Electroacupuncture for Opioid-Sparing Analgesia and Enhanced Recovery after Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Electroacupuncture for Opioid-Sparing Analgesia and Enhanced Recovery after Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials | 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 Systematic Review Electroacupuncture for Opioid-Sparing Analgesia and Enhanced Recovery after Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Jiayu Huang, Zhenke Xiao, Junming Lao, Lingli Pan, Zhou Chen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8047427/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Objective This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluates the efficacy of electroacupuncture (EA) for opioid-sparing analgesia and examines its role in facilitating enhanced recovery after surgery. Methods A comprehensive literature search was conducted across PubMed, the Cochrane Library, Web of Science, Embase, CNKI, Wangfang, and Cqvip. This search was aimed at identifying RCTs that evaluated the effects of EA versus sham acupuncture on opioid consumption and postoperative recovery outcomes in surgical patients. The literature search was finalized on July 20, 2025. Data extraction and subsequent meta-analysis were performed using Stata version 15.0. Result In a meta-analysis of 13 RCTs (n = 967), EA was associated with a significant reduction in total postoperative opioid use (weighted mean difference [WMD] = − 11.65 morphine milligram equivalents [MMEs], 95% confidence interval [CI]: −18.61 to − 4.70), and intraoperative opioid requirements (WMD = − 2.15 MME, 95% CI: −3.85 to − 0.46) compared to sham acupuncture. Furthermore, EA was associated with improved pain control, reduced postoperative nausea and vomiting (PONV), and attenuated inflammatory response, underscoring its role as an effective opioid-sparing strategy within enhanced recovery protocols. Conclusion Our study shows that EA does not compromise analgesic efficacy compared to sham acupuncture. Additionally, it exerts a pronounced opioid-sparing effect, significantly lowering postoperative opioid consumption while concurrently enhancing the overall recovery outcomes. Electroacupuncture Opioid-sparing Postoperative recovery Meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 1. Introduction Effective management of perioperative acute pain is essential for optimal surgical recovery and patient satisfaction. Although opioid-based multimodal analgesia is extensively employed in clinical practice, growing evidence indicates that postoperative persistent opioid use constitutes a major contributor to the opioid crisis [ 1 – 3 ] . A range of dose-dependent adverse effects, including respiratory depression (17%–40% incidence), gastrointestinal paralysis (prolonging recovery by 24–48 h), opioid-induced hyperalgesia, and immunosuppression, impede postoperative rehabilitation and contradict the core principles of Enhanced Recovery After Surgery (ERAS) [ 4 , 5 ] . Among non-pharmacological interventions, electroacupuncture (EA) has gained considerable attention due to its combined neuromodulatory and anti-inflammatory effects [ 4 ] . Extensive preclinical studies support its analgesic efficacy. Stimulation at specific frequencies (e.g., 2/100 Hz dense–dispersed waves) activates peripheral sensory nerve fibers and triggers descending inhibitory pathways in the spinal cord and brainstem, leading to the release of endogenous opioids, such as endorphins, enkephalins, and dynorphins [ 6 ] . Recent high-impact neuroscience studies have demonstrated that locus coeruleus noradrenergic-spinal projections, along with the downstream α(2A)-adrenoceptor–CaMKII signaling cascade, play a key role in mediating the antinociceptive effects of EA in postoperative pain [ 7 ] . In addition, EA elicits systemic anti-inflammatory responses through neuro–immune modulation, particularly via the cholinergic anti-inflammatory pathway, thereby reducing postoperative concentrations of pro-inflammatory cytokines, such as IL-6 and tumor necrosis factor (TNF) -α [ 8 ] . Collectively, these findings suggest that EA serves as a comprehensive intervention that maintains perioperative physiological homeostasis rather than merely providing analgesia. Clinically, meta-analyses have suggested that EA may reduce perioperative opioid consumption; however, the reported effect sizes vary widely, with opioid-sparing effects ranging from approximately 15% to 65% across trials [ 9 , 10 ] . This heterogeneity is likely influenced by factors, such as differences in surgical type (e.g., open versus laparoscopic), anesthetic method (volatile versus intravenous agents, use of regional blocks), EA application parameters (intensity, waveform, acupoint selection), and timing in relation to surgery (preemptive versus postoperative) [ 11 – 13 ] . Most existing systematic reviews have not adequately addressed these sources of variability through subgroup analysis or meta‑regression, leaving uncertainty regarding optimal EA integration into multimodal analgesia protocols [ 14 ] . Moreover, whether the opioid-sparing effect of EA depends on surgical magnitude or other perioperative variables remains unclear [ 15 ] . To address these challenges, this systematic review and meta-analysis synthesizes high-quality evidence from randomized controlled trials (RCTs) to assess the effect of EA on perioperative opioid consumption as the primary outcome. Secondary outcomes include postoperative pain scores during movement, incidence of postoperative nausea and vomiting (PONV), and levels of inflammatory biomarkers [ 10 , 16 , 17 ] . Preplanned subgroup and sensitivity analyses will further examine the influence of surgical, anesthetic, and EA-related factors on treatment effects. The results aim to clarify EA’s role within evidence-based opioid reduction strategies and guide its standardized application in perioperative practice. 2. Methods The methodology for this systematic review was guided by a protocol that was prospectively registered on PROSPERO (International Prospective Register of Systematic Reviews; ID: CRD420251121682). Clinical trial number: Not applicable. 2.1 Inclusion and Exclusion Criteria This meta-analysis included RCTs involving adult patients undergoing elective surgical procedures, in which EA was directly compared with sham electroacupuncture (SA). The primary outcomes included total postoperative opioid consumption, measured in morphine milligram equivalents (MMEs), and postoperative pain scores assessed using the Visual Analogue Scale (VAS). Secondary outcomes included intraoperative opioid consumption (expressed in MME), the incidence of PONV, and serum TNF-α levels measured 24 h postoperatively. Studies were excluded if they were meta-analyses, systematic reviews, conference abstracts, animal studies, case reports, incomplete publications, or if they failed to report any of the pre-specified outcomes of interest. 2.2 Literature Retrieval RCTs evaluating the opioid-sparing and ERAS effects of EA combined with conventional analgesia versus conventional analgesia alone were systematically searched across PubMed, Cochrane Library, Embase, Web of Science, CNKI, Wanfang, and CQVIP databases. The literature search, completed on July 20, 2025, employed a comprehensive strategy combining MeSH terms and free-text keywords, including “Electroacupuncture,” “Analgesics, Opioid,” and “postoperative.” The detailed search strategies are presented in Table S1 . 2.3 Data Extract According to established inclusion and exclusion criteria, two independent reviewers conducted a comprehensive literature search. Discrepancies were resolved through discussion or consultation with a third reviewer for an impartial opinion. The extracted data included the author, country of study, publication year, sample size (EA and SA groups), sex distribution, age range, type of surgery, intervention details, and reported outcomes. 2.4 Included studies' risk of bias The risk of bias in the included studies was independently assessed by two reviewers using the Cochrane Collaboration's tool. The risk was classified into three categories: low, unclear, or high. The assessment evaluated seven key domains: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other potential sources of bias. Disagreements between reviewers were resolved through discussion or, if necessary, by consultation with a third reviewer. Studies that met all the criteria were judged as having a “low risk” of bias, indicating high methodological quality. Those that partially met the criteria were categorized as “unclear risk,” suggesting a moderate potential for bias. Studies that failed to meet the criteria were classified as “high risk,” indicating substantial bias and low methodological quality. The assessment was performed using Review Manager (RevMan) software, version 5.4. 