Comments on “Acupuncture and Moxibustion in the Treatment of Gynecological Perioperative Anxiety: A Systematic Review and Meta-Analysis” [Letter]

Dear editor

We have read with great interest the article titled “Acupuncture and Moxibustion in the Treatment of Gynecological Perioperative Anxiety: A Systematic Review and Meta-Analysis” published in the Journal of Pain Research.¹ This meta-analysis included 20 randomized controlled trials (RCTs) involving a total of 3254 patients. The authors concluded that acupuncture and moxibustion therapy can alleviate anxiety during the perioperative period of gynecological surgery. We greatly appreciate the significant contribution of this study. However, several aspects warrant further discussion.

Firstly, the study conducted a subgroup analysis based on the type of acupuncture, type of surgery, and interventions in the control groups. The authors proposed that these factors could be potential sources of heterogeneity. However, the subgroup analysis revealed that heterogeneity remained substantial within each subgroup, with only a few subgroups achieving controlled heterogeneity, while some subgroups included only a single study. Furthermore, the authors did not conduct a meta-regression analysis to further investigate whether the type of acupuncture, type of surgery, and control group interventions contributed to the observed heterogeneity. Therefore, we suspect that these three factors may not represent the true sources of heterogeneity. The sources of heterogeneity in this study remain unclear. To address the high heterogeneity observed, other potential factors that may influence heterogeneity should also be considered. For example, we propose stratifying patients based on their history of previous surgeries and the reasons for those surgeries, such as pregnancy, gynecological tumors, or ovarian cysts, to explore the effectiveness of acupuncture in alleviating perioperative anxiety across different patient populations.

Secondly, regarding publication bias, the funnel plot indicated that most studies fell outside the 95% confidence interval, raising concerns about the reliability of the findings. Additionally, the included RCTs span a long timeframe, during which advancements in surgical techniques and clinical practices may have introduced biases that could affect the robustness of the results.

Thirdly, during the literature search and study selection phase, 33 studies were excluded after a full-text review. Given the considerable number of excluded studies, we recommend providing a list of these references in the supplementary materials to enhance the transparency and rigor of the systematic review.

Finally, transcutaneous acupoint electrical stimulation (TEAS) is a non-invasive acupuncture technique that has demonstrated effectiveness in alleviating perioperative anxiety.² We suggest that future studies incorporate research on TEAS to comprehensively evaluate the effects of acupuncture interventions on perioperative anxiety in gynecological surgeries.

In conclusion, Wang et al’s research represents a significant advancement in the application of acupuncture and moxibustion for managing perioperative anxiety in gynecological surgery. Our comments are intended to further refine and strengthen this excellent study. We look forward to more research exploring this important area.