Possible dose dependent effect of perioperative dexamethasone and laparoscopic surgery on the postoperative systemic inflammatory response and complications following surgery for colon cancer
Introduction
Long term survival following surgery for colorectal cancer is primarily related to disease stage, however postoperative morbidity is also a negative prognostic factor [1]. These complications have a high price in terms of both health care costs, and impact on wider society, due to prolonged hospital stay and delay in return to function.
Postoperative complications have been reported to be associated with an exaggerated systemic inflammatory response following surgery for colorectal cancer [2]. The acute phase marker C-reactive protein (CRP) is increasingly recognised to be a reliable measure of this postoperative systemic inflammatory response (SIR) [3]. Postoperative CRP concentrations are now considered to be a useful, early surrogate marker for developing postoperative complications [4]. In addition, increasing evidence suggests that the postoperative SIR may have a causal influence on postoperative complications, and a negative impact on oncologic outcomes following surgery for colorectal cancer [5].
Corticosteroids are commonly administered at the induction of anaesthesia in colorectal surgery for the prevention of postoperative nausea and vomiting (PONV) [6]. A recent meta-analysis has reported that pre-operative administration of corticosteroids is associated with a reduction in the post-operative systemic inflammatory response, measured by CRP, and complications following surgery for gastrointestinal cancers [7]. A further recent randomised controlled trial (RCT) of perioperative corticosteroids in pancreatic cancer surgery reported a reduction in postoperative complications in patients given preoperative steroids [8]. In colorectal cancer surgery a recent observational study reported a significant association between dexamethasone, administered to reduce risk of PONV, and a reduction in both postoperative CRP concentrations and complications [9].
Despite this, no study has sought to detect whether a dose response relationship exists between perioperative steroids and either the postoperative systemic inflammatory response or complications. Furthermore, some concerns have been raised regarding the possibility of increased rates of disease recurrence in patients given perioperative steroids [10]. Therefore, the aims of the present study were to examine the impact of varying doses of dexamethasone given in the perioperative period to prevent PONV, on the postoperative systemic inflammatory response, complications, and survival following elective surgery for colon cancer.
Section snippets
Patients
This was a retrospective observational study of patients with histologically confirmed colonic cancer, undergoing potentially curative resection, at a single centre from March 2008 to June 2017 were included. Those excluded from analysis were patients for whom there was no available anaesthetic record, those prescribed long term steroids, with diagnosed inflammatory conditions, with rectal cancer, who had emergency surgery, or palliative resection.
Each case was discussed at a specialist
Patients
The study included 480 patients in total, who had undergone surgery for colonic cancer with curative intent over the study period. The majority were female (264, 55%), over 65 years old (334, 70%), with node negative disease (297, 62%). 196 patients (41%) had a laparoscopic resection with the remainder having open surgery. 166 patients (35%) were given 4 mg of dexamethasone, 105 patients (21%) were given 8 mg of dexamethasone and the remainder (209, 44%) did not receive dexamethasone. Of all
Discussion
The present study reports a possible dose response relationship between attenuation of the postoperative systemic inflammatory response measured by the poGPS and postoperative complications, through a combination of dexamethasone given at the induction of anaesthesia and laparoscopic surgery. Indeed, when patients were grouped by surgical approach and perioperative dexamethasone, there was a linear association between the magnitude of the surgical injury, postoperative systemic inflammatory
Conclusions
The present retrospective study in patients undergoing elective surgery for colonic cancer reports a possible dose dependent reduction in the postoperative systemic inflammatory response, and fewer complications, associated with the combination of laparoscopic surgery and dexamethasone. The use of dexamethasone was not associated with any negative prognostic impact. These findings should be assessed in prospective randomised studies to allow consideration as to whether dexamethasone should be
Disclosure/financial support
None.
Conflicts of interest
None.
Sources of funding
None.
Acknowledgments
We thank the surgical department and Consultant Colorectal Surgeons of Glasgow Royal Infirmary for their input.
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2019, Annals of Medicine and SurgeryCitation Excerpt :It would be of interest to examine within a randomised control trial the effect of steroid administration at induction of anaesthesia on the postoperative systemic inflammatory response and postoperative short/long-term outcomes in patients undergoing a curative resection for colorectal cancer. An observational study by McSorley et al., 2019 [23] suggested a dose dependent effect of dexamethasone with higher doses of dexamethasone being associated with a reduced postoperative systemic inflammatory response and postoperative complications. Therefore, a trial which incorporated a low-dose steroid arm (e.g. dexamethasone 4 mg) and high-dose steroid arm (e.g. dexamethasone 8 mg) would be worthwhile.
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