Laparoscopically assisted vaginal and abdominal hysterectomy: comparison of postoperative pain, fatigue and systemic response. A case-control study. Eur J Anaesthesiol. 2001;18:530-539. [PMID: 11473560 DOI: 10.1097/00003643-200108000-00008]

Effect of propofol and sevoflurane on postoperative fatigue after laparoscopic hysterectomy

BACKGROUND

Postoperative fatigue syndrome (POFS) is an important factor in postoperative recovery. However, the effect of anesthetic drugs on postoperative fatigue in female patients has been rarely studied. This study compared the effects of maintaining general anesthesia with propofol or sevoflurane on the incidence of POFS in patients undergoing laparoscopic hysterectomy.

METHODS

This prospective, single-blind, randomized controlled trial enrolled patients scheduled for laparoscopic hysterectomy. Eligible patients were randomized into the propofol and sevoflurane groups. The primary outcome was the incidence of POFS within 30 Days, defined by a simplified identity consequence fatigue scale (ICFS-10) scores≥24 or Visual Analogue Scale (VAS) scores of fatigues>6. Secondary outcomes were perioperative grip strength, early ambulation and anal exhaust after surgery, and inpatient days.

RESULTS

32 participants were assigned to the propofol group (P) and 33 to the sevoflurane group (S). Incidence of POFS on postoperative D1 was P (8/32) vs. S (10/33) (p = 0.66, 95% confidence interval [CI]: 16.4-27.00); D3 P (2/32) vs. S (5/33) (p = 0.45,95% CI:5.96-23.76). POFS were not found on postoperative D5 and D30. There were no differences in perioperative grip strength, early ambulation and anal exhaust after surgery, and inpatient days between the two groups.

CONCLUSIONS

POFS after scheduled laparoscopic hysterectomy was unaffected by anesthesia with propofol vs. sevoflurane. The incidence of POFS was highest on the first postoperative day, at 27.7%, and declined progressively over the postoperative 30 days. Trial registration Chinese Clinical Trial Registry (No. ChiCTR 2,000,033,861), registered on 14/06/2020).

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Laparoscopic versus open splenectomy in dogs

In the last few years, the use of laparoscopy in veterinary medicine has expanded and consequently so was the need for studies that establish the advantages, disadvantages and possible complications of each procedure. The purpose of the current study was to describe a laparoscopic splenectomy technique and the alterations due to this access, and compare it to the open procedure in dogs. A total of 15 healthy female mongrel dogs were used, with mean weight of 17.4±2.5kg. The animals were distributed into three groups: Group IA of open splenectomy (laparotomy) using double ligation of the vessels of the splenic hilum with poliglicolic acid, Group IB of open splenectomy (laparotomy) with bipolar electrocoagulation of the splenic hilum, and Group II of laparoscopic access with bipolar electrocoagulation of the splenic hilum. Operative time, blood loss, size of incisions, complications during and after surgery were evaluated. Other parameters included pain scores, white blood cell (WBC) counts and postoperative serum concentrations of alanine aminotransferase (ALT), alkaline phosphatase (ALP), creatine kinase (CK), C-reactive protein (CRP), glucose and cortisol. No differences were found in the evaluation of parameters between both open splenectomy techniques employed. Laparoscopic access presented significant differences (p<0,05) when compared with open surgery: Longer operative time, smaller abdominal access, decrease in blood loss, lower concentrations of CRP, higher levels of CK and ALP, and lower scores in the pain scale. Laparoscopic surgery showed fewer complications of the surgical wound. No significant differences were observed between groups in the postoperative temperature, WBC, ALT, cortisol and glucose concentrations. In conclusion, the laparoscopic technique is useful for splenectomy in dogs, being advantageous in terms of blood loss, surgical stress and surgical wounds. However, it expends more operative time and causes transitory increase in hepatic and muscular enzymes.

Psychological intervention and pharmacological analgesia during hepatic arterial chemoembolization therapy: an analysis of 216 cases

AIM: To evaluate the pain relief effect of psychological intervention and pharmacological analgesia during hepatic arterial chemoem-bolization procedure.

METHODS: Two hundred and sixty-two patients underwent hepatic arterial chemoembolization for unresectable hepatic carcinoma were randomized into pharmacological analgesia group (n = 46) and combined therapy group (n = 216, psychological intervention and medication were performed in turn). The baseline characteristics, psychological status and NRS-10 scores before pain control showed no statistical difference between two groups. All patients were measured with Symptom Checklist-90 (SCL-90) before embolization and pain Numeric Rating Scale-10 (NRS-10) score were recorded before psychological intervention/medication, after psychological intervention (only in combined therapy group) and following medication during therapeutic process.

RESULTS: Postembolization pain was significantly relieved after medication, psychological intervention or combined therapy (t' = 4.47, 5.79, 20.24, P < 0.01). There were obvious differences among the curative effect scores (pre-therapy NRS-10 score-post-therapy NRS-10 score) of the above three therapeutic methods (F = 21.98, P < 0.01). According to the curative effect scores, medication and combined therapy were more satisfactory than psychological intervention (2.71 ± 4.05, 3.40 ± 3.82 vs 1.24 ± 2.76; both P < 0.01). Combined therapy was the best method for pain relief, but its curative effect score indicated no statistical difference from that of medication.

