The plasma ACTH, AVP, CRH and catecholamine responses to conventional and laparoscopic cholecystectomy.

OBJECTIVES: We compared the responses of the stress hormones, cortisol, ACTH, vasopressin (AVP), corticotrophin releasing hormone (CRH) and catecholamines to elective conventional and laparoscopic cholecystectomy. DESIGN: A right upper quadrant transverse incision was used for conventional cholecystectomy, and four 1-2-cm incisions for the laparoscopic procedure (for insertion of surgical instruments, diathermy, fibreoptic telescope and light source, and carbon dioxide insufflation). Blood was sampled immediately prior to premedication (temazepam), after induction of anaesthesia (fentanyl and thiopentone) and at 10-minute intervals until the end of the procedure (N2O maintenance, vecuronium relaxation). A blood sample was taken after reversal, and then at 10-minute intervals for 50 minutes. Plasma sodium and blood pressure were measured at similar intervals. Results are expressed as mean +/- standard error. PATIENTS: Twelve patients were studied (six in each group). MEASUREMENTS: Peptide hormones were measured by radioimmunoassay, cortisol by ELISA and catecholamines by HPLC. RESULTS: The mean premedication hormone values for the conventional and laparoscopic procedures did not increase significantly after induction of anaesthesia. Within 10 minutes of the first incision, however, there was a marked concordant rise in mean plasma ACTH and AVP levels for both procedures (conventional: ACTH, from a premedication value of 10.2 +/- 1.7 to 80.1 +/- 14.3 pmol/l, AVP from 1.2 +/- 0.4 to 117 +/- 24 pmol/l, P < 0.01 for both hormones; laparoscopic: ACTH from 5.8 +/- 2.6 to 55.1 +/- 26.0 pmol/l, AVP from 1.6 +/- 0.11 to 49.2 +/- 27.09 pmol/l). At the end of both types of operation mean levels of ACTH and AVP were still elevated, although the ACTH: AVP ratio had increased. Greater variability in ACTH and AVP responses was seen in the laparoscopic than in the conventional procedure, three patients showing a relatively small response to surgery. Total secretion of ACTH during both types of surgery was not significantly less both during (P < 0.05), and after (P < 0.01) laparoscopic surgery. For both procedures, the timing of AVP and ACTH peaks was significantly related (P < 0.002). A small but significant rise in CRH was observed 30 minutes after the start of surgery for both procedures P < 0.05). The timing of CRH and ACTH peaks was unrelated. The maximum mean plasma cortisol level for the conventional procedure (1268 +/- 147 nmol/l) was reached 20 minutes after reversal of anaesthesia and remained at this level until the end of sampling. The cortisol response was comparable during the laparoscopic procedure but was beginning to fall at 60 minutes post-operatively. Plasma adrenaline responses to the two types of surgery were not significantly different, but the plasma total noradrenaline response to laparoscopic surgery as indicated by the response area during the first 20 minutes was significantly increased (P < 0.02). Plasma sodium, renin activity and initial systolic blood pressure fall were not significantly different during the two procedures. CONCLUSIONS: For both procedures, the peak of ACTH secretion after incision is likely to be AVP dependent, and the timing of peak levels of these two hormones was significantly related. Subsequent ACTH secretion may be the result of an interaction between AVP and CRH. Laparoscopic cholecystectomy results in a smaller AVP rise than does the conventional procedure, and plasma AVP falls more rapidly post-operatively. During the period of observation, ACTH, CRH, cortisol and adrenaline responses were not significantly lessened by the laparoscopic approach, but there was a significant increase in the noradrenaline response. Stress hormone monitoring may assist further improvements in surgical technique.

The blood pressure response to unilateral adrenalectomy in primary aldosteronism.

The factors determining the outcome of blood pressure after removal of the aldosterone-secreting adenoma in primary aldosteronism are largely unknown. We have studied the results of surgery in 21 patients with this disorder, all of whom were investigated and treated in a single referral centre, and evaluated the contributions of clinical, biochemical and pathological factors to blood pressure outcome. Blood pressure before surgery was high (mean 210/121 mmHg), but after an average period of 5.4 years 12 patients (60 per cent) were considered by their primary physician not to require antihypertensive medication and a further seven had reduced drug requirements. In only two patients was arterial pressure unimproved by surgery. Blood pressure recordings within six months of surgery were not a good predictor of later levels. Of the clinical, electrolyte, hormone and pathological features assessed, only the systolic pressure before surgery, and abnormalities in the optic fundi, correlated statistically with final blood pressure ranking. There was no relationship between the severity of vascular changes in the adrenal or kidney biopsy tissue and final blood pressure. These results show that while the blood pressure response to the removal of a single adrenal adenoma is usually good, it is not possible to predict accurately the final blood pressure response using these criteria.

Avulsion versus dissection and ligation of the varicose short saphenous trunk.

Avulsion of the varicose short saphenous trunk in the popliteal fossa is a safe, effective and cosmetic way of dealing with this type of venous incompetence. In addition it effects a great saving in time, a consideration of some importance in the surgical treatment of varicose veins.

Intestinal volvulus: a new concept.

A concept of the aetiology of intestinal volvulus is presented based on the fact that bowel when distended becomes elongated. The antimesenteric border of the bowel elongates more than the mesenteric border and this provides the driving force which initiates and sustains the volvulus. It is, therefore, a secondary event resulting from distention.

Lithium associated thyroid cancer.

This report documents papillary cell carcinoma of the thyroid occurring in a 55-year-old woman after three-and-a-half years of lithium therapy. She presented with unilateral thyroid enlargement causing tracheal deviation. There was no clinical suspicion of malignancy and the histological findings were totally unexpected.

Adrenal venography and sampling in the diagnosis and treatment of primary aldosteronism.

Adrenal venography and adrenal venous blood sampling for aldosterone and cortisol estimations have been attempted in eight patients with primary aldosteronism. The techniques accurately predicted the location of the aldosterone secreting tumour in all six patients in whom an adrenal vein cannulation was possible. The techniques are useful in the surgical management of solitary adrenal adenomas and are important in the choice of optimal therapy for the variety of disorders presenting as primary aldosteronism.