2.5 Data analysis Data analysis was conducted using Stata software (version 15.0). For continuous variables, the weighted mean difference (WMD) with 95% confidence intervals (CIs) was calculated. For dichotomous outcomes, the relative risk (RR) with 95% CIs was calculated. Heterogeneity among the included studies was assessed using the I 2 statistic and Q-test. I 2 values of 0%, 25%, 50%, and 75% were considered to indicate no, low, moderate, and high heterogeneity, respectively. A fixed-effects model was applied when I 2 < 50%; otherwise, a random-effects model was used. Sensitivity analyses and Egger’s test were conducted to explore potential sources of heterogeneity. 3. Results 3.1 Study Selection Figure 1 presents the flowchart of our literature search process. Of the 304 records initially identified, 120 duplicates were removed. Titles and abstracts screening excluded 154 studies, and full-text assessment eliminated another 17. Ultimately, 13 RCTs [ 1 , 9 – 12 , 16 – 23 ] were included in the final analysis. 3.2 Essential characteristics and risk of bias of the included studies Figure 1 illustrates the process of our literature search. Initially, we identified 304 documents. After eliminating 120 duplicates, we excluded 17 articles according to their titles, and an additional 13 articles were excluded after a thorough review of the full text. As a result, 13 RCTs [ 1 , 9 – 12 , 16 – 23 ] were included in the analysis. These studies collectively involved 967 participants, comprising 479 individuals in the EA group and 488 in the Sham acupuncture (SA) group. EA was applied at defined acupoints with varying frequencies and durations, while the SA procedure involved superficial needling at non-acupoints without electrical stimulation. Table 1 summarizes the baseline features of these studies. All trials clearly described their randomization methods, and the risk-of-bias assessment (Figs. 2 and 3 ) further supports the reliability of the included studies. 3.3 Result of meta-analysis 3.3.1 Total Postoperative Opioid Consumption (MME) Six studies [ 11 , 12 , 17 , 18 , 20 , 21 ] encompassing 205 patients in the EA group and 204 in the SA group reported total postoperative opioid consumption (expressed in MME). Owing to high heterogeneity (I² = 92.9%, p < 0.001), a random-effects meta-analysis was conducted, revealing that EA significantly reduced postoperative opioid use compared to SA (Fig. 4 ), with a weighted mean difference (WMD) of − 11.65 MME and a 95% confidence interval (CI) of − 18.61 to − 4.70. Subgroup analysis based on surgical approach (Fig. 5 ) revealed significant reductions for both minimally invasive surgery (WMD = − 3.40, 95% CI: −5.40 to − 1.41; I 2 = 47.0%) and open surgery (WMD = − 19.52, 95% CI: −24.19 to − 14.86; I 2 = 14.7%). The effect was greater with lower heterogeneity in the open surgery group. The overall heterogeneity may partly result from the wide confidence intervals and low statistical weight of certain studies, such as those of Deng et al. Sensitivity analysis using the leave-one-out method (Supplementary Figures S1 − S3) showed consistent results, and neither the funnel plot nor Egger’s test indicated significant publication bias, confirming the robustness of the findings. 3.3.2 Postoperative Pain Score (VAS) Eight studies [ 9 – 12 , 18 , 20 , 22 , 23 ] involving 670 patients (335 per group) evaluated the effect of EA versus SA on postoperative pain scores (VAS). A random-effects meta-analysis indicated significantly lower pain scores with EA than with SA (Fig. 6 ) (WMD = − 0.72, 95% CI: −1.07 to − 0.36), despite substantial heterogeneity (I² = 87.9%, p < 0.001). Subgroup analysis (Fig. 7 ) showed statistically significant pain reduction in major surgeries (WMD = − 0.93, 95% CI: −1.21 to − 0.65) but not in minor surgeries (WMD = − 0.17, 95% CI: −0.36 to 0.01). Sensitivity analysis (Supplementary Figures S4–S6) confirmed the robustness of the results, and the absence of publication bias was supported by the funnel plot and Egger's test ( p > 0.05). 3.3.3 Postoperative Nausea and Vomiting Ten studies [ 1 , 9 , 11 , 16 , 17 , 19 – 23 ] reported the incidence of PONV among 367 patients who received EA and 377 who received SA. Because moderate heterogeneity was observed among these studies (Fig. 8 ), (I 2 = 52.7%, p = 0.025), a random-effects model was applied. The pooled results demonstrated that EA was associated with a significantly lower risk of PONV than SA (RR = 0.54, 95% CI: 0.34–0.85). Subgroup analysis based on surgical extent (Fig. 9 ) revealed a statistically significant reduction in PONV risk among patients undergoing minor surgery (RR = 0.21, 95% CI: 0.10 to 0.48; I 2 = 0.0%), whereas the reduction in the major surgery subgroup was not statistically significant (RR = 0.67, 95% CI: 0.44 to 1.05; I 2 = 39.5%). The overall treatment effect remained consistent in sensitivity analysis (Supplementary Figures S7–S9) conducted using the leave-one-out approach. Furthermore, the funnel plot inspection and Egger’s test indicated no substantial publication bias, thereby reinforcing the reliability and robustness of these findings. 3.3.4 Intraoperative Opioid Consumption Five studies [ 10 , 11 , 18 , 19 , 21 ] reported intraoperative opioid consumption (expressed in MME) in 190 patients who received EA and 191 who received SA. A random-effects model was employed, revealing no significant heterogeneity detected among studies (I 2 = 0.0%, p = 0.691). The pooled results demonstrated that EA was associated with a substantial reduction in intraoperative opioid consumption compared to SA (Fig. 10 ) (WMD = − 2.15 MME, 95% CI: −3.85 to − 0.46). Sensitivity analysis (Supplementary Figures S10–S12) using the leave-one-out approach confirmed the stability of this effect. Additionally, both visual inspection of the funnel plot and Egger’s test showed no evidence of publication bias, confirming the robustness of these findings. 3.3.5 Postoperative serum TNF-αconcentration (24 h) Two studies [ 1 , 18 ] reported postoperative serum TNF-α concentration at 24 h, including a total of 93 patients in both EA and SA groups. Owing to substantial heterogeneity observed between the studies (I 2 = 78.7%, p = 0.030), a random-effects model was applied for the analysis. The results (Fig. 11 ) demonstrated that EA significantly reduced TNF-α levels compared to SA (WMD = − 1.08 pg/mL; 95% CI: −1.82 to − 0.35). Owing to the substantial heterogeneity observed, a sensitivity analysis (Supplementary Figures S13) using the leave-one-out method was performed, which confirmed the stability of the overall treatment effect. 3.3.6 Published Bias Egger’s regression test was performed to assess potential publication bias across the four primary outcomes: total postoperative opioid consumption (measured using MME), postoperative pain intensity (measured using the VAS score), incidence of PONV, and intraoperative opioid consumption (MME). The results indicated no evidence of significant publication bias, as all Egger’s test P-values exceeded 0.05, and the corresponding funnel plots demonstrated symmetrical distributions (Supplementary Figures S1 –S4). These results substantiate the robustness and validity of the meta-analytic conclusions, indicating that the results are methodologically sound and free from substantial bias. 4. Discussion This systematic review and meta-analysis present robust evidence that adjunctive EA within ERAS protocols significantly reduces perioperative opioid requirements. The analysis of 13 RCTs encompassing 967 surgical patients demonstrates that EA significantly decreased total postoperative opioid consumption, with a weighted mean difference of 11.65 mg in intravenous morphine equivalents compared to sham controls. This reduction, representing a clinically meaningful magnitude, holds particular importance in the context of the ongoing opioid crisis, wherein postoperative opioid prescriptions are a well-recognized contributor to prolonged use and dependence [ 24 ] . By mitigating opioid exposure, EA may substantially lower the risk of severe opioid-related adverse events, including respiratory depression, gastrointestinal paralysis, and opioid-induced hyperalgesia [ 25 ] . The clinical significance of this reduction extends beyond numerical value. In clinical practice, a decrease of 11.65 mg in morphine milligram equivalents represents a substantial improvement, facilitating earlier patient mobilization, faster recovery of bowel function, and a reduced risk of opioid-related cognitive dysfunction. In addition to its significant opioid-sparing effects, EA demonstrates comprehensive therapeutic advantages encompassing various aspects of postoperative recovery. The present analysis revealed concurrent improvements in pain control (WMD = − 0.72 on the VAS), a marked reduction in the incidence of PONV (RR = 0.54), and mitigation of the systemic inflammatory response as indicated by reduced serum TNF-α levels and intraoperative opioid requirements. The notable effect on PONV, particularly when EA is administered at the PC6 acupoint [ 16 ] , aligns with emerging evidence suggesting that EA modulates autonomic nervous system balance and