Gut-liver axis management and its surgical application: A perspective from “liver governing free flow”

Abstract

On the basis of the traditional Chinese medicine (TCM) theory of “liver governing free flow” and modern gut-liver axis (GLA) research, this study systematically explores integrative strategies for preventing and treating digestive system diseases. It summarizes the regulatory approaches under this theoretical framework, discussing the mechanisms and applications of common Chinese herbs, acupuncture, acupressure, and dietary interventions targeting GLA. The roles of intestinal microbiota, probiotics, and prebiotics are examined from a modern medical perspective, alongside relevant pharmacological agents. Innovatively, a digestive surgery perspective is incorporated, addressing perioperative intestinal function maintenance, postoperative liver recovery, and the potential influence of GLA theory on surgical strategies. Finally, the complementarity between TCM and modern medicine in GLA modulation is analyzed, and future research directions are proposed.

Key Words: Liver main detoxification; Intestinal-liver axis; Digestive diseases; Integration of Chinese and western medicine; Traditional Chinese medicine; Digestive surgery

Core Tip: This article innovatively integrates the traditional Chinese medicine theory of “liver governing free flow” with the modern medical concept of the gut-liver axis, extending its application to perioperative management in digestive surgery. By reviewing intervention strategies such as herbal medicine, acupuncture, and dietary therapy, it explores their potential mechanisms in regulating intestinal microecology, improving barrier function, and influencing hepatic metabolism. This provides a new theoretical perspective and practical pathway for the integrated prevention and treatment of digestive system diseases through the combination of traditional Chinese and western medicine.

INTRODUCTION

With the progress of modern life sciences, the study of the gut-liver axis (GLA) has gradually been emphasized by scientists in recent years. GLA refers to the close connection that exists between the intestine and the liver, and the two interact and regulate each other through various pathways such as bile acids and portal blood flow[1,2]. Modern medical research has found that changes in the intestinal microbiota can affect the function of the liver through GLA, which, in turn, is involved in the development of various digestive diseases such as non-alcoholic fatty liver disease (NAFLD) and cirrhosis[3,4].

Meanwhile, the traditional Chinese medicine (TCM) theory of “liver governing unblocking and dispersing” offers a unique theoretical perspective for understanding gut-liver interactions. According to TCM theory, “liver governing unblocking and dispersing” is one of the liver’s core functions, referring to its role in dredging, regulating, and dispersing, which enables it to regulate the movement of qi, blood, and body fluids[5,6]. This function shows significant convergence with the liver’s roles in metabolism, detoxification, and immune regulation in modern medicine. During the processes of digestion, absorption, and excretion of metabolic waste, the liver works synergistically with the spleen, stomach, and other organs to collectively maintain the homeostatic balance of the digestive system.

A growing body of evidence from contemporary research supports the connection between TCM theory and GLA. Sun et al[7] found that a herbal combination significantly modulated the intestinal flora of patients with NAFLD and reduced hepatic inflammation and fibrosis through GLA. Maslennikov et al’s significantly reduced portal hypertension and improved the prognosis of patients with cirrhosis by adjusting the intestinal microbial balance[8]. The present paper aims to systematically investigate the regulatory strategies for GLA under the guidance of the TCM theory of “liver governing unblocking and dispersing” to provide new perspectives for the prevention and treatment of digestive system diseases.

THEORETICAL BASIS AND MODERN INTERPRETATION OF “LIVER GOVERNING FREE FLOW” IN TCM AND ITS DIALOGUE WITH GLA THEORY

Connotation and origins of “liver governing free flow” theory

The theory that “the liver is the main regulator of qi” is an important Chinese medicine theory, which involves the function of the liver in regulating qi, emotions, and blood circulation. The historical origin of this theory can be traced back to the ancient Chinese medical classic “Yellow Emperor’s Classic of Internal Medicine”, in which the liver’s function of draining qi was first proposed, emphasizing the liver’s important role in the regulation of qi and blood in the human body[9]. Through continuous development and refinement by physicians across generations, the theory of “the liver serving as the master of regulation” has evolved into a systematic theoretical framework. Its connotation extends far beyond the anatomical function of a single organ. It conceptualizes the liver as a physiological-psychological synergistic system centered on the function of “free flow”. This system encompasses multiple dimensions, including emotion regulation, energy distribution, assistance in digestion (aiding spleen and stomach transformation), and blood storage and regulation[10-13].

