperlipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.374-1.710)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.564\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.457\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.471-4.510)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.513\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eInduction dose of remifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.941-1.319)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eDose of anesthetic maintenance drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Propofol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.994-1.010)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.846\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Remifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.998-1.004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eDuration of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.928-1.075)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.32432432432432%\"\u003e\n \u003cp\u003eDuration of anesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e(0.906-1.055)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.55855855855856%\"\u003e\n \u003cp\u003e0.557\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOR: odds ratio; CI: confidence interval; TEAS: Transcutaneous electrical acupoint stimulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.5 Patient Satisfaction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA scale with a maximum score of 10 was utilized to evaluate patient satisfaction after ESD surgery. In TEAS and sham groups, the mean ranks of patient satisfaction scores were 73.0 and 48.8, respectively. In comparison with the sham group, patient satisfaction in the TEAS group was considerably higher (\u003cem\u003eP\u003c/em\u003e＜0.001).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, our data suggested that in patients undergoing\u0026nbsp;gastroesophageal ESD surgery\u0026nbsp;under general anesthesia, pretreating with TEAS could effectively improve the early postoperative pain of patients, reduce the incidence of moderate to severe pain, and decrease the application of morphine after surgery. In addition, the results showed that the type of surgery was a risk factor for postoperative pain. Patients undergoing gastric ESD surgery had a much lower incidence of VAS scores \u0026ge; 4 than patients undergoing\u0026nbsp;esophageal\u0026nbsp;ESD. Moreover, this treatment\u0026nbsp;could reduce the occurrence of PONV, and correspondingly achieve higher patient satisfaction.\u003c/p\u003e\n\u003cp\u003eESD, an unusual endoscopic technique, has been reported to be completely effective for early\u0026nbsp;gastroesophageal\u0026nbsp;cancer with higher en bloc and has a histologically complete resection rate and lower local recurrence. As its apparently minimally invasive nature, post-ESD pain is often neglected by physicians. However, based on recently published data, the incidence of moderate to severe pain induced by ESD was as high as 44.9% to 62.8%\u0026nbsp;\u003csup\u003e[6-8]\u003c/sup\u003e. The same conclusion was obtained in Kim\u0026rsquo;s study \u003csup\u003e[23]\u003c/sup\u003e. In our research, we found that the incidence of moderate to severe pain in the sham group was 64.5%. It was further demonstrated that the rate of post-ESD pain is high enough for physicians to pay more attention and make active pain management. However, at present, there is no unified measure of how to carry out good postoperative analgesia for patients undergoing\u0026nbsp;gastroesophageal\u0026nbsp;ESD.\u0026nbsp;Fortunately, our study found that TEAS can effectively alleviate post-ESD pain. In this regard, several recently published investigations confirmed that TEAS can provide powerful protection against postoperative pain for a variety of procedures, like laparoscopy surgery \u003csup\u003e[24]\u003c/sup\u003e, gastric and colorectal surgery \u003csup\u003e[16]\u003c/sup\u003e as well as pediatric orthopedic surgery \u003csup\u003e[25]\u003c/sup\u003e.\u0026nbsp;More importantly, we also found that pretreating with TEAS was\u0026nbsp;a protective factor associated with reduced incidence of\u0026nbsp;moderate to severe pain\u0026nbsp;according to logistic regression analysis.\u0026nbsp;All this\u0026nbsp;evidence paved TEAS as an attractively therapeutic avenue for post-ESD pain.\u003c/p\u003e\n\u003cp\u003eBased on published data,\u0026nbsp;post-ESD pain is more severe in the early postoperative period (within 1-4h after surgery)\u0026nbsp;\u003csup\u003e[6-8]\u003c/sup\u003e.\u0026nbsp;In fact, this was also confirmed in our preliminary experiment\u0026nbsp;\u003csup\u003e[22]\u003c/sup\u003e. In line with these results, we\u0026nbsp;emphatically\u0026nbsp;followed\u0026nbsp;up\u0026nbsp;the VAS scores\u0026nbsp;of patients in the early postoperative period. Moreover, we\u0026nbsp;appropriately extended the visit to 48 hours after surgery.\u0026nbsp;Further investigation showed that TEAS could improve post-ESD pain at 5 min, 10 min, 20 min, 30 min, and 1 h after surgery. No statistical difference was detected at other postoperative time points.