mitigates the neuroendocrine stress response induced by surgery. These physiological effects confer tangible clinical benefits, including diminished reliance on rescue antiemetic medications, stabilization of perioperative fluid balance by preventing emesis-related losses, and enhanced overall patient satisfaction with the surgical experience. Similarly, the observed reduction in pro-inflammatory markers corroborates experimental data demonstrating that EA suppresses NF-κB signaling and modulates neuro-immune crosstalk [ 26 ] . These mechanisms play a crucial role in alleviating surgical stress and may prevent the transition from acute to chronic pain. This observation is of considerable clinical importance, given the substantial burden of chronic postsurgical pain on both patient well-being and healthcare resources. The observed multimodal benefits of EA arise from a complex interplay of neurophysiological mechanisms that collectively define its therapeutic profile. Preclinical evidence indicates that EA concurrently activates endogenous descending inhibitory pathways through opioidergic signaling while modulating central pain processing via multiple non-opioid receptors, including adenosine A1 [ 26 ] and GABAergic systems [ 27 ] . The role of the endogenous opioid mechanism is further substantiated by recent findings [ 28 ] , demonstrating EA stimulates β-endorphin release mediated by immune cells. In parallel, the adenosine-mediated mechanism has been specifically elucidated in [ 26 ] , which reports that EA triggers adenosine release through Adora-3 signaling. Evidence of GABAergic involvement has been demonstrated in [ 29 ] , which identified that EA influences GABA within the rostral ventromedial medulla (RVM) through CB1 receptor mediation. Furthermore, EA appears to modulate immune function by promoting the polarization of microglia toward the M2 phenotype, thereby fostering an anti-inflammatory milieu [ 30 ] . These multifaceted mechanisms are particularly significant, as preoperative pain sensitivity has been shown to predict both increased postoperative pain intensity and greater analgesic demand [ 31 ] . Collectively, these findings suggest that EA may play a preventive role against central sensitization in patients at elevated risk of severe postoperative pain. Importantly, the convergence of these neural and immunological pathways underscores a synergistic therapeutic effect, whereby EA contributes not only to analgesia but also to comprehensive postoperative recovery. Building upon this mechanistic foundation, the clinical efficacy of EA must be evaluated within the wider framework of contemporary opioid-sparing strategies. Notably, the observed reduction in opioid consumption associated with EA (WMD = − 11.65 MME) appears comparable to, and in some cases may surpass, the effects observed with interventions, such as ketamine infusions [ 32 ] and comprehensive ERAS protocols [ 33 ] . Perioperative administration of ketamine has been reported to reduce cumulative opioid consumption by 97.3 mg within 24 h, indicating that these interventions may offer comparable analgesic efficacy [ 32 ] . However, EA demonstrates a superior safety profile, as ketamine was associated with a higher incidence of hallucinations and confusion, which may impede recovery and extend hospital stays. This safety advantage of EA becomes particularly evident when compared with other non-pharmacological analgesic strategies. For instance, while transcutaneous electrical nerve stimulation (TENS) provided a reduction in pain intensity with a standardized mean difference (SMD) of − 0.96, EA offers comprehensive neuromodulatory effects through multiple pathways that extend beyond analgesia to include autonomic regulation and modulation of immune modulation [ 34 ] . A key finding was the heterogeneity in treatment effect, with a more pronounced opioid-sparing impact observed in open versus minimally invasive surgeries [ 12 ] . This pattern indicates that the effectiveness of EA is proportional to the degree of surgical insult and the subsequent inflammatory response, highlighting its particular utility in major procedures where opioid requirements are typically the highest and the risk of opioid-related adverse effects is greatest. This differential efficacy aligns with the principles of precision medicine and underscores the potential of EA as a tailored approach within perioperative care. Its benefits appear particularly pronounced among patients with higher preoperative pain sensitivity or undergoing extensive surgical procedures. Clinically, these findings suggest that EA should be strategically implemented in surgical contexts characterized by significant tissue injury, where patients are most likely to experience meaningful reductions in opioid requirements and enhanced postoperative recovery. Several limitations warrant careful consideration. The clinical heterogeneity in EA parameters, including differences in acupoint selection, stimulation settings, and treatment timing, contributes to clinical heterogeneity, which was partially addressed through the application of random-effects models. Although the use of sham controls mitigates performance bias, the inherent challenge of achieving complete blinding in acupuncture trials persists. Furthermore, the limited number of studies reporting inflammatory biomarkers necessitates a cautious interpretation of these outcomes. These limitations underscore several critical avenues for future research. First, there is a need to standardize EA protocols across surgical subtypes. Second, large-scale RCTs are warranted to assess long-term outcomes, including persistent postoperative pain and cost-effectiveness. Third, mechanistic studies should examine potential synergistic effects between EA and other non-opioid analgesics. Finally, focused clinical trials are necessary in vulnerable populations, such as patients with chronic pain or established opioid tolerance. In conclusion, this meta-analysis provides robust evidence that EA serves as an effective multi-mechanistic component of multimodal analgesia protocols incorporated within ERAS pathways. EA not only confers substantial opioid-sparing effects but also promotes comprehensive improvements in postoperative recovery through neuromodulatory and immunoregulatory mechanisms. Its therapeutic impact is particularly pronounced in major surgery, and its non-pharmacological nature offers a superior safety profile. These findings provide strong evidence for the formal integration of evidence-based EA protocols into perioperative anesthetic care, aiming to reduce opioid-related complications and enhance overall surgical outcomes. 5. Conclusion This meta-analysis provides robust evidence that EA exerts significant opioid-sparing effects and accelerates postoperative recovery, thereby supporting its integration into ERAS protocols. The consistent reduction in opioid consumption, coupled with modulation of inflammatory response and improved gastrointestinal function, demonstrates its multimodal therapeutic value. However, the interpretation of these results is constrained by methodological limitations, including the heterogeneity of study protocols and the brevity of follow-up durations. To substantiate the long-term effectiveness and facilitate optimal clinical application, future research should prioritize the development of standardized protocols and undertake larger trials with extended follow-up durations. Declarations Ethics approval and consent to participate Not applicable; Clinical Trial Number: Not applicable. Consent for publication Not applicable Availability of data and materials The data used to support the findings of this study are included within the article. Conflict of interest The authors declare that there are no conflicts of interest. Funding 1. Key Medical Disciplines of Guangzhou (2025-2027). 2. Plan on enhancing scientific research in GMU (GMUCR2025-02030). 3. General Program of Guangdong Natural Science Foundation (2023A1515011117). 4. Research Project of Guangdong Provincial Administration of Traditional Chinese Medicine (20261289). 5. Guangzhou Science and Technology Plan Project (2024A03J0787). 6. 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Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterials.docx PRISMA2020checklist.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 14 May, 2026 Reviews received at journal 05 May, 2026 Reviews received at journal 21 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers agreed at journal 11 Apr, 2026 Reviews received at journal 22 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviews received at journal 20 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor invited by journal 19 Dec, 2025 Editor assigned by journal 18 Nov, 2025 Submission checks completed at journal 18 Nov, 2025 First submitted to journal 06 Nov, 2025 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. 