Health: As a painkiller, they're pretty sharp: Acupuncture needles can dramatically reduce the use of anaesthetics in operations. German doctors are making advances; will Britain follow? Richard Davy reports

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THE NEEDLES, about two inches long, are inserted to their full length down the side of the face, just in front of the ear, reaching nearly to the lower jaw. When they have been wired up to a machine that delivers a low-voltage, low-frequency current, the surgeon starts cutting.

In case the reader is about to faint at this point, it should be mentioned that the patient gets a short-acting anaesthetic before the needles go in.

The technique, derived from acupuncture and called electro-stimulation-analgesia (ESA), works largely by stimulating production of the body's own pain-killers, endorphins. The effect has been tested by using nalaxone, an opiate antagonist, to block it.

Several anaesthetists in Germany, Holland and Austria use ESA, but few if any now in Britain.

In Berlin, Dr Elke Leube, consultant anaesthetist at the Waldfriede hospital, has used ESA in about 6,000 operations in the past 10 years. She says it enables her to administer about half the normal quantity of anaesthetic during an operation, and half the painkillers afterwards, although amounts vary for different patients. This means less risk, especially for elderly or fragile patients, and a much quicker recovery.

It also saves money. Dr Leube reckons that her department probably saves about 10,000 marks (pounds 4,000) a year on drugs by using acupuncture, and further savings are made on painkillers and convalescent care.

Most patients are fresh and alert when they wake up, and are usually allowed to drink tea or coffee an hour after the operation. Maria Gunther, now 79, one of Dr Leube's patients, is enthusiastic about the effects. A few years ago, under normal anaesthesia, she had an operation for a complex ankle fracture. More recently she had an abdominal hysterectomy with acupuncture administered by Dr Leube.

'There was no comparison,' she says. 'After the ankle operation, I felt dreadful for days, whereas after the hysterectomy I was fine, and was up almost immediately.' Of course, other factors may have been involved, but anecdotal evidence accumulates, and many patients request Dr Leube's services at other hospitals.

Some surgeons are doubtful because they do not understand the technique, or are not keen on the idea of patients being half-awake during operations.

Dr Leube normally gives patients a choice: total or partial anaesthesia. Either way, they feel no pain. Mrs Gunther was apparently just able to talk during her operation, but does not remember it.

Statistically it is impossible to prove a higher safety record from a sample of 6,000 patients, in view of widely varying ages and conditions. In Britain, the Confidential Enquiry into Perioperative Deaths (Cepod), published by the Nuffield Provincial Hospitals Trust in 1991, reported on half a million operations. It found that anaesthesia was implicated in 410 deaths and responsible for three.

Dr Leube claims she has had no deaths attributable to anaesthesia, although this comparison is statistically meaningless - as British doctors are quick to point out.

ESA has few disadvantages. The main one is that preparation of the patient can take longer. Half an hour before surgery, Dr Leube attaches electrodes to the patient's ear to stimulate the production of endorphins. Then she re-attaches them after the operation and leaves them on for about 24 hours to reduce post-operative pain. But the surgeon's schedule is not affected, and time is saved for the other staff thanks to the much shorter recovery time.

The main reason for the sparse use of ESA is that it has not penetrated normal medical training, so anyone who wants to learn it has to make a special effort, requiring time and money. Dr Leube says that if ESA were included in the conventional training of anaesthetists, it would require about an extra six months, because a thorough knowledge of acupuncture is necessary.

There is also too little research because drug companies have no interest in spending money on a method that halves the use of their products.

Dr C D Broedersdorff, of Hilden in the Rhineland, disagrees with Dr Leube about the time needed for training; he says it is not necessary to be a trained acupuncturist. His technique, on which he has written a research paper, involves putting two needles into each ear with only reasonable accuracy. Any anaesthetist can quickly learn this, he says.

Dr Broedersdorff, who has used his method in nearly 4,000 operations, says he has had no cardiac arrests or fatalities. He points out that ESA slightly raises the patient's blood pressure, whereas most anaesthetics lower it, so the patient's system remains more active with ESA. If the patient has high blood pressure, corrective measures can be taken.

He starts the operation by giving the patient a light sleeping drug and relaxant, then mostly uses only laughing gas during the operation. His patients wake up the moment the current is switched off. Therafter they need only about one-third of the usual quantity of painkillers - even though, unlike Dr Leube, he does not use post-operative ESA.

The techniques used in Germany have been much simplified since the early days when practitioners stuck masses of needles into points relating to the area of surgery. Now, it seems, one or two needles in or near each ear is all that is required.

Dr Leube studied acupuncture for about three years as a sideline after leaving her job as a senior university doctor to care for her father. She learnt a lot from a Chinese neurologist from Canton, who was working in Germany at the time.

She still uses acupuncture extensively for pain management on about 2,000 of the 3,000 sufferers from joint problems who attend the Waldfriede hospital each year.

British anaesthetists, sceptical after earlier investigations into Chinese techniques, know little about German advances in ESA, but they do not reject it out of hand. Dr Edmond Charlton, former secretary of the British Association of Anaesthetists, says acupuncture has a well-established place in pain management, but its role in anaesthesia has yet to be established.

'If these reports from Germany are correct, they should be studied most carefully, as the apparent improvement would be welcome. Naturally, all anaesthetists are concerned first and foremost with the safety of the patient.' He was anxious, however, to dismiss any statistical comparisons based on the Cepod report.

Dr Jacqueline Filshie is a consultant anaesthetist at the Royal Marsden Hospital, which specialises in cancer. She is also secretary of the British Medical Acupuncture Society, and uses acupuncture extensively for pain management - but remains sceptical about its practical value in anaesthesia.

'We should study the techniques in a series of well-constructed, randomised, placebo-controlled trials to establish their efficacy. If we find that post-operative recovery is improved by simple and safe use of acupuncture, we may consider more widespread use of it in the perioperative period.'

Are British doctors using academic rigour as an excuse for conservatism? It is obviously difficult to set up totally conclusive tests, but there is nothing to stop British anaesthetists from spending a few days' observation in Germany. And, unlike new drugs, ESA can be tested without risk, because if it does not seem to be working the anaesthetist need only step up the dose of drugs.

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