Redefining the stress cortisol response to surgery

Khoo, Bernard; Boshier, Piers R.; Freethy, Alexander; Tharakan, George; Saeed, Samerah; Hill, Neil; Williams, Emma; Moorthy, Krishna; Tolley, Neil; Jiao, Long R.; Spalding, Duncan; Palazzo, Fausto; Meeran, Karim; Tan, Tricia

doi:10.1111/cen.13439

Cited by 51 publications

(42 citation statements)

References 32 publications

(42 reference statements)

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“…[92][93][94][95][96][97][98] Recently, Khoo et al 99 reported on the peri-operative cortisol response after stratifying surgical procedures according to the POSSUM scoring system 100 and observed a positive correlation of cortisol peak to the invasiveness of the surgical procedure. 99 We believe that several elements can account for the differences compared to the results of our systematic review, abdominal surgery up to POD-7 and showed that cortisol levels remained elevated for more than 3 days after surgery, with a loss of the circadian rhythm. 23 However, it is important to highlight that our results regarding the cortisol response after POD-3 derive only from a limited number of studies with small sample sizes.…”

Section: Discussionmentioning

confidence: 56%

“…Studies included in the current systematic review were highly heterogeneous in terms of patient selection, surgical and anaesthetic techniques, peri‐operative care and methodological aspects—all these factors can affect the cortisol stress response to surgery (Table S6). Recently, Khoo et al reported on the peri‐operative cortisol response after stratifying surgical procedures according to the POSSUM scoring system and observed a positive correlation of cortisol peak to the invasiveness of the surgical procedure . We believe that several elements can account for the differences compared to the results of our systematic review, including a different classification system, differences in demographics and differences in procedures.…”

Section: Discussionmentioning

confidence: 66%

“…Five per cent of serum cortisol is free (not protein bound), and this is its bioactive form . Several authors have observed a drop of CBG after surgery (up to 23%‐44% compared to baseline) . This drop correlates with the severity of surgery and can be interpreted as an adaptive mechanism to increase the delivery of bioactive cortisol to target tissues .…”

Section: Discussionmentioning

confidence: 99%

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The cortisol stress response induced by surgery: A systematic review and meta‐analysis

Prete

Yan

Al-Tarrah

et al. 2018

Clinical Endocrinology

116

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SummaryObjective: Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. Design:We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. Methods:We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in metaanalysis and plotted over time. Results:We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, womenand patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response. Conclusions:The peri-operative cortisol stress response is dynamic and influenced by patient-specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response. K E Y W O R D Sadrenal cortex, adrenal insufficiency, cortisol, hydrocortisone, pituitary-adrenal system, stress, surgery | 555 PRETE ET al. | INTRODUC TI ONThe controlled trauma of a surgical insult activates adaptive changes in the neuro-hormonal system and the inflammation response.1 The primary mechanism responsible for cortisol hypersecretion in response to stress is executed by the afferent nerve signals derived from the surgical site, which in turn stimulate the hypothalamus to release corticotropin-releasing hormone and arginine vasopressin.

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Section: Discussionmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

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The cortisol stress response induced by surgery: A systematic review and meta‐analysis

Prete

Yan

Al-Tarrah

et al. 2018

Clinical Endocrinology

116

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“…To evaluate the influence of the type of anesthesia on cortisol level, the severity of surgical intervention must possibly be regarded as well. In a study from 2017, it was shown that peak cortisol levels positively correlated with the severity of surgical intervention [23]. Severity might additionally prolong the postoperative duration of elevated cortisol levels.…”

Section: Discussionmentioning

confidence: 99%

Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study

et al. 2020

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Background: Sentinel lymph node excision (SLNE) can be performed in tumescent local anesthesia (TLA) or general anesthesia (GA). Perioperative cortisol level changes and anxiety are common in surgical interventions and might be influenced by the type of anesthesia. In this study, we intended to determine whether the type of anesthesia impacts the patients' perioperative levels of salivary cortisol (primary outcome) and the feeling of anxiety evaluated by psychological questionnaires (secondary outcome). Methods: All melanoma patients of age undergoing SLNE at the University Hospital Essen, Germany, could be included in the study. Exclusion criteria were patients' intake of glucocorticoids or psychotropic medication during the former 6 months, pregnancy, age under 18 years, and BMI ≥ 30 as salivary cortisol levels were reported to be significantly impacted by obesity and might confound results.

