Clinical Research—Adult
Systemic inflammatory response syndrome and surgical stress in thoracic surgery

https://doi.org/10.1016/j.jcrc.2005.07.001Get rights and content

Abstract

Purpose

To evaluate the clinical usefulness of postoperative systemic inflammatory response syndrome (SIRS) as an index of surgical stress in patients undergoing thoracic surgery.

Methods

Forty-five consecutive patients who underwent thoracic surgery with thoracotomy were enrolled. The SIRS criteria were examined daily during the first 7 postoperative days. The serum interleukin-6 (IL-6) level, operation time, intraoperative blood loss, amount of thoracic drainage, and C-reactive protein levels were also measured.

Results

Sixteen cases were categorized into the SIRS group, whereas 29 cases were categorized into the non-SIRS group. Among the patients who underwent thoracic surgery, the physiological responses of the patients to the surgery, such as serum IL-6 levels and C-reactive protein levels, were significantly higher in the SIRS group than in the non-SIRS group (P = .002 and .024, respectively). The serum IL-6 level on the first postoperative day was an independent factor associated with SIRS (95% CI 1.002-1.041; P = .030). Furthermore, there was a correlation between the number of SIRS days and the duration of the postoperative hospital stay (r = 0.379, P = .012).

Conclusions

Our results demonstrated that SIRS reflected the degree of surgical stress, especially thoracotomic procedures, through the IL-6 levels, and affected the postoperative hospital stay. Systemic inflammatory response syndrome can be useful for the postoperative management of patients undergoing thoracic surgery.

Introduction

Excessive surgical stress results in a disruption of the homeostasis, and, as a result, various postoperative complications arise. Therefore, the objective evaluation of surgical stress is an important issue for postoperative management. The surgical method, operation time, and intraoperative blood loss have been used as surgical stress indices and are thought to be closely associated with the occurrence of postoperative complications [1], [2], [3], [4]. However, the physiological responses vary even when these factors remain the same, suggesting that these factors are inadequate in predicting the occurrence of complications. Other studies have reported that changes in the neuroendocrine response such as cortisols and catecholamines, or immune responses such as cytokines, reflect the degree of surgical stress [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. However, none of these methods are used as a marker in a clinical setting. The development of clinically useful indices is needed for the prevention and early detection of complications, which are the most important goals of postoperative management.

Proposed in 1992 by the American College of Chest Physicians–Society of Critical Care Medicine Consensus Conference Committee, SIRS is a concept that embodies the physiological responses against stress [15]. Systemic inflammatory response syndrome is a nonspecific systemic inflammatory response defined by abnormalities in more than 2 of the following 4 diagnostic criteria: temperature, heart rate, respiratory rate, and white blood cell count. It has been reported that SIRS is a preliminary stage in the development of more critical pathological states such as sepsis, multiple organ dysfunction syndrome, and multiple organ failure [16], [17]. This pathology is caused by hypercytokinemia including IL-6, which is induced by cytokine network activation in response to primary stress to the body. Among the human body responses, cytokines have been frequently tested as an index to evaluate surgical stress. In particular, the serum IL-6 level has been reported to be a sensitive indicator of the physiological response that reflects the degree of surgical stress [5], [10]. Thoracic surgeries are no exception: an increasing number of reports support the serum IL-6 level as an indicator of the degree of surgical stress, and it is becoming well established that thoracoscopic surgery is less stressful than a conventional thoracotomy [18], [19]. The usefulness of IL-6 as a stress marker is almost clear, but there are few clinics that are equipped with facilities to measure cytokine levels, and thus this method cannot be fully exploited in a clinical setting.

Haga et al [20], in their examination of gastrointestinal surgery, suggested that postoperative SIRS is potentially useful for the evaluation of the degree of surgical stress and for the detection of postoperative complications. Sakamoto et al [11] suggested that the thoracotomic procedure is a stress factor that is independent of the intraoperative blood loss and the operation time, and that is thought to be an important factor in evaluating surgical stress. However, there have been few studies reporting SIRS as an index to evaluate stress after thoracic surgery performed by the thoracotomic procedure. We hypothesized that SIRS may have a correlation with surgical stress in thoracic surgery and examined the clinical usefulness of postoperative SIRS in patients who underwent thoracic surgery.

Section snippets

Patients

The subjects consisted of 71 patients who underwent scheduled thoracic surgery with thoracotomic procedure under general anesthesia at the Department of Thoracic Surgery in Kishiwada City Hospital between October 2000 and February 2002. Informed consent was taken from all patients. The factors that were likely to interfere with our analysis were used as exclusion criteria such as:

  • 1.

    Cases with preoperative SIRS.

  • 2.

    Non-SIRS cases in which the preoperative C-reactive protein (CRP) was high (>1.0 mg/dL)

Systemic inflammatory response syndrome and clinical features

Sixteen of 45 cases developed postoperative SIRS. As a result, 16 cases were categorized into the SIRS group, whereas 29 cases were categorized into the non-SIRS group. The patient's background for each group is summarized in Table 1. The average age and sex ratio did not differ significantly between the 2 groups.

Relationship between SIRS and surgical stress parameters

The surgical parameters from each group are shown in Table 2. The SIRS group seemed to have a longer operation time, a larger amount of blood loss, and a larger volume of postoperative

Discussion

In this study, we demonstrated that SIRS correlated with the physiological responses of the patient to the surgery, such as serum IL-6 and CRP levels. Moreover, SIRS was a predictive factor of the duration of the postoperative hospital stay. These results demonstrated that SIRS might be useful for evaluating surgical stress in thoracic surgery.

In this study, among the patients who underwent thoracic surgery, the postoperative serum IL-6 level was significantly higher in the SIRS group than in

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