CONCLUSION: Pharmacological analgesia combined with psychological intervention is able to relieve pain efficiently during hepatic arterial chemoembolization procedure.

Psychological intervention reduces postembolization pain during hepatic arterial chemoembolization therapy: A complementary approach to drug analgesia

AIM: To assess whether psychological intervention reduces postembolization pain during hepatic arterial chemoembolization therapy.

METHODS: Two hundred and sixty-two patients, who required hepatic arterial chemoembolization for hepatic malignancy and postembolization pain, were randomized into control group (n = 46, receiving medication) and intervention group (n = 216, receiving psychological intervention and medication in turn). The symptom checklist-90 (SCL-90) was used to scale the psychological symptoms of the patients before operation. Pain was scored with a 0 to 10 numeric rating scale (NRS-10) before and after analgesia as well as after psychological intervention (only in intervention group).

RESULTS: All psychological symptomatic scores measured with SCL-90 in the intervention group were higher than the normal range in Chinese (P < 0.05). The somatization, phobia and anxiety symptomatic scores were associated with pain numerical rating score before analgesia (r = 0.141, 0.157 and 0.192, respectively, P < 0.05). Patients in both groups experienced pain relief after medication, psychotherapy or psychotherapy combined with medication during the procedure (P < 0.01). Only some patients in the intervention group reported partial or entire pain relief (29.17% and 2.31%) after psychological intervention. The pain score after analgesia in the intervention group was significantly lower than that in the control group (P < 0.01).

CONCLUSION: Severe psychological distress occurs in patients with hepatic malignancy. Psychological intervention reduces pain scores significantly during hepatic arterial chemoembolization therapy and is thus, highly recommended as a complementary approach to drug analgesia.

Cytokine response is lower after lung volume reduction through bilateral thoracoscopy versus sternotomy

BACKGROUND

Lung volume reduction surgery performed through bilateral video-assisted thoracoscopy (BVATS) was associated in the National Emphysema Treatment Trial with a statistically significant reduction in intensive care unit days, failure to wean, hospital stay, and cost, and earlier recovery compared with median sternotomy. Studies comparing other minimally invasive techniques with "open" procedures, including pulmonary lobectomy, have demonstrated reduced serum proinflammatory mediators postoperatively. We measured these levels after lung volume reduction surgery through BVATS and sternotomy.

METHODS

Serum cytokine levels were measured by radioimmunoassay in 9 consecutive, steroid-free patients undergoing sternotomy and lung volume reduction surgery and 6 undergoing BVATS and lung volume reduction surgery. The groups were not statistically different with respect to age, partial pressure of arterial carbon dioxide, percent forced expiratory volume in 1 second, percent residual volume, percent total lung capacity, diffusion capacity of the lung for carbon monoxide, 6-minute walk, or apical perfusion fraction. Proinflammatory interleukin 6 and interleukin 8 and antiinflammatory interleukin 10 were evaluated preoperatively and postoperatively on days 1, 4, and 5. Clinical data were prospectively collected.

RESULTS

There were no major postoperative complications or deaths. Interleukin 6 levels were lower in the BVATS than the sternotomy group (p = 0.016 by repeated measures analysis of variance). Interleukin 8 levels were lower in the BVATS group at most postoperative time points, but there were no significant differences in interleukin 8 or interleukin 10 levels between the sternotomy and BVATS groups at any individual time point or by analysis of variance.

CONCLUSIONS

Use of a BVATS approach to lung volume reduction surgery is associated with reduced postoperative release of proinflammatory cytokines compared with a sternotomy approach. This may account for the reduction in recovery time and some measures of postoperative morbidity seen with the BVATS approach.

Salivary cortisol as a predictor of postoperative fatigue

OBJECTIVE

Some patients with chronic fatigue syndrome (CFS) exhibit low basal cortisol levels, but it is not known whether low cortisol is a cause of CFS, predates the onset of CFS symptoms, or is an epiphenomenon caused by the behavioral changes typical of CFS. Because elective surgery is one of the few predictable risk factors for chronic fatigue, in this study, we followed a cohort of surgery patients from before to 6 months after their operation to test these theories.

METHOD

One hundred sixty-one patients completed fatigue questionnaires and provided salivary cortisol samples before undergoing an elective inpatient surgical procedure, and then 2 days, 3 weeks, and 6 months afterward.

RESULTS

Controlling for relevant demographic and surgical variables and for preoperative fatigue, low preoperative cortisol did not predict postoperative fatigue severity on any occasion (p > .05). Similarly, there was no correlation between low postoperative cortisol and postoperative fatigue severity at 3 weeks or 6 months (p > .05). Although 16 patients met our case definition for "chronic fatigue" at the 6-month follow up, low preoperative and low postoperative cortisol did not significantly predict fatigue caseness (p > .05).

CONCLUSIONS

Any association between chronic fatigue and low cortisol would seem to develop after the onset of fatigue symptoms. Low cortisol is therefore unlikely to be the primary cause of chronic fatigue states.