\u0026nbsp;In addition,\u0026nbsp;a\u0026nbsp;recently published retrospective study\u0026nbsp;confirmed\u0026nbsp;that\u0026nbsp;gender,\u0026nbsp;operation\u0026nbsp;duration, and lesion site\u0026nbsp;were\u0026nbsp;clear factors\u0026nbsp;affecting\u0026nbsp;postoperative\u0026nbsp;pain\u0026nbsp;in ESD\u0026nbsp;\u003csup\u003e[8]\u003c/sup\u003e. Strikingly, our study revealed that\u0026nbsp;patients undergoing gastric ESD surgery had a much lower incidence of medium-to-severe pain than esophageal ESD surgery. This may be due to the different mechanisms of pain transmission in different organs. Moreover, we cannot rule out the possibility that increased peristalsis at the esophageal site and frequent contractions may also lead to aggravated postoperative pain after ESD.\u003c/p\u003e\n\u003cp\u003eIn this study, peri-operative TEAS treatment decreased the cases of PONV, this result is similar to our previous study in gastrointestinal surgery \u003csup\u003e[16]\u003c/sup\u003e. As known, LI4, PC6, ST36, and ST37 are the most commonly used acupoints for regulating the intestines and stomach, channeling the channels and collaterals. It was well documented that stimulating these acupoints could improve intestinal motility, and regulate endocrine function, which helps reduce PONV \u003csup\u003e[26]\u003c/sup\u003e. However, the data from this study failed to confirm that TEAS improved gastrointestinal function in patients after\u0026nbsp;gastroesophageal ESD. This result is inconsistent with another study by our research team\u0026nbsp;\u003csup\u003e[16]\u003c/sup\u003e.\u0026nbsp;In this regard, we consider that ESD is a minimally invasive surgery in nature, it has little interference with gastrointestinal function, so it has almost no impact on the exhaust function of patients. What is more, the eating and drinking time of patients after ESD surgery is basically carried out according to the doctor\u0026rsquo;s advice, the time of all patients is therefore relatively fixed.\u003c/p\u003e\n\u003cp\u003eThere are several limitations to this study. First, TEAS was performed only during the operation, and there was no continuous intervention after surgery. Although, in our previous observation, we found that the postoperative pain of most patients was concentrated in the early postoperative period. Hence, TEAS was not administered after patients returned to the ward. However, we still cannot rule out that this may be related to the lack of difference in pain 1h after ESD between the TEAS group and the sham group. Second, this study could not measure some analgesic substances such as endorphins, or some injury-related factors such as interleukin-6 to quantitatively compare the postoperative pain response between the two groups. It is also about our cost budget.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eData from this study showed that pretreating with TEAS could effectively improve the early postoperative pain of patients, and reduce the incidence of moderate to severe pain. Considering that there is no unified consensus and effective method for post-ESD pain, our study may provide a feasible strategy for relieving it.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"560\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.142857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eESD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.85714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eendoscopic submucosal dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.142857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eERAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.85714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eenhanced recovery after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.142857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCONSORT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNRS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBIS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePACU\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePONV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.85714285714286%\" valign=\"top\"\u003e\n \u003cp\u003etranscutaneous electrical acupoint stimulation\u003c/p\u003e\n \u003cp\u003eConsolidated Standards of Reporting Trials\u003c/p\u003e\n \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\n \u003cp\u003ebody mass index\u003c/p\u003e\n \u003cp\u003eVisual Analogue Scale\u003c/p\u003e\n \u003cp\u003eNumeric Rating Scale\u003c/p\u003e\n \u003cp\u003ebispectral\u003c/p\u003e\n \u003cp\u003epost-anesthesia care unit\u003c/p\u003e\n \u003cp\u003estandard deviation\u003c/p\u003e\n \u003cp\u003einterquartile range\u003c/p\u003e\n \u003cp\u003eodds ratio\u003c/p\u003e\n \u003cp\u003econfidence interval\u003c/p\u003e\n \u003cp\u003epostoperative nausea and vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis trial was approved by the Ethics Committee of Beijing Friendship Hospital affiliated to Capital Medical University (Approval number: 2021-P2-315-01). Each patient signed an informed consent form when recruited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by Beijing Municipal Administration of Traditional Chinese Medicine (No. BJZYQN-2023-22), and\u0026nbsp;the Capital\u0026rsquo;s Funds for Health Improvement and Research, PR China (Grant No. CFH 2022-2-20210).