Impaired neutrophil bactericidal activity correlates with the infection occurring after surgery for esophageal cancer

Analysis of risk factors for pulmonary infection in patients with minimally invasive esophagectomy

Clinical manifestations of patients with pulmonary infection after minimally invasive esophagectomy were analyzed. A total of 500 patients undergoing minimally invasive esophagectomy in Sichuan Cancer Hospital and Institute from January 2015 to December 2016 were consecutively selected, among which 124 patients with pulmonary infection after surgery were taken as the infection group, and the remaining 376 patients were taken as the control group. The clinical data of all patients were collected. The pulmonary infection rate after minimally invasive esophagectomy was calculated, and clinical factors with difference were analyzed using the multivariate logistic regression analysis. There were significant differences in age, long-term smoking history, presence or absence of concurrent basic diseases and vital capacity (P<0.01). The application time of antibiotics and antacids and hospitalization duration in the infection group were obviously longer than those in the control group (P<0.01). Age, long-term smoking history, vital capacity, application time of antibiotics and antacids, hospitalization duration and concurrent diabetes mellitus/coronary heart disease/diseases of respiratory system increase the risk of postoperative pulmonary infection in patients with esophageal cancer, and age, long-term smoking history, diabetes mellitus, diseases of respiratory system and hospitalization duration are independent risk factors for pulmonary infection in patients after minimally invasive esophagectomy.

Perioperative granulocyte colony-stimulating factor does not prevent severe infections in patients undergoing esophagectomy for esophageal cancer: a randomized placebo-controlled clinical trial

OBJECTIVE

Esophagectomy for esophageal cancer is associated with substantial postoperative morbidity as a result of infectious complications. In a prior phase II study, granulocyte colony-stimulating factor (G-CSF) was shown to improve leukocyte function and to reduce infection rates after esophagectomy. The aim of the current randomized, placebo-controlled, multicenter phase III trial was to investigate the clinical efficacy of perioperative G-CSF administration in reducing infection and mortality after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

One hundred fifty five patients with resectable esophageal cancer were randomly assigned to perioperative G-CSF at standard doses (77 patients) or placebo (76 patients), administered from 2 days before until day 7 after esophagectomy. The G-CSF and placebo groups were comparable as regards age, gender, risk, cancer stage, frequency of neoadjuvant radiochemotherapy, and type of esophagectomy (transthoracic or transhiatal esophageal resection).

RESULTS

Of 155 randomized patients, 153 were eligible for the intention-to-treat analysis. The rate of infection occurring within the first 10 days after esophagectomy was 43.4% (confidence interval 32.8-55.9%) in the placebo and 44.2% (confidence interval 32.1-55.3%) in the G-CSF group (P = 0.927). 30-day mortality amounted to 5.2% in the G-CSF group versus 5.3% in the placebo group (P = 0.985). Similar results were found in the per-protocol analysis.

CONCLUSION

Perioperative administration of G-CSF failed to reduce postoperative morbidity, infection rate, or mortality in patients with esophageal cancer who underwent esophagectomy.

Patients with postoperative infections have sticky neutrophils before operation

Appropriate polymorphonuclear neutrophil (PMN) recruitment is essential for host defense against infection. We investigated the significance of the preoperative PMN adhesion-migration process, as assessed by the flow chamber method, on postoperative infectious complications. Thirty-one consecutive patients with gastrointestinal malignancies, 21 colorectal and 10 gastric, who were undergoing elective surgery were enrolled. PMNs, isolated preoperatively from each patient's venous blood, were perfused onto a tumor necrosis factor alpha-stimulated human umbilical vein endothelial cell (HUVEC) monolayer through the flow chamber. We evaluated the adherent PMN number, the migrated PMN number, and the stuck PMN number by directly inspecting PMN interactions with a HUVEC monolayer under continuous shear flow simulating postcapillary venules. The expression of adhesion molecules on circulating PMNs was also measured. Patients were grouped into an infectious and a noninfectious group according to the occurrence of postoperative infectious complications defined by the Centers for Disease Control criteria. Eleven patients developed postoperative infectious complications. Although the number of preoperative in vitro adherent PMNs in patients with postoperative infection was significantly higher than in those without postoperative infection (P = 0.01), migrated PMN number was similar in both groups. Stuck PMN number tended to be higher in the infectious group than in the noninfectious group. The migrated PMN number showed a significant positive correlation with the adherent PMN number in the noninfectious group but not in the infectious group. Preoperative CD31 expression on circulating PMNs was significantly lower in the infectious group than in the noninfectious group. Preoperative in vitro derangement of the PMN adhesion-migration process is closely associated with postoperative infectious complications.

Bactericidal/permeability-increasing protein preserves leukocyte functions after major liver resection

OBJECTIVE

To analyze postoperative leukocyte functions in patients undergoing hemihepatectomy, and to assess the effect of treatment with the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21).

SUMMARY BACKGROUND DATA

Extensive liver resection is associated with a high incidence of infectious complications. Because elimination of pathogenic microorganisms occurs mainly by leukocytes, this increased rate of infections is most likely due to an impaired function of these cells. Endotoxin, translocated from the gut into the systemic circulation as a result of increased gut permeability and reduced hepatic clearance function after major liver resection, may play an important role in the impairment of posthepatectomy leukocyte function.

