title: Randomized clinical trial investigating the stress response from two different methods of analgesia after laparoscopic colorectal surgery.
abstract: BACKGROUND
  One of the key elements of managed recovery is thought to be suppression of the neuroendocrine response using regional analgesics. This may be superfluous in laparoscopic colorectal surgery with small wounds. This trial assessed the effects of spinal analgesia versus intravenous patient-controlled analgesia (PCA) on neuroendocrine responses in that setting.
  
  
  METHODS
  A randomized clinical trial was conducted with participation of patients undergoing laparoscopic colorectal surgery within a managed recovery programme. Consenting patients were allocated randomly to spinal analgesia or morphine PCA as primary postoperative analgesia. The primary outcome was interleukin (IL) 6 levels; secondary outcomes were levels of cortisol, glucose, insulin and other cytokines, pain scores, morphine use and length of hospital stay. Stress response analysis was conducted before operation, and 3, 6, 12, 24 and 48 h after surgery.
  
  
  RESULTS
  Of 143 eligible patients, 133 were randomized and 120 completed the study. Baseline patient characteristics were similar in the two groups. There were no significant differences in median levels of insulin, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, interferon γ, tumour necrosis factor α or vascular endothelial growth factor between the spinal analgesia and PCA groups at any time point. Three hours after surgery (but at no other time point) median (i.q.r.) levels of cortisol (468 (329-678) versus 701 (429-820) nmol/l; P = 0.004) and glucose (6.1 (5.4-7.5) versus 7.0 (6.0-7.7) mmol/l; P = 0.012) were lower in the spinal analgesia group than in the PCA group. Median (i.q.r.) levels of total intravenous morphine were lower in the spinal analgesia group (10.0 (3.3-15.8) versus 45.5 (34.0-60.5) mg; P < 0.001).
  
  
  CONCLUSIONS
  Spinal analgesia reduced early neuroendocrine responses and overall parenteral morphine use.
  
  
  BACKGROUND
  NCT01128088 (http://www.clinicaltrials.gov).
authors.affiliation: Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK.
authors.forename: A R
authors.initials: AR
authors.lastname: Day
authors.affiliation: Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK.
authors.forename: R V P
authors.initials: RV
authors.lastname: Smith
authors.affiliation: Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK.|Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK.
authors.forename: M J P
authors.initials: MJ
authors.lastname: Scott
authors.affiliation: Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK.|Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK.
authors.forename: W J
authors.initials: WJ
authors.lastname: Fawcett
authors.affiliation: Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK.
authors.forename: T A
authors.initials: TA
authors.lastname: Rockall
mesh_terms: D000368:Aged; D016058:Analgesia, Patient-Controlled / Q000379:methods*; D000700:Analgesics / Q000008:administration & dosage*; D000775:Anesthesia, Spinal / Q000379:methods*; D015179:Colorectal Neoplasms / Q000097:blood / Q000601:surgery*; D003107:Colorectal Surgery / Q000379:methods*; D016207:Cytokines / Q000097:blood; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000517:prevention & control; D013312:Stress, Physiological / Q000187:drug effects*
chemical_list: D000700:Analgesics; D016207:Cytokines