Preoperative Steroids for Laparoscopic Surgery

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Laparoscopic surgery provides spectacular benefits to patients. Pain and disfigurement are much less, allowing for better cosmesis, shortened recovery time, and quicker return to preoperative well-being and normal activity. Despite the minimally invasive nature of laparoscopy, host physiologic responses to stress are still variably activated. The same gamut of metabolic, hormonal, inflammatory, and immune responses activated by open surgery are also induced by laparoscopy, but to a lesser degree and proportionate to the extent of surgical injury.1 There are as many differences as there are similarities in the mechanisms and magnitudes of the relative stress responses. Intuitively, one might expect that any effort to modulate these responses would also depend on the extent of stress. What might work well for open or major surgery may not for laparoscopic or minor surgery and vice versa.In this issue of Annals of Surgery, Bisgaard et al2 from the University of Copenhagen test this concept in a randomized controlled trial evaluating preoperative steroids for laparoscopic surgery. On the basis of their findings, the authors recommend that patients undergoing laparoscopic cholecystectomy should routinely receive a single dose of glucocorticoid preoperatively. Although the risks seem minimal, what is to be gained?Fifty years have passed since the realities of perioperative steroid administration were first highlighted. Frasier et al3 demonstrated that 2 young patients being treated with long-term glucocorticoid therapy died unexpectedly after routine orthopedic surgical procedures. Their deaths were attributed to adrenal insufficiency. In normal patients, the acute physiological stress induced by surgery and trauma activates the hypothalamic-pituitary-adrenal (HPA) axis, and a protective physiologic response ensues.4 Patients receiving long-term corticosteroid therapies have an iatrogenic HPA axis suppression that many presume leaves them unable to mount an optimal protective stress response. To avert potentially life-threatening secondary adrenal insufficiency, clinicians today provide such patients perioperative “stress steroid” boosts.5 This traditional and empiric standard of care, however, is being challenged more and more. Critics cite insufficient evidence-based evaluation of perioperative stress steroids and poor correlation between biochemical data of HPA axis function, chronic steroid use, and clinical outcome.6 Indeed, many of these patients have undergone major surgery uneventfully without stress steroids.In the Bisgaard et al article,2 all patients likely had an intact HPA axis as they underwent their elective, uncomplicated laparoscopic cholecystectomy. They did not receive stress steroid boosts, but instead a single dose of 8 mg of dexamethasone intravenously exactly 90 minutes preoperatively. This was purely an attempt to modulate the systemic physiologic response to the limited stress of a standardized laparoscopic procedure. Compared with placebo, this precise dosing of dexamethasone, as emphasized by the authors, reduced pain, fatigue, opioid use, nausea and vomiting, and duration of convalescence. Compared with historical controls for open cholecystectomy, these placebo-treated patients also did very well, as we now expect for laparoscopic cholecystectomy. Nonetheless, this simple, inexpensive, and apparently innocuous dose of preoperative steroid delivered just that much more benefit to patients. What is not clear is why it did.To understand this, one can begin by considering the clinical efficacy of single-dose steroid therapy in elective major and minor surgery. There are several published trials available; however, variability in study populations, surgical procedures, protocols for steroid dosing, and endpoints of clinical outcome preclude any consensus. Holte and Kehlet,7 also from this unit in Denmark, provide a comprehensive review of these trials and endorse the use of single-dose preoperative steroids. As an immune modulation strategy, such therapy does appear to shift the balance of inflammation in favor of antiinflammatory mediators in a variety of surgical procedures.

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