The cortisol stress response induced by surgery: A systematic review and meta-analysis

Alessandro Prete, Qi Yan, Khaled Al-Tarrah, Halis K. Akturk, Larry J. Prokop, Fares Alahdab, Mark A. Foster, Janet M. Lord, Niki Karavitaki, John A. Wass, Mohammad H. Murad, Wiebke Arlt, Irina Bancos

Research output: Contribution to journalReview articlepeer-review

32 Scopus citations


Objective: Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. Design: We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. Methods: We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta-analysis and plotted over time. Results: We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, women and patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response. Conclusions: The peri-operative cortisol stress response is dynamic and influenced by patient-specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response.

Original languageEnglish (US)
Pages (from-to)554-567
Number of pages14
JournalClinical Endocrinology
Issue number5
StatePublished - Nov 2018


  • adrenal cortex
  • adrenal insufficiency
  • cortisol
  • hydrocortisone
  • pituitary-adrenal system
  • stress
  • surgery

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Endocrinology


Dive into the research topics of 'The cortisol stress response induced by surgery: A systematic review and meta-analysis'. Together they form a unique fingerprint.

Cite this