METHODS

To investigate whether hemihepatectomy results in impaired leukocyte functions and to determine the role of endotoxin in this process, leukocyte oxidative burst and leukocyte antigen expression were studied in three groups of patients: patients undergoing a hemihepatectomy and receiving rBPI21 treatment, patients undergoing hemihepatectomy and receiving placebo, and as an extra control group patients undergoing other major abdominal surgeries. Blood samples were collected before surgery, 2 hours after surgery, and at days 1, 2, 5, and 7. Phorbol myristate acetate-stimulated oxidative burst was measured using dihydrorhodamine, and leukocyte surface expression of the antigens CD11b, CD16, and CD14 was investigated by indirect immunofluorescence. Both oxidative burst and membrane surface expression were quantified by flow cytometry. An indication of the antiendotoxin effect of rBPI21 treatment was provided by assessment of plasma lipopolysaccharide binding protein (LBP) levels by enzyme-linked immunosorbent assay.

RESULTS

The oxidative burst in the hemihepatectomized patients receiving placebo and the controls increased 2 hours after surgery, whereas it decreased in the rBPI21-treated patients, resulting in significant differences between the groups. On day 1, neutrophil CD11b expression and monocyte CD14 expression in the rBPI21-treated patients and controls were significantly lower than in the placebo group. At 2 hours, CD16 expression in the placebo-treated patients was significantly higher than in the rBPI21-treated patients and controls. On day 5 and day 7, plasma LBP levels were significantly higher in the placebo-treated patients compared with the rBPI21-treated patients.

CONCLUSIONS

The results of this study show that patients undergoing major liver resection have an increased activation of leukocytes compared with those undergoing other major abdominal surgery. This enhanced activation may contribute to the increased risk of infection in these patients. Administration of the endotoxin-neutralizing agent rBPI21 to hemihepatectomy patients was shown to reduce plasma LBP levels, to preserve leukocyte functions partially, and to reduce leukocyte activation to the level of other, nonhepatic abdominal surgery.

Effect of preoperative prophylaxis with filgrastim in cancer neck dissection

BACKGROUND

Cancer surgery is known to lead to a deterioration in host defence mechanisms and an increase in susceptibility to infection after operation. Filgrastim enhances important antimicrobial functions of neutrophils including chemotaxis, phagocytosis and oxidative killing mechanisms.

METHODS

The effects of additional (all patients received perioperative 3 ' 25 mg kg-1 cefotiam and 1 ' 20 mg kg-1 metronidazole) preoperative prophylaxis with filgrastim (5 microg kg-1 12 h prior to surgery plus 5 microg kg-1 0 h prior to surgery) on neutrophil phagocytosis and reactive oxygen radical production and postoperative infections in 24 patients undergoing cancer neck dissection were studied. Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labelled Escherichia coli and Staphylococcus aureus by flow cytometry. Reactive oxygen generation after phagocytosis was estimated by determining the amount of dihydrorhodamine 123 converted to rhodamine 123, intracellularly.

RESULTS

In the filgrastim-treated patients a higher neutrophil phagocytic capacity was seen intraoperatively, and 1-5 days postoperative, but not prior to surgery. Reactive oxygen radical production was significantly higher in filgrastim-treated patients prior to surgery, intraoperative and postoperative (1-5 days). 2/12 (17%) patients had postoperative infections in the filgrastim group and 9/12 (75%) patients had infections in the placebo group (P < 0.001). In particular, wound infections were recorded more often in the placebo group (1/12 vs. 6/12; P = 0.004).

CONCLUSION

We conclude that filgrastim enhances perioperative neutrophil function and could be useful in the prophylaxis of postoperative wound infections in patients undergoing cancer neck dissection.

Factors related to impaired bactericidal activity in patients with esophageal cancer

We examined the possible factors that could contribute to the impairment of polymorphonuclear neutrophil (PMN) bactericidal activities in patients with esophageal cancer, based on the discovery that a depression of the intracellular killing (KI) activity, with an elevation of the superoxide anion-producing capacity (SOP), of PMN is associated with the occurrence of infectious complications following surgery for esophageal cancer. KI, SOP, and myeloperoxidase (MPO) activity were measured in 30 patients with esophageal cancer and 33 patients with gastric cancer. Sex, age, and cancer stage were not significantly associated with impaired bactericidal activities; however, malnutrition was significantly correlated with both a depression in KI (r = 0.58, P < 0.001) and an elevation in SOP (r = -.36, P < 0.05) in the patients with esophageal cancer, but not in those with gastric cancer. The incidence of chronic obstructive pulmonary disease (COPD) was significantly higher in the esophageal cancer patients whose SOP was elevated, at 39% versus 0% (P < 0.05). These results suggest that malnutrition and probably also latent infections associated with COPD contribute to the impaired bactericidal activities of PMN in patients with esophageal cancer.

Antibody response correlates with septic complications following esophagectomy for cancer

Correlations between preoperative antibody response and postoperative septic complications were examined in patients with esophageal cancer. Thirty-three patients and 9 age-matched controls were immunized with 23-valent pneumococcal polysaccharide (PPS) vaccine, and serum anti-PPS IgG, IgA, and IgM were measured. Of 28 patients undergoing transthoracic esophagectomy, 9 had postoperative septic complications (SCP) and 19 did not (SCN). Median titers of anti-PPS IgG-producing capacity were 158 ELISA units (EU) (interquartile range, 71-1,862 EU) in the SCP group and 1,349 EU (interquartile range, 741-2,951 EU) in the SCN group (P = 0.01). No significant differences in anti-PPS IgA and IgM were found between the two groups. These results indicated that low antibody response to polysaccharides is associated with the occurrence of postoperative septic complications in patients with esophageal cancer. Thus, a preoperative evaluation of antibody-producing capacity may serve to predict these complications.