Dexamethasone Improves Postoperative Symptoms in Patients Undergoing Elective Laparoscopic Cholecystectomy: A Randomised Clinical Trial.

Patients and methods

Patients Between January 2007 and August 2008, 210 patients undergoing LC were studied in accordance with a prospective, randomized, double-blind clinical trial. Patients were randomized to receive intravenous dexamethasone (8 mg) or homologated placebo 60 minutes before skin incisions, using an equal number of blind envelopes. Patients of American Society of Anesthesiologists (ASA) classes III and IV were excluded. Further exclusion criteria were age more than 80 years; pregnancy; treatment with steroids; severe diabetes mellitus (HbA1c > 8%); use of opioids, sedatives or any kind of analgesics less than one week before LC; a history of alcohol or drug abuse; preoperative diagnosis of acute cholecystitis, acute pancreatitis, choledocolithiasis, gallbladder carcinoma and/or conversion of the LC to an open procedure. All patients were followed from hospital admission until 30 days after the surgical procedure.

Anesthesia and surgery All patients underwent a standardized general anesthesia procedure. Induction used intravenous midazolam (1.5 mg) and fentanyl (3-5 mcg/kg of body weight) and propofol (2 mg/kg body weight). Anesthesia was maintained with 2 to 3% sevoflurane and 100% oxygen concentration. Neuromuscular blocking was maintained with intravenous vecuronium (0.1 mg/kg body weight). All patients were monitored with indirect determinations of arterial pressure and heart rate using the standard technique as well as expired CO2 content and oxygen blood saturation. A nasogastric tube was placed in all patients during the operation and taken out at the end of the surgical procedure. Afterwards, all patients were extubated and transferred to the immediate postsurgical care unit with cardiovascular and oxygen monitoring.

All patients received preoperative intravenous antibiotics (1 g of intravenous first-generation cephalosporin). LC was performed using a 2-handed, 4-trocar technique with 2 10-mm ports and 2 5-mm ports. A 10-mm subumbilical port was introduced by the open method, subsequently creating a pneumoperitoneum, maintained at 12 to 14 mmHg of intra-abdominal pressure. All of the laparoscopic treatments were performed by expert surgeons, each having sufficient experience of laparoscopic surgery (more than 150 LCs per year). The skin was closed with single nonabsorbable sutures. Closed suction drains were placed in the inferior surface of the liver, using a 5-mm lateral port in some patients according to each surgeon's preference. The drains were removed during the following 12-24 h.

Analgesia and antiemetics Pain and fatigue were assessed preoperatively and immediately on return to the recovery room, and at 6, 12 and 24 h after the operation using a visual analogue scale (VAS; 0 = no pain/fatigue to 10 = most severe pain/fatigue) [7,15,16]. Analgesia was given as intravenous sodium ketorolac (30 mg every 8 h). Intramuscular buprenorphine (0.15-0.30 mcg) was used as a backup analgesic medication. The incidence of PONV was recorded immediately on return to the recovery room and at 6, 12 and 24 h, after the operation, using a four-point ordinal scale (0 = none, 1 = nausea, 2 = nausea with request for antiemetic, 3 = vomiting). Intravenous ondansetron (4-8 mg) was given for antiemetic treatment on demand.