[Metabolic response to surgical stress and therapeutic perspectives]. Wu Guohao Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery Perioperative patients usually suffer from metabolic response. This metabolic state is usually the result of some blend of response to partial starvation and to injury or specific diseases. Metabolic response to starvation and acute injury is inbuilt response to ensure maximal survival with a limited food intake. Yet, progressive loss of body tissue may have lethal consequences. Enhanced recovery after surgery is an optimized strategy of perioperative treatment based on variations of meta bolic state. It can reduce damage and acute injury, as well as facilitating early recovery after major surgery.

Surgical Stress Response and Enhanced Recovery after Laparoscopic Surgery - A systematic review. Crippa Jacopo,Mari Gulio M,Miranda Angelo,Costanzi Andrea Tm,Maggioni Dario Chirurgia (Bucharest, Romania : 1990) Enhanced Recovery Program (ERP) is a multimodal perioperative protocol. Its feasibility and benefits on short term outcomes have been widely reported. These well described improvements, like shorter length of stay and early resumption of body's functions, represent the consequence of an attenuated surgical stress response (SSR). When this response is uncontrolled, it leads to postoperative complications and poor long-term outcomes. SSR can be easily monitored through the analyses of mediators in the bloodstream. Available evidences do not achieve to tell if ERP allows a measurable surgical stress reduction. In this review, we searched for papers investigating the surgical stress response and ERP applied to elective mini-invasive procedures, in order to better understand the level of evidence regarding the effectiveness of ERP in minimizing the surgical stress response. A systematic review of published literature was performed using PubMed, Cochrane, EMBASE and Google Scholar database, following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Included studies concerned SSR analysis in ERP patients undergoing laparoscopic surgery through different surgical specialties. Eight studies with a total of 632 patients were included. The three steps of SSR, endocrine, inflammatory and nutritional were all reported in the papers included in this review. Results showed no powerful evidence of difference in endocrine phase while an attenuated inflammatory response was reported for ERP patients when Interleukin-6 (IL-6) and C Reactive Protein (CRP) were dosed. Nutritional status was also preserved as albumin, pre-albumin and transferrin had better values in these patients. ERP applied to different types of laparoscopic surgery has a role in reducing SSR. This can be shown by the analysis of mediators such as IL-6, CRP and nutritional markers. 10.21614/chirurgia.113.4.455

The cortisol stress response induced by surgery: A systematic review and meta-analysis. Clinical endocrinology OBJECTIVE: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 meta-analysis 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, women and 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. 10.1111/cen.13820

Metabolic and the Surgical Stress Response Considerations to Improve Postoperative Recovery. Helander Erik M,Webb Michael P,Menard Bethany,Prabhakar Amit,Helmstetter John,Cornett Elyse M,Urman Richard D,Nguyen Viet H,Kaye Alan David Current pain and headache reports PURPOSE OF REVIEW:Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes. RECENT FINDINGS:A PubMed literature search was performed for articles that included the terms of metabolic surgical stress response considerations to improve postoperative recovery. The surgical stress response occurs due to direct and indirect injuries during surgery. Direct surgical injury can result from the dissection, retraction, resection, and/or manipulation of tissues, while indirect injury is secondary to events including hypotension, blood loss, and microvascular changes. Greater degrees of tissue injury will lead to higher levels of inflammatory mediator and cytokine release, which ultimately drives immunologic, metabolic, and hormonal processes in the body resulting in the stress response. These processes lead to altered glucose metabolism, protein catabolism, and hormonal dysregulation among other things, all which can impede recovery and increase morbidity. Fluid therapy has a direct effect on intravascular volume and cardiac output with a resultant effect on oxygen and nutrient delivery, so a balance must be maintained without excessively loading the patient with water and salt. All in all, attenuation of the surgical stress response and maintaining organ and thus whole-body homeostasis through enhanced recovery protocols can speed recovery and reduce complications. The present investigation summarizes the clinical application of enhanced recovery pathways, and we will highlight the key elements that characterize the metabolic surgical stress response and improved postoperative recovery. 10.1007/s11916-019-0770-4