Page 50 - CASA Bulletin of Anesthesiology 2022; 9(3)-1 (1)

CASA Bulletin of Anesthesiology

Perioperative organ injury: Impact and surgical outcomes

Lingzhi Wu, BSc, MRes and Daqing Ma, MD, PhD, FRCA, MAE

Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of
Medicine, Imperial College London, Chelsea & Westminster Hospital,
London SW10 9NH, UK

rd
Postoperative death currently ranks as the 3 greatest
contributor to death globally, with an estimated 4.2 million
1
deaths occurring within 30 days after surgery each year .
Increasing clinical evidence suggests that surgery per se could
inflict trauma and stress to the body to cause dysfunction or
failure of multiple organs (MOD/MOF) . Postoperative
2
MOD/MOF represents a formidable challenge to patient survival
and quality of life, and greater effort is required to understand
and monitor its development to improve long-term outcome.
Surgery-induced organ ischemia-reperfusion and systemic
inflammatory responses are believed to play important roles in
the pathogenesis of MOD/MOF .
3
It has long been found that major noncardiac surgery can be followed by dysfunction of
multiple organs, encompassing the cardiovascular, pulmonary, gastrointestinal and renal systems
3-6 . Within the first week to 30 days after noncardiac procedures (e.g. gastrointestinal, thoracic,
renal, or transplantation surgery), postoperative MOD can manifest distant from the site of
6
primary injury/operated organ and is often accompanied by excessive systemic inflammation .
The systemic inflammatory response syndrome (SIRS) was initially suggested to result from
surgery-associated microbial infection, later studies showed that postoperative SIRS developed
without detectable infection .
5
Hypoperfusion during/immediately after surgery is also considered to be the initiating event
in postoperative MOD, whereby multiple organs are subjected to ischaemia and subsequent
reperfusion. Ischaemia-reperfusion (I/R) injury leads to cellular death within solid organs and
activation of the resident immune cells. Controlled activation of the resident macrophages,
neutrophils and endothelial cells is normally beneficial against infection and enable repair;
however, over-activation will result in excessive production of pro-inflammatory cytokines .
7
The locally-produced cytokines act as “paracrine” or “spill over” into the systemic circulation to
reach distant organs (and resident immune cells) and/or activate circulating immune cells, thus
7
culminating to SIRS where multiple organs exhibit pathological inflammation and dysfunction .
Clinical and laboratory data strongly support the hypothesis of injurious cross-talk between vital
organs, whereby a “first-hit” injury to an organ inflicts a “second” injury in a distant
organ/system . One such example is the onset of respiratory failure in acute kidney injury (AKI)
8
patients, and the onset of renal dysfunction in lung injury patients. The development of kidney,
hepatic and cardiac injuries in pneumonic patients from the recent SARS-CoV-2 infection further
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