Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial

Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial Mohammad Rashdan, Salam Daradkeh, Mutasim Al-Ghazawi, Jareer Heider Abuhmeidan, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2697210/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Sep, 2023 Read the published version in BMC Research Notes → Version 1 posted 4 You are reading this latest preprint version Abstract Objective We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers. Background The standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12–14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines. Methods A prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8–10 mmHg) vs. standard-pressure (12–14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022). Results one hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs 6, p -value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons. Conclusion low-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Clinical trial low pressure insufflation pneumoperitoneum laparoscopic cholecystectomy pain inflammatory marker Figures Figure 1 Figure 2 Figure 3 Introduction Laparoscopic cholecystectomy was first performed by professor Med Erich Mühe of Böblingen, Germany, on September 12, 1985. 1 It became the gold standard procedure to remove the gall bladder for different indications. 2 Majority of laparoscopic procedures require the creation of pneumoperitoneum to establish a working space, the standard pressure used is set at 12–15 mmHg. 3 Low pressure pneumoperitoneum is introduced with pressure set of 6–10 mmHg 4 has challenged to compare the complications and feasibility of standard pressure pneumoperitoneum. 5 , 6 Clinical trials have compared low pressure vs. standard in terms of perioperative complications, post-operative pain, hospital length of stay, stress response and surgeon comfort. 6 , 7 In this trail we conducted a randomized comparison between low pressure and standard pressure pneumoperitoneum for laparoscopic cholecystectomy in terms of postoperative pain, inflammatory markers, timing of surgery and surgeon comfort. This trial adds to the literature the extensive study of inflammatory markers associated with stress of surgery, and the surgeon comfort level along with safety of the procedure with performed by non-experienced surgeons (senior residents). Methodology The study has been reported in line with the CONSORT statement. 8 It is registered on ClinicalTrials.gov under the identifier NCT05530564 and approved by the hospital institutional review board (IRB). This is a clinical trial, designed to look for a statistical difference in pain and inflammatory markers after operation, comparing two parallel groups, with an allocation ratio of 1:1. Participants were eligible for the study if they were above the age of 12 years old, with low anaesthesia risk defined as American Society of Anaesthesiologists (ASA) score 1 or 2, and having symptomatic gallbladder stone disease whom were booked for elective laparoscopic cholecystectomy. The study is prospective, all patients admitted during the study period were assessed for eligibility, the study stopped enrolment when hundred eligible patients were selected. The enrolment period extended over a year, from January 2020 to January 2021. Patients not included in the study were those currently or previously diagnosed with acute cholecystitis confirmed by ultrasonography, or those who underwent previous upper gastrointestinal surgeries except bariatric and anti-reflux surgeries, or those currently on immunosuppressants, or currently diagnosed with drug addiction, also pregnant and breastfeeding females were excluded. Those in the intervention group were scheduled to undergo laparoscopic cholecystectomy at a low-pressure pneumoperitoneum defined as gas insufflation set point between 8–10 mmHg, and those in the control group were scheduled to undergo laparoscopic cholecystectomy at a standard-pressure pneumoperitoneum defined as gas insufflation set point between 12–14 mmHg. Pain scores were assessed using the 11-point short pain scale (SPS-11) according to patient perception at 6 hours, 12 hours, 24 hours, and 7th day post-operatively. The following inflammatory markers were investigated: white blood cell (WBC) count (10^3 cells/mm), platelet (Plt) count (10^9/L), erythrocyte sedimentation rate (ESR) (millimetres per hour), C reactive protein (CRP) level (mg/L), albumin (Alb) level (g/dL), free serum cortisol level (nmol/L), interlukein-6 (IL-6) level (pg/mL), interlukein-17 (IL-17) level (pg/mL), interlukein-1 beta (IL-1β) level (pg/mL), tumour necrosis factor alpha (TNF-α) level (pg/mL). Blood samples were withdrawn at the morning of surgery as baseline for all inflammatory markers. Four hours post-op cortisol levels were reassessed. Twenty-four hours post-op the remining markers were reassessed. The primary outcome of the trial was to look for a significant difference in pain on the 11-point short pain scale (SPS-11) at four set points 6-hour, 12-hour, 24-hour, and 7-days post-op. Also, to look for a significant change in the collected inflammatory markers from baseline, with a p -value set at 0.05. The secondary outcomes were to look for difference in surgery difficulty and operation time between the two groups. A convenient sample of 100 participants was decided, divided into 50 for each study arm. The two study arms were colour coded. The colour codes were used for randomization, data entry and analysis. All the participants, investigators, observers, and analyst were blinded to the colour code reference. After closure of the study, the colour codes were disclosed to the public. Allocation was random according to a pre-set computer-generated list. Patients found to have intra operative adhesions and evidence of previous inflammation were kept in the study, ensuring no previously documented diagnosis of acute cholecystitis. Method of pneumoperitoneum induction was left for the operating surgeon to decide as per trained, closed technique was done using veress needle, open technique was done with an infra-umbilical incision and insufflation of abdomen after 12 mm trocar insertion, optical technique utilized 12 mm optiview trocar. The trocars position was inserted for the four-trocar technique at 12 mm umbilical, 12 mm sub xiphisternum, 5 mm medial subcostal, and 5 mm lateral subcostal. For the three-trocar technique one 5 mm trocar was inserted subcostal instead of two. Each operator adhered to steps of safe laparoscopic cholecystectomy with use of critical view of safety method. The principal investigator ensured adherence to protocol and data validity. Records were reviewed monthly, and a progress summary written and provided to study regulatory every three months. Some patients where administered dexamethasone intravenously at time of surgery induction by anaesthesia team, so subgroup analysis for dexamethasone was done to eliminate its effect on the study results. Analysis was conducted using SPSS version 1.0.0.1406. Gender, smoking status, ASA score, and difficulty of surgery were analyzed using Chi-square cross table. Mean duration of total operative time, insufflation time, and mean hospital-stay were analyzed using Student’s 2-tailed t-test. The mean intensity of pain was analyzed using Mann-Whitney U test. Inflammatory markers (WBC, Plt, ESR, CRP, Albumin, Cortisol, IL-6, IL-17, TNF-α, IL-1β) levels were analyzed using Welch's t-test. Subgroup analysis for the inflammatory markers was done to eliminate the effect of dexamethasone given by anesthesia team at the time of anesthesia induction, analysis was done using Welch's t-test. All test set p -value was set at 0.05 to consider results significant. Results A hundred patients were included in the analysis, with 50 patients in each study arm (n = 50). (Graph 1) The sample was normally distributed. Age and BMI were analyzed using Student’s t-test (Table 1 ). Gender, smoking status, and ASA score were analyzed using Chi-square cross table analysis (Table 2 ) with a p -value set at 0.05. Table 1 Group characteristics I Low-pressure group Mean ± SD Standard-pressure group Mean ± SD * p -value Age (years) 43.82 ± 15.57 42.78 ± 13.53 0.722 BMI (kg/m 2 ) 29.33 ± 5.57 28.78 ± 5.56 0.620 No significant difference in mean between both groups in terms of age and BMI * p -value < 0.05 Table 2 Group characteristics II Low-pressure group n (%) Standard-pressure group n (%) * p -value Gender Male 13 (26%) 12 (24%) 0.500 Female 37 (74%) 38 (76%) Smoking status Smoker 19 (38%) 19 (38%) 0.582 Non-smoker 31 (62%) 31 (62%) ASA score I 25 (50% 21 (42%) 0.547 II 25 (50%) 29 (58% No significant difference in mean between both groups in terms of gender, smoking status and ASA score * p -value < 0.05 The mean duration of total operative time, insufflation time, and mean hospital-stay were similar across groups with no significant difference. Analysis done using Student’s t-test (Table 3 ) with a p -value of 0.05. Table 3 Operation observations Low-pressure group Mean ± SD Standard-pressure group Mean ± SD * p -value Total operative time (min) 55.0 ± 17.43 54.2 ± 19.67 0.830 Insufflation time (min) 44 ± 15.98 43.2 ± 18.20 0.807 Post-op hospital-stay (day) 1.08 ± 0.34 1.02 ± 0.14 0.253 No significant difference in mean between both groups in terms of total operative time, insufflation time and post-op hospital stay * p -value < 0.05 None of the groups had major intraoperative complications. Three patients in the low-pressure group had a change of pneumoperitoneum initial set of pressure: two patients due to operating surgeon inexperience (senior resident) and one due to uncommon anatomy of the callout’s triangle. None had conversion to open cholecystectomy, none had more than minor intra-op blood loss, and none of the patients died during the study period. Four patients were readmitted within the 30-day period post-op: one patient from the standard-pressure group had severe vomiting and electrolyte disturbance that required in-hospital fluid resuscitation, two patients from the low-pressure group developed obstructive jaundice secondary to common bile duct (CBD) stones that required endoscopic intervention, another patient from the low-pressure group developed small bowel obstruction secondary to trocar site evisceration which was treated with reoperation and laparoscopic repair. There was no significant difference in difficulty of surgery between low-pressure and standard-pressure groups, with a p -value of 0.2 obtained using Chi-square cross table (Table 4 ). As the trial was conducted in a teaching hospital, surgeries were done by three different types of operating surgeons: consultants, surgery fellows, and senior residents. The settings of operation were not adjusted for the study, and surgeon level of experience was chosen randomly. It was observed that no significant correlation between operator level and surgery difficulty ( p -value = 0.369) using spearmen correlation, Spearman’s correlation (-0.091) for all cases, Spearman’s correlation (-0.221) for low-pressure group, Spearman’s correlation (-0.039) for Standard-pressure group. Table 4 Difficulty of surgery and operator level of experience Low-pressure group n (%) Standard-pressure group n (%) * p -value Difficulty of surgery Easy 33 (66%) 38 (76%) 0.371 Moderate 15 (30%) 8 (16%) Difficult 2 (4%) 4 (8%) Operator level of experience Consultant 18 (36%) 13 (26%) 0.352 Fellow 1 (2%) 2 (4%) Resident 31 (62%) 35 (70%) No significant difference between both groups in terms of surgery difficulty and operator level of experience. * p -value < 0.05 The mean intensity of pain was lower and showed significant difference at the 6-hour post-op time point in the low-pressure group with a p -value of 0.021 