An understanding of the factors which contribute to postoperative fatigue may benefit the rehabilitation of patients after surgery. Subjective feelings of fatigue and fatigue measured objectively in the adductor pollicis muscle after ulnar nerve stimulation have been studied in relation to changes in cardiorespiratory function and muscular efficiency both at rest and when walking on a treadmill at a work rate of 20 and 56 kpm min-1. Twelve patients admitted for elective abdominal surgery were studied before operation and again on the third postoperative day. The postoperative period was characterized by an increased feeling of fatigue. Surgery had no effect upon fatigue in the adductor pollicis muscle suggesting that the genesis of postoperative fatigue is partly central in origin. Muscular efficiency (s.d.) fell from 34(6) per cent before operation to 22(3) per cent (P less than 0.05) on the third postoperative day and was accompanied by a 19 per cent rise in the net energy (s.d.) expenditure (7.3(0.8) to 8.6(0.3) kJ min-1; P less than 0.03) required to perform a given workload. The increased cardiorespiratory effort and reduced muscular efficiency associated with the performance of low-intensity exercise may limit mobilization after surgery and contribute to a greater feeling of fatigue.

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A breast FNA cytology service for palpable breast lumps was commenced in 1989 using the cytospin method. Over the following 6 years 2314 aspirates were received. The results were audited in detail in 1990, 1991/1992 and 1994. Multidisciplinary clinical audit meetings followed each audit cycle. Practice change was agreed after each audit. Each audit cycle was followed by demonstrable improvement in the complete sensitivity of the technique, being respectively 79%, 88% and 96%. The cytospin method is a viable alternative to the conventional smear method.

Many patients complain of excessive tiredness after surgery and some experience a feeling of fatigue which may persist long after the direct effect of trauma has subsided. This inability to return to preoperative levels of activity has been termed the 'postoperative fatigue syndrome'. It is not uncommon and occurs in about 30 per cent of patients who have undergone uncomplicated inguinal herniorrhaphy ' .The development of postoperative fatigue would appear to be related to the magnitude of the surgical procedure and the catabolic changes induced by it2. Patients who complain of excessive tiredness after surgery perform ambulatory tests poorly. The increased cardiorespiratory effort and reduced muscular efficiency associated with the performance of low-intensity exercise in the early postoperative period may limit mobilization after surgery and contribute to a greater feeling of fatigue3. Although patients may feel tired, peripheral muscle functions normally when stimulated electrically3. Findings similar to these have been described in patients with the myalgic encephalomyelitis syndrome4 and the genesis of both conditions may be mediated, at least in part, by mechanisms which act centrally.It has been suggested that therapeutic measures to limit postoperative fatigue should be aimed at a reduction in the metabolic response to surgery and should have actions at both central and peripheral sites'.Neurogenic afferent stimuli from the area of trauma to the central nervous system play an important part in the endocrine-metabolic response to surgery'. An afferent neurogenic blockade by analgesia administered into the epidural space reduces the catabolic response to hip and pelvic surgery' ' and improves nitrogen balance'. Although the metabolic effects are less pronounced in patients undergoing upper abdominal this method of analgesia is commonly used to treat postoperative pain in such patients" and has been shown to be more effective in achieving adequatePresented to the Surgical Research Societj, in January 1989 andpublished in uhstraci,form (Br J Surg 1989 76: 643) pain control after elective cholecystectomy than intramuscular opiates' I . The use ofepidural analgesia during and after surgery has been associated with a lower incidence of respiratory infections' and deep vein t h r o m b o~i s '~, a shorter hospital stay, and earlier a m b~l a t i o n '~. Whether the use of epidural analgesia will influence the development of postoperative fatigue is unknown. This study was designed to test that hypothesis.