Interpretation and mapping from the perspective of modern medicine

With the advancement of modern science, interpreting the physiological essence of “liver governing free flow” from the holistic regulatory perspectives of neural, endocrine, and immune networks has become a significant pathway in integrative medicine research. Studies suggest that this function may be associated with the regulation of the digestive system by the autonomic nervous system, brain-gut axis interactions, and the integrative actions of the neuro-endocrine-immune network[14,15] (Figure 1). For instance, the state of liver qi stagnation (impaired free flow function) is often accompanied with autonomic nervous dysfunction, abnormal intestinal motility, and immune-inflammatory responses. This exhibits a certain degree of phenotypic overlap with the GLA dysregulation observed in modern research, such as intestinal microbiota imbalance, impaired barrier function, and liver inflammation[16,17] (Figure 2). This overlap provides an entry point for dialogue between the two theoretical systems at the level of clinical effects, suggesting that regulating the “free flow” function may indirectly improve GLA imbalance and vice versa.

Figure 1  Schematic diagram of the relationship between qi, blood and fluids.

Figure 2  The liver is the main regulator of drainage and qi regulation.

Dialogue between theoretical systems: Complementarity and incommensurability

The concepts of the “liver” and “free flow” in TCM and the “liver organ” and “GLA” pathway in modern medicine belong to distinctly different theoretical paradigms, exhibiting fundamental incommensurability. In terms of theoretical foundations, the “liver governing free flow” is rooted in the holistic view and symbolic thinking of TCM. Its “liver” is a functional complex, and “free flow” is a generalized description of a series of interrelated physiological and psychological states. It emphasizes holistic dynamic balance rather than singular anatomical localization or linear causality. In terms of research paradigms, the modern medical “GLA” is built upon the empirical sciences of anatomy, molecular biology, and microbiology. It is a concept of a physical and biochemical pathway constructed on the basis of tangible structures (intestines, liver, portal vein, bile acids, microbes, and signaling molecules) and specific mechanisms (e.g., LPS-TLR4 pathway and bile acid-FXR axis). Therefore, drawing simple, direct equivalences or mechanistic analogies between the two (e.g., equating “regulating qi dynamics” with “modulating the autonomic nervous system) is not rigorous, and it can easily lead to conceptual confusion. However, this does not preclude them from demonstrating complementarity in practice. TCM theory, with its holistic view and treatment based on syndrome differentiation, provides a unique theoretical framework and methodological inspiration for understanding the complex clinical manifestations of GLA diseases (e.g., emotion-digestion symptom comorbidity) and developing individualized, multitargeted regulatory strategies (e.g., herbal formulations and acupuncture). It focuses on adjusting the overall “state”. Modern medicine, with its precise mechanistic research and targeted interventions (e.g., specific probiotics and pharmaceuticals), provides scientific and technological pathways for verifying and elucidating the efficacy of TCM formulas and exploring biomarkers. It focuses on identifying specific “targets”. This study is precisely based on such “complementarity” rather than “equivalence”. It explores how strategies such as herbal medicine, acupuncture, and dietary therapy, guided by the holistic theoretical framework of “liver governing free flow”, can indirectly influence and regulate specific aspects of the modern medical-defined “GLA” (e.g., microbiota, barrier function and inflammatory signaling) through the synergistic effects of multiple components, pathways, and targets. This approach aims to provide a more integrated perspective for the prevention and treatment of digestive system diseases.

STRATEGIES AND MECHANISMS OF REGULATING GLA WITH TCM

Herbal regulation strategies

Under the guidance of the theory of “the liver is the main regulator of excretion”, the strategy of regulating the intestinal-hepatic axis by TCM has become an important field of modern medical research. Several commonly used Chinese medicines have shown remarkable effects in regulating GLA, especially in the prevention and treatment of digestive diseases (Table 1).

Table 1 Commonly used Chinese medicines and their main effects and clinical applications.