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Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhenke","middleName":"","lastName":"Xiao","suffix":""},{"id":591537784,"identity":"f5984d37-1f7b-40cb-8ba2-b40c740f6652","order_by":2,"name":"Junming Lao","email":"","orcid":"","institution":"The Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Junming","middleName":"","lastName":"Lao","suffix":""},{"id":591537786,"identity":"89e3130b-b8d9-4096-834b-b128e61f6e2c","order_by":3,"name":"Lingli Pan","email":"","orcid":"","institution":"The Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lingli","middleName":"","lastName":"Pan","suffix":""},{"id":591537787,"identity":"39274778-9f53-4261-b373-ecebcf06f6f5","order_by":4,"name":"Zhou Chen","email":"","orcid":"","institution":"The Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhou","middleName":"","lastName":"Chen","suffix":""},{"id":591537793,"identity":"4fe25809-6b25-4294-9cea-64440d42bad4","order_by":5,"name":"Yi Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACfmbGxgcfKiTq+9mbDzAwNoAFDfBqkWxvbjacccaGcWbPsQTitBicOd4mzdmWxrhhRo4BcVoYbiS2STOwHWY2kMj5/PLnjm2JDezN2yQYau7g1ME4I7HZuoDnMJs5z9ttFpJnbic28Bwrk2A49gynFmaJxMbbMyQO81i2524zMGwDapHIMZNgbDiMUwubRGKDNI/BYQmDAznPDBJBWuTf4NfCw3OwSZonIc3A4EQO84ODYFt48GuRYG8EBvIBmwTJnmNmjI1tt43beNKKLRKO4dZif5j94YOP/yQS+NmbH3/82XZbtp/98MYbH2pwa0H1F5gEEQlEaQCG3gciFY6CUTAKRsEIAwBY3mDNGX7ZQgAAAABJRU5ErkJggg==","orcid":"","institution":"The Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yi","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2025-11-06 11:23:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8047427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8047427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102981950,"identity":"bf859505-eb87-410f-af1b-f9583ae64566","added_by":"auto","created_at":"2026-02-19 09:11:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":438159,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of the study process\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/61aa2ff5b5cbce5bcf877f19.png"},{"id":102981995,"identity":"7eba2d70-d014-47f8-b9b6-aa38ddcc6265","added_by":"auto","created_at":"2026-02-19 09:12:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":177312,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias graph\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/3d975d92207316a2dfbab4e4.png"},{"id":102981948,"identity":"3e6000fc-a9bf-47d6-8c54-a6904fd7b5a7","added_by":"auto","created_at":"2026-02-19 09:11:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":631585,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias summary\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/b8d557b6a3abf0d3397369fd.png"},{"id":102981970,"identity":"98820707-308a-4573-9ecf-68000ae88614","added_by":"auto","created_at":"2026-02-19 09:11:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":102060,"visible":true,"origin":"","legend":"\u003cp\u003eTotal Postoperative Opioid Consumption (MME)\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/b5abafff418f33052dadad8c.png"},{"id":102982070,"identity":"75d28ef6-fe09-4cd9-be2d-0ec5f0e21b5c","added_by":"auto","created_at":"2026-02-19 09:12:13","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":352335,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of Total Postoperative Opioid Consumption (MME)\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/bfa58ab4b11d04f8f12bfe57.png"},{"id":102981937,"identity":"9acfd4c1-9c02-4c80-9b77-df683e564530","added_by":"auto","created_at":"2026-02-19 09:11:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":298760,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative Pain Score (VAS)\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/40485daaa9251944e6edd8d4.png"},{"id":102981987,"identity":"01bcd524-3299-45a9-a45c-f01a848880d8","added_by":"auto","created_at":"2026-02-19 09:12:01","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":355612,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of Postoperative Pain Score (VAS)\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/f9abac281d88addb529312c2.png"},{"id":102982073,"identity":"91ca66ba-c0ad-4640-9fd2-c8a1c0aea70c","added_by":"auto","created_at":"2026-02-19 09:12:14","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":339364,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative Nausea and Vomiting (PONV)\u003c/p\u003e","description":"","filename":"Figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/aec55e4c07925e3bc080ea64.png"},{"id":102981935,"identity":"1a47fe1b-3cc9-4673-b7bc-188493cd15e0","added_by":"auto","created_at":"2026-02-19 09:11:47","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":421988,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of Postoperative Nausea and Vomiting (PONV)\u003c/p\u003e","description":"","filename":"Figure9.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/2f8c5a51644ef913d8b28fdb.png"},{"id":102982000,"identity":"7ec32089-0836-4756-b76a-1fdf1f860ca0","added_by":"auto","created_at":"2026-02-19 09:12:05","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":246172,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative Opioid Consumption (MME)\u003c/p\u003e","description":"","filename":"Figure10.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/d90d41c830381a7d8df16ab7.png"},{"id":102981997,"identity":"48f4431f-5e37-4bbc-a5e2-543907549420","added_by":"auto","created_at":"2026-02-19 09:12:04","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":176272,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative serum TNF-αconcentration (24 h)\u003c/p\u003e","description":"","filename":"Figure11.png","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/41c1624ac689f3d38033658b.png"},{"id":102982137,"identity":"7200009f-a400-4c67-965e-c6dc73a8e842","added_by":"auto","created_at":"2026-02-19 09:12:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4039535,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/44c2d19a-d258-4c46-a459-5bfa672b92fe.pdf"},{"id":102981930,"identity":"58dcb927-cde5-46e1-be88-c167297868e3","added_by":"auto","created_at":"2026-02-19 09:11:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":862065,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/b0e558f0d923946dd7458674.docx"},{"id":102981936,"identity":"77b056e2-c981-41ab-af61-1b3444e27080","added_by":"auto","created_at":"2026-02-19 09:11:47","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30228,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8047427/v1/0b5a072965c0eae546b740e7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Electroacupuncture for Opioid-Sparing Analgesia and Enhanced Recovery after Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEffective management of perioperative acute pain is essential for optimal surgical recovery and patient satisfaction. Although opioid-based multimodal analgesia is extensively employed in clinical practice, growing evidence indicates that postoperative persistent opioid use constitutes a major contributor to the opioid crisis\u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA range of dose-dependent adverse effects, including respiratory depression (17%\u0026ndash;40% incidence), gastrointestinal paralysis (prolonging recovery by 24\u0026ndash;48 h), opioid-induced hyperalgesia, and immunosuppression, impede postoperative rehabilitation and contradict the core principles of Enhanced Recovery After Surgery (ERAS)\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmong non-pharmacological interventions, electroacupuncture (EA) has gained considerable attention due to its combined neuromodulatory and anti-inflammatory effects\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Extensive preclinical studies support its analgesic efficacy. Stimulation at specific frequencies (e.g., 2/100 Hz dense\u0026ndash;dispersed waves) activates peripheral sensory nerve fibers and triggers descending inhibitory pathways in the spinal cord and brainstem, leading to the release of endogenous opioids, such as endorphins, enkephalins, and dynorphins\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Recent high-impact neuroscience studies have demonstrated that locus coeruleus noradrenergic-spinal projections, along with the downstream α(2A)-adrenoceptor\u0026ndash;CaMKII signaling cascade, play a key role in mediating the antinociceptive effects of EA in postoperative pain\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In addition, EA elicits systemic anti-inflammatory responses through neuro\u0026ndash;immune modulation, particularly via the cholinergic anti-inflammatory pathway, thereby reducing postoperative concentrations of pro-inflammatory cytokines, such as IL-6 and tumor necrosis factor (TNF) -α\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Collectively, these findings suggest that EA serves as a comprehensive intervention that maintains perioperative physiological homeostasis rather than merely providing analgesia.