obtained using Mann-Whitney U test. (Table 5 ) (Fig. 1 , Fig. 2 ) Total analgesia count administered post-op showed no significant difference across groups ( p -value = 0.412) but the median count was lower in the low-pressure group. Table 5 Post-operative pain score Low-pressure group (Median pain score) Standard-pressure group (Median pain score) * p -value Post-op timing 6-hour 5 6 * 0.021 12-hour 3 4 0.441 24-hour 2 3 0.273 7th -day 0 1 0.294 A significant difference was observed between the two groups in pain score collected at 6-hour post-op time point with a p -value of 0.021 0.05). * p -value < 0.05 Inflammatory markers were assessed pre and post operatively for both groups using Welch's t-test and a p -value set at 0.05 (Table 6 ). A significant difference was observed in free serum cortisol levels with a p -value of 0.003, favoring a significant reduction of cortisol in standard pressure group with a value of 189.7 ± 306.9 (mean ± SD), compared to a value of 1.064 ± 309.64 (mean ± SD) in the low-pressure group. (Fig. 3 ) Table 6 Inflammatory markers levels Marker Timing Low-pressure group Standard-pressure group p -value Count Mean ± SD Count Mean ± SD WBC Pre op 48 7.52 ± 2.4 47 7.85 ± 2.26 0.49 Post op 48 10.0 ± 4.1 47 10.39 ± 2.9 0.62 ∆ WBC 48 2.49 ± 3.64 47 2.53 ± 2.37 0.96 Platelet Pre op 48 284.167 ± 6 9.94 47 275.91 ± 77.41 0.58 Post op 48 271.188 ± 88.38 47 269.94 ± 81.65 0.94 ∆ Plt 48 -12.979 ± 53.48 47 -5.98 ± 35.63 0.45 ESR Pre op 43 16.54 ± 12.1 43 18.98 ± 18.1 0.46 Post op 42 20.66 ± 13.74 43 22.93 ± 16.36 0.49 ∆ ESR 43 3.65 ± 7.38 43 3.95 ± 8.65 0.86 CRP Pre op 47 4.5 ± 5.51 47 6.41 ± 8.135 0.18 Post op 47 18.85 ± 15.57 47 23.1 ± 39.45 0.49 ∆ CRP 47 14.355 ± 13.84 47 16.68 ± 38.08 0.69 Albumin Pre op 47 4.42 ± 0.333 48 4.512 ± 0.28 0.144 Post op 47 4.16 ± 0.34 48 4.25 ± 0.31 0.186 ∆ Alb 47 -0.26 ± 3.461 48 -0.265 ± 0.257 0.934 Cortisol Pre op 50 380.26 ± 228.47 49 496.17 ± 236.59 *0.015 Post op 50 381.3 ± 272.73 49 306.48 ± 242.51 0.153 ∆ cortisol 50 1.064 ± 309.64 49 -189.7 ± 306.9 *0.003 IL-6 Pre op 45 27.82 ± 121.944 32 2.82 ± 9.643 0.25 Post op 45 2.92 ± 4.05 32 4.89 ± 10.62 0.26 ∆ IL-6 45 -24.892 ± 121.5 32 2.079 ± 5.693 0.214 IL-17 Pre op 45 27.977 ± 42.83 32 18.735 ± 25.290 0.28 Post op 45 28.77 ± 44.686 32 17.93 ± 25.219 0.22 ∆ IL-17 45 0.794 ± 5.253 32 -0.804 ± 5.273 0.193 IL1-β Pre op 45 50.344 ± 131.901 32 41.73 ± 84.911 0.74 Post op 45 20.2622 ± 54.99 32 31.42 ± 48.203 0.359 ∆ IL-1 β 45 -30.082 ± 134.3 33 -9.99 ± 91.968 0.461 TNF-α Pre op 45 84.36 ± 89.982 32 89.305 ± 107.856 0.827 Post op 45 50.44 ± 63.089 32 47.099 ± 45.122 0.798 ∆ TNF-α 45 -33.916 ± 99.85 33 -40.926 ± 103.05 0.763 * p -value < 0.05 Subgroup analysis was done to eliminate the effect of dexamethasone administered by anesthesia team at the time of anesthesia induction. Patients were classified into two groups: those that were given dexamethasone and those who were not (Graph 2). Analysis done using Welch's t-test. The results showed persistence of significant difference in the free serum cortisol level in favor of standard pressure group. (Table 7 , Table 8 ) Table 7 Inflammatory markers levels, subgroup analysis for dexamethasone Marker Timing Low-pressure group Standard- pressure group no Dexamethasone group Count Mean ± SD Count Mean ± SD p-value WBC Pre op 22 8.10 ± 2.63 19 8.10 ± 1.66 1.00 Post op 22 10.94 ± 3.529 19 10.18 ± 2.84 0.45 ∆ WBC 22 2.845 ± 3.824 19 2.082 ± 2.094 0.44 Platelet Pre op 22 297.909 ± 59.063 19 278 ± 61.24 0.297 Post op 22 277.86 ± 65.44 19 265.421 ± 65.47 0.55 ∆ Plt 22 -20.045 ± 46.781 19 -12.579 ± 29.77 0.553 ESR Pre op 21 17.00 ± 12.87 17 21.94 ± 16.854 0.308 Post op 20 20.15 ± 13.27 17 24.82 ± 12.177 0.275 ∆ ESR 21 2.190 ± 8.45 17 2.88 ± 8.49 0.804 CRP Pre op 21 4.27 ± 5.57 19 6.06 ± 5.04 0.296 Post op 21 17.48 ± 13.23 19 24.416 ± 29.450 0.335 ∆ CRP 21 13.209 ± 13.524 19 18.352 ± 27.200 0.447 Albumin Pre op 21 4.353 ± 0.357 19 4.405 ± 0.243 0.598 Post op 21 4.07 ± 0.3422 19 4.154 ± 0.305 0.416 ∆ Alb 21 -0.283 ± 0.2806 19 -0.251 ± 0.243 0.697 Cortisol Pre op 23 366.47 ± 258.39 20 418.459 ± 177.04 0.453 Post op 23 339.822 ± 243.71 20 369.498 ± 249.383 0.69 ∆ cortisol 23 -26.651 ± 238.62 20 -48.96 ± 314.793 0.793 IL-6 Pre op 19 2.32 ± 6.780 13 4.845 ± 14.605 0.515 Post op 19 3.246 ± 5.155 13 7.69 ± 15.245 0.245 ∆ IL-6 19 0.9178 ± 9.182 13 2.852 ± 6.596 0.520 IL-17 Pre op 19 38.00 ± 55.22 13 30.736 ± 24.985 0.661 Post op 19 39.563 ± 58.054 13 28.856 ± 25.355 0.538 ∆ IL-17 19 1.555 ± 7.557 13 -1.88 ± 7.951 0.226 IL-1β Pre op 19 34.272 ± 49.926 13 28.8215 ± 29.233 0.726 Post op 19 5.863 ± 10.926 13 21.04 ± 33.632 0.075 ∆ IL-1β 19 -28.40 ± 51.707 13 -7.781 ± 45.879 0.256 TNF-α Pre op 19 81.231 ± 78.524 13 70.49 ± 45.222 0.66 Post op 19 41.5684 ± 34.556 13 45.971 ± 57.77 0.789 ∆TNF-α 19 -39.66 ± 70.3148 13 -24.520 ± 74.122 0.563 Showing difference in inflammatory markers for patients not given dexamethasone injection at induction of surgery. No significant difference was observed across groups. * p -value < 0.05 Table 8 Inflammatory markers levels, subgroup analysis for dexamethasone Marker Timing Low-pressure group Standard-pressure group Dexamethasone group Count Mean ± SD Count Mean ± SD p-value WBC Pre op 26 7.0412 ± 2.069 28 7.69 ± 2.610 0.317 Post op 26 9.247 ± 4.5 28 10.526 ± 2.976 0.22 ∆ WBC 26 2.206 ± 3.543 28 2.834 ± 2.53 0.455 Platelet Pre op 26 272.538 ± 77.206 28 274.5 ± 87.775 0.931 Post op 26 265.538 ± 104.95 28 273.00 ± 92.06 0.782 ∆ Plt 26 -7.00 ± 85.80 28 -1.500 ± 38.99 0.685 ESR Pre op 22 16.09 ± 11.592 26 17.04 ± 19.055 0.840 Post op 22 21.14 ± 14.44 26 21.69 ± 18.725 0.910 ∆ ESR 22 5.045 ± 6.051 26 4.654 ± 8.845 0.861 CRP Pre op 26 4.681 ± 5.577 28 6.66 ± 9.780 0.371 Post op 26 19.96 ± 17.40 28 22.2 ± 45.514 0.815 ∆ CRP 26 15.280 ± 14.291 28 15.54 ± 44.437 0.977 Albumin Pre op 26 4.47 ± 0.31 29 4.582 ± 0.285 0.176 Post op 26 4.231 ± 0.32 29 4.31 ± 0.297 0.364 ∆ Alb 26 -0.241 ± 0.396 29 -0.269 ± 0.27 0.711 Cortisol Pre op 27 392.01 ± 203.88 29 549.77 ± 259.61 *0.015 Post op 27 416.68 ± 295.131 29 263.023 ± 232.00 *0.034 ∆ cortisol 27 24.674 ± 362.285 29 -286.74 ± 265.36 *0.001 IL-6 Pre op 26 46.44 ± 159.00 19 1.43 ± 3.60 0.225 Post op 26 2.69 ± 3.11 19 2.98 ± 5.44 0.220 ∆ IL-6 26 -43.75 ± 158.211 19 1.551 ± 5.10 0.520 IL-17 Pre op 26 20.65 ± 30.01 19 10.52 ± 22.59 0.223 Post op 26 20.88 ± 30.57 19 10.46 ± 22.84 0.217 ∆ IL-17 26 0.238 ± 2.584 19 -0.067 ± 2.081 0.674 IL-1β Pre op 26 62.09 ± 168.78 19 50.56 ± 107.91 0.795 Post op 26 30.78 ± 70.46 19 38.53 ± 55.82 0.694 ∆ IL-1β 26 -31.304 ± 172.62 19 -11.428 ± 113.624 0.641 TNF-α Pre op 26 86.64 ± 98.98 19 102.177 ± 135.06 0.658 Post op 26 56.93 ± 77.7 19 47.87 ± 35.77 0.639 ∆ TNF-α 26 -29.717 ± 118.08 19 -51.59 ± 118.796 0.538 Showing difference in inflammatory markers for patients given dexamethasone injection at induction of surgery. Significant difference in cortisol level was observed across groups. * p -value < 0.05 Discussion Until today, there is no consensus on the standard pressure to operate during laparoscopic surgeries, but majority of surgical societies agrees on “the lowest intra-abdominal pressure allowing adequate exposure of the operative field rather than a routine pressure” to be used. 9 Low-pressure pneumoperitoneum, defined in literature as pressure of 10 mmHg or less, has been used to avoid the adverse physiological effects of intra-abdominal gas insufflation. 10 , 11 This trial has been designed to assess laparoscopic cholecystectomy operated at a low-pressure pneumoperitoneum with a set pressure between 8–10 mmHg compared to a standard of 12–14 mmHg. The study design added to its strength, validity and generalisability being a prospective, randomised, double-blinded controlled clinical trial. But the study was limited to patients with low-anaesthesia risk of ASA score I and II and non-complicated gallbladder disease. As the study was conducted at a teaching hospital, the difficulty of surgery could be assessed when operated by non-experienced surgeons in contrary to other trials that required low-pressure pneumoperitoneum surgeries to be operated by experienced surgeons. In our study sample, majority of the operations was done by non-experienced surgeons (senior residents), the distribution of surgeries done by residents was non-significantly different between the two groups. We found no correlation between the surgery difficulty and level of operator experience, indicating that low-pressure pneumoperitoneum surgery is feasible in the hands of non-experienced surgeons. Regarding the safety of low-pressure pneumoperitoneum, Mandal et.al. found no significant increase in terms of difficulty of surgery, conversion rate, or post-op complication rate of low-pressure pneumoperitoneum when done in the hands of experienced surgeon. They found that the operative visual field was also not compromised. 12 Hua et.al had similar results. 10 Our trial supports similar results even in the hands of non-experienced surgeons. Mahajan et.al suggested to standardize low-pressure laparoscopic cholecystectomy in day care surgery, as they found the procedure to be safe and feasible, with no significant difference when compared to standard pressure pneumoperitoneum in terms of adequacy of surgical field, contact of parietal peritoneum to the underlying viscera during secondary port insertion, duration of surgery, complication rates, and surgery difficulty. 13 In this trial the total operative time, insufflation time and total hospital stay was similar across both groups. None of the patients had major intraoperative complication, 30-day mortality rate was zero in both groups, only 3 patients in the low-pressure group had a change from initial set pressure point, and 4 patients required re-admission within the 30-day period post-op, none of the reasons for readmission were significant nor resulted a long-term morbidity. The benefits of operating at a low-pressure pneumoperitoneum are many and reported in multiple clinical trials 11 . Post operative pain is thoroughly studied, many reported a significant reduction of post-op pain and shoulder tip pain post laparoscopic cholecystectomy among patients operated at a low-pressure pneumoperitoneum 10 , 14 – 16 . Although, a recent study by Chang et.al. reported contradicting results of no significant difference in postoperative pain when operating at various pneumoperitoneum pressures, including low and very low pressures. 17 Moro et.al reported similar results. 18 Our results on pain supports the added benefit of low-pressure pneumoperitoneum of decreased pain perception post-op, our four chosen pain assessment points showed lower median pain score in the low pressure group, with a significant difference observed at the 6-hour post-op point. The total analgesia administered post-op was lower in the low-pressure group, but we could not find a significant difference. Some other clinical trials also showed a significant reduction of post operative nausea, early resumption of oral feeding and hospital stay in low-pressure groups. 1012 In observing the hemodynamic effects of reduced pressure pneumoperitoneum, the heart rate, mean arterial pressure and end tidal carbon dioxide is found to have variation intraoperatively. 4 There were contradicting results of decreased vs no impact of low-pressure pneumoperitoneum on those parameters. Dr. Vidyanand Tripathi et.al found an increase of heart rate in standard-pressure group after 10 mins of surgery that was demonstrated in the low-pressure group, but this difference is not statistically significant. 19 Singh et.al demonstrated a significant difference after 10 mins of surgery, and a significant difference in systolic and diastolic blood pressure after 30 mins of surgery. 20 However, a study by Kanwer et al did not find any statistical difference in systolic or diastolic blood pressure. 