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Comparison of Systemic Stress Response in Open Surgery Versus Laparoscopic Surgery in Children

Man Mohan Harjai, Anil Kumar
Department of Paediatric Surgery, Surgical Division
Base Hospital Delhi Cantt
(Affiliated to Army College of Medical Sciences), New Delhi, India

 

Correspondence 

Col Man Mohan Harjai
Professor & Senior Advisor in Surgery & Paediatric Surgery
Department of Paediatric Surgery; Surgical Division, Base Hospital Delhi Cantt
(Affiliated to Army College of Medical Sciences)
New Delhi; Pin 110010; India
tel: 91-11-23337037; fax: 91-11-25693453
e-mai: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract
Introduction: Surgical trauma is associated with metabolic and endocrine responses characterized by hyperglycemia, increase in ACTH, cortisol, prolactin, ADH and a decrease in insulin. Minimal literature is available on the subject. We compared the metabolic response to surgical trauma in open and laparoscopic group to observe and validate the response in paediatric age group in our setup.
Material and methods: All children undergoing elective surgery were randomly divided into two groups. Each group consisted of 30 children undergoing laparoscopic or open surgery. Blood sample of 5 ml were collected at the time of admission (preoperative) and 6 hours after surgery (post-operative).

Results:Rise was seen in cortisol (statistically insignificant), insulin (p<0.003 in laparoscopic surgery and p<0.002 after open surgery), glucose (statistically insignificant), and TSH (p<0.0035 in lap surgery and p<0.003 in open surgery). Prolactin levels decreased after surgery in both (laparoscopic p<0.003 and open surgery p<0.002) groups. CRP level also rose after surgery significantly.

Conclusion: We found in our study that paediatric population responds to stress is similar to adults and stress response in open surgery is slightly more comparative to laparoscopic surgery. Thus, less invasive is the better. The laparoscopic surgery is preferable over open surgery as it involves less tissue trauma and less stress response.
Key words: laparoscopic surgery, open surgery, stress response, tissue trauma, children.

 

 

Introduction

Almost all operations that are classically performed as open surgery have now a laparoscopic surgical variant. The reason for performing this form of surgery obeys the Hippocratic principle: the less invasive the better. Moreover there is scientific evidence that the less trauma, the less stress response and the less immunosuppression. There are few studies on stress responses to surgical trauma (open or laparoscopic) in children. Extensive search of literature revealed only one study comparing metabolic and endocrine response to laparoscopic versus open surgery in pediatric age groups [1] in which author compared the endocrine and metabolic changes in emergency cases only. This study was under taken to assess the metabolic response to surgical trauma in open and laparoscopic group to observe and validate the re- sponses in paediatric age group in our setup.

Materials and methods

All children undergoing elective surgery were randomly divided into two groups. Each group consisted of 30 children undergoing laparoscopic or open surgery. Infants to 12 years of age children were included in the study from October 2006 to April 2008. Type of surgery, duration and postoperative course of events were recorded in each group. Preoperative and postoperative levels of metabolic (prolactin, cortisol, insulin, T3, T4, TSH, glucose) and acute phase (C-reactive protein) responses were measured in each group. Children undergoing emergency surgery were excluded from the study. Blood sample of 5 ml were collected at the time of admission (preoperative) and 6 hours after surgery (post-operative). Serum, which separated after the blood had coagulated, was used for the measurement of various hormone levels. All the stress response parameters except CRP level were analyzed in endocrinology department, while the CRP levels were carried out in the pathology department. We measured stress response markers using an enzyme-linked immuno- sorbent assay.