Name of Chinese medicine	Main effects	Regulatory mechanism	Clinical application
Chenopodium album	Clearing heat, inducing diuresis and relieving yellow fever	Regulation of intestinal flora, improvement of intestinal barrier function, inhibition of hepatocyte apoptosis and inflammatory response	Treatment of fatty liver, liver fibrosis, etc.
Salvia miltiorrhiza	Promoting blood circulation and removing blood stasis, clearing the mind and removing vexation	Improve intestinal microcirculation, reduce intestinal inflammation, inhibit liver fibrosis	Chronic hepatitis, cirrhosis
Atractylodes macrocephala	Strengthening the spleen, promoting vital energy, drying dampness and inducing diuresis	Regulates intestinal flora, enhances intestinal barrier function, reduces intestinal permeability	Chronic gastritis, indigestion
Milk vetch root	Qi tonic, immune booster, anti-inflammatory and antioxidant	Regulating the balance of intestinal flora, enhancing intestinal immune function, increasing IgA secretion	Hepatitis, cirrhosis and its complications

Artemisia capillaris is a commonly used TCM for the treatment of liver and gallbladder diseases, with the effects of clearing heat. removing dampness, and relieving yellowness. Modern pharmacological studies indicate that its hepatoprotective effect is closely related to the targeted regulation of GLA. Research has found that the extract of A. capillaris can specifically increase the abundance of beneficial bacteria in the intestines, such as Lactobacillus and Bifidobacterium, while inhibiting the growth of conditional pathogens like Enterobacteriaceae, thereby optimizing the microbiota structure[18]. This modulation of the microbiota enhances the expression levels of intestinal epithelial tight junction proteins (e.g., occludin and ZO-1), improves intestinal barrier function, and reduces endotoxin (LPS) translocation[19]. The decrease in LPS entering the portal vein subsequently reduces the activation of the TLR4/NF-κB pathway in hepatic Kupffer cells, ultimately alleviating liver inflammation[20,21]. This process reflects the TCM principle of “clearing heat and draining dampness” to “promote the free flow” of liver-gallbladder constrained heat, thereby reducing the liver’s burden at the intestinal source.

Salvia miltiorrhiza (S. miltiorrhiza) regulates the intestinal-liver axis mainly by activating blood circulation and removing blood stasis, clearing the heart and removing vexation. Studies have shown that the modern interpretation of its efficacy in “promoting blood circulation and removing blood stasis” at the level of GLA involves multitargeted improvement of the intestinal microenvironment. First, active components of S. miltiorrhiza (such as tanshinone IIA and salvianolic acid B) can improve intestinal microvascular endothelial function, promote local blood perfusion, and alleviate intestinal mucosal ischemia and hypoxia, in alignment with the concept of “activating blood” to improve microcirculation[22-24]. Second, S. miltiorrhiza and its components can modulate the metabolic profile of the gut microbiota, such as by increasing short-chain fatty acid (SCFA) production. SCFAs not only provide energy for the intestinal epithelium and strengthen the barrier but also enter the liver via the portal vein, activating the hepatic AMPK signaling pathway and inhibiting hepatic lipid synthesis and fibrosis progression[25]. Additionally, by reducing intestinal inflammation through its anti-inflammatory and antioxidant effects, S. miltiorrhiza indirectly protects the liver, thereby achieving the “dredging the meridians” function to restore the normal flow of qi, blood, and body fluids between the intestine and liver, in alignment with the concept of “free flow”.

Atractylodes macrocephala (A. macrocephala) and Astragalus membranaceus are known for invigorating the spleen, drying dampness and inducing diuresis, and tonifying qi and enhancing immunity, respectively. From the perspective of GLA, their spleen-invigorating effect is partially reflected in regulating gut microbiota homeostasis and strengthening the physical barrier. Studies have found that polysaccharides from A. macrocephala can promote the proliferation of beneficial gut bacteria, such as Bifidobacterium and Akkermansia, which help maintain an acidic intestinal environment and produce beneficial metabolites[26]. Simultaneously, A. macrocephala can upregulate the expression of the intestinal tight junction protein claudin-1, reduce intestinal permeability, and mechanically decrease the entry of gut-derived toxins into the liver. A. membranaceus has the effects of tonifying qi and enhancing immunity. Modern research revealed that its “strengthening healthy qi” effect is closely related to its regulation of GLA immunity. Components such as astragaloside can selectively modulate the gut microbiota, enhance intestinal immune function, and promote immunoglobulin A secretion, thereby alleviating liver injury caused by gut-derived endotoxins[27]. This mechanism offers a modern scientific explanation for the TCM theory of “reinforcing healthy qi and eliminating pathogens.” In clinical practice, A. macrocephala is commonly used in the treatment of chronic gastritis and dyspepsia, and Astragalus is widely used in the treatment of hepatitis, cirrhosis, and its complications; both have achieved favorable efficacy[28].

