Elsevier

Surgery

Volume 157, Issue 2, February 2015, Pages 362-380
Surgery

Infection
Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: A systematic review

https://doi.org/10.1016/j.surg.2014.09.009Get rights and content

Background

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

Methods

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

Results

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

Conclusion

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Section snippets

Methods

A literature search was performed with the keywords surgery, endocrine response, systemic inflammatory response, acute phase response, cortisol, IL-6, WCC, and CRP was made of the US National Library of Medicine (MEDLINE), the Excerpta Medica Database (ie, EMBASE), PubMed, and the Cochrane Database of Systemic Reviews (ie, CDSR) for articles that reported cortisol, IL-6, WCC, and CRP after operation. From this, titles of studies and abstracts were analyzed for relevance. Bibliographies of

Study selection process

The selection process is summarized in Fig. With the aforementioned search criteria, abstracts were identified, and the bibliographies of these articles were hand searched for additional articles. In total 296 abstracts were identified and full text obtained. Subsequent analysis of the full text of these articles resulted in 132 being excluded from analysis: 3 were unavailable in English language, 12 were review articles, 5 were animal studies, 14 articles involved emergency or trauma

Discussion

The present review shows that cortisol, IL-6, WCC, and CRP all peak after all types of elective operations, minor and major, laparoscopic and open. The peak responses after operation occur at approximately 0–4 hours for cortisol, 12–24 hours for IL-6, 24–48 hours for WCC, and 24–72 hours for CRP. Only IL-6 and CRP consistently were associated with the magnitude of operative injury. Therefore, IL-6 and CRP would appear to be useful markers for assessing the magnitude of the SIR after elective

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