The Somatic Connection  |   July 2013
Visceral Manipulation Is Shown to Reduce Postoperative Ileus in an Animal Model
Author Affiliations
  • Hollis H. King, DO, PhD
    University of Wisconsin School of Medicine and Public Health, Madison
Article Information
The Somatic Connection   |   July 2013
Visceral Manipulation Is Shown to Reduce Postoperative Ileus in an Animal Model
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 575-577. doi:
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 575-577. doi:
Chapelle SL, Bove GM. Visceral massage reduces postoperative ileus in a rat model. J Bodyw Mov Ther. 2013;17(1):83-88.  
The development of postoperative ileus after abdominal surgery often extends patient hospitalization and results in increased hospitalization costs. In the tradition of osteopathic research using animal models that showed that the lymphatic pump technique increases both lymphatic flow1 and immune system function,2 researchers Chapelle and Bove investigated whether visceral manipulation could reduce postoperative ileus in Long-Evans rats. To identify potential associations with visceral manipulation, the authors also sought to assess intraperitoneal inflammation, which is considered to prolong postoperative ileus.3-6 
In this tightly designed study, 40 adult, female Long-Evans rats weighing 225 g each were randomly assigned to 1 of 4 experimental groups in a 2 × 2 factorial design. The 4 groups were surgery and treatment (ST), surgery and no treatment (SNT), no surgery and treatment (NST), and no surgery and no treatment (NSNT). 
Before undergoing operations, the 20 rats assigned to the ST and SNT groups were appropriately anesthetized with isoflurane in pure oxygen and underwent sterile procedures for preoperative preparation. Each operation began with a midline incision. The small intestine was carefully “exteriorized,” and its entire length was gently rolled between gloved thumb and forefingers in a process taking 5 minutes. Saline-soaked gauze was then draped over the small intestine, where it was left in place for 10 minutes. After this time, the small intestine was returned to the abdominal cavity and the incision closed. The start of the experiment was defined as the moment when the rats received a subcutaneous injection of morphine sulphate, 0.3 mg/kg of body weight. (Rats that did not undergo surgical procedures also received morphine injections, to control for the effects of morphine.) The rats were then wrapped in a soft pad for the recovery period. All rats were housed in separate enclosures, to facilitate the counting of fecal pellets and to provide the animals with easy access to food and water. The end of the experiment was defined as the point in time 24 hours after administration of the morphine injection. 
A massage therapist (S.L.C.) whose practice has emphasized postoperative care provided manual therapy to the ST and NST groups, thereby ensuring that therapy was standardized. Visceral manipulation involved 1 minute of gentle mobilization. For the first 15 seconds, a side-to-side motion was applied with the thumb and index fingers placed lateral to the descending and ascending colon, respectively. For the next 45 seconds, the index finger was moved in small, clockwise circular motions over the ascending, transverse, and descending colon, starting from the lower right quadrant of the abdomen and moving to the lower left quadrant. The first 4 therapy sessions were applied every 15 minutes for the first hour, and the next 4 sessions were administered every 30 minutes over the next 2 hours. Four additional therapy sessions were given every 2 hours until 12 hours after the operation. To control for possible nonspecific effects of visceral manipulation, the rats in the SNT and NSNT groups were picked up and handled for approximately 1 minute, according to the same schedule used for the ST and NST rats. 
It is with some envy and appreciation that I report these researchers' application of their manual therapy protocol to a rat population. Chapelle and Bove reported that the Long-Evans rats did not bite and that they did not require anesthetization for visceral manipulation. From my experience working with Lisa M. Hodge, PhD, as she strives to develop a manual therapy protocol in her studies of rats,7 I can report that the Sprague Dawley rats used by Dr Hodge did indeed bite and that they also required anesthesia before they received manual therapy. 
Primary outcome measures included the time to production of the first fecal pellet, the number of fecal pellets counted at 6, 12, and 24 hours, gastrointestinal transit duration, total protein concentration in the intraperitoneal fluid, and intraperitoneal inflammatory cell counts. After the fecal pellet count was completed at 24 hours, the rats received gavage of approximately 1 mL of a slurry of 10% charcoal and 1% arabic acid in water. The rats were then humanely killed 30 minutes later. The length of the small intestine from the pylorus to the ileocecal valve was removed, stretched, and measured using a tape measure. The distance that the slurry had traveled from the pylorus was measured to determine gastrointestinal transit over 30 minutes, which was expressed as a percentage of the total length of the small intestine. Lavage fluid was collected and used to determine inflammatory cell (leukocyte) counts. 
All the rats that underwent surgical procedures had statistically significant reductions in both gastrointestinal transit time (P<.001) and fecal pellet count (P<.05), thereby supporting the contention of the authors that surgical procedures produce ileus. A statistically significant reduction in time to first fecal pellet discharge was noted in the ST group compared with the SNT group (P<.01), and although not statistically significant at 12 hours after the surgical procedures, by 24 hours the total fecal pellet count for rats in the ST group was statistically significantly greater than that in the SNT group (P<.005). The authors concluded that visceral manipulation substantially increased gastrointestinal function and reduced postoperative ileus in the rat population studied. 
The authors also believed that ileus was due to inflammation and that visceral manipulation could reduce ileus by suppressing inflammation. To support this belief, they cited data indicating that rats in the ST group had statistically significantly fewer intraperitoneal cells than rats in the SNT group (P<.05). 
Overall, the findings of Chapelle and Bove regarding the nature of postoperative ileus in the animal model studied are worthy of consideration and extrapolation to future research on postoperative ileus in humans. For now, the relatively well-accepted notion that osteopathic manipulative treatment reduces postoperative ileus has received some additional support from this study. Although I taught the application of osteopathic manipulative treatment for postoperative ileus when I was on the faculties of the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth and the A.T. Still University-School of Osteopathic Medicine Arizona (Mesa), I will do so with greater confidence in the future, given the results of this study. 
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