Regulation strategies in Chinese medicine

Under the guidance of the theory of “the liver is the main regulator”, the application of acupuncture, Tui Na, and other Chinese medicine techniques in regulating the intestinal-liver axis has been widely noticed and studied. These traditional therapies have shown good clinical effects and scientific basis by regulating meridian qi and blood, dredging liver and gallbladder meridians, and improving the function of the digestive system (Table 2).

Table 2 Application of Chinese medicine techniques in regulating the gut-liver axis.

Chinese medicine technology	Main effects	Regulatory mechanism	Clinical application
Give or have acupuncture and moxibustion	Regulates meridians, qi and blood, promotes liver function recovery	Stimulates specific acupoints, improves intestinal motility, regulates autonomic nervous system	Chronic liver disease, intestinal inflammation
Tui Na (form of Chinese manual therapy)	Improvement of intestinal function and enhancement of intestinal barrier function	Manual stimulation, improvement of intestinal microcirculation, reduction of inflammatory response	Functional gastrointestinal disorders, constipation, irritable bowel syndrome

Acupuncture, as an important part of TCM, regulates meridians and qi and blood through the stimulation of specific acupoints, thus achieving the purpose of treating diseases. Studies have shown that acupuncture can effectively regulate intestinal peristalsis and improve the intestinal microecological environment, which, in turn, regulates the function of the intestinal-liver axis by stimulating Zusanli, Taichong, and other acupoints[29]. Especially in patients with chronic liver disease, acupuncture promotes the recovery of liver function and reduces the burden on the liver by dredging the liver and gallbladder meridians. Research have shown that acupuncture and moxibustion can regulate the secretion of brain gut peptide and affect the inflammatory reaction of liver through vagus nerve[30,31]. In addition, acupuncture can indirectly protect the liver by regulating the autonomic nervous system, relieving intestinal inflammation and promoting the recovery of intestinal barrier function.

As one of the external treatments in Chinese medicine, Tui Na stimulates the skin, muscles, and meridians through manipulation to regulate the operation of qi and blood in the human body. Studies have shown that Tui Na can effectively improve intestinal function, regulate intestinal flora, and enhance intestinal barrier function, thus reducing the burden on the liver. Tui Na therapy can protect liver health by improving intestinal microcirculation, reducing inflammatory reactions and promoting the discharge of toxins in the intestinal tract. In clinical application, Tui Na is commonly used in the treatment of functional gastrointestinal diseases, constipation, and irritable bowel syndrome (IBS), and it has shown good efficacy.

Dietary and microbiota regulation strategies

The TCM concept of “medicinal and edible homology” integrates with modern nutrition and microecology, forming a unique dietary regulation strategy. This approach adheres to the principle of “harmonizing the five flavors”, which emphasizes the correspondence between food properties and organ functions. Increasing dietary fiber intake promotes intestinal motility, an effect that converges with the TCM theory of “unblocking the fu-organs and dispelling turbidity”. Adequate consumption of high-quality protein supports liver repair, aligning with the principle of “reinforcing the healthy qi and consolidating the root”. Supplementing with probiotics and prebiotics regulates the balance of intestinal flora, embodying the preventive philosophy that “when healthy qi resides internally, pathogenic factors cannot interfere”[32,33].

Modern research has shown that the gut microbiota plays a key role in GLA, and changes in its composition and function have a profound effect on the health of the liver and the overall digestive system. Through metabolic activities, the gut microbiota generates various metabolites, such as SCFAs, vitamins, and amino acids, which are directly involved in the host’s immune regulation, nutrient absorption, and metabolic homeostasis. Meanwhile, the integrity of the gut barrier function depends on a healthy microbiota to prevent cross-barrier transfer of harmful substances and pathogenic bacteria.

In recent years, research on probiotics and prebiotics in regulating the intestinal microbiota has achieved remarkable progress[34-36]. Probiotics such as Bifidobacterium bifidum and Lactobacillus lactis have been widely studied, showing remarkable effects in improving the balance of intestinal flora, enhancing the intestinal barrier function, and regulating immune responses. Prebiotics such as oligofructose and inulin improve the intestinal environment by selectively promoting the growth of beneficial bacteria, thereby enhancing overall health. For example, studies have shown that long-term intake of prebiotics can significantly reduce the incidence of NAFLD, and prebiotic supplementation can help to improve the gut health of patients with metabolic syndrome.