\u003c/p\u003e \u003cp\u003eClinically, meta-analyses have suggested that EA may reduce perioperative opioid consumption; however, the reported effect sizes vary widely, with opioid-sparing effects ranging from approximately 15% to 65% across trials\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. This heterogeneity is likely influenced by factors, such as differences in surgical type (e.g., open versus laparoscopic), anesthetic method (volatile versus intravenous agents, use of regional blocks), EA application parameters (intensity, waveform, acupoint selection), and timing in relation to surgery (preemptive versus postoperative)\u003csup\u003e[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Most existing systematic reviews have not adequately addressed these sources of variability through subgroup analysis or meta‑regression, leaving uncertainty regarding optimal EA integration into multimodal analgesia protocols\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Moreover, whether the opioid-sparing effect of EA depends on surgical magnitude or other perioperative variables remains unclear\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo address these challenges, this systematic review and meta-analysis synthesizes high-quality evidence from randomized controlled trials (RCTs) to assess the effect of EA on perioperative opioid consumption as the primary outcome. Secondary outcomes include postoperative pain scores during movement, incidence of postoperative nausea and vomiting (PONV), and levels of inflammatory biomarkers\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Preplanned subgroup and sensitivity analyses will further examine the influence of surgical, anesthetic, and EA-related factors on treatment effects. The results aim to clarify EA\u0026rsquo;s role within evidence-based opioid reduction strategies and guide its standardized application in perioperative practice.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe methodology for this systematic review was guided by a protocol that was prospectively registered on PROSPERO (International Prospective Register of Systematic Reviews; ID: CRD420251121682). Clinical trial number: Not applicable.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eThis meta-analysis included RCTs involving adult patients undergoing elective surgical procedures, in which EA was directly compared with sham electroacupuncture (SA). The primary outcomes included total postoperative opioid consumption, measured in morphine milligram equivalents (MMEs), and postoperative pain scores assessed using the Visual Analogue Scale (VAS). Secondary outcomes included intraoperative opioid consumption (expressed in MME), the incidence of PONV, and serum TNF-α levels measured 24 h postoperatively. Studies were excluded if they were meta-analyses, systematic reviews, conference abstracts, animal studies, case reports, incomplete publications, or if they failed to report any of the pre-specified outcomes of interest.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Literature Retrieval\u003c/h2\u003e \u003cp\u003eRCTs evaluating the opioid-sparing and ERAS effects of EA combined with conventional analgesia versus conventional analgesia alone were systematically searched across PubMed, Cochrane Library, Embase, Web of Science, CNKI, Wanfang, and CQVIP databases. The literature search, completed on July 20, 2025, employed a comprehensive strategy combining MeSH terms and free-text keywords, including \u0026ldquo;Electroacupuncture,\u0026rdquo; \u0026ldquo;Analgesics, Opioid,\u0026rdquo; and \u0026ldquo;postoperative.\u0026rdquo; The detailed search strategies are presented in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Extract\u003c/h2\u003e \u003cp\u003eAccording to established inclusion and exclusion criteria, two independent reviewers conducted a comprehensive literature search. Discrepancies were resolved through discussion or consultation with a third reviewer for an impartial opinion. The extracted data included the author, country of study, publication year, sample size (EA and SA groups), sex distribution, age range, type of surgery, intervention details, and reported outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Included studies' risk of bias\u003c/h2\u003e \u003cp\u003eThe risk of bias in the included studies was independently assessed by two reviewers using the Cochrane Collaboration's tool. The risk was classified into three categories: low, unclear, or high. The assessment evaluated seven key domains: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other potential sources of bias. Disagreements between reviewers were resolved through discussion or, if necessary, by consultation with a third reviewer. Studies that met all the criteria were judged as having a \u0026ldquo;low risk\u0026rdquo; of bias, indicating high methodological quality. Those that partially met the criteria were categorized as \u0026ldquo;unclear risk,\u0026rdquo; suggesting a moderate potential for bias. Studies that failed to meet the criteria were classified as \u0026ldquo;high risk,\u0026rdquo; indicating substantial bias and low methodological quality. The assessment was performed using Review Manager (RevMan) software, version 5.4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data analysis\u003c/h2\u003e \u003cp\u003eData analysis was conducted using Stata software (version 15.0). For continuous variables, the weighted mean difference (WMD) with 95% confidence intervals (CIs) was calculated. For dichotomous outcomes, the relative risk (RR) with 95% CIs was calculated. Heterogeneity among the included studies was assessed using the I\u003csup\u003e2\u003c/sup\u003e statistic and Q-test. I\u003csup\u003e2\u003c/sup\u003e values of 0%, 25%, 50%, and 75% were considered to indicate no, low, moderate, and high heterogeneity, respectively. A fixed-effects model was applied when I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;50%; otherwise, a random-effects model was used. Sensitivity analyses and Egger\u0026rsquo;s test were conducted to explore potential sources of heterogeneity.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Selection\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the flowchart of our literature search process. Of the 304 records initially identified, 120 duplicates were removed. Titles and abstracts screening excluded 154 studies, and full-text assessment eliminated another 17. Ultimately, 13 RCTs\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e were included in the final analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Essential characteristics and risk of bias of the included studies\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the process of our literature search. Initially, we identified 304 documents. After eliminating 120 duplicates, we excluded 17 articles according to their titles, and an additional 13 articles were excluded after a thorough review of the full text. As a result, 13 RCTs\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e were included in the analysis. These studies collectively involved 967 participants, comprising 479 individuals in the EA group and 488 in the Sham acupuncture (SA) group. EA was applied at defined acupoints with varying frequencies and durations, while the SA procedure involved superficial needling at non-acupoints without electrical stimulation. Table\u0026nbsp;1 summarizes the baseline features of these studies. All trials clearly described their randomization methods, and the risk-of-bias assessment (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) further supports the reliability of the included studies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Result of meta-analysis\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Total Postoperative Opioid Consumption (MME)\u003c/h2\u003e \u003cp\u003eSix studies\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e encompassing 205 patients in the EA group and 204 in the SA group reported total postoperative opioid consumption (expressed in MME). Owing to high heterogeneity (I\u0026sup2; = 92.