21 The study of hemodynamic effects of low-pressure pneumoperitoneum was out of scope and not reported in this trial. The use of low-pressure pneumoperitoneum also demonstrated a reduced effect on derangement of hepatic blood flow 22 , and significant reduction in the rise of liver enzymes. 23 Neogi et.al could observe a rise of bilirubin and liver enzymes 24 hours post-op in standard-pressure pneumoperitoneum that is not demonstrated in low-pressure group, 24 recommending the use of low-pressure pneumoperitoneum in patients with impaired hepatic function. Our clinical trial did not study such effects. The effect on immune response has been reported in few studies only, our trial was focused on ten inflammatory mediators affected by the stress of surgery. Schietroma et.al. observed a significant decrease in interleukin IL-1, IL-6, and CRP. 25 Basgul et al. observed a significant lower increase in IL-6 up to 24 h after surgery, yet higher levels of IL-2 during low-pressure pneumoperitoneum. 26 In the contrary, some other trials failed to detect a benefit. 27 , 28 We in this trial could detect a reduction of 8 out of 10 inflammatory markers in the low-pressure group, but the difference was not significant. Regarding cortisol hormone levels, the difference was significant but in favour of standard-pressure pneumoperitoneum group, this contradicting result from what is expected could be due to our poor understanding of cortisol as a stress hormone 29 and the effect of diurnal variation on the interpretation of its levels. 30 We failed to report if the surgery was done in morning or evening, as so a subgroup analysis to eliminate the diurnal variation could not be done. The levels of cortisol were assessed at morning of surgery day for all patients, but the post-op levels were assessed at a 4-hour point after the end of surgery defined as deflation of the abdomen. The rational of choosing this point is based on the known rise of cortisol as early as 4–6 hours post major surgeries. 31 32 This trial was limited to laparoscopic cholecystectomy, but in reviewing the literature we found that the beneficial effects of low-pressure pneumoperitoneum have been exploited to other surgeries. The PAROS 6 and RECOVERY 33 trials are two trials that were made to study the effects of low-pressure pneumoperitoneum in laparoscopic colectomy in regards to pain, hospital stay, and quality of recovery. Their results are not published yet. Also, in laparoscopic pelvic surgeries it was shown that various pneumoperitoneum pressures affect the level of ovarian hormones, and this effect was observed during the first menstrual cycle post-surgery and vanishes as going towards the third menstrual cycle. 34 In laparoscopic nephrectomy, Dita Aditianingsih et.al demonstrated an attenuation of the inflammatory response, including IL- 6, in the low-pressure pneumoperitoneum group (8 mmHg) compared to standard-pressure (12 mmHg). 35 In conclusion, this clinical trial demonstrated a reduction of pain and inflammatory markers post laparoscopic cholecystectomy in patients operated at a low-pressure (8–10 mmHg) compared to a standard-pressure (12–14 mmHg), although the difference was not significant except for the 6-hour post-op pain scores. No significant difference could be observed between the two groups regarding total surgery time, also the difficulty of surgery was not significant even in the hands of non-experienced surgeons. Thereby we recommend a larger trial to confirm the benefits of low-pressure pneumoperitoneum to establish a new standard of care in laparoscopic cholecystectomy and other similar procedures utilising intra-abdominal insufflation, and to extend the benefits to high anaesthesia risk patients such as elderly. Declarations Ethics approval and consent to participate: The study has been approved by The University of Jordan Institutional Review Board (IRB). It has been reported in line with the CONSORT statement and Helsinki declaration. The study has been registered on ClinicalTrials.gov under the identifier NCT05530564 on September 7 th , 2022. Written informed consent was obtained from participants before enrolment in the study. Consent for publication: Not applicable. Availability of data and material: All data generated or analysed during this study is included in this published article. Competing interests: The authors declare they have no competing interests. Funding: This trial received funding from The University of Jordan/ Deanship of Scientific Research, Grant number 1169. Authors' contributions: M.R. is the main investigator and surgeon, S.D. is the secondary investigator and surgeon, A.M ensured accuracy of lab results, M.G. and J.H.A did data analysis, tables and charts generation, GO did data collection and was the study financial manager, M.Q. written the introduction section and part of literature review, I.S. did data collection, writing the title page, and reviewed references, S.H., L.S., S.S., Y.B. and M.S. did data collection, T.G. wrote the result section, H.M. is the site manager, data collection, protocol writing, written the abstract and discussion sections. All authors reviewed the manuscript. Acknowledgements: The authors thank Jordan University Hospital clerks and laboratory staff for the ease they provided in conducting this research. References Reynolds WJ. The first laparoscopic cholecystectomy. JSLS J Soc Laparoendosc Surg . 2001;5(1):89-94. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new “gold standard”? Arch Surg . 1992;127(8):913-917. doi:10.1001/archsurg.1992.01420080051008 Hypólito OHM, Azevedo JLMC, de Lima Alvarenga Caldeira FMS, et al. Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar. Surg Endosc . 2010;24(7):1663-1669. doi:10.1007/s00464-009-0827-2 Özdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer GJ, Pouwels S, Wever KE, Warlé MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc . 2016;30(5):2049-2065. doi:10.1007/s00464-015-4454-9 Gohil A. Comparison of low pressure versus standard pressure pneumoperitoneum for elective laparoscopic cholecystectomy in a tertiary care institute of western India. Int Surg J . 2018;5(5):1776. doi:10.18203/2349-2902.isj20181569 Celarier S, Monziols S, Francois MO, et al. Randomized trial comparing low-pressure versus standard-pressure pneumoperitoneum in laparoscopic colectomy: PAROS trial. Trials . 2020;21(1). doi:10.1186/s13063-020-4140-7 Bhattacharjee HK, Jalaludeen A, Bansal V, et al. Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial. Surg Endosc . 2017;31(3):1287-1295. doi:10.1007/s00464-016-5108-2 Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ . 2010;340. doi:10.1136/bmj.c332 S EAE, Neudecker J, Sauerland S, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Published online 2002:1121-1143. doi:10.1007/s00464-001-9166-7 Hua J, Gong J, Yao L, Zhou B, Song Z. Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: A systematic review and meta-analysis. Am J Surg . 2014;208(1):143-150. doi:10.1016/j.amjsurg.2013.09.027 Laarhoven KCJHM Van, Scheffer G, Pouwels S, Wever KE, Warle MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Published online 2016:2049-2065. doi:10.1007/s00464-015-4454-9 Mandal A, Ghosh A, Bakshi S. Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy: a comparative study. Int Surg J . 2020;7(5):1551. doi:10.18203/2349-2902.isj20201868 Mahajan S, Shankar M, Garg VK, Gupta V, Sorout J. Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study. Int Surg J . 2017;4(11):3679. doi:10.18203/2349-2902.isj20174885 Access O. Comparison of low and standard pressure gas injection at abdominal cavity on postoperative nausea and vomiting in laparoscopic cholecystectomy. 2014;30(5):1083-1087. Agarwal L, Kumawat S, Jain SA, Yadav A, Sharma S. Correlation of shoulder tip pain in case of low pressure and standard pressure pneumoperitoneum post laparoscopic cholecystectomy. Int Surg J . 2021;8(5):1522. doi:10.18203/2349-2902.isj20211820 Barczyński M, Herman RM. A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc . 2003;17(4):533-538. doi:10.1007/s00464-002-9121-2 Chang W, Yoo T, Cho WT, Cho G. Comparing postoperative pain in various pressure pneumoperitoneum of laparoscopic cholecystectomy: A double-blind randomized controlled study. Ann Surg Treat Res . 2021;100(5):276-281. doi:10.4174/astr.2021.100.5.276 Moro ET, Pinto PCC, Neto AJMM, et al. Quality of recovery in patients under low- or standard-pressure pneumoperitoneum. A randomised controlled trial. Acta Anaesthesiol Scand . 2021;65(9):1240-1247. doi:10.1111/aas.13938 Dr. Vidyanand Tripathi, Dr. Angela B Marak, Dr. Resen Rajan S Methikkalam, Dr. Y Priyabarta Singh, Dr. S Tombisana, Prof. S Ranita Devi PGSM. A Comparative Study Between The Low Pressure Versus Standard Pressure Pneumoperitoneum In Laparoscopic Cholecyst... J Dent Med Sci . 2020;19(7):01-10. doi:10.9790/0853-1907140110 Sodhi KS, Saxena AK, Ahuja CK, Rao K, Menon P, Kandelwal N. Postoperative appearances of esophageal atresia repair: retrospective study of 210 patients with review of literature - what the radiologist should know. Acta Radiol . 2013;54(2):221-225. doi:10.1258/ar.2012.120274 Kanwer DB, Kaman L, Nedounsejiane M, Medhi B, Verma GR, Bala I. Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy--a randomised controlled trial. Trop Gastroenterol . 2009;30(3):171-174. Özdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer G-J, Pouwels S, Wever KE, Warlé MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc . 2016;30(5):2049-2065. doi:10.1007/s00464-015-4454-9 Aggarwal M, Kumar A, Garg S, Pruthi A, Resident S. Effect of Low Pressure Versus High Pressure Pneumoperitoneum on Liver Functions in Laparoscopic Cholecystectomy. Int J Anat Radiol Surg . 2020;9(2):01-03. Neogi P, Kumar P, Kumar S. Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Surg Laparosc Endosc Percutan Tech . 2020;30(1):30-34. doi:10.1097/SLE.0000000000000719 Schietroma M, Carlei F, Mownah A, et al. Changes in the blood coagulation, fibrinolysis, and cytokine profile during laparoscopic and open cholecystectomy. Surg Endosc . 2004;18(7):1090-1096. doi:10.1007/s00464-003-8819-0 Basgul E, Bahadir B, Celiker V, Karagoz AH, Hamaloglu E, Aypar U. Effects of low and high intra-abdominal pressure on immune response in laparoscopic cholecystectomy. Saudi Med J . 2004;25(12):1888-1891. Perrakis E, Vezakis A, Velimezis G, et al. Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech . 2003;13(4):245-249. doi:10.1097/00129689-200308000-00004 Torres K, Torres A, Staśkiewicz GJ, Chrościcki A, Loś T, Maciejewski R. A comparative study of angiogenic and cytokine responses after laparoscopic cholecystectomy performed with standard- and low-pressure pneumoperitoneum. Surg Endosc . 2009;23(9):2117-2123. doi:10.1007/s00464-008-0234-0 Manou-Stathopoulou V, Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. Br J Anaesth . 2019;123(5):570-583. doi:10.1016/j.bja.2019.08.011 Kwon YS, Jang JS, Hwang SM, Tark H, Kim JH, Lee JJ. Effects of surgery start time on postoperative cortisol, inflammatory cytokines, and postoperative hospital day in hip surgery: Randomized controlled trial. Medicine (Baltimore) . 2019;98(24):e15820. doi:10.1097/MD.0000000000015820 Burton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. Contin Educ Anaesth Crit Care Pain . 2004;4(5):144-147. doi:10.1093/bjaceaccp/mkh040 Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med . 1987;147(7):1273-1278. Albers KI, Polat F, Panhuizen IF, et al. The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): Study protocol for a randomized controlled . Trials . 2020;21(1). doi:10.1186/s13063-020-04496-8 Qin J, Song G, Jiang Y, Liu Q, Lin H. Low-pressure pneumoperitoneum reduces influence on ovarian hormones in infertile women: A randomised trial. Ann Palliat Med . 