Kashiwabara Moto, Miyashita Masao, Nomura Tsutomu, Makino Hiroshi, Matsutani Takeshi, Kim Chol, Takeda Shinhiro, Yamashita Kiyohiko, Chaudry Irshad H, Tajiri Takashi
Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
J Nippon Med Sch. 2007 Aug;74(4):274-83. doi: 10.1272/jnms.74.274.
The hypothalamic-pituitary-adrenal axis is an essential component for the maintenance of homeostasis following trauma. Major surgical trauma often induces overwhelming inflammatory responses leading to sepsis and organ dysfunction. This study was designed to evaluate the adrenal responses both before and after various degrees of surgical trauma and to determine the incidence of postoperative relative adrenal insufficiency resulting in the marked inflammatory response often associated with postoperative complications. Fifty-one surgical patients were divided into groups who underwent major, moderate, and minor surgeries. Before the operation and during resting conditions, a short corticotropin (ACTH) stimulation test was performed in each patient. The postoperative concentrations of serum cortisol, interleukin (IL)-6, IL-10, C-reactive protein (CRP), and plasma ACTH were measured. Fifty of 51 patients were identified as responders to ACTH. The postoperative cortisol levels were the same as those obtained by ACTH stimulation in highly and moderately stressful surgeries. The increases in postoperative IL-6 and CRP levels were greatest with major surgery, intermediate with moderate surgery, and least with minor surgery. Furthermore, plasma ACTH levels increased after major and moderate surgeries; however, there was no significant differences in postoperative serum IL-10 levels. Systemic inflammatory response syndrome (SIRS) was found in 11 of 17 patients (64.7%) who underwent major surgery and in 4 of 16 patients (25%) who underwent moderate surgery (p=0.037). The duration of SIRS was significantly longer in patients undergoing major surgery (62+/-20 hrs) than in patients undergoing moderate surgery (21+/-3 hrs, p=0.038). Postoperative complications were more frequent in patients undergoing major surgery (41.2%) than in patients undergoing moderate surgery (6.3%, p=0.039). Furthermore, there were significant differences in the length of the postoperative stay among the three groups (p<0.01). One nonresponder had serious postoperative inflammatory complications. These results suggest that a short ACTH stimulation test performed preoperatively is a helpful method for determining the maximal cortisol response to surgical trauma and to identify high-risk individuals and that a relative postoperative adrenal insufficiency may be closely related to the decreased cortisol secretion following major surgical trauma.
下丘脑 - 垂体 - 肾上腺轴是创伤后维持体内稳态的重要组成部分。重大手术创伤常引发强烈的炎症反应，导致脓毒症和器官功能障碍。本研究旨在评估不同程度手术创伤前后的肾上腺反应，并确定术后相对性肾上腺功能不全的发生率，该不全导致了常与术后并发症相关的明显炎症反应。51例手术患者被分为接受大手术、中等手术和小手术的组。在手术前及静息状态下，对每位患者进行短程促肾上腺皮质激素（ACTH）刺激试验。测定术后血清皮质醇、白细胞介素（IL）-6、IL-10、C反应蛋白（CRP）及血浆ACTH的浓度。51例患者中有50例被确定为对ACTH有反应者。在高应激和中等应激手术中，术后皮质醇水平与ACTH刺激后测得的水平相同。术后IL-6和CRP水平的升高在大手术中最大，中等手术中次之，小手术中最小。此外，大手术和中等手术后血浆ACTH水平升高；然而，术后血清IL-10水平无显著差异。17例接受大手术的患者中有11例（64.7%）发生全身炎症反应综合征（SIRS），16例接受中等手术的患者中有4例（25%）发生SIRS（p = 0.037）。接受大手术患者的SIRS持续时间（62±20小时）显著长于接受中等手术的患者（21±3小时，p = 0.038）。接受大手术患者的术后并发症（41.2%）比接受中等手术的患者（6.3%，p = 0.039）更频繁。此外，三组患者的术后住院时间存在显著差异（p < 0.01）。1例无反应者发生了严重的术后炎症并发症。这些结果表明，术前进行的短程ACTH刺激试验是确定手术创伤最大皮质醇反应及识别高危个体的有用方法，且术后相对性肾上腺功能不全可能与重大手术创伤后皮质醇分泌减少密切相关。
