Post-surgical Complications Treated by Acupuncture and Chinese Herbal Medicine Case 1 – Discharge and ascites caused byportal hypertension and hypoproteinaemia following liver tumour
JB, a 47‑year‑old female patient, presented four months after undergoing surgical resection of multiple liver tumours complaining of abdominal pain, weight loss, amenorrhoea and continuous discharge from the sites of the drainage tubes that had been inserted into her chest and abdomen. Three years previously JB had been diagnosed with primary liver cancer ‑ as confirmed by liver biopsy ‑ after complaining of right upper quadrant pain, depression, anxiety and insomnia. There had been multiple tumours concentrated around the portal vessels, the largest measuring six by seven centimetres and the smallest measuring one centimetre square; this had made resection difficult and dangerous, and thus she was not given any treatment. JB had suffered from breast cancer thirteen years previously, although the liver tumors were thought to be unrelated. As she had previously experienced benefits from TCM during her breast cancer treatment, she returned for treatment of the liver cancer. She was given acupuncture and herbal medicine to move Liver qi and relieve blood stasis, and after two years of TCM treatment her general condition had improved – her complexion was healthy, her appetite was good, her menstrual cycle was regular and she had regular bowel movements. The tumours did not reduce in size, however, but actually grew slightly bigger. She was therefore referred back for WM treatment, and her hepatobiliary surgeon decided to operate in September 2009. Six tumours of various sizes were resected and shown by histological tests to be neuroendocrine in nature. Due to the large amount of fluid produced by the wounds, chest and liver drains were inserted on her right side two months after surgery.
When JB returned for TCM treatment four months after the operation she reported abdominal distension and pain, breathlessness and dizziness on exertion, nausea, tiredness, anorexia, poor sleep, weight loss (over 10 kilogrammes since the operation ‑ her BMI was low), amenorrhoea and bilateral swelling of the legs. She constantly had to lean towards her left side and was unable to lie supine due to pain at site of the chest drain where inflammation and infection was affecting the bottom of the right lung. She also had to move very slowly, as movement exacerbated the pain in her abdomen and at the drain sites. There was generalised abdominal distension and tenderness on palpation, with shifting dullness heard with a stethoscope on percussion (confirming the presence Journal of Chinese Medicine • Number 96 • June 2011 Post-surgical Complications Treated by Acupuncture and Chinese Herbal Medicine 41 of ascites). The right‑sided chest drain was draining pale yellow fluid (over 100 millilitres per day) and there was splenomegaly. Her tongue was pale and plump with a slippery white coat, and her pulse was wiry and fine.
Ascites and leg oedema secondary to portal hypertension
Qi and yang deficiency of the Spleen and Kidney
Excess dampness and internal fluid accumulation
As JB could not comfortably lie supine, acupuncture was not used and she received only herbal medicine. An integrated approach to treatment was used, in which TCM and WM treatment regimens were divided into three stages, as follows:
Huang Qi (Astragali Radix) 30g and Dang Gui (Angelicae sinensis Radix) 10g: the large dose of Huang Qi strengthens the central (zhong) qi, whilst Dang Gui nourishes blood and works together with Huang Qi to strengthen the upright (zheng) qi.
Yi Yi Ren (Coicis Semen) 30g, Fu Ling (Poria, changed from Zhu Ling in the original formula, with an increased dose) 10g and Ting Li Zi (Lepidii/Descurainiae Semen) 10g all drain excessive fluid. Ting Li Zi was chosen as it enters the Lung channel.
Gui Zhi (Cinnamomi Ramulus) 10g stimulates the yang qi in order to move fluids.
Hou Po (Magnoliae officinalis Cortex) 10g and Zhi Shi (Aurantii Fructus immaturus) 10g move qi in the abdomen to help to move fluids.
Shan Zha (Crataegi Fructus) 10g, Sha Ren (Amomi Fructus) 10g and Shen Qu (Massa medicata fermentata) 10g harmonise Stomach qi and revive the appetite.
Zhi Gan Cao (Glycyrrhizae Radix preparata) 5g protects the Stomach and harmonises the whole prescription.
The herbs were decocted and taken twice a day. Additionally one 10 millilitre bottle of Ren Shen (Ginseng Radix) extract containing 3800 milligrammes of Ren Shen was prescribed twice daily to further strengthen the qi. After commencing herbal treatment JB reported a gradual decline in abdominal pain and distension, a return of her appetite and a reduction in the amount of fluid discharge (down to eight to ten millilitres per day). After six weeks of treatment the fluid output had reduced enough for the chest drain to be removed.