2021;10(5):5746-5753. doi:10.21037/apm-21-476 Aditianingsih D, Mochtar CA, Lydia A, et al. Effects of low versus standard pressure pneumoperitoneum on renal syndecan-1 shedding and VEGF receptor-2 expression in living-donor nephrectomy: A randomized controlled study. BMC Anesthesiol . 2020;20(1). doi:10.1186/s12871-020-0956-7 Graphs Graphs 1 and 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files G1.png Graph 1: Patients flow chart G2.png Graph 2: subgroup analysis for dexamethasone effect Cite Share Download PDF Status: Published Journal Publication published 28 Sep, 2023 Read the published version in BMC Research Notes → Version 1 posted Editorial decision: Major revision 23 Mar, 2023 Editor assigned by journal 23 Mar, 2023 Submission checks completed at journal 20 Mar, 2023 First submitted to journal 15 Mar, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2697210","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":184864994,"identity":"add28f8f-89bc-420a-b79c-c164427bb76c","order_by":0,"name":"Mohammad Rashdan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBAC+wYGNgYeBgZmIGpg+MDAkEBQi8EBiBZ2BgbGxsYZpGjhB2lp5iFKy/Hjzx68qbkjLd9+sP2xbZtdHj97A+OHjzl4/NKTY24459gzY4MziY3NuW3JxZI9B5glZ27DrcWOIYdNmoftcLIBA1gLc+KGGwlszLx4tBjzP38mzfPvcP38/oeNzZZt9YS1GM5IMJPmbTvMzHADaAtj22HCWgxuvDGTnNt3mNngxsPGmT3njifO7DnYjNcvBufTn0m8+XaYWb4/+cCHH2XVif3szQc/fMSjBRUwsoHJBmLVg8AfUhSPglEwCkbBSAEAfx5azYdfGeoAAAAASUVORK5CYII=","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Rashdan","suffix":""},{"id":184864998,"identity":"3cce00ae-9170-44be-9c88-2e9cc0bc9bd2","order_by":1,"name":"Salam Daradkeh","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Salam","middleName":"","lastName":"Daradkeh","suffix":""},{"id":184864999,"identity":"1cee3905-e92e-408d-a3d3-fff6afddd61b","order_by":2,"name":"Mutasim Al-Ghazawi","email":"","orcid":"","institution":"The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mutasim","middleName":"","lastName":"Al-Ghazawi","suffix":""},{"id":184865002,"identity":"0c229782-459e-48c5-923d-047735af1ab9","order_by":3,"name":"Jareer Heider Abuhmeidan","email":"","orcid":"","institution":"Dr. Mohammed Alfagih Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jareer","middleName":"Heider","lastName":"Abuhmeidan","suffix":""},{"id":184865003,"identity":"3110a93c-6ac7-41d3-97e9-6ccd27353758","order_by":4,"name":"Azmi Mahafthah","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azmi","middleName":"","lastName":"Mahafthah","suffix":""},{"id":184865004,"identity":"ff8d2f2c-6fc1-474c-a931-9ad9e8044efc","order_by":5,"name":"Ghada Odeh","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ghada","middleName":"","lastName":"Odeh","suffix":""},{"id":184865005,"identity":"d4e5d640-1a48-4fe7-b6f2-f6e67278f4e7","order_by":6,"name":"Mohammad Al-Qaisi","email":"","orcid":"","institution":"King Hussein Cancer Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Al-Qaisi","suffix":""},{"id":184865006,"identity":"943c4b1b-47e7-4d54-9f8c-bc013fb1d1af","order_by":7,"name":"Ikram Salameh","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ikram","middleName":"","lastName":"Salameh","suffix":""},{"id":184865007,"identity":"50f6fac6-4a2f-483b-861d-6cbc80f5cec4","order_by":8,"name":"Shahed Halaseh","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shahed","middleName":"","lastName":"Halaseh","suffix":""},{"id":184865008,"identity":"5cd9c945-79bd-435a-b7e5-3f8cd65b6fc6","order_by":9,"name":"Lana Al-Saba","email":"","orcid":"","institution":"Jordan University Hospital, The University of Jordan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lana","middleName":"","lastName":"Al-Saba","suffix":""},{"id":184865009,"identity":"6a826730-ecaf-424c-8d95-f6998cf8a297","order_by":10,"name":"Yousef B. 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A difference is observed at the 6-hour time point, but the mean of pain score at 12-hour and 24-hour time points is equal\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/00c9bc4134db6bff315bd900.png"},{"id":34654937,"identity":"574380ac-0f4b-4ec4-b68c-54066cc3989c","added_by":"auto","created_at":"2023-03-22 14:45:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64776,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBox plot of post-operative pain at 6-houre\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eshowing box plot of pain score at 6-hour time point, the horizontal line represents median score which is different between the two groups\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/2853adf39f3627d850f0795a.png"},{"id":34654935,"identity":"3e6151c7-0fb7-44f1-940c-294e00ff7a47","added_by":"auto","created_at":"2023-03-22 14:45:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":78105,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBox plot of mean difference in free serum cortisol level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBox plot shows difference in the median of change in free cortisol levels between the two groups standard Vs low pressure group, with significant difference\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/f4c451457159509304646af2.png"},{"id":43974610,"identity":"d6538408-8d4d-4dba-8133-042ad26f52a2","added_by":"auto","created_at":"2023-10-02 15:08:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":625679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/9b116121-2390-4753-8665-e61a0f750c85.pdf"},{"id":34656643,"identity":"ab829c69-9c4a-4ebb-9f5b-1ffa4e463b0e","added_by":"auto","created_at":"2023-03-22 15:01:40","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21795,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph 1: Patients flow chart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"G1.png","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/064acfe31c4d7fbb4eb6697c.png"},{"id":34654933,"identity":"182057c8-146d-4d69-b6be-79926d41b8c7","added_by":"auto","created_at":"2023-03-22 14:45:40","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30116,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph 2: subgroup analysis for dexamethasone effect\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"G2.png","url":"https://assets-eu.researchsquare.com/files/rs-2697210/v1/69cf806a2d6fc259271ac438.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic cholecystectomy was first performed by professor Med Erich M\u0026uuml;he of B\u0026ouml;blingen, Germany, on September 12, 1985. \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e It became the gold standard procedure to remove the gall bladder for different indications. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Majority of laparoscopic procedures require the creation of pneumoperitoneum to establish a working space, the standard pressure used is set at 12\u0026ndash;15 mmHg. \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Low pressure pneumoperitoneum is introduced with pressure set of 6\u0026ndash;10 mmHg \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e has challenged to compare the complications and feasibility of standard pressure pneumoperitoneum. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Clinical trials have compared low pressure vs. standard in terms of perioperative complications, post-operative pain, hospital length of stay, stress response and surgeon comfort. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In this trail we conducted a randomized comparison between low pressure and standard pressure pneumoperitoneum for laparoscopic cholecystectomy in terms of postoperative pain, inflammatory markers, timing of surgery and surgeon comfort. This trial adds to the literature the extensive study of inflammatory markers associated with stress of surgery, and the surgeon comfort level along with safety of the procedure with performed by non-experienced surgeons (senior residents).\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThe study has been reported in line with the CONSORT statement. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e It is registered on ClinicalTrials.gov under the identifier NCT05530564 and approved by the hospital institutional review board (IRB).\u003c/p\u003e \u003cp\u003eThis is a clinical trial, designed to look for a statistical difference in pain and inflammatory markers after operation, comparing two parallel groups, with an allocation ratio of 1:1. Participants were eligible for the study if they were above the age of 12 years old, with low anaesthesia risk defined as American Society of Anaesthesiologists (ASA) score 1 or 2, and having symptomatic gallbladder stone disease whom were booked for elective laparoscopic cholecystectomy. The study is prospective, all patients admitted during the study period were assessed for eligibility, the study stopped enrolment when hundred eligible patients were selected. The enrolment period extended over a year, from January 2020 to January 2021. Patients not included in the study were those currently or previously diagnosed with acute cholecystitis confirmed by ultrasonography, or those who underwent previous upper gastrointestinal surgeries except bariatric and anti-reflux surgeries, or those currently on immunosuppressants, or currently diagnosed with drug addiction, also pregnant and breastfeeding females were excluded.\u003c/p\u003e \u003cp\u003eThose in the intervention group were scheduled to undergo laparoscopic cholecystectomy at a low-pressure pneumoperitoneum defined as gas insufflation set point between 8\u0026ndash;10 mmHg, and those in the control group were scheduled to undergo laparoscopic cholecystectomy at a standard-pressure pneumoperitoneum defined as gas insufflation set point between 12\u0026ndash;14 mmHg.\u003c/p\u003e \u003cp\u003ePain scores were assessed using the 11-point short pain scale (SPS-11) according to patient perception at 6 hours, 12 hours, 24 hours, and 7th day post-operatively.\u003c/p\u003e \u003cp\u003eThe following inflammatory markers were investigated: white blood cell (WBC) count (10^3 cells/mm), platelet (Plt) count (10^9/L), erythrocyte sedimentation rate (ESR) (millimetres per hour), C reactive protein (CRP) level (mg/L), albumin (Alb) level (g/dL), free serum cortisol level (nmol/L), interlukein-6 (IL-6) level (pg/mL), interlukein-17 (IL-17) level (pg/mL), interlukein-1 beta (IL-1β) level (pg/mL), tumour necrosis factor alpha (TNF-α) level (pg/mL). Blood samples were withdrawn at the morning of surgery as baseline for all inflammatory markers. Four hours post-op cortisol levels were reassessed. Twenty-four hours post-op the remining markers were reassessed.\u003c/p\u003e \u003cp\u003eThe primary outcome of the trial was to look for a significant difference in pain on the 11-point short pain scale (SPS-11) at four set points 6-hour, 12-hour, 24-hour, and 7-days post-op. Also, to look for a significant change in the collected inflammatory markers from baseline, with a \u003cem\u003ep\u003c/em\u003e-value set at 0.05. The secondary outcomes were to look for difference in surgery difficulty and operation time between the two groups.\u003c/p\u003e \u003cp\u003eA convenient sample of 100 participants was decided, divided into 50 for each study arm. The two study arms were colour coded. The colour codes were used for randomization, data entry and analysis. All the participants, investigators, observers, and analyst were blinded to the colour code reference. After closure of the study, the colour codes were disclosed to the public. Allocation was random according to a pre-set computer-generated list. Patients found to have intra operative adhesions and evidence of previous inflammation were kept in the study, ensuring no previously documented diagnosis of acute cholecystitis. Method of pneumoperitoneum induction was left for the operating surgeon to decide as per trained, closed technique was done using veress needle, open technique was done with an infra-umbilical incision and insufflation of abdomen after 12 mm trocar insertion, optical technique utilized 12 mm optiview trocar. The trocars position was inserted for the four-trocar technique at 12 mm umbilical, 12 mm sub xiphisternum, 5 mm medial subcostal, and 5 mm lateral subcostal. For the three-trocar technique one 5 mm trocar was inserted subcostal instead of two. Each operator adhered to steps of safe laparoscopic cholecystectomy with use of critical view of safety method.