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Correspondence |
Rome, Italy
To the Editor:
Stress-induced changes in postoperative organ function may be implicated in the development of perioperative complications. Modulation of stress response to surgery might favourably influence postoperative morbidity.
We compared the perisurgical stress response using total iv anesthesia (TIVA) or sevoflurane anesthesia in patients undergoing laparoscopic surgery for benign ovarian cysts.1–3 This model allowed us to investigate the effect of anesthesia without interference from factors known to affect hormonal response (extensive tissue trauma, high blood loss, high level of postoperative pain).
After obtaining approval by the local Ethic Committee and written patient consent, 20 patients underwent laparoscopic surgery using TIVA (group A = 10) or sevoflurane anesthesia (B = 10).
Randomization was performed using a computer-generated random allocation. Both groups were similar with respect to age, weight, operation time and ASA physical status I. All patients were operated by the same surgeon using a standard technique.4 Surgery started between 8:30 and 9 a.m. after pre-medication with oral diazepam 0.2 mL·kg–1.
In group A, a remifentanil infusion of 1 µg·kg–1·min–1 was administered for one minute then decreased to 0.5 µg·kg–1·min–1. Anesthesia was induced with propofol 1.5 mg·kg–1 followed by an infusion of 150 µg·kg–1·min–1until laparoscopy. Propofol was then reduced to 100 µg·kg–1·min–1and stopped with skin closure. Remifentanil was reduced to 0.3 to 0.25 µg·kg–1·min–1 after pneumoperitoneum and stopped when surgeons removed the surgical instrumentation.
Patients in group B received fentanyl 3 µg·kg–1 and thiopental 5 mg·kg–1. After loss of consciousness, patients in both groups received vecuronium 0.1 mg·kg–1 and the trachea was intubated. Sevoflurane was administered at end-tidal concentrations of 1.8 to 2%. Sevoflurane was discontinued with the end of skin closure. Ketorolac 30 mg was administered for postoperative analgesia in both groups.
Venous samples were collected at 8:00; 30 min after the beginning of surgery; after extubation and two and four hours after the end of surgery (time 0, 1, 2, 3, 4).
Concentrations of norepinephrine, epinephrine ACTH, cortisol, and GH were measured. Differences were analyzed by one way ANOVA and unpaired Student’s t test.
Norepinephrine (time 1–3), epinephrine, ACTH and cortisol (time 1–2–3), and GH levels (time 1–2–3–4) were higher in group B (Figure
). Inhibition of the ACTH-cortisol response and of catecholamine release in group A was most likely due to remifentanil but propofol could have partially contributed via the GABA receptor.5
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References
1 Marana R, Margutti F, Catalano GF, Marana E. Stress responses to endoscopic surgery. Curr Opin Obstet Gynecol 2000; 12: 303–7.[Medline]
2 Muzii L, Marana R, Marana E, et al. Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy. J Am Assoc Gynecol Laparosc 1996; 3: 229–34.[Medline]
3 Marana E, Scambia G, Maussier ML, et al. Neuroendocrine stress response in patients undergoing benign ovarian cyst surgery by laparoscopy, minilaparotomy, and laparotomy. J Am Assoc Gynecol Laparosc 2003; 10: 109–15.
4 Marana R, Caruana P, Muzii L, Catalano GF, Mancuso S. Operative laparoscopy for ovarian cysts. Excision vs. aspiration. J Reprod Med 1996; 41: 435–8.[Medline]
5 Chrousos GP. The hypotalamic-pituitary-adrenal axis and immune-mediated inflammation. N Engl J Med 1995; 18: 1350–63.
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