Results

Sixty patients in age group 0-12 years were included in this study, thirty each in laparoscopic and open surgery group. Metabolic (prolactin, cortisol, insulin, T3, T4, TSH, glucose) and acute phase (C-reactive protein) responses were compared between laparoscopic and open surgery groups. There was a male preponderance; the median age in laparoscopic surgery was 4 years and 1 year in open surgery. Youngest patient in laparoscopic surgery was of 7 months and eldest was of 5 years, while in open surgery it was 4 months and 11 years, respectively. The sex ratio in laparoscopic group was male/female: 80/20, while in open group it was male/female: 87/13 (Table 1). Repair of congenital inguinal hernia was the most common surgical procedure performed in both groups. Twenty-five cases of inguinal hernia were performed laparoscopically while only 6 cases were carried out by open surgical method. The other laparoscopic procedures performed were - multiple colonic biopsies in Hirschsprung’s disease, orchidopexy for impalpable testes and rectopexy for rectal prolapse. The open surgery was done for vesico-ureteric reflux, extra hepatic biliary atresia, hypospadias, congenital inguinal hernia, chronic thrombocytopenic purpura, hydrocephalus, cleft palate and impalpable testis. Comparison of metabolic (prolactin, cortisol, insulin, T3, FIG 2a T4, TSH, glucose) and acute phase (C-reactive protein) responses in laparoscopic versus open surgery are depicted in the bar diagrams and their findings are described in their legends. The frequencies and grouping variables are shown in Table 2. Statistical analysis was performed by using the Mann-Whitney U, Wilcoxon W and Asymp.sig. (2-tailed) Test. Rise was seen in cortisol (statistically insignificant), insulin (p<0.003 in laparoscopic surgery and p<0.002 after open surgery), glucose (statistically insignificant), and TSH (p<0.0035 in laparoscopic surgery and p<0.003 in open surgery). Prolactin levels decreased after surgery in both (laparoscopic p<0.003 and open surgery p<0.002). CRP level also rose after surgery significantly (Table 3 – 18). 

table 1

TABLE 1: Sex ration comparison

table2a 

table 2b 

TABLE 2. Frequencies of open versus laparoscopic surgery (statistics)

table 3 

Figure 3,4. Prolactin level did not raise after surgery both in laparoscopy, as well as open surgery. Infact, there was slight fall in prolactin level.

table 4

 Figure 5,6. Cortisol level increased after surgery in both laparoscopic and open group, however the rise after open surgery was more. Cortisol level increased after lap surgery, being 1.2 times.

table 5

Figure 7,8. Insulin level raise after open surgery 2.3 times while the rise was 1.6 times following laparoscopic surgery

table 6

Figure 9,10. T3 level did not raise following surgery in open group as well laparoscopic group. There was fall in the level of T3 as depicted.

table 7 

Figure 11,12. There was slight increase in T4 level following open and laparoscopic surgery as depicted. Following laparoscopic the rise being about 1.2 times

table 8

Figure 13,14. TSH level rise was 1-1.2 times following open and laparoscopic surgery

table 9 

Figure 15,16. Glucose level rise was 1.4 times following open surgery and 1.2 times in laparoscopic group

table 10

Figure 17,18. CRP levels increased three times after open surgery and 1.5 times after laparoscopic surgery

Discussion

Surgery is associated with metabolic and endocrine responses characterized by hyperglycemia, increase in ACTH, cortisol, prolactin, ADH, and a decrease in insulin. When human is exposed to any of an immense variety of noxious or potentially noxious stimuli, there is an increased secretion of ACTH and consequently a rise in the circulatory glucocorticoids levels. This rise is essential for survival. In a study by Kehlet H. et al [2] found that T3 level fall after surgery in young patients while T4 level did not change significantly with time. In our study T3 level did not rise following surgery in both laparoscopic as well as open surgery. There was a slight increase in T4 and TSH level following surgery in both the groups In human prolactin secretion is increased by exercise, surgical and psychological stress and stimulation of nipple. The plasma prolactin level rises during sleep, the rise starting after the onset of the sleep and persisting throughout the sleep period. Bozkurt P et al [1] comparing metabolic and endocrine response to laparoscopic versus open surgery in pediatric age groups, compared stress response during operations for abdominal pain performed via laparoscopy or open surgery in children [n=29] and found that prolactin level increased after surgery in both laparoscopic as well as open surgery. Rise was however 1.6-2.0 times following surgery, while in contrast to that in our study prolactin level did not rise after surgery in both the groups and in fact it fell after surgery. This is most likely due to pulsatile release of prolactin or due to single sample collection in our study.

Bozkurt [1] also noticed raised cortisol level after surgery in both laparoscopic as well as open surgery. Rise was around 1.01.2 times following surgery. We also noticed high levels of cortisol after surgery in both laparoscopic as well as open surgery and the rise was around 1.2-1.9 times. The rise in glucose level was there in laparoscopic as well as open surgery; however, rise after open surgery was more than after laparoscopic surgery. After laparoscopic surgery it was around 1.2 times, while in open surgery it was around 1.4 times. Insulin level rise was 1.7 times following surgery in study conducted by Bozkurt while in our study rise was 2.0 times following surgery. Thus the metabolic response to stress in children was comparable to other in literature except prolactin response.