\u003c/p\u003e \u003cp\u003eThe principal investigator ensured adherence to protocol and data validity. Records were reviewed monthly, and a progress summary written and provided to study regulatory every three months. Some patients where administered dexamethasone intravenously at time of surgery induction by anaesthesia team, so subgroup analysis for dexamethasone was done to eliminate its effect on the study results.\u003c/p\u003e \u003cp\u003eAnalysis was conducted using SPSS version 1.0.0.1406. Gender, smoking status, ASA score, and difficulty of surgery were analyzed using Chi-square cross table. Mean duration of total operative time, insufflation time, and mean hospital-stay were analyzed using Student\u0026rsquo;s 2-tailed t-test. The mean intensity of pain was analyzed using Mann-Whitney U test. Inflammatory markers (WBC, Plt, ESR, CRP, Albumin, Cortisol, IL-6, IL-17, TNF-α, IL-1β) levels were analyzed using Welch's t-test. Subgroup analysis for the inflammatory markers was done to eliminate the effect of dexamethasone given by anesthesia team at the time of anesthesia induction, analysis was done using Welch's t-test. All test set \u003cem\u003ep\u003c/em\u003e-value was set at 0.05 to consider results significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA hundred patients were included in the analysis, with 50 patients in each study arm (n\u0026thinsp;=\u0026thinsp;50). (Graph 1) The sample was normally distributed. Age and BMI were analyzed using Student\u0026rsquo;s t-test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Gender, smoking status, and ASA score were analyzed using Chi-square cross table analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with a \u003cem\u003ep\u003c/em\u003e-value set at 0.05.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup characteristics I\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e43.82\u0026thinsp;\u0026plusmn;\u0026thinsp;15.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e42.78\u0026thinsp;\u0026plusmn;\u0026thinsp;13.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e29.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.620\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNo significant difference in mean between both groups in terms of age and BMI\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup characteristics II\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eASA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (58%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNo significant difference in mean between both groups in terms of gender, smoking status and ASA score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean duration of total operative time, insufflation time, and mean hospital-stay were similar across groups with no significant difference. Analysis done using Student\u0026rsquo;s t-test (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) with a \u003cem\u003ep\u003c/em\u003e-value of 0.05.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperation observations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e55.0\u0026thinsp;\u0026plusmn;\u0026thinsp;17.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufflation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e43.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op hospital-stay (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNo significant difference in mean between both groups in terms of total operative time, insufflation time and post-op hospital stay\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNone of the groups had major intraoperative complications. Three patients in the low-pressure group had a change of pneumoperitoneum initial set of pressure: two patients due to operating surgeon inexperience (senior resident) and one due to uncommon anatomy of the callout\u0026rsquo;s triangle. None had conversion to open cholecystectomy, none had more than minor intra-op blood loss, and none of the patients died during the study period. Four patients were readmitted within the 30-day period post-op: one patient from the standard-pressure group had severe vomiting and electrolyte disturbance that required in-hospital fluid resuscitation, two patients from the low-pressure group developed obstructive jaundice secondary to common bile duct (CBD) stones that required endoscopic intervention, another patient from the low-pressure group developed small bowel obstruction secondary to trocar site evisceration which was treated with reoperation and laparoscopic repair.\u003c/p\u003e \u003cp\u003eThere was no significant difference in difficulty of surgery between low-pressure and standard-pressure groups, with a \u003cem\u003ep\u003c/em\u003e-value of 0.2 obtained using Chi-square cross table (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). As the trial was conducted in a teaching hospital, surgeries were done by three different types of operating surgeons: consultants, surgery fellows, and senior residents. The settings of operation were not adjusted for the study, and surgeon level of experience was chosen randomly. It was observed that no significant correlation between operator level and surgery difficulty (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.369) using spearmen correlation, Spearman\u0026rsquo;s correlation (-0.091) for all cases, Spearman\u0026rsquo;s correlation (-0.221) for low-pressure group, Spearman\u0026rsquo;s correlation (-0.039) for Standard-pressure group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifficulty of surgery and operator level of experience\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDifficulty of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEasy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOperator level of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNo significant difference between both groups in terms of surgery difficulty and operator level of experience.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean intensity of pain was lower and showed significant difference at the 6-hour post-op time point in the low-pressure group with a \u003cem\u003ep\u003c/em\u003e-value of 0.021 obtained using Mann-Whitney U test. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) Total analgesia count administered post-op showed no significant difference across groups (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.412) but the median count was lower in the low-pressure group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-operative pain score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003cp\u003e(Median pain score)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003cp\u003e(Median pain score)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePost-op timing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6-hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e*\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12-hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24-hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7th -day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eA significant difference was observed between the two groups in pain score collected at 6-hour post-op time point with a \u003cem\u003ep\u003c/em\u003e-value of 0.021\u0026thinsp;\u0026lt;\u0026thinsp;0.05, no significant difference was observed in the other time points (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eInflammatory markers were assessed pre and post operatively for both groups using Welch's t-test and a \u003cem\u003ep\u003c/em\u003e-value set at 0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A significant difference was observed in free serum cortisol levels with a \u003cem\u003ep\u003c/em\u003e-value of 0.003, favoring a significant reduction of cortisol in standard pressure group with a value of 189.7\u0026thinsp;\u0026plusmn;\u0026thinsp;306.9 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), compared to a value of 1.064\u0026thinsp;\u0026plusmn;\u0026thinsp;309.64 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) in the low-pressure group. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInflammatory markers levels\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTiming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ WBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e284.167\u0026thinsp;\u0026plusmn;\u0026thinsp;6 9.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e275.91\u0026thinsp;\u0026plusmn;\u0026thinsp;77.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e271.188\u0026thinsp;\u0026plusmn;\u0026thinsp;88.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e269.94\u0026thinsp;\u0026plusmn;\u0026thinsp;81.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Plt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-12.979\u0026thinsp;\u0026plusmn;\u0026thinsp;53.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.98\u0026thinsp;\u0026plusmn;\u0026thinsp;35.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.54\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.98\u0026thinsp;\u0026plusmn;\u0026thinsp;18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.66\u0026thinsp;\u0026plusmn;\u0026thinsp;13.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.93\u0026thinsp;\u0026plusmn;\u0026thinsp;16.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ ESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.65\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.41\u0026thinsp;\u0026plusmn;\u0026thinsp;8.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.85\u0026thinsp;\u0026plusmn;\u0026thinsp;15.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;39.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ CRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.355\u0026thinsp;\u0026plusmn;\u0026thinsp;13.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.68\u0026thinsp;\u0026plusmn;\u0026thinsp;38.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.512\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Alb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.265\u0026thinsp;\u0026plusmn;\u0026thinsp;0.257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e380.26\u0026thinsp;\u0026plusmn;\u0026thinsp;228.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e496.17\u0026thinsp;\u0026plusmn;\u0026thinsp;236.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e*0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e381.3\u0026thinsp;\u0026plusmn;\u0026thinsp;272.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e306.48\u0026thinsp;\u0026plusmn;\u0026thinsp;242.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ cortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.064\u0026thinsp;\u0026plusmn;\u0026thinsp;309.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-189.7\u0026thinsp;\u0026plusmn;\u0026thinsp;306.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e*0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.82\u0026thinsp;\u0026plusmn;\u0026thinsp;121.944\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.82\u0026thinsp;\u0026plusmn;\u0026thinsp;9.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.89\u0026thinsp;\u0026plusmn;\u0026thinsp;10.