Physiological, Metabolic, and Immunological Responses after Intestinal Resection

ABSTRACT

Major surgery leads to an activation of inflammatory and endocrine responses resulting in catabolism, immunosuppression, and adverse physiological effects in various organ systems. In addition, hypothermia, opioid administration, immobilization, and semistarvation may amplify the negative effects of the stress responses on perioperative organ physiology. Currently available options to modify the stress response activation per se are epidural local anesthetics, minimally invasive surgery, and a single high-dose glucocorticoid. Recent studies indicate that the stress-induced perioperative impairment in various organ functions may be profoundly reduced by multimodal rehabilitation programs aiming to control perioperative pathophysiology and thereby improve recovery.

KEYWORDS

Surgical stress - postoperative complications - postoperative analgesia - minimally invasive surgery

REFERENCES

• 1 Wilmore D W. Metabolic response to severe surgical illness: Overview.  World J Surg . 2000;  24 705-711
• 2 Mannick J A, Rodrick M L, Lederer J A. The immunologic response to injury.  J Am Coll Surg . 2001;  193 237-244
• 3 Holte K, Kehlet H. Epidural anaesthesia and analgesia-effects on surgical stress responses and implications for postoperative nutrition.  Clin Nutr . 2002;  21 199-206
• 4 Ljungqvist O, Nygren J, Thorell A. Insulin resistance and elective surgery.  Surgery . 2000;  128 757-760
• 5 Sessler D I. Complications and treatment of mild hypothermia.  Anesthesiology . 2001;  95 531-543
• 6 Kehlet H. Surgical stress response: does endoscopic surgery confer an advantage?.  World J Surg . 1999;  23 801-807
• 7 Gupta A, Watson D I. Effect of laparoscopy on immune function.  Br J Surg . 2001;  88 1296-1306
• 8 Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiological effects and clinical implications.  J Am Coll Surg . 2002;  195 694-712
• 9 Warner D O. Preventing postoperative pulmonary complications: the role of the anesthesiologist.  Anesthesiology . 2000;  92 1467-1472
• 10 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.  Br J Anaesth . 1997;  78 606-617
• 11 Chapman A E, Levitt M D, Hewett P, Woods R, Sheiner H, Maddern G J. Laparoscopic-assisted resection of colorectal malignancies: a systematic review.  Ann Surg . 2001;  234 590-606
• 12 Grantcharov T P, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery.  Eur J Surg . 2001;  167 260-267
• 13 Rodgers A, Walker N, Schug S. et al . Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.  BMJ . 2000;  321 1493-1497
• 14 Ballantyne J C, Carr D B, deFerranti S. et al . The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.  Anesth Analg . 1998;  86 598-612
• 15 Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome.  Br J Anaesth . 2001;  87 62-72
• 16 Holte K, Sharrock N E, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess.  Br J Anaesth . 2002;  89 622-632
• 17 Arieff A I. Fatal postoperative pulmonary edema: pathogenesis and literature review.  Chest . 1999;  115 1371-1377
• 18 Basse L, Hjort J D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection.  Ann Surg . 2000;  232 51-57
• 19 Basse L, Jakobsen D H, Billesbolle P, Lund C, Werner M, Kehlet H. [Accelerated rehabilitation after colon resection].  Ugeskr Laeger . 2001;  163 913-917
• 20 Basse L, Raskov H H, Hjort J D. et al . Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition.  Br J Surg . 2002;  89 446-453
• 21 Mangano D T, Browner W S, Hollenberg M. et al . Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery.  N Engl J Med . 1990;  323 1781-1788
• 22 Warltier D C, Pagel P S, Kersten J R. Approaches to the prevention of perioperative myocardial ischemia.  Anesthesiology . 2000;  92 253-259
• 23 Fleisher L A, Eagle K A. Clinical practice. Lowering cardiac risk in noncardiac surgery.  N Engl J Med . 2001;  345 1677-1682
• 24 Auerbach A D, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: clinical applications.  JAMA . 2002;  287 1445-1447
• 25 Kehlet H. Modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain, 3rd ed Philadelphia: Lippincott-Raven 1998: 129-175
• 26 Beattie W S, Badner N H, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.  Anesth Analg . 2001;  93 853-858
• 27 Holte K, Kehlet H. Postoperative ileus: a preventable event.  Br J Surg . 2000;  87 1480-1493
• 28 Kehlet H, Holte K. Review of postoperative ileus.  Am J Surg . 2001;  182 S3-S10
• 29 Holte K, Kehlet H. Postoperative ileus: progress towards effective management.  Drugs . 2002;  62 2603-2615
• 30 Jorgensen H, Wetterslev J, Moiniche S, Dahl J B. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery (Cochrane Review). In: The Cochrane Library, Issue 1, 2002 Oxford: Update Software
• 31 Park W Y, Thompson J S, Lee K K. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study.  Ann Surg . 2001;  234 560-569