Drug treatment strategies

In terms of medication for the regulation of GLA, modern medicine has developed various drugs that play an important role in the regulation of the intestinal microbiota, the protection of the liver, and the prevention and treatment of digestive system diseases. Several commonly used drugs and their applications in regulating GLA are introduced below, and their effects are discussed in conjunction with clinical studies. Table 3 shows the commonly used drugs and their applications.

Table 3 Commonly used drugs and their applications.

Name of drug	Primary role	Machine	Clinical application	Study
Rifaximin	Regulates intestinal flora and reduces endotoxins	Inhibits the growth of harmful bacteria	Irritable bowel syndrome, hepatic encephalopathy	Improved cognitive function and reduced relapse rates
Ursodeoxycholic acid	Protects liver cells and improves bile flow	Reduces bile acid toxicity	Primary biliary cirrhosis	Slowing disease progression and improving survival
Probiotic preparation	Regulates the balance of intestinal flora and protects the liver	Increases beneficial bacteria and reduces inflammatory response	Non-alcoholic fatty liver disease, cirrhosis	Improve liver function and reduce fat content

Rifaximin is a broad-spectrum antibiotic used primarily in the treatment of IBS and hepatic encephalopathy (HE). Its mechanism of action is to reduce the burden on the liver by regulating the intestinal flora and reducing the production and absorption of intestinal endotoxins. Clinical studies have shown that rifaximin treatment significantly improves cognitive function and reduces disease recurrence in patients with HE[37].

Ursodeoxycholic acid (UDCA) is a bile acid agent widely used in the treatment of primary biliary cirrhosis (PBC) and cholestatic liver disease. Its main mechanisms of action include protecting hepatocytes, reducing bile acid toxicity, and improving bile flow. Clinical trials have shown that UDCA can significantly delay the progression of PBC and improve patient survival.

Probiotic preparations such as B. bifidum and L. lactis are used to regulate the balance of intestinal flora and prevent and treat liver diseases such as NAFLD and cirrhosis. Studies have shown that long-term use of probiotics can protect liver health by improving intestinal barrier function and reducing inflammatory responses.

INTEGRATION OF MODERN MEDICAL UNDERSTANDING OF GLA WITH TCM

Concept and physiological basis of GLA

GLA is an important concept that has attracted much attention in recent years in the study of the digestive system, emphasizing the complex and close physiological connection between the gut and the liver. GLA encompasses not only the direct interactions between the gut and the liver but also their key roles in maintaining systemic metabolic homeostasis and immune homeostasis[38].

As an important concept in modern medical research, GLA reveals the complex interrelationship between the gut and the liver and their critical role in maintaining human health. GLA not only reflects the anatomical and physiological connections between the two but also demonstrates their close synergy in metabolism, immunity, and signaling[39]. An in-depth understanding of the concept of GLA and its physiological basis is important for exploring the etiology of digestive diseases and their prevention and treatment strategies. The intestine-liver axis realizes the direct anatomical connection between the intestine and the liver through the portal vein system (Figure 3). Nutrients, microbial metabolites, and various bioactive molecules absorbed from the intestines enter the liver through the portal venous system, where the liver performs preliminary screening, metabolism, and detoxification of these substances, and then releases the processed substances into the systemic circulatory system. The portal venous system serves as the core channel of the intestinal–hepatic axis, enabling the intestinal contents to directly influence the physiological function of the liver, thereby maintaining the balance and stability of metabolism in the body[40].

Figure 3 Communication between the intestinal-hepatic axis. VLDL: Very low-density lipoprotein.

GLA plays an important role in the immune system. The gut, as the largest immune organ, and its microbiota regulate local and systemic immune responses through interactions with the host immune system. Immune cells, such as Kupffer cells in the liver, protect the body from pathogens by capturing and processing antigens and microbial products entering from the gut and preventing them from entering the systemic circulation[41]. In addition, the liver is involved in the acute phase response, responding to inflammation and infection by synthesizing acute phase proteins. GLA plays a crucial role in metabolic regulation. The intestinal microbiota produces SCFAs through fermentation of undigested carbohydrates, and these metabolites enter the liver through the portal vein, directly affecting the metabolic functions of the liver. SCFAs not only regulate lipid and glucose metabolism in the liver but also influence systemic energy homeostasis through signaling pathways[42]. They affect systemic energy balance through signaling pathways. The liver regulates the composition and function of the intestinal microbiota through the secretion of bile acids, forming a bidirectional feedback regulatory system, thus maintaining metabolic homeostasis.