By this point, JB had regained weight, started menstruating again, had normal urinary and bowel functions, and experienced a significant reduction in the amount of fluid in her abdomen and legs. She still suffered from pain, swelling and mild discharge around the drainage site at the bottom of lung, however, and occasionally felt feverish. Her tongue was light red with a white coat, and her pulse was wiry and fine. At this point a seven‑day course of antibiotics was prescribed by her GP for the infection, and a district nurse was coming to change her dressings every other day. During this second phase of treatment the WM treatment principles were to reduce local inflammation and strengthen the patient’s general condition, whilst the TCM treatment principles were to regulate Liver qi, tonify Spleen qi, eliminate excessive fluid, reduce blood stasis and clear toxic heat. The TCM prescription was based on a mixture of Xiao Chai Hu Tang (Minor Bupleurum Decotion) and Wu Wei Xiao Du Yin (Five‑Ingredient Drink to Eliminate Toxins), as follows:
Chai Hu (Bupleuri Radix) 10g regulates qi, especially of the Liver and abdomen. • Huang Qin (Scutellariae Radix) 10g and Chuan Lian Zi (Toosendan Fructus) 10g clear heat from the Lung and Liver.
Ban Xia (Pinelliae ternatae Rhizoma) 10g resolves stagnant phlegm and harmonises the Stomach.
Jin Yin Hua (Lonicerae Flos) 10g, Pu Gong Ying (Taraxaci Herba) 10g and Chi Shao (Paeoniae Radix rubra) 10g detoxify and clear heat from the blood.
Huang Qi (Astragali Radix) 15g strengthens the upright qi.
Zhu Ling (Sclerotium Polypori Umbellati) 10g drains any remaining fluid.
Sha Ren (Amomi Fructus) 10g, Shan Zha (Crataegi Fructus) 10g and Zhi Gan Cao (Glycyrrhizae Radix preparata) 5g harmonise the Stomach, promote appetite and harmonise the whole prescription.
The above herbs were decocted and taken twice daily.
By this time the wound around the drain‑site had completely healed and all the excess fluid in JB’s abdomen and legs had disappeared. However, she had developed a cough and breathlessness as a result of the fibrosis at the bottom of the lung, and splenomegaly was again 42 Post-surgical Complications Treated by Acupuncture and Chinese Herbal Medicine Journal of Chinese Medicine • Number 96 • June 2011 noticed on ultrasound, which was caused by the portal hypertension. The WM treatment principles were therefore to support gastrointestinal function (involving promoting circulation between the intestines and the Liver in order to reduce portal hypertension), reduce the production of phlegm in the lungs and support general recovery. The TCM treatment principles were to strengthen the Spleen and Kidney, eliminate dampness and resolve blood stasis. The TCM prescription was based on a combination of Xiang Sha Liu Jun Zi Tang (Six‑Gentlemen Decoction with Aucklandia and Amomum) and Wu Ling San (Five‑Ingredient Pill with Poria).
Xiang Fu (Cyperi Rhizoma) 10g and Sha Ren (Amomi Fructus) 10g regulate Stomach qi and promote appetite.
Huang Qi (Astragali Radix, changed from Dang Shen [Codonopsis Radix] in the original formula) 30g, Bai Zhu (Atractylodis macrocephalae Rhizoma) 10g and Fu Ling (Poria) 10g strengthen central qi.
Shan Zha (Crataegi Fructus) 10g and Chao Mai Ya (dry‑fried Hordei Fructus germinantus) 10g harmonise Stomach qi.
Hou Po (Magnoliae officinalis Cortex) 10g and Zhi Qiao (Aurantii Fructus) 10g move qi in the abdomen.
Yan Hu So (Corydalis Rhizoma) 10g treats chest and abdominal pain.
Yi Yi Ren (Coicis Semen) 30g and Gui Zhi (Cinnamomi Ramulus) 8g stimulate yang qi to move accumulated dampness.
Dang Gui (Angelicae sinensis Radix) 10g and Chi Shao (Paeoniae Radix rubra) 10g nourish yin and blood and soften blood stasis in the Lung and Liver.
Zhi Gan Cao (Glycyrrhizae Radix preparata) 5g harmonises the other herbs, relaxes the Stomach and regulates the whole prescription.
All of the herbs were decocted and taken twice daily. Additionally one 10 millilitre bottle of Ren Shen (Ginseng Radix) extract containing 3800 milligrammes of Ren Shen was prescribed twice daily to further strengthen the qi. After receiving TCM treatment for six months the patient recovered completely
For full report please read:
Dan Jiang,Lily Li, Post-surgical Complications Treated by Acupuncture and Chinese Herbal Medicine,Journal of Chinese Medicine. Number 96. June 2011