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a random-effects meta-analysis was conducted, revealing that EA significantly reduced postoperative opioid use compared to SA (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with a weighted mean difference (WMD) of \u0026minus;\u0026thinsp;11.65 MME and a 95% confidence interval (CI) of \u0026minus;\u0026thinsp;18.61 to \u0026minus;\u0026thinsp;4.70. Subgroup analysis based on surgical approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) revealed significant reductions for both minimally invasive surgery (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.40, 95% CI: \u0026minus;5.40 to \u0026minus;\u0026thinsp;1.41; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;47.0%) and open surgery (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;19.52, 95% CI: \u0026minus;24.19 to \u0026minus;\u0026thinsp;14.86; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;14.7%). The effect was greater with lower heterogeneity in the open surgery group. The overall heterogeneity may partly result from the wide confidence intervals and low statistical weight of certain studies, such as those of Deng et al. Sensitivity analysis using the leave-one-out method (Supplementary Figures \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u0026thinsp;\u0026minus;\u0026thinsp;S3) showed consistent results, and neither the funnel plot nor Egger\u0026rsquo;s test indicated significant publication bias, confirming the robustness of the findings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Postoperative Pain Score (VAS)\u003c/h2\u003e \u003cp\u003eEight studies\u003csup\u003e[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e involving 670 patients (335 per group) evaluated the effect of EA versus SA on postoperative pain scores (VAS). A random-effects meta-analysis indicated significantly lower pain scores with EA than with SA (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.72, 95% CI: \u0026minus;1.07 to \u0026minus;\u0026thinsp;0.36), despite substantial heterogeneity (I\u0026sup2; = 87.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Subgroup analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e) showed statistically significant pain reduction in major surgeries (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.93, 95% CI: \u0026minus;1.21 to \u0026minus;\u0026thinsp;0.65) but not in minor surgeries (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.17, 95% CI: \u0026minus;0.36 to 0.01). Sensitivity analysis (Supplementary Figures S4\u0026ndash;S6) confirmed the robustness of the results, and the absence of publication bias was supported by the funnel plot and Egger's test (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Postoperative Nausea and Vomiting\u003c/h2\u003e \u003cp\u003eTen studies\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e reported the incidence of PONV among 367 patients who received EA and 377 who received SA. Because moderate heterogeneity was observed among these studies (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e), (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;52.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025), a random-effects model was applied. The pooled results demonstrated that EA was associated with a significantly lower risk of PONV than SA (RR\u0026thinsp;=\u0026thinsp;0.54, 95% CI: 0.34\u0026ndash;0.85). Subgroup analysis based on surgical extent (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e) revealed a statistically significant reduction in PONV risk among patients undergoing minor surgery (RR\u0026thinsp;=\u0026thinsp;0.21, 95% CI: 0.10 to 0.48; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%), whereas the reduction in the major surgery subgroup was not statistically significant (RR\u0026thinsp;=\u0026thinsp;0.67, 95% CI: 0.44 to 1.05; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;39.5%). The overall treatment effect remained consistent in sensitivity analysis (Supplementary Figures S7\u0026ndash;S9) conducted using the leave-one-out approach. Furthermore, the funnel plot inspection and Egger\u0026rsquo;s test indicated no substantial publication bias, thereby reinforcing the reliability and robustness of these findings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.3.4 Intraoperative Opioid Consumption\u003c/h2\u003e \u003cp\u003eFive studies\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e reported intraoperative opioid consumption (expressed in MME) in 190 patients who received EA and 191 who received SA. A random-effects model was employed, revealing no significant heterogeneity detected among studies (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.691). The pooled results demonstrated that EA was associated with a substantial reduction in intraoperative opioid consumption compared to SA (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e) (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.15 MME, 95% CI: \u0026minus;3.85 to \u0026minus;\u0026thinsp;0.46). Sensitivity analysis (Supplementary Figures S10\u0026ndash;S12) using the leave-one-out approach confirmed the stability of this effect. Additionally, both visual inspection of the funnel plot and Egger\u0026rsquo;s test showed no evidence of publication bias, confirming the robustness of these findings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.5 Postoperative serum TNF-αconcentration (24 h)\u003c/h2\u003e \u003cp\u003eTwo studies\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e reported postoperative serum TNF-α concentration at 24 h, including a total of 93 patients in both EA and SA groups. Owing to substantial heterogeneity observed between the studies (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;78.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030), a random-effects model was applied for the analysis. The results (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e) demonstrated that EA significantly reduced TNF-α levels compared to SA (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.08 pg/mL; 95% CI: \u0026minus;1.82 to \u0026minus;\u0026thinsp;0.35). Owing to the substantial heterogeneity observed, a sensitivity analysis (Supplementary Figures S13) using the leave-one-out method was performed, which confirmed the stability of the overall treatment effect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.6 Published Bias\u003c/h2\u003e \u003cp\u003eEgger\u0026rsquo;s regression test was performed to assess potential publication bias across the four primary outcomes: total postoperative opioid consumption (measured using MME), postoperative pain intensity (measured using the VAS score), incidence of PONV, and intraoperative opioid consumption (MME). The results indicated no evidence of significant publication bias, as all Egger\u0026rsquo;s test P-values exceeded 0.05, and the corresponding funnel plots demonstrated symmetrical distributions (Supplementary Figures \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u0026ndash;S4). These results substantiate the robustness and validity of the meta-analytic conclusions, indicating that the results are methodologically sound and free from substantial bias.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis systematic review and meta-analysis present robust evidence that adjunctive EA within ERAS protocols significantly reduces perioperative opioid requirements. The analysis of 13 RCTs encompassing 967 surgical patients demonstrates that EA significantly decreased total postoperative opioid consumption, with a weighted mean difference of 11.65 mg in intravenous morphine equivalents compared to sham controls. This reduction, representing a clinically meaningful magnitude, holds particular importance in the context of the ongoing opioid crisis, wherein postoperative opioid prescriptions are a well-recognized contributor to prolonged use and dependence\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. By mitigating opioid exposure, EA may substantially lower the risk of severe opioid-related adverse events, including respiratory depression, gastrointestinal paralysis, and opioid-induced hyperalgesia\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The clinical significance of this reduction extends beyond numerical value. In clinical practice, a decrease of 11.65 mg in morphine milligram equivalents represents a substantial improvement, facilitating earlier patient mobilization, faster recovery of bowel function, and a reduced risk of opioid-related cognitive dysfunction.\u003c/p\u003e \u003cp\u003eIn addition to its significant opioid-sparing effects, EA demonstrates comprehensive therapeutic advantages encompassing various aspects of postoperative recovery. The present analysis revealed concurrent improvements in pain control (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.72 on the VAS), a marked reduction in the incidence of PONV (RR\u0026thinsp;=\u0026thinsp;0.54), and mitigation of the systemic inflammatory response as indicated by reduced serum TNF-α levels and intraoperative opioid requirements. The notable effect on PONV, particularly when EA is administered at the PC6 acupoint\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, aligns with emerging evidence suggesting that EA modulates autonomic nervous system balance and mitigates the neuroendocrine stress response induced by surgery. These physiological effects confer tangible clinical benefits, including diminished reliance on rescue antiemetic medications, stabilization of perioperative fluid balance by preventing emesis-related losses, and enhanced overall patient satisfaction with the surgical experience. Similarly, the observed reduction in pro-inflammatory markers corroborates experimental data demonstrating that EA suppresses NF-κB signaling and modulates neuro-immune crosstalk\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. These mechanisms play a crucial role in alleviating surgical stress and may prevent the transition from acute to chronic pain. This observation is of considerable clinical importance, given the substantial burden of chronic postsurgical pain on both patient well-being and healthcare resources.