Makir GG et al [3] studied 41 patients of adult group undergoing laparoscopic cholecystectomy and 42 patients undergoing open cholecystectomy found that plasma levels of cortisol and catecholamines increased during and after both lapaparoscopic and open cholecystectomy. However the post operative responses were significantly higher after open cholecystectomy group. Glucose and CRP level also increased after operation and were significantly higher in open cholecystectomy group. Similarly Haque Z et al [4] compared stress response between laparoscopic and open cholecystectomy and found that cortisol, glucose increased in postoperative period in open cholecystectomy then in laparoscopic cholecystectomy. In our study in children cortisol and glucose level also increased after surgery. The cortisol level increased 1.9 times in open surgery and 1.2 times following laparoscopic surgery. Glucose level also increased following surgery, being 1.4 times in open surgery and 1.2times following laparoscopic surgery. CRP level preoperatively were negative while Fig 7ab - TSH level rise was 1-1.2 times following open and laparoscopic surgery following surgery it became positive. This signifies that children behave in similar fashion as adults to stress.

Schauer PR. et al [5] found that plasma concentration of glucose and cortisol increased after surgery (cortisol level increased 1.9 times in open surgery and 1.2 times following lap surgery) in both the groups, being more in open surgery then in lap surgery, which was comparable to our study. Muzii L. et al [6] found that cortisol and prolactin level were high after open cholecystectomy as compared to lap cholecystectomy, while in our study although, cortisol level increased after surgery but prolactin decreased after surgery. This could be related to pulsatile release of prolactin. Also, it could be due to absence of mass pooling. Akhtar K et al [7] compared metabolic and inflammatory responses after laparoscopic and open inguinal hernia repair. They studied 10 patients in each group and found that cortisol level increased in both groups with open hernia repair having a higher acute phase response, similar to response seen in children. H.Kehlet [2] studied influence of age on endocrine metabolic response to surgery. He found that plasma cortisol concentration increased from a basal mean level in young subjects, serum T4 did not change significantly with time, the T3 level fell after surgery and plasma insulin level raised after surgery. While we noticed slight increase in level of T4 following surgery and a decrease in level of T3 following surgery. Significant elevations of both ACTH and cortisol were noticed after surgery in laparoscopic as well as open surgery by Mansour et al [8].

 

References 

  1. Bozkurt P.Kaya G, Altintas F, et al. Systemic stress response during operations for abdominal pain performed via laparoscopy or laparotomy in children, J. Anaesth 2000; 55: 5-9. 
  2. Kehlet H. Surgical stress response: does endoscopic surgery confer an advantage? World J Surg. 1999; 23: 801-7.
  3. Makri GG, Karayiannakis AJ, Mantzioka A, Karousos D, Karatzas G. Systemic stress response after laparoscopic or open cholecystectomy: a randomized trial. br J Surg. 1997; 84: 467-71.
  4. Haque Z, Rahman M, Siddique Ma, et al. Metabolic and stress responses of the body to trauma: produced by the laparoscopic and open cholecystectomy. mymensingh med J. 2004; 13: 48-52.
  5. Schauer Pr, Sirinek Kr. The laparoscopic approach reduces the endocrine response to elective cholecystectomy. J. am Surg. 1995; 61: 106-11.
  6. Muzii L, Marana R, Marana E, Paielli Fv, Meo F, Maussier Ml, Sciarra M, Mancuso S. Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy. J Am Assoc Gynecol Laparosc. 1996; 3: 229-34.
  7. Akhtar K, Kamalky-Asl Id, Lamb Wr, Laing I, Walton l, Pearson RC, Parrott Nr. Metabolic and inflammatory responses after laparoscopic and open inguinal hernia repair. ann r Coll Surg engl. 1998; 80: 125-30.
  8. Mansour MA, Steigmann G.V., Yamamoto M. et Al. Neuroendocrine response after minimally invasive surgery in pigs. Surg endosc 2006; 6: 294-7.