In pathological states, dysregulation of GLA is closely associated with various digestive disorders. Disruption of intestinal barrier function and imbalance of the intestinal microbiota can lead to the entry of bacteria and toxins into the liver via the portal vein, triggering hepatic inflammation and injury such as NAFLD and cirrhosis. In turn, liver dysfunction can lead to intestinal disorders, such as inflammatory bowel disease, by altering bile acid metabolism and the intestinal immune environment[43]. Therefore, GLA is important in the maintenance of digestive health and disease prevention.

Pathologic mechanisms of GLA in various digestive disorders

The pathomechanism of the intestinal–hepatic axis in various digestive diseases is of great research value. By understanding the specific mechanism of action of the intestinal-hepatic axis in these diseases, new ideas and methods can be provided for clinical treatment. Table 3 shows the pathologic mechanisms of the enterohepatic axis in various digestive diseases. Cirrhosis is the end stage of chronic liver disease, characterized by severe destruction of liver structure and functional failure. The role of GLA in cirrhosis is mainly characterized by impaired intestinal barrier function, dysbiosis of the microbiota, and abnormalities in the hepatic immune response. Patients with cirrhosis are often associated with a weakened intestinal barrier function, resulting in eased entry of intestinal toxins and pathogens into the liver through the portal vein, inducing an inflammatory response in the liver. The progression of cirrhosis leads to portal hypertension, which disrupts the intestinal flora and exacerbates the vicious cycle of liver damage and fibrosis.

Fatty liver, especially NAFLD, is another disease closely related to GLA. The gut microbiota influences lipid metabolism in the liver through SCFAs and other metabolites that regulate fat synthesis and catabolism. When the gut microbiota is dysregulated, disturbances in lipid metabolism lead to the accumulation of fat in hepatocytes and the formation of fatty liver[44]. Further inflammatory responses and oxidative stress promote the development of steatohepatitis, which may eventually progress to liver fibrosis and cirrhosis. In addition, impaired intestinal barrier function makes it easier for endotoxins to enter the liver, exacerbating the inflammatory response and hepatocellular damage.

IBS is a common functional intestinal disorder with a complex etiology that is closely related to GLA interactions. Patients with IBS often exhibit dysregulation of the intestinal microbiota, which leads to a weakened intestinal barrier function and an enhanced intestinal inflammatory response. These changes affect hepatic immune and metabolic functions through the portal system and may lead to mild inflammation and metabolic abnormalities in the liver. Symptoms of IBS may also indirectly affect the balance of the gut–hepatic axis through the regulation of bile acid metabolism in the liver and alterations in intestinal motility. The pathomechanisms of the gut-hepatic axis in inflammatory diseases of the intestine, such as Crohn’s disease and ulcerative colitis, are of interest. These diseases are characterized by chronic inflammation and dysregulated immune responses in the gut.

GLA from the perspective of digestive surgery

In the clinical practice of digestive surgery, the theory of GLA holds significant guiding importance. The management during the perioperative period, the selection of surgical strategies, and postoperative recovery are all closely related to the functional status of the intestines and liver.

Perioperative bowel preparation and liver function protection: Traditional bowel preparation aims to cleanse the intestines to reduce intraoperative contamination but may disrupt the balance of intestinal microbiota and compromise barrier function. In light of the theory of “liver governing free flow”, excessive purgation can deplete qi and yin, impairing the liver’s functions of storing blood and regulating free flow. Modern perspectives suggest optimizing bowel preparation protocols, such as by using gentler agents and considering preoperative prophylactic administration of probiotics or specific Chinese herbal medicines (e.g., formulas containing A. macrocephala and A. membranaceus), to maintain intestinal microecological stability and reduce endotoxin translocation, thereby mitigating the risk of postoperative liver inflammation and dysfunction[45,46]. This is particularly crucial for major surgeries such as hepatectomy and pancreaticoduodenectomy.

