World J. Surg. 17, 601-607, 1993 O WORLD Journal of SURGERY 9 1993 by the Soci›233 Internationale de Chirurgie Endocrine-Metabolic Response to Abdominal Aortic Surgery: A Randomized Trial of General Anesthesia versus General Plus Epidural Anesthesia Harm J. Smeets, M.D., Job Kievit, M.D,, Frans T. Dulfer, B.Sc., and Jack W. van Kleef, M.D. Departments of General Surgery and Anesthesiology, University Hospital Leiden, Leiden, The Netherlands The influence of epidural anesthesia on the endocrine-metabolic response following abdominal aortic reconstruction was studied in a prospective randomized trial. Cortisoi and catecholamine responses and nitrogen balance were measured in two groups of rive patients receiving general anesthesia only (group 1) or generai anesthesia combined with epidural bupivacaine (group 2). The study l~ted from preoperatively until the first postoperative day. At 2100 hours on the day of surgery serum cortisol concentrations were higher in group 1 than in group 2 (1.41 versus 0.82 /zmol/L; p < 0.01). Likewise the total perioperative hypercortisolemia, expressed as the area under the curve, was significantly higher in group 1 (11.7 versus 5.7/zmol/L/hr, p < 0.01). Intraoperative urinary excretion of epinephrine and postoperative norepinephrine excretion were signifi- cantly higher in group 1 than in group 2. Urinary excretion of free cortisol and cumulative nitrogen balance were not different between the groups. AIthough the number of patients was limited and the sensory nerve block level was not measured perioperatively, this study suggests that epidural anesthesia attenuates the stress response to aortic surgery. Despite improvements in surgical practice and postoperative care, elective abdominal aortic reconstructive surgery is still associated with a high postoperative morbidity and mortality rate [1]. It has been suggested that, apart from surgical- technical problems, these complications may be related to the posttraumatic endocrine-metabolic response [2]. Attenuation of this endocrine-metabolic response might therefore reduce the frequency of postoperative complications, as some authors have reported [3, 4]. In several studies the endocrine-metabolic response follow- ing lower abdominal and lower extremity surgery was found to be attenuated by epidural anesthesia [5-8]. However, those articles that concern the influence of epidural anesthesia in abdominal aortic surgery report contradictory effects, although in these studies only cortisol response was measured [9, 10]. The effect of epidural anesthesia on catecholamine response after abdominal aortic surgery has not been investigated before. To elucidate the influence of epidurai anesthesia on cate- cholamine and cortisol responses following elective abdominal aortic reconstruction, we prospectively studied patients who Offprint requests: H.J. Smeets, M.D., Department of General Sur- gery, University Hospital Leiden, P.O. Box 9600, 2300RC Leiden, The Netherlands. were operated under general anesthesia with or without epi- dural anesthesia. Materials and Methods Population Participants for the study were recruited from maie patients undergoing elective infrarenal aortic reconstruction for aneu- rysm or occlusive disease between November 1988 and March 1989. Patients were not asked to participate if any of the following exclusion criteria were applicable: malnourishment (recent weight loss, albumin < 35 g/L, inappropriate food intake), proteinuria (> 1 g protein/L), urinary incontinence, hypertension (diastolic pressure > 100 mmHg), diabetes melli- tus (treated with oral antidiabetic medication, insulin, or both), lower limb ischemia (Fontaine grade III or IV), or use of one of the following medications: corticosteroids, cimetidine,/3-block- ers, or ketoconazole. After entry in the study patients were excluded if reoperation was necessary or if postoperative organ system failure occurred, as defined by Knaus et al. [11]. The study design was explained to all patients, and oral and written consent was obtained. Of the 17 patients operated, 11 complied with the entry criteria, and ail agreed to participate. Eleven patients were randomized for either general anesthe- sia (group 1, n = 6) or general anesthesia combined with epidural anesthesia (group 2, n -- 5) by selecting closed enve- lopes. As one patient in group 1 had to be excluded owing to an early reoperation for thrombosis of the aortic prosthesis, a total of l0 patients remained (rive patients in each group). The study was approved by the Leiden University Hospital Ethical Com- mittee. Anesthesia Technique Ail patients were premedicated with atropine 0.25 to 0.50 mg IM and temazepam 10 to 20 mg PO 30 to 60 minutes prior to surgery. In group 1 (general anesthesia only), general anesthe- sia was induced with fentanyl 2.5 ~g/kg and thiopentone 2 to 4 mg/kg. Suxamethonium 1 mg/kg or pancuronium 0.1 mg/kg was given to facilitate intubation of the trachea. Prior to intubation