\u003c/p\u003e \u003cp\u003eThe observed multimodal benefits of EA arise from a complex interplay of neurophysiological mechanisms that collectively define its therapeutic profile. Preclinical evidence indicates that EA concurrently activates endogenous descending inhibitory pathways through opioidergic signaling while modulating central pain processing via multiple non-opioid receptors, including adenosine A1\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e and GABAergic systems\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. The role of the endogenous opioid mechanism is further substantiated by recent findings\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, demonstrating EA stimulates β-endorphin release mediated by immune cells. In parallel, the adenosine-mediated mechanism has been specifically elucidated in\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, which reports that EA triggers adenosine release through Adora-3 signaling. Evidence of GABAergic involvement has been demonstrated in\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, which identified that EA influences GABA within the rostral ventromedial medulla (RVM) through CB1 receptor mediation.\u003c/p\u003e \u003cp\u003eFurthermore, EA appears to modulate immune function by promoting the polarization of microglia toward the M2 phenotype, thereby fostering an anti-inflammatory milieu\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. These multifaceted mechanisms are particularly significant, as preoperative pain sensitivity has been shown to predict both increased postoperative pain intensity and greater analgesic demand\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Collectively, these findings suggest that EA may play a preventive role against central sensitization in patients at elevated risk of severe postoperative pain. Importantly, the convergence of these neural and immunological pathways underscores a synergistic therapeutic effect, whereby EA contributes not only to analgesia but also to comprehensive postoperative recovery.\u003c/p\u003e \u003cp\u003eBuilding upon this mechanistic foundation, the clinical efficacy of EA must be evaluated within the wider framework of contemporary opioid-sparing strategies. Notably, the observed reduction in opioid consumption associated with EA (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;11.65 MME) appears comparable to, and in some cases may surpass, the effects observed with interventions, such as ketamine infusions\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e and comprehensive ERAS protocols\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. Perioperative administration of ketamine has been reported to reduce cumulative opioid consumption by 97.3 mg within 24 h, indicating that these interventions may offer comparable analgesic efficacy\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. However, EA demonstrates a superior safety profile, as ketamine was associated with a higher incidence of hallucinations and confusion, which may impede recovery and extend hospital stays. This safety advantage of EA becomes particularly evident when compared with other non-pharmacological analgesic strategies. For instance, while transcutaneous electrical nerve stimulation (TENS) provided a reduction in pain intensity with a standardized mean difference (SMD) of \u0026minus;\u0026thinsp;0.96, EA offers comprehensive neuromodulatory effects through multiple pathways that extend beyond analgesia to include autonomic regulation and modulation of immune modulation\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA key finding was the heterogeneity in treatment effect, with a more pronounced opioid-sparing impact observed in open versus minimally invasive surgeries\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. This pattern indicates that the effectiveness of EA is proportional to the degree of surgical insult and the subsequent inflammatory response, highlighting its particular utility in major procedures where opioid requirements are typically the highest and the risk of opioid-related adverse effects is greatest. This differential efficacy aligns with the principles of precision medicine and underscores the potential of EA as a tailored approach within perioperative care. Its benefits appear particularly pronounced among patients with higher preoperative pain sensitivity or undergoing extensive surgical procedures. Clinically, these findings suggest that EA should be strategically implemented in surgical contexts characterized by significant tissue injury, where patients are most likely to experience meaningful reductions in opioid requirements and enhanced postoperative recovery.\u003c/p\u003e \u003cp\u003eSeveral limitations warrant careful consideration. The clinical heterogeneity in EA parameters, including differences in acupoint selection, stimulation settings, and treatment timing, contributes to clinical heterogeneity, which was partially addressed through the application of random-effects models. Although the use of sham controls mitigates performance bias, the inherent challenge of achieving complete blinding in acupuncture trials persists. Furthermore, the limited number of studies reporting inflammatory biomarkers necessitates a cautious interpretation of these outcomes. These limitations underscore several critical avenues for future research. First, there is a need to standardize EA protocols across surgical subtypes. Second, large-scale RCTs are warranted to assess long-term outcomes, including persistent postoperative pain and cost-effectiveness. Third, mechanistic studies should examine potential synergistic effects between EA and other non-opioid analgesics. Finally, focused clinical trials are necessary in vulnerable populations, such as patients with chronic pain or established opioid tolerance.\u003c/p\u003e \u003cp\u003eIn conclusion, this meta-analysis provides robust evidence that EA serves as an effective multi-mechanistic component of multimodal analgesia protocols incorporated within ERAS pathways. EA not only confers substantial opioid-sparing effects but also promotes comprehensive improvements in postoperative recovery through neuromodulatory and immunoregulatory mechanisms. Its therapeutic impact is particularly pronounced in major surgery, and its non-pharmacological nature offers a superior safety profile. These findings provide strong evidence for the formal integration of evidence-based EA protocols into perioperative anesthetic care, aiming to reduce opioid-related complications and enhance overall surgical outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis meta-analysis provides robust evidence that EA exerts significant opioid-sparing effects and accelerates postoperative recovery, thereby supporting its integration into ERAS protocols. The consistent reduction in opioid consumption, coupled with modulation of inflammatory response and improved gastrointestinal function, demonstrates its multimodal therapeutic value.\u003c/p\u003e \u003cp\u003eHowever, the interpretation of these results is constrained by methodological limitations, including the heterogeneity of study protocols and the brevity of follow-up durations. To substantiate the long-term effectiveness and facilitate optimal clinical application, future research should prioritize the development of standardized protocols and undertake larger trials with extended follow-up durations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable; Clinical Trial Number: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are included within the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Key Medical Disciplines of Guangzhou (2025-2027).\u003c/p\u003e\n\u003cp\u003e2. Plan on enhancing scientific research in GMU (GMUCR2025-02030).\u003c/p\u003e\n\u003cp\u003e3. General Program of Guangdong Natural Science Foundation (2023A1515011117).\u003c/p\u003e\n\u003cp\u003e4. Research Project of Guangdong Provincial Administration of Traditional Chinese Medicine (20261289).\u003c/p\u003e\n\u003cp\u003e5. Guangzhou Science and Technology Plan Project (2024A03J0787).\u003c/p\u003e\n\u003cp\u003e6. Major Clinical Innovation Technology Construction Project for Integrated Traditional Chinese and Western Medicine in Guangzhou.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. \u003cstrong\u003eJiayu Huang\u003c/strong\u003e: Conceptualization, Methodology, Software, Writing- Original draft, Data curation, Visualization were performed; \u003cstrong\u003eZhenke Xiao, Junming Lao, Lingli Pan and Zhou Chen\u003c/strong\u003e: Investigation, Writing - Original Draft, Writing - Reviewing and Editing were performed; \u003cstrong\u003eYi Lu\u003c/strong\u003e: Conceptualization, Supervision, Project administration were performed. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e赵紫健, 冯峰, 王浩然, et al. 