• 32 Rigg J R, Jamrozik K, Myles P S. et al . Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial.  Lancet . 2002;  359 1276-1282
• 33 Norris E J, Beattie C, Perler B A. et al . Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.  Anesthesiology . 2001;  95 1054-1067
• 34 Kehlet H, Wilmore D W. Multimodal strategies to improve surgical outcome.  Am J Surg . 2002;  183 630-641
• 35 Paulsen E K, Porter M G, Helmer S D, Linhardt P W, Kliewer M L. Thoracic epidural versus patient-controlled analgesia in elective bowel resections.  Am J Surg . 2001;  182 570-577
• 36 Cali R L, Meade P G, Swanson M S, Freeman C. Effect of Morphine and incision length on bowel function after colectomy.  Dis Colon Rectum . 2000;  43 163-168
• 37 Taguchi A, Sharma N, Saleem R M. et al . Selective postoperative inhibition of gastrointestinal opioid receptors.  N Engl J Med . 2001;  345 935-940
• 38 Lobo D N, Bostock K A, Neal K R, Perkins A C, Rowlands B J, Allison S P. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial.  Lancet . 2002;  359 1812-1818
• 39 Cheatham M L, Chapman W C, Key S P, Sawyers J L. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.  Ann Surg . 1995;  221 469-476
• 40 Basse L, Madsen L, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative.  Br J Surg . 2001;  88 1498-1500
• 41 Ting S D, Seow-Choen F. Prophylaxis for deep vein thrombosis.  Clin Colon Rectal Surg . 2003;  16 109-117
• 42 Rosenberg-Adamsen S, Kehlet H, Dodds C, Rosenberg J. Postoperative sleep disturbances: mechanisms and clinical implications.  Br J Anaesth . 1996;  76 552-559
• 43 Spath-Schwalbe E, Hansen K, Schmidt F. et al . Acute effects of recombinant human interleukin-6 on endocrine and central nervous sleep functions in healthy men.  J Clin Endocrinol Metab . 1998;  83 1573-1579
• 44 Rosenberg-Adamsen S, Skarbye M, Wildschiodtz G, Kehlet H, Rosenberg J. Sleep after laparoscopic cholecystectomy.  Br J Anaesth . 1996;  77 572-575
• 45 Gogenur I, Rosenberg-Adamsen S, Kiil C, Kjaersgaard M, Kehlet H, Rosenberg J. Laparoscopic cholecystectomy causes less sleep disturbance than open abdominal surgery.  Surg Endosc . 2001;  15 1452-1455
• 46 Drummond G B, Stedul K, Kingshott R, Rees K, Nimmo A F, Wraith P. et al . Automatic CPAP compared with conventional treatment for episodic hypoxemia and sleep disturbance after major abdominal surgery.  Anesthesiology . 2002;  96 817-826
• 47 Rosenberg J. Late postoperative hypoxaemia. Mechanisms and clinical implications.  Dan Med Bull . 1995;  42 40-46
• 48 Rosenberg J, Pedersen M H, Gebuhr P, Kehlet H. Effect of oxygen therapy on late postoperative episodic and constant hypoxaemia.  Br J Anaesth . 1992;  68 18-22
• 49 Rosenberg J, Kehlet H. Postoperative mental confusion: association with postoperative hypoxemia.  Surgery . 1993;  114 76-81
• 50 Mangano D T, Wong M G, London M J, Tubau J F, Rapp J A. Perioperative myocardial ischemia in patients undergoing noncardiac surgery: II. Incidence and severity during the 1st week after surgery.  J Am Coll Cardiol . 1991;  17 851-857
• 51 Rosenberg-Adamsen S, Lie C, Bernhard A, Kehlet H, Rosenberg J. Effect of oxygen treatment on heart rate after abdominal surgery.  Anesthesiology . 1999;  90 380-384
• 52 Greif R, Akca O, Horn E P, Kurz A, Sessler D I. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection.  N Engl J Med . 2000;  342 161-167
• 53 Moller J T, Cluitmans P, Rasmussen L S. et al . Long-term postoperative cognitive dysfunction in the elderly.  Lancet . 1998;  351 857-861
• 54 Johnson T, Monk T, Rasmussen L S. et al . Postoperative cognitive dysfunction in middle-aged patients.  Anesthesiology . 2002;  96 1351-1357
• 55 Abildstrom H, Rasmussen L S, Rentowl P. et al . Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly.  Acta Anaesthesiol Scand . 2002;  44 1246-1251
• 56 Kehlet H, Rosenberg J. Surgical stress: pain, sleep and convalescence. In: Kinney JM, Tucker HN, eds. Physiology, Stress and Malnutrition: Functional Correlates, Nutritional Interventions Philadelphia, PA: Lippincott-Raven 1997: 95-112
• 57 Rubin G J, Hotopf M. Systematic review and meta-analysis of interventions for postoperative fatigue.  Br J Surg . 2002;  89 971-984
• 58 Senagore A J, Whalley D, Delaney C P, Mekhail N, Duepree H J, Fazio V W. Epidural anesthesia-analgesia shortens length of stay after laparoscopic segmental colectomy for benign pathology.  Surgery . 2001;  129 672-676
• 59 Delaney C P, Fazio V W, Senagore A J, Robinson B, Halverson A L, Remzi F H. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery.  Br J Surg . 2001;  88 1533-1538
• 60 Hjort Jakobsen D, Sonne E, Basse L, Bisgaard T, Kehlet H. Convalescence after colonic resection with a fast-track versus conventional care programme (submitted). 
• 61 Kehlet H. Clinical trials and laparoscopic surgery: the second round will require a change of tactics.  Surg Laparosc Endosc Percutan Tech . 2002;  12 137-138