Dexamethasone in Patients Undergoing Elective Laparoscopic Cholecystectomy Improves Postoperative Symptoms

Abstract

Surgeons are afraid of steroids. These magical hormones, so commonly used by internists for a wide variety of indications with proven efficacy, are responsible for significant side effects. And when these side effects are threatening to spoil the marvelous job the surgeon has just completed (wound infection, anastomotic leak), we easily look aside even when evidence is placed directly in our face. In this issue of WJS, Dr. Sanchez-Rodriguez and his colleagues present a nice, double-blind, prospective, randomized trial examining the efficacy of a single preoperative dose of dexamethasone to reduce adverse effects after laparoscopic cholecystectomy [1]. Not only postoperative nausea and vomiting (PONV) rate was reduced, but also other parameters such as pain and fatigue. Dexamethasone antiemetic effect is well known, and a quick Medline search (dexamethasone ? nausea) yielded 1,036 hits: 237 hits specifically related to PONV and 29 articles examined its effect after laparoscopic cholecystectomy. A recent meta-analysis examined 17 trials and concluded that dexamethasone is indeed superior to placebo in reducing PONV and pain after laparoscopic cholecystectomy [2]. Fatigue also was found to be reduced in another recent trial, without increasing the incidence of side effects related to the use of steroids [3]. With such abundance of data, one wonders how many practicing surgeons are aware of these benefits. If so, how many actually use prophylactic dexamethasone before laparoscopic cholecystectomy (or other operations), and if not, why not? It seems that the fear of steroids is not the main reason to avoid their use to improve the patient’s postoperative well being. A single dose is hardly harmful, which was repeatedly shown in many trials that examined the safety of such regimen. Many surgeons simply consider preoperative medications the responsibility of the anesthesiologist. They may prescribe antiemetic medications for the postoperative period; however, prevention of PONV is more effective than its treatment. Although the study by Sanchez-Rodriguez et al., like many previous similar studies, demonstrated the overall advantage of dexamethasone, the question still arises whether every patient should be treated, or is it possible to identify ‘‘high-risk’’ patients who can actually benefit from it. Several scores were created to stratify the risk of PONV, and the Apfel score [4] is probably simple and accurate enough to be incorporated into the preoperative evaluation. Four parameters (female gender, history of PONV or motion sickness, nonsmoking, and the use of postoperative opioids) are used to evaluate the risk, because universal PONV prophylaxis is probably not costeffective. It is not easy to change the practice of surgeons, especially in perioperative aspects that may be considered the responsibility of others. Nevertheless, we should remember that as surgeons we are responsible for the well being of our patients, and we are the team-leaders of the caregivers involved. Reducing PONV, pain, and fatigue is a worthy goal, and if dexamethasone is effective then it should be our responsibility to incorporate it into the premedication, probably by establishing an institutional protocol. If this study, however redundant and repetitive, gave some surgeons the extra push to change their practice, then it was worth publishing.