全麻复合电针处理对颅内动脉瘤介入治疗患者围术期阿片类药物相关不良事件发生率的影响 [J]. 徐州医科大学学报, 2025, 45(05): 352-6.\u003c/li\u003e\n\u003cli\u003eZORRILLA-VACA A, RAMIREZ P T, INIESTA-DONATE M, et al. Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study [J]. Can J Anaesth, 2022, 69(12): 1477-92.\u003c/li\u003e\n\u003cli\u003eSITTER T, FORGET P. Persistent postoperative opioid use in Europe: A systematic review [J]. Eur J Anaesthesiol, 2021, 38(5): 505-11.\u003c/li\u003e\n\u003cli\u003eSHANTHANNA H, LADHA K S, KEHLET H, JOSHI G P. Perioperative Opioid Administration [J]. Anesthesiology, 2021, 134(4): 645-59.\u003c/li\u003e\n\u003cli\u003eMCCALL E, SHORES R, MCDONOUGH J. 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Electroacupuncture at different frequencies improves visceral pain in IBS rats through different pathways [J]. Neurogastroenterol Motil, 2024, 36(10): e14874.\u003c/li\u003e\n\u003cli\u003eHARGETT J, CRISWELL A, PALOKAS M. Nonpharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review [J]. JBI Evid Synth, 2022, 20(11): 2697-720.\u003c/li\u003e\n\u003cli\u003eZHANG Q, ZHOU M, HUO M, et al. Mechanisms of acupuncture-electroacupuncture on inflammatory pain [J]. Mol Pain, 2023, 19: 17448069231202882.\u003c/li\u003e\n\u003cli\u003eLEE S, LEE M S, CHOI D H, LEE S K. Electroacupuncture on PC6 prevents opioid-induced nausea and vomiting after laparoscopic surgery [J]. Chinese journal of integrative medicine, 2013, 19(4): 277‐81.\u003c/li\u003e\n\u003cli\u003ePRAVEENA SEEVAUNNAMTUM S, BHOJWANI K, ABDULLAH N. Intraoperative electroacupuncture reduces postoperative pain, analgesic requirement and prevents postoperative nausea and vomiting in gynaecological surgery: A randomised controlled trial [J]. Anesthesiology and Pain Medicine, 2016, 6(6).\u003c/li\u003e\n\u003cli\u003e周利, 周大春. 超声引导下竖脊肌平面阻滞联合电针刺激对老年胸腔镜肺叶切除术患者的麻醉效果 [J]. 中国老年学杂志, 2024, 44(13): 3127-30.\u003c/li\u003e\n\u003cli\u003e王保, 马树霖, 尧新华, et al. 术中电针镇痛对全麻甲状腺手术患者气管插管应激反应的影响 [J]. 实用医学杂志, 2024, 40(8): 1132-6.\u003c/li\u003e\n\u003cli\u003e裘宝玉, 习建华, 罗贤哲, et al. 电针联合羟考酮自控静脉镇痛用于胃癌根治术患者的镇痛效果观察 [J]. 浙江中医杂志, 2022, 57(10): 752-3.\u003c/li\u003e\n\u003cli\u003e陆黎, 朱洪生. 电针联合地佐辛对瑞芬太尼诱发患者术后痛觉过敏的影响 [J]. 中华麻醉学杂志, 2017, 37(12): 1434-7.\u003c/li\u003e\n\u003cli\u003eDENG G, WONG W D, GUILLEM J, et al. A Phase II, Randomized, Controlled Trial of Acupuncture for Reduction of Postcolectomy Ileus [J]. Annals of Surgical Oncology, 2013, 20(4): 1164-9.\u003c/li\u003e\n\u003cli\u003eSAHMEDDINI M A, FARBOOD A, GHAFARIPUOR S. Electro-acupuncture for pain relief after nasal septoplasty: a randomized controlled study [J]. Journal of alternative and complementary medicine (New York, NY), 2010, 16(1): 53‐7.\u003c/li\u003e\n\u003cli\u003eWYLIE J A, KONG L, BARTH R J, JR. Opioid Dependence and Overdose After Surgery: Rate, Risk Factors, and Reasons [J]. Ann Surg, 2022, 276(3): e192-e8.\u003c/li\u003e\n\u003cli\u003eTASSOU A, RICHEBE P, RIVAT C. Mechanisms of chronic postsurgical pain [J]. Reg Anesth Pain Med, 2025, 50(2): 77-85.\u003c/li\u003e\n\u003cli\u003eKIANI F A, LI H, NAN S, et al. Electroacupuncture Relieves Neuropathic Pain via Adenosine 3 Receptor Activation in the Spinal Cord Dorsal Horn of Mice [J]. Int J Mol Sci, 2024, 25(19).\u003c/li\u003e\n\u003cli\u003eZHU Y, SUN H, XIAO S, et al. Electroacupuncture inhibited carrageenan-induced pain aversion by activating GABAergic neurons in the ACC [J]. Mol Brain, 2024, 17(1): 69.\u003c/li\u003e\n\u003cli\u003eSHI J T, CAO W Y, ZHANG X N, et al. Local analgesia of electroacupuncture is mediated by the recruitment of neutrophils and released \u0026beta;-endorphins [J]. Pain, 2023, 164(9): 1965-75.\u003c/li\u003e\n\u003cli\u003eWAN K, XU Q, SHI Y, et al. Electroacupuncture produces analgesic effects via cannabinoid CB1 receptor-mediated GABAergic neuronal inhibition in the rostral ventromedial medulla [J]. Chin Med, 2025, 20(1): 30.\u003c/li\u003e\n\u003cli\u003eWU Q, ZHENG Y, YU J, et al. Electroacupuncture alleviates neuropathic pain caused by SNL by promoting M2 microglia polarization through PD-L1 [J]. Int Immunopharmacol, 2023, 123: 110764.\u003c/li\u003e\n\u003cli\u003eANGADI S P, RAMACHANDRAN K, SHETTY A P, et al. Preoperative pain sensitivity predicts postoperative pain severity and analgesics requirement in lumbar fusion surgery - a prospective observational study [J]. Spine J, 2023, 23(9): 1306-13.\u003c/li\u003e\n\u003cli\u003eMEYER-FRIE\u0026szlig;EM C H, LIPKE E, WEIBEL S, et al. Perioperative ketamine for postoperative pain management in patients with preoperative opioid intake: A systematic review and meta-analysis [J]. J Clin Anesth, 2022, 78: 110652.\u003c/li\u003e\n\u003cli\u003eLEVYTSKA K, YU Z, WALLY M, et al. Enhanced recovery after surgery (ERAS) protocol is associated with lower post-operative opioid use and a reduced office burden after minimally invasive surgery [J]. Gynecol Oncol, 2022, 166(3): 471-5.\u003c/li\u003e\n\u003cli\u003eJOHNSON M I, PALEY C A, JONES G, et al. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study) [J]. BMJ Open, 2022, 12(2): e051073.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Electroacupuncture, Opioid-sparing, Postoperative recovery, Meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-8047427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8047427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis of randomized controlled trials (RCTs) evaluates the efficacy of electroacupuncture (EA) for opioid-sparing analgesia and examines its role in facilitating enhanced recovery after surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA comprehensive literature search was conducted across PubMed, the Cochrane Library, Web of Science, Embase, CNKI, Wangfang, and Cqvip. This search was aimed at identifying RCTs that evaluated the effects of EA versus sham acupuncture on opioid consumption and postoperative recovery outcomes in surgical patients. The literature search was finalized on July 20, 2025. Data extraction and subsequent meta-analysis were performed using Stata version 15.0.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eIn a meta-analysis of 13 RCTs (n\u0026thinsp;=\u0026thinsp;967), EA was associated with a significant reduction in total postoperative opioid use (weighted mean difference [WMD]\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;11.65 morphine milligram equivalents [MMEs], 95% confidence interval [CI]: \u0026minus;18.61 to \u0026minus;\u0026thinsp;4.70), and intraoperative opioid requirements (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.15 MME, 95% CI: \u0026minus;3.85 to \u0026minus;\u0026thinsp;0.46) compared to sham acupuncture. Furthermore, EA was associated with improved pain control, reduced postoperative nausea and vomiting (PONV), and attenuated inflammatory response, underscoring its role as an effective opioid-sparing strategy within enhanced recovery protocols.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study shows that EA does not compromise analgesic efficacy compared to sham acupuncture. Additionally, it exerts a pronounced opioid-sparing effect, significantly lowering postoperative opioid consumption while concurrently enhancing the overall recovery outcomes.\u003c/p\u003e","manuscriptTitle":"Electroacupuncture for Opioid-Sparing Analgesia and Enhanced Recovery after Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 09:10:01","doi":"10.21203/rs.3.rs-8047427/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-14T11:40:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T16:59:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T10:17:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137478318477852500989755977551232119272","date":"2026-04-14T12:49:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188334058766352886342510156544308003169","date":"2026-04-11T09:52:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T03:08:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35696182518787868754125773484287645323","date":"2026-03-22T10:14:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T04:54:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198701360064843594239361332409522483005","date":"2026-02-13T05:06:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T05:03:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-19T11:59:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-18T09:30:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T09:30:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2025-11-06T11:20:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"557bf907-a49b-41f7-9abd-1c84c1c061a1","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-14T11:40:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T16:59:23+00:00","index":64,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T11:53:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 09:10:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8047427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8047427","identity":"rs-8047427","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}