title: Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial.
abstract: BACKGROUND
  Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol.
  
  
  METHODS
  Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates.
  
  
  RESULTS
  There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints.
  
  
  CONCLUSIONS
  There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.
authors.affiliation: Yeovil District Hospital Foundation, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.
authors.forename: J
authors.initials: J
authors.lastname: Barr
authors.forename: C
authors.initials: C
authors.lastname: Boulind
authors.forename: J D
authors.initials: JD
authors.lastname: Foster
authors.forename: P
authors.initials: P
authors.lastname: Ewings
authors.forename: J
authors.initials: J
authors.lastname: Reid
authors.forename: J T
authors.initials: JT
authors.lastname: Jenkins
authors.forename: B
authors.initials: B
authors.lastname: Williams-Yesson
authors.forename: N K
authors.initials: NK
authors.lastname: Francis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000009:adverse effects*; D000700:Analgesics / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage; D003106:Colon / Q000601:surgery*; D004311:Double-Blind Method; D004837:Epinephrine / Q000097:blood; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007263:Infusions, Parenteral / Q000009:adverse effects*; D007328:Insulin / Q000097:blood; D015850:Interleukin-6 / Q000097:blood; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D010359:Patient Readmission; D010865:Pilot Projects; D011183:Postoperative Complications / Q000453:epidemiology; D012007:Rectum / Q000601:surgery*; D013312:Stress, Physiological / Q000187:drug effects*; D013997:Time Factors
chemical_list: D000700:Analgesics; D000779:Anesthetics, Local; C508600:IL6 protein, human; D007328:Insulin; D015850:Interleukin-6; D006854:Hydrocortisone; D004837:Epinephrine