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“…Traditionally, CRP is measured down to concentrations of 3 to 5 mg/L; highsensitivity C-reactive protein (hsCRP) is measured down to concentrations of approximately 0.3 mg/L. Surgical trauma is associated with a stress response that varies in accordance with the nature and degree of tissue damage (Khoo, et al 2017). Critical to this response is the release of cortisol, mediated by the hypothalamic-pituitary-adrenal axis.…”

Section: Tissue Damage and Recoverymentioning

confidence: 99%

On Quality Improvement in Gynaecological Cancer Surgery

Lundin

2020

Linköping University Medical Dissertations

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Objectives: The overall purpose of this thesis was to find medical and surgical treatment methods of improving the perioperative care of gynaecological cancer patients. The specific objectives were to determine whether a single dose tranexamic acid given immediately before surgery for presumed advanced ovarian cancer reduces perioperative blood loss and the need for blood transfusions, and to determine whether postoperative recovery, tissue damage, and inflammatory response markers differ between women operated with robotic and abdominal hysterectomy for low-risk endometrial cancer in an enhanced recovery after surgery (ERAS) programme, and to evaluate costs for hospital stay and postoperative recovery in relation to health impact. Material and Methods: The thesis was based on two randomised trials. The first trial was a randomised double-blind placebo-controlled multicentre study conducted in four hospitals in the southeast and central of Sweden between March 2008 and May 2012. One hundred women with presumed advanced ovarian cancer who had been scheduled for radical debulking surgery were included; 50 received tranexamic acid and 50 received a placebo. The main outcomes were blood loss and red blood cell transfusions. The second trial was a randomised open single centre trial at a Swedish university hospital, which included 50 women with low-risk endometrial cancer scheduled for radical surgery between February 2012 and May 2016; 25 women underwent robotic hysterectomy and 25 had abdominal hysterectomy. Anaesthesia and perioperative care followed an ERAS protocol in both groups. The EuroQol Group form EQ-5D-3L and the Short Form-36 evaluated the health-related quality of life. The Swedish Postoperative Symptoms Questionnaire assessed symptoms perioperatively until six weeks postoperatively. Venous blood samples were collected on several occasions until six weeks postoperatively and were analysed for markers reflecting inflammatory response and tissue damage. In addition, a health-economy analysis was conducted comparing total costs, quality-adjusted life years (QALYs) and cost per QALY between the surgical methods. Results: Total blood loss volume and transfusion rate following surgery in advanced ovarian cancer were significantly lower in the tranexamic group compared with the placebo group. Women with early endometrial cancer treated by robotic hysterectomy recovered significantly faster in the EQ-5D health index, and reached their preoperative level nearly two weeks earlier than the abdominal group. Differences regarding improvement in health-related quality of life (Short Form-36) comprising general health and social functioning were more favourable in the robotic hysterectomy group. Consumption of analgesics, pain intensity, postoperative symptom sum score and length of hospital stay were equal between the groups. The occurrence of complications was an independent risk factor and influenced most of the outcome measures adversely. Postoperative inflammatory response and tissue damage were lower after roboti...

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Redefining the stress cortisol response to surgery

Abstract: Background

Cited by 51 publications

References 32 publications

The cortisol stress response induced by surgery: A systematic review and meta‐analysis

The cortisol stress response induced by surgery: A systematic review and meta‐analysis

Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study

On Quality Improvement in Gynaecological Cancer Surgery

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