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-24.892\u0026thinsp;\u0026plusmn;\u0026thinsp;121.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.079\u0026thinsp;\u0026plusmn;\u0026thinsp;5.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.977\u0026thinsp;\u0026plusmn;\u0026thinsp;42.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.735\u0026thinsp;\u0026plusmn;\u0026thinsp;25.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.77\u0026thinsp;\u0026plusmn;\u0026thinsp;44.686\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.93\u0026thinsp;\u0026plusmn;\u0026thinsp;25.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.794\u0026thinsp;\u0026plusmn;\u0026thinsp;5.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.804\u0026thinsp;\u0026plusmn;\u0026thinsp;5.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL1-β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.344\u0026thinsp;\u0026plusmn;\u0026thinsp;131.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.73\u0026thinsp;\u0026plusmn;\u0026thinsp;84.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.2622\u0026thinsp;\u0026plusmn;\u0026thinsp;54.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.42\u0026thinsp;\u0026plusmn;\u0026thinsp;48.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-1 β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-30.082\u0026thinsp;\u0026plusmn;\u0026thinsp;134.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-9.99\u0026thinsp;\u0026plusmn;\u0026thinsp;91.968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.36\u0026thinsp;\u0026plusmn;\u0026thinsp;89.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e89.305\u0026thinsp;\u0026plusmn;\u0026thinsp;107.856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.44\u0026thinsp;\u0026plusmn;\u0026thinsp;63.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47.099\u0026thinsp;\u0026plusmn;\u0026thinsp;45.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ TNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-33.916\u0026thinsp;\u0026plusmn;\u0026thinsp;99.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-40.926\u0026thinsp;\u0026plusmn;\u0026thinsp;103.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubgroup analysis was done to eliminate the effect of dexamethasone administered by anesthesia team at the time of anesthesia induction. Patients were classified into two groups: those that were given dexamethasone and those who were not (Graph 2). Analysis done using Welch's t-test. The results showed persistence of significant difference in the free serum cortisol level in favor of standard pressure group. (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInflammatory markers levels, subgroup analysis for dexamethasone\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTiming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eStandard- pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003eno Dexamethasone group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ WBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.845\u0026thinsp;\u0026plusmn;\u0026thinsp;3.824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.082\u0026thinsp;\u0026plusmn;\u0026thinsp;2.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e297.909\u0026thinsp;\u0026plusmn;\u0026thinsp;59.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e278\u0026thinsp;\u0026plusmn;\u0026thinsp;61.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.297\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e277.86\u0026thinsp;\u0026plusmn;\u0026thinsp;65.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e265.421\u0026thinsp;\u0026plusmn;\u0026thinsp;65.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Plt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-20.045\u0026thinsp;\u0026plusmn;\u0026thinsp;46.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.579\u0026thinsp;\u0026plusmn;\u0026thinsp;29.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.94\u0026thinsp;\u0026plusmn;\u0026thinsp;16.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.15\u0026thinsp;\u0026plusmn;\u0026thinsp;13.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.82\u0026thinsp;\u0026plusmn;\u0026thinsp;12.177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ ESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.190\u0026thinsp;\u0026plusmn;\u0026thinsp;8.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;8.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.48\u0026thinsp;\u0026plusmn;\u0026thinsp;13.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.416\u0026thinsp;\u0026plusmn;\u0026thinsp;29.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ CRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.209\u0026thinsp;\u0026plusmn;\u0026thinsp;13.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.352\u0026thinsp;\u0026plusmn;\u0026thinsp;27.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.353\u0026thinsp;\u0026plusmn;\u0026thinsp;0.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.405\u0026thinsp;\u0026plusmn;\u0026thinsp;0.243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.154\u0026thinsp;\u0026plusmn;\u0026thinsp;0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Alb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.283\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2806\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.251\u0026thinsp;\u0026plusmn;\u0026thinsp;0.243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e366.47\u0026thinsp;\u0026plusmn;\u0026thinsp;258.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e418.459\u0026thinsp;\u0026plusmn;\u0026thinsp;177.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e339.822\u0026thinsp;\u0026plusmn;\u0026thinsp;243.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e369.498\u0026thinsp;\u0026plusmn;\u0026thinsp;249.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ cortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-26.651\u0026thinsp;\u0026plusmn;\u0026thinsp;238.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-48.96\u0026thinsp;\u0026plusmn;\u0026thinsp;314.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.32\u0026thinsp;\u0026plusmn;\u0026thinsp;6.780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.845\u0026thinsp;\u0026plusmn;\u0026thinsp;14.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.246\u0026thinsp;\u0026plusmn;\u0026thinsp;5.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.69\u0026thinsp;\u0026plusmn;\u0026thinsp;15.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9178\u0026thinsp;\u0026plusmn;\u0026thinsp;9.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.852\u0026thinsp;\u0026plusmn;\u0026thinsp;6.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.00\u0026thinsp;\u0026plusmn;\u0026thinsp;55.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.736\u0026thinsp;\u0026plusmn;\u0026thinsp;24.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.563\u0026thinsp;\u0026plusmn;\u0026thinsp;58.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.856\u0026thinsp;\u0026plusmn;\u0026thinsp;25.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.555\u0026thinsp;\u0026plusmn;\u0026thinsp;7.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-1β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.272\u0026thinsp;\u0026plusmn;\u0026thinsp;49.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.8215\u0026thinsp;\u0026plusmn;\u0026thinsp;29.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.863\u0026thinsp;\u0026plusmn;\u0026thinsp;10.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.04\u0026thinsp;\u0026plusmn;\u0026thinsp;33.632\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-1β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-28.40\u0026thinsp;\u0026plusmn;\u0026thinsp;51.707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-7.781\u0026thinsp;\u0026plusmn;\u0026thinsp;45.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.231\u0026thinsp;\u0026plusmn;\u0026thinsp;78.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.49\u0026thinsp;\u0026plusmn;\u0026thinsp;45.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.5684\u0026thinsp;\u0026plusmn;\u0026thinsp;34.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.971\u0026thinsp;\u0026plusmn;\u0026thinsp;57.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆TNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-39.66\u0026thinsp;\u0026plusmn;\u0026thinsp;70.3148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-24.520\u0026thinsp;\u0026plusmn;\u0026thinsp;74.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eShowing difference in inflammatory markers for patients not given dexamethasone injection at induction of surgery. No significant difference was observed across groups.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInflammatory markers levels, subgroup analysis for dexamethasone\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTiming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLow-pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eStandard-pressure group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003eDexamethasone group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0412\u0026thinsp;\u0026plusmn;\u0026thinsp;2.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.247\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.526\u0026thinsp;\u0026plusmn;\u0026thinsp;2.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ WBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.206\u0026thinsp;\u0026plusmn;\u0026thinsp;3.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.834\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e272.538\u0026thinsp;\u0026plusmn;\u0026thinsp;77.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e274.5\u0026thinsp;\u0026plusmn;\u0026thinsp;87.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.931\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e265.538\u0026thinsp;\u0026plusmn;\u0026thinsp;104.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e273.00\u0026thinsp;\u0026plusmn;\u0026thinsp;92.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.782\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Plt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;85.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.500\u0026thinsp;\u0026plusmn;\u0026thinsp;38.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.09\u0026thinsp;\u0026plusmn;\u0026thinsp;11.592\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.04\u0026thinsp;\u0026plusmn;\u0026thinsp;19.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.69\u0026thinsp;\u0026plusmn;\u0026thinsp;18.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ ESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.045\u0026thinsp;\u0026plusmn;\u0026thinsp;6.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.654\u0026thinsp;\u0026plusmn;\u0026thinsp;8.845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.681\u0026thinsp;\u0026plusmn;\u0026thinsp;5.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.66\u0026thinsp;\u0026plusmn;\u0026thinsp;9.780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.96\u0026thinsp;\u0026plusmn;\u0026thinsp;17.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;45.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ CRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.280\u0026thinsp;\u0026plusmn;\u0026thinsp;14.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.54\u0026thinsp;\u0026plusmn;\u0026thinsp;44.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.582\u0026thinsp;\u0026plusmn;\u0026thinsp;0.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.231\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ Alb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.241\u0026thinsp;\u0026plusmn;\u0026thinsp;0.