The brain: a psychoneuroimmunological approach

PURPOSE OF REVIEW

An overview is provided that discusses brain dysfunctions in intensive care unit patients in the context of psychoneuroimmunology. Recent findings are discussed within the context of the relationship between behavioural aspects and immune functions. The concept of 'sickness behaviour' is introduced to understand the more differential aspects of stress, fatigue and mood.

RECENT FINDINGS

Psychoneuroimmunology is a relatively new field of study that investigates interactions between behaviour and the immune system, mediated by the nervous system. 'Sickness behaviour' describes behavioural changes or reactions of an (infected) organism to cope with illness. Sickness behaviour should be seen as an adaptation to an infection that also influences the process of recovery or further illness.

SUMMARY

There are plausible explanations of how psychological factors (such as aspects of mood) might influence immunity and immune system-mediated disease. There is substantial evidence that psychological factors can influence both cellular and humoral indicators of immune status and function. There are consistent and convincing reports of links between stress and disease onset and progression.

Psychological factors in postoperative fatigue

OBJECTIVE

To assess whether the fatigue commonly reported by patients following surgery is partly a result of somatization and/or cognitive-behavioral factors.

METHODS

One hundred eighty-three patients completed questionnaires before surgery and then 2 days, 3 weeks and 6 months afterward. Multiple regressions were used to assess which of the following factors were important in predicting self-reported postoperative fatigue, controlling for preoperative fatigue and for various demographic and surgical variables: negative mood, history of mood disorder, preoperative expectations of fatigue, preoperative worry or optimism about surgery, preoperative beliefs about the benefits of activity or rest, self-reported postoperative activity, self-reported cardiovascular deconditioning, and availability of social support.

RESULTS

Controlling for demographic and surgical variables and preoperative fatigue, postoperative fatigue showed significant associations with negative mood at each stage of follow-up (p < .001) and was significantly predicted by history of mood disorder at 2 days postoperatively (p = .02). Higher fatigue expectations were self-fulfilling at 3 weeks after surgery (p = .02), whereas preoperative belief in physical activity as being beneficial to recovery predicted reduced fatigue at 6 months (p < .001). Finally, self-reported breathlessness after exercise, an indicator of cardiovascular deconditioning, was also significantly associated with greater fatigue at 6 months (p = .02).

CONCLUSION

The results indicate that psychological processes may well be relevant in the etiology of postoperative fatigue. In particular, the results relating to mood and expectations suggest that somatization may be particularly important in the first few weeks following surgery, whereas cognitive-behavioral factors and cardiovascular deconditioning may be more important in determining later-stage recovery.

A systematic review and meta-analysis of the incidence and severity of postoperative fatigue

OBJECTIVE

Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues.

METHOD

Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses.

RESULTS

Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue.

CONCLUSION

Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.

Systematic review and meta-analysis of interventions for postoperative fatigue

BACKGROUND

Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques.

METHODS

Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed.

RESULTS

Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom.

CONCLUSION

While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.

Temperature control and recovery of bowel function after laparoscopic or laparotomic colorectal surgery in patients receiving combined epidural/general anesthesia and postoperative epidural analgesia

We compared the effects of a laparoscopic (n = 23) versus laparotomic (n = 21) technique for major abdominal surgery on temperature control in 44 patients undergoing colorectal surgery during a combined epidural/general anesthesia. A thoracic epidural block up to T4 was induced with 6-10 mL of 0.75% ropivacaine; general anesthesia was induced with thiopental, fentanyl, and atracurium IV and maintained with isoflurane. Core temperature was measured with a bladder probe and recorded every 15 min after the induction. In both groups, core temperature decreased to 35.2 degrees C (range, 34 degrees C-36 degrees C) at the end of surgery. After surgery, normothermia returned after 75 min (60-120 min) in the Laparoscopy group and 60 min (45-180 min) in the Laparotomy group (P = 0.56). No differences in postanesthesia care unit discharge time were reported between the two groups. The degree of pain during coughing was smaller after laparoscopy than laparotomy from the 24th to the 72nd observation times (P < 0.01). Morphine consumption was 22 mg (2-65 mg) in the Laparotomy group and 5 mg (0-45 mg) in the Laparoscopy group (P = 0.02). The time to first flatus was shorter after laparoscopy (24 h [16-72 h]) than laparotomy (72 h [26-96 h]) (P = 0.0005), and the first intake of clear liquid occurred after 48 h (24-72 h) in the Laparoscopy group and after 96 h (90-96 h) in the Laparotomy group (P = 0.0005). Although laparoscopic surgery provides positive effects on the degree of postoperative pain and recovery of bowel function, the reduction in heat loss produced by minimizing bowel exposure with laparoscopic surgery does not compensate for the anesthesia-related effects on temperature control, and active patient warming must also be used with laparoscopic techniques.

IMPLICATIONS

This prospective, randomized, controlled study demonstrates that laparoscopic colorectal surgery results in less postoperative pain and earlier recovery of bowel function than conventional laparotomy but does not reduce the risk for perioperative hypothermia. Accordingly, active warming must be provided to patients also during laparoscopic procedures.