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn LX and Li WJ are the chief investigators who are responsible for quality control of the topic selection, design, trial overseeing, and paper revision. They contributed equally to this article and are co-corresponding authors of this trial. Liu XM and Qi YX recruited participants, analyzed the data, improved the study protocol, and drafted this manuscript. They contributed equally to this work and should be considered as co-first authors. Zheng JY, Chang XL, Hao WW, and Du Y worked for data collection and performed anesthesia and intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express sincere thanks to the gastroenterologists and all patients for their understanding and support of this trial.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMaple JT, Abu Dayyeh BK, Chauhan SS, et al. Endoscopic submucosal dissection. \u003cem\u003eGastrointest Endosc. \u003c/em\u003e2015;81(6):1311-1325.\u003c/li\u003e\n\u003cli\u003eLiu Q, Ding L, Qiu X, Meng F. Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis. \u003cem\u003eInt J Surg. \u003c/em\u003e2020;73:28-41.\u003c/li\u003e\n\u003cli\u003eMisumi Y, Nonaka K. Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection. \u003cem\u003eJ Clin Med. \u003c/em\u003e2021;10(11).\u003c/li\u003e\n\u003cli\u003eHayashi T, Kudo SE, Miyachi H, et al. Management and risk factor of stenosis after endoscopic submucosal dissection for colorectal neoplasms. \u003cem\u003eGastrointest Endosc. \u003c/em\u003e2017;86(2):358-369.\u003c/li\u003e\n\u003cli\u003eToyonaga T, Man-i M, East JE, et al. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. \u003cem\u003eSurg Endosc. \u003c/em\u003e2013;27(3):1000-1008.\u003c/li\u003e\n\u003cli\u003eChoi HS, Kim KO, Chun HJ, et al. 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Complications of endoscopic resection in the upper gastrointestinal tract. Clin Endosc. 2023; 56(4): 409-422.\u003c/li\u003e\n\u003cli\u003eTanabe S, Ishido K, Matsumoto T, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a multicenter collaborative study. Gastric Cancer. 2017; 20(Suppl 1): 45\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003ePyo JH, Lee H, Min YW, Min BH, Lee JH, Rhee PL, et al. A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm. Gut Liver. 2016; 10(4): 549-55.\u003c/li\u003e\n\u003cli\u003eKim B, Lee H, Chung H, Park JC, Shin SK, Lee SK, et al. The efficacy of topical bupivacaine and triamcinolone acetonide injection in the relief of pain after endoscopic submucosal dissection for gastric neoplasia: a randomized double-blind, placebo-controlled trial. 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Anaesth Crit Care Pain Med. 2023; 42(6): 101273.\u003c/li\u003e\n\u003cli\u003eHou L, Xu L, Shi Y, Gu F. \u003cu\u003eEffect of electric acupoint stimulation on\u003c/u\u003e \u003cu\u003egastrointestinal hormones and motility among geriatric postoperative patients with gastrointestinal tumors.\u003c/u\u003e J Tradit Chin Med. 2016; 36(4): 450\u0026ndash;45\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4062875/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4062875/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground: \u003c/em\u003ePostoperative abdominal pain is one of the most common minor adverse events of endoscopic submucosal dissection (ESD) surgery which is a well-established treatment for early gastrointestinal neoplasms. Transcutaneous electrical acupoint stimulation (TEAS) is a potential treatment option for reducing postoperative pain and improving gastrointestinal function. This study aims to assess the efficacy of TEAS for postoperative pain and gastrointestinal function recovery in patients after ESD surgery for early gastric and esophageal neoplasms.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods: \u003c/em\u003eA total of 129 patients undergoing ESD surgery were randomized into the TEAS group or the sham group and were stratified by the surgical type (i.e., gastric or esophageal ESD surgery). Patients in the TEAS group were treated bilaterally at the Acupoint Hegu (L14), Neiguan (PC6), Zusanli (ST36), and Shangjuxu (ST37). Patients in the sham group were treated at sham acupoints. The TEAS and sham stimulations are both given from 30 min before surgery to the end of the surgery. Postoperative pain was measured by a visual analog scale. T-tests, Mann-Whitney U test, chi-square test, Fisher's test, and univariate and multivariate logistic regression analysis were used to analyze the data of this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults: \u003c/em\u003eCompared with the sham group, the pain levels of the TEAS group improved from 5 min after surgery to 1 hour after surgery (P＜0.05). The incidence of moderate to severe pain, postoperative nausea and vomiting, and cases needing morphine were significantly lower in the TEAS group (P＜0.05). There was no statistically significant difference between the two groups in the postoperative recovery of gastrointestinal function.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion:\u003c/em\u003ePretreating with TEAS could effectively improve the early postoperative pain of patients, reduce the incidence of moderate to severe pain, decrease the application of morphine after surgery, and reduce the occurrence of postoperative nausea and vomiting.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrial registration: \u003c/em\u003eChinese Clinical Trial Registry, ChiCTR2100052837. 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