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.269\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e392.01\u0026thinsp;\u0026plusmn;\u0026thinsp;203.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e549.77\u0026thinsp;\u0026plusmn;\u0026thinsp;259.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e*0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e416.68\u0026thinsp;\u0026plusmn;\u0026thinsp;295.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e263.023\u0026thinsp;\u0026plusmn;\u0026thinsp;232.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e*0.034\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ cortisol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.674\u0026thinsp;\u0026plusmn;\u0026thinsp;362.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-286.74\u0026thinsp;\u0026plusmn;\u0026thinsp;265.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e*0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.44\u0026thinsp;\u0026plusmn;\u0026thinsp;159.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-43.75\u0026thinsp;\u0026plusmn;\u0026thinsp;158.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.551\u0026thinsp;\u0026plusmn;\u0026thinsp;5.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.65\u0026thinsp;\u0026plusmn;\u0026thinsp;30.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.52\u0026thinsp;\u0026plusmn;\u0026thinsp;22.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.88\u0026thinsp;\u0026plusmn;\u0026thinsp;30.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.46\u0026thinsp;\u0026plusmn;\u0026thinsp;22.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.238\u0026thinsp;\u0026plusmn;\u0026thinsp;2.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.067\u0026thinsp;\u0026plusmn;\u0026thinsp;2.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIL-1β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.09\u0026thinsp;\u0026plusmn;\u0026thinsp;168.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.56\u0026thinsp;\u0026plusmn;\u0026thinsp;107.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.78\u0026thinsp;\u0026plusmn;\u0026thinsp;70.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.53\u0026thinsp;\u0026plusmn;\u0026thinsp;55.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ IL-1β\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-31.304\u0026thinsp;\u0026plusmn;\u0026thinsp;172.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-11.428\u0026thinsp;\u0026plusmn;\u0026thinsp;113.624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.64\u0026thinsp;\u0026plusmn;\u0026thinsp;98.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102.177\u0026thinsp;\u0026plusmn;\u0026thinsp;135.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.93\u0026thinsp;\u0026plusmn;\u0026thinsp;77.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47.87\u0026thinsp;\u0026plusmn;\u0026thinsp;35.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.639\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ TNF-α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-29.717\u0026thinsp;\u0026plusmn;\u0026thinsp;118.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-51.59\u0026thinsp;\u0026plusmn;\u0026thinsp;118.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eShowing difference in inflammatory markers for patients given dexamethasone injection at induction of surgery. Significant difference in cortisol level was observed across groups.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUntil today, there is no consensus on the standard pressure to operate during laparoscopic surgeries, but majority of surgical societies agrees on \u0026ldquo;the lowest intra-abdominal pressure allowing adequate exposure of the operative field rather than a routine pressure\u0026rdquo; to be used.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Low-pressure pneumoperitoneum, defined in literature as pressure of 10 mmHg or less, has been used to avoid the adverse physiological effects of intra-abdominal gas insufflation. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis trial has been designed to assess laparoscopic cholecystectomy operated at a low-pressure pneumoperitoneum with a set pressure between 8\u0026ndash;10 mmHg compared to a standard of 12\u0026ndash;14 mmHg. The study design added to its strength, validity and generalisability being a prospective, randomised, double-blinded controlled clinical trial. But the study was limited to patients with low-anaesthesia risk of ASA score I and II and non-complicated gallbladder disease.\u003c/p\u003e \u003cp\u003eAs the study was conducted at a teaching hospital, the difficulty of surgery could be assessed when operated by non-experienced surgeons in contrary to other trials that required low-pressure pneumoperitoneum surgeries to be operated by experienced surgeons. In our study sample, majority of the operations was done by non-experienced surgeons (senior residents), the distribution of surgeries done by residents was non-significantly different between the two groups. We found no correlation between the surgery difficulty and level of operator experience, indicating that low-pressure pneumoperitoneum surgery is feasible in the hands of non-experienced surgeons. Regarding the safety of low-pressure pneumoperitoneum, Mandal et.al. found no significant increase in terms of difficulty of surgery, conversion rate, or post-op complication rate of low-pressure pneumoperitoneum when done in the hands of experienced surgeon. They found that the operative visual field was also not compromised.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Hua et.al had similar results.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Our trial supports similar results even in the hands of non-experienced surgeons. Mahajan et.al suggested to standardize low-pressure laparoscopic cholecystectomy in day care surgery, as they found the procedure to be safe and feasible, with no significant difference when compared to standard pressure pneumoperitoneum in terms of adequacy of surgical field, contact of parietal peritoneum to the underlying viscera during secondary port insertion, duration of surgery, complication rates, and surgery difficulty.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this trial the total operative time, insufflation time and total hospital stay was similar across both groups. None of the patients had major intraoperative complication, 30-day mortality rate was zero in both groups, only 3 patients in the low-pressure group had a change from initial set pressure point, and 4 patients required re-admission within the 30-day period post-op, none of the reasons for readmission were significant nor resulted a long-term morbidity.\u003c/p\u003e \u003cp\u003eThe benefits of operating at a low-pressure pneumoperitoneum are many and reported in multiple clinical trials \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Post operative pain is thoroughly studied, many reported a significant reduction of post-op pain and shoulder tip pain post laparoscopic cholecystectomy among patients operated at a low-pressure pneumoperitoneum \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Although, a recent study by Chang et.al. reported contradicting results of no significant difference in postoperative pain when operating at various pneumoperitoneum pressures, including low and very low pressures.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Moro et.al reported similar results.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Our results on pain supports the added benefit of low-pressure pneumoperitoneum of decreased pain perception post-op, our four chosen pain assessment points showed lower median pain score in the low pressure group, with a significant difference observed at the 6-hour post-op point. The total analgesia administered post-op was lower in the low-pressure group, but we could not find a significant difference. Some other clinical trials also showed a significant reduction of post operative nausea, early resumption of oral feeding and hospital stay in low-pressure groups. \u003csup\u003e1012\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn observing the hemodynamic effects of reduced pressure pneumoperitoneum, the heart rate, mean arterial pressure and end tidal carbon dioxide is found to have variation intraoperatively. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e There were contradicting results of decreased vs no impact of low-pressure pneumoperitoneum on those parameters. Dr. Vidyanand Tripathi et.al found an increase of heart rate in standard-pressure group after 10 mins of surgery that was demonstrated in the low-pressure group, but this difference is not statistically significant.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Singh et.al demonstrated a significant difference after 10 mins of surgery, and a significant difference in systolic and diastolic blood pressure after 30 mins of surgery. \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e However, a study by Kanwer et al did not find any statistical difference in systolic or diastolic blood pressure.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The study of hemodynamic effects of low-pressure pneumoperitoneum was out of scope and not reported in this trial.\u003c/p\u003e \u003cp\u003eThe use of low-pressure pneumoperitoneum also demonstrated a reduced effect on derangement of hepatic blood flow \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, and significant reduction in the rise of liver enzymes.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Neogi et.al could observe a rise of bilirubin and liver enzymes 24 hours post-op in standard-pressure pneumoperitoneum that is not demonstrated in low-pressure group, \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e recommending the use of low-pressure pneumoperitoneum in patients with impaired hepatic function. Our clinical trial did not study such effects.\u003c/p\u003e \u003cp\u003eThe effect on immune response has been reported in few studies only, our trial was focused on ten inflammatory mediators affected by the stress of surgery. Schietroma et.al. observed a significant decrease in interleukin IL-1, IL-6, and CRP.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Basgul et al. observed a significant lower increase in IL-6 up to 24 h after surgery, yet higher levels of IL-2 during low-pressure pneumoperitoneum.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In the contrary, some other trials failed to detect a benefit. \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e We in this trial could detect a reduction of 8 out of 10 inflammatory markers in the low-pressure group, but the difference was not significant. Regarding cortisol hormone levels, the difference was significant but in favour of standard-pressure pneumoperitoneum group, this contradicting result from what is expected could be due to our poor understanding of cortisol as a stress hormone \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and the effect of diurnal variation on the interpretation of its levels. \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e We failed to report if the surgery was done in morning or evening, as so a subgroup analysis to eliminate the diurnal variation could not be done. The levels of cortisol were assessed at morning of surgery day for all patients, but the post-op levels were assessed at a 4-hour point after the end of surgery defined as deflation of the abdomen. The rational of choosing this point is based on the known rise of cortisol as early as 4\u0026ndash;6 hours post major surgeries. \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e 32\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis trial was limited to laparoscopic cholecystectomy, but in reviewing the literature we found that the beneficial effects of low-pressure pneumoperitoneum have been exploited to other surgeries. The PAROS\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e and RECOVERY\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e trials are two trials that were made to study the effects of low-pressure pneumoperitoneum in laparoscopic colectomy in regards to pain, hospital stay, and quality of recovery. Their results are not published yet. Also, in laparoscopic pelvic surgeries it was shown that various pneumoperitoneum pressures affect the level of ovarian hormones, and this effect was observed during the first menstrual cycle post-surgery and vanishes as going towards the third menstrual cycle. \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e In laparoscopic nephrectomy, Dita Aditianingsih et.al demonstrated an attenuation of the inflammatory response, including IL- 6, in the low-pressure pneumoperitoneum group (8 mmHg) compared to standard-pressure (12 mmHg).