Postoperative gastrointestinal function recovery and prevention of liver injury: Gastrointestinal motility disorders (such as postoperative ileus) are common after abdominal surgery, affecting nutrient intake and bile excretion, which may exacerbate the burden on the liver. TCM posits that postoperative disruption of qi dynamics and blood stasis obstructing the collaterals constitute the core pathogenesis. Acupuncture (at points such as Zusanli (ST36) and Neiguan (PC6) and Chinese herbal medicine (such as formulas that unblock the fu organs, regulate qi, and promote blood circulation to remove stasis) have been demonstrated to facilitate the recovery of postoperative gastrointestinal function[47,48]. A modified combination of Chaihu Shugan San (Bupleurum Liver-Soothing Powder) and Liujunzi Tang (Six Gentlemen Decoction) can be selected to enhance clinical guidance, such as in addressing the common syndrome of “liver depression and spleen deficiency” after hepatectomy. A 2025 randomized controlled trial demonstrated that Chaihu Shugan San promotes gastric emptying in patients with functional dyspepsia by modulating bacterial community structure, thereby significantly enhancing gastrointestinal function recovery in patients who have undergone liver surgery[49]. This finding suggests that the therapeutic effects of TCM formulations in regulating GLA can be objectively evaluated through multidimensional indicators such as gastrointestinal motility, liver enzymes, and systemic inflammatory markers.

Implications of GLA theory for specific surgeries: In the surgical management of portal hypertension (such as shunt procedures or devascularization), the surgery directly affects the hemodynamics of the portal venous system, thereby altering the pathways of material exchange within GLA. Understanding the improvement of intestinal congestion, changes in microbiota postoperatively, and their effect on liver regeneration and fibrosis represents a new dimension for evaluating the long-term outcomes of these surgeries[50]. For patients with colorectal cancer liver metastases, treatment strategies must comprehensively address the primary and metastatic lesions. Regulating GLA can serve as an adjunctive strategy. For example, clinical research has explored the combined use of TCM formulations with the effects of “strengthening healthy qi and eliminating pathogens” [such as Jianpi Jiedu Fang (spleen-fortifying and toxin-resolving formula)] and specific probiotics (e.g., Bifidobacterium longum) during surgery and chemotherapy. A 2023 prospective study indicated that this combined approach helps maintain the stability of the patient’s gut microbiota, alleviates chemotherapy-related diarrhea, and may improve liver tolerance to chemotherapeutic agents by reducing abnormal changes in serum LPS and bile acid profiles. The efficacy of this regimen was associated with an increasing trend in the clearance rate of circulating tumor DNA (ctDNA)[51]. This provides preliminary clinical evidence and a potential therapeutic biomarker (e.g., ctDNA) for the integrated use of TCM and Western medicine in modulating GLA to improve the tumor microenvironment and support systemic therapy.

Surgical nutritional support and GLA: Nutritional support is critical for patients undergoing digestive surgery. Enteral nutrition is more effective in maintaining intestinal mucosal barrier integrity and microbiota stability than parenteral nutrition. This aligns with the TCM concept that “the spleen and stomach are the foundation of postnatal life” and supports the balance of GLA. Specific nutrients (such as glutamine and ω-3 fatty acids), along with integrated TCM dietary therapies, exhibit synergistic effects in supporting hepatic anabolism and mitigating oxidative stress[52]. At the implementation level, early enteral nutrition combined with glutamine supplementation has been proven to significantly reduce the incidence of postoperative infectious complications and liver dysfunction for patients undergoing extensive hepatectomy. Concurrently, medicated diets can be applied on the basis of syndrome differentiation. For example, for postoperative patients with qi and blood deficiency, astragalus and angelica soup can be used; for those with damp-turbidity internal obstruction, coix seed and Chinese yam congee may be beneficial. These dietary approaches assist the medicinal effects, targeting the “spleen and stomach” as the acquired foundation to support the functional recovery of GLA.

CONCLUSION

TCM and modern medicine exhibit unique complementarity in strategies for regulating GLA. TCM emphasizes a holistic approach and treatment that is based on syndrome differentiation, employing methods, such as herbal medicine, acupuncture, and massage, to regulate the internal environment and promote the “liver governing free flow” function to maintain intestinal health. By contrast, modern medicine, grounded in microbiology and molecular biology, focuses on targeted regulation of gut microbiota and liver metabolism through pharmaceuticals, probiotics, and other means. The integration of both approaches can provide a comprehensive strategy for preventing and treating digestive system diseases, combining a holistic framework with precise mechanisms.