\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn conclusion, this clinical trial demonstrated a reduction of pain and inflammatory markers post laparoscopic cholecystectomy in patients operated at a low-pressure (8\u0026ndash;10 mmHg) compared to a standard-pressure (12\u0026ndash;14 mmHg), although the difference was not significant except for the 6-hour post-op pain scores. No significant difference could be observed between the two groups regarding total surgery time, also the difficulty of surgery was not significant even in the hands of non-experienced surgeons. Thereby we recommend a larger trial to confirm the benefits of low-pressure pneumoperitoneum to establish a new standard of care in laparoscopic cholecystectomy and other similar procedures utilising intra-abdominal insufflation, and to extend the benefits to high anaesthesia risk patients such as elderly.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been approved by The\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eUniversity of Jordan Institutional Review Board (IRB). It has been reported in line with the\u0026nbsp;CONSORT statement and\u0026nbsp;Helsinki declaration. The study has been\u0026nbsp;registered on ClinicalTrials.gov under the identifier NCT05530564 on\u0026nbsp;September 7\u003csup\u003eth\u003c/sup\u003e,\u0026nbsp;2022. Written informed consent was obtained from participants before enrolment in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study is included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis trial received funding from The University of Jordan/ Deanship of Scientific Research, Grant number 1169.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.R. is the main investigator and surgeon, S.D. is the secondary investigator and surgeon, A.M ensured accuracy of lab results, M.G. and J.H.A did data analysis, tables and charts generation, GO did data collection and was the study financial manager, M.Q. written the introduction section and part of literature review, I.S. did data collection, writing the title page, and reviewed references,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.H., L.S., S.S., Y.B. and M.S. did data collection, T.G. wrote the result section, H.M. is the site manager, data collection, protocol writing, written the abstract and discussion sections. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Jordan University Hospital clerks and laboratory staff for the ease they provided in conducting this research.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eReynolds WJ. The first laparoscopic cholecystectomy. \u003cem\u003eJSLS J Soc Laparoendosc Surg\u003c/em\u003e. 2001;5(1):89-94.\u003c/li\u003e\n \u003cli\u003eSoper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new \u0026ldquo;gold standard\u0026rdquo;? \u003cem\u003eArch Surg\u003c/em\u003e. 1992;127(8):913-917. doi:10.1001/archsurg.1992.01420080051008\u003c/li\u003e\n \u003cli\u003eHyp\u0026oacute;lito OHM, Azevedo JLMC, de Lima Alvarenga Caldeira FMS, et al. Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2010;24(7):1663-1669. doi:10.1007/s00464-009-0827-2\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer GJ, Pouwels S, Wever KE, Warl\u0026eacute; MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2016;30(5):2049-2065. doi:10.1007/s00464-015-4454-9\u003c/li\u003e\n \u003cli\u003eGohil A. Comparison of low pressure versus standard pressure pneumoperitoneum for elective laparoscopic cholecystectomy in a tertiary care institute of western India. \u003cem\u003eInt Surg J\u003c/em\u003e. 2018;5(5):1776. doi:10.18203/2349-2902.isj20181569\u003c/li\u003e\n \u003cli\u003eCelarier S, Monziols S, Francois MO, et al. Randomized trial comparing low-pressure versus standard-pressure pneumoperitoneum in laparoscopic colectomy: PAROS trial. \u003cem\u003eTrials\u003c/em\u003e. 2020;21(1). doi:10.1186/s13063-020-4140-7\u003c/li\u003e\n \u003cli\u003eBhattacharjee HK, Jalaludeen A, Bansal V, et al. Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2017;31(3):1287-1295. doi:10.1007/s00464-016-5108-2\u003c/li\u003e\n \u003cli\u003eSchulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. \u003cem\u003eBMJ\u003c/em\u003e. 2010;340. doi:10.1136/bmj.c332\u003c/li\u003e\n \u003cli\u003eS EAE, Neudecker J, Sauerland S, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. 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Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study. \u003cem\u003eInt Surg J\u003c/em\u003e. 2017;4(11):3679. doi:10.18203/2349-2902.isj20174885\u003c/li\u003e\n \u003cli\u003eAccess O. Comparison of low and standard pressure gas injection at abdominal cavity on postoperative nausea and vomiting in laparoscopic cholecystectomy. 2014;30(5):1083-1087.\u003c/li\u003e\n \u003cli\u003eAgarwal L, Kumawat S, Jain SA, Yadav A, Sharma S. Correlation of shoulder tip pain in case of low pressure and standard pressure pneumoperitoneum post laparoscopic cholecystectomy. \u003cem\u003eInt Surg J\u003c/em\u003e. 2021;8(5):1522. doi:10.18203/2349-2902.isj20211820\u003c/li\u003e\n \u003cli\u003eBarczyński M, Herman RM. 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A Comparative Study Between The Low Pressure Versus Standard Pressure Pneumoperitoneum In Laparoscopic Cholecyst... \u003cem\u003eJ Dent Med Sci\u003c/em\u003e. 2020;19(7):01-10. doi:10.9790/0853-1907140110\u003c/li\u003e\n \u003cli\u003eSodhi KS, Saxena AK, Ahuja CK, Rao K, Menon P, Kandelwal N. Postoperative appearances of esophageal atresia repair: retrospective study of 210 patients with review of literature - what the radiologist should know. \u003cem\u003eActa Radiol\u003c/em\u003e. 2013;54(2):221-225. doi:10.1258/ar.2012.120274\u003c/li\u003e\n \u003cli\u003eKanwer DB, Kaman L, Nedounsejiane M, Medhi B, Verma GR, Bala I. Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy--a randomised controlled trial. \u003cem\u003eTrop Gastroenterol\u003c/em\u003e. 2009;30(3):171-174.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer G-J, Pouwels S, Wever KE, Warl\u0026eacute; MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2016;30(5):2049-2065. doi:10.1007/s00464-015-4454-9\u003c/li\u003e\n \u003cli\u003eAggarwal M, Kumar A, Garg S, Pruthi A, Resident S. Effect of Low Pressure Versus High Pressure Pneumoperitoneum on Liver Functions in Laparoscopic Cholecystectomy. \u003cem\u003eInt J Anat Radiol Surg\u003c/em\u003e. 2020;9(2):01-03.\u003c/li\u003e\n \u003cli\u003eNeogi P, Kumar P, Kumar S. Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial. \u003cem\u003eSurg Laparosc Endosc Percutan Tech\u003c/em\u003e. 2020;30(1):30-34. doi:10.1097/SLE.0000000000000719\u003c/li\u003e\n \u003cli\u003eSchietroma M, Carlei F, Mownah A, et al. 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A comparative study of angiogenic and cytokine responses after laparoscopic cholecystectomy performed with standard- and low-pressure pneumoperitoneum. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2009;23(9):2117-2123. doi:10.1007/s00464-008-0234-0\u003c/li\u003e\n \u003cli\u003eManou-Stathopoulou V, Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. \u003cem\u003eBr J Anaesth\u003c/em\u003e. 2019;123(5):570-583. doi:10.1016/j.bja.2019.08.011\u003c/li\u003e\n \u003cli\u003eKwon YS, Jang JS, Hwang SM, Tark H, Kim JH, Lee JJ. Effects of surgery start time on postoperative cortisol, inflammatory cytokines, and postoperative hospital day in hip surgery: Randomized controlled trial. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2019;98(24):e15820. doi:10.1097/MD.0000000000015820\u003c/li\u003e\n \u003cli\u003eBurton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. \u003cem\u003eContin Educ Anaesth Crit Care Pain\u003c/em\u003e. 2004;4(5):144-147. doi:10.1093/bjaceaccp/mkh040\u003c/li\u003e\n \u003cli\u003eChernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. \u003cem\u003eArch Intern Med\u003c/em\u003e. 1987;147(7):1273-1278.\u003c/li\u003e\n \u003cli\u003eAlbers KI, Polat F, Panhuizen IF, et al. The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): Study protocol for a randomized controlled . \u003cem\u003eTrials\u003c/em\u003e. 2020;21(1). doi:10.1186/s13063-020-04496-8\u003c/li\u003e\n \u003cli\u003eQin J, Song G, Jiang Y, Liu Q, Lin H. 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Effects of low versus standard pressure pneumoperitoneum on renal syndecan-1 shedding and VEGF receptor-2 expression in living-donor nephrectomy: A randomized controlled study. \u003cem\u003eBMC Anesthesiol\u003c/em\u003e. 2020;20(1). doi:10.1186/s12871-020-0956-7\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Graphs","content":"\u003cp\u003eGraphs 1 and 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical trial, low pressure insufflation, pneumoperitoneum, laparoscopic cholecystectomy, pain, inflammatory marker","lastPublishedDoi":"10.21203/rs.3.rs-2697210/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2697210/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eWe aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers.\u003c/p\u003e\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12\u0026ndash;14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8\u0026ndash;10 mmHg) vs. standard-pressure (12\u0026ndash;14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eone hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs 6, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003elow-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care.\u003c/p\u003e","manuscriptTitle":"Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-22 14:45:36","doi":"10.21203/rs.3.rs-2697210/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-23T15:54:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-23T15:40:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-20T08:41:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2023-03-15T15:49:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"328d1f9f-6031-407b-ab68-e169cbad4335","owner":[],"postedDate":"March 22nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-02T15:06:01+00:00","versionOfRecord":{"articleIdentity":"rs-2697210","link":"https://doi.org/10.1186/s13104-023-06492-y","journal":{"identity":"bmc-research-notes","isVorOnly":false,"title":"BMC Research Notes"},"publishedOn":"2023-09-28 15:02:13","publishedOnDateReadable":"September 28th, 2023"},"versionCreatedAt":"2023-03-22 14:45:36","video":"","vorDoi":"10.1186/s13104-023-06492-y","vorDoiUrl":"https://doi.org/10.1186/s13104-023-06492-y","workflowStages":[]},"version":"v1","identity":"rs-2697210","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2697210","identity":"rs-2697210","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}