Peritoneal macrophage and blood monocyte functions after open and laparoscopic-assisted cecectomy in rats

Shaping the immune landscape: Multidimensional environmental stimuli refine macrophage polarization and foster revolutionary approaches in tissue regeneration

In immunology, the role of macrophages extends far beyond their traditional classification as mere phagocytes; they emerge as pivotal architects of the immune response, with their function being significantly influenced by multidimensional environmental stimuli. This review investigates the nuanced mechanisms by which diverse external signals ranging from chemical cues to physical stress orchestrate macrophage polarization, a process that is crucial for the modulation of immune responses. By transitioning between pro-inflammatory (M1) and anti-inflammatory (M2) states, macrophages exhibit remarkable plasticity, enabling them to adapt to and influence their surroundings effectively. The exploration of macrophage polarization provides a compelling narrative on how these cells can be manipulated to foster an immune environment conducive to tissue repair and regeneration. Highlighting cutting-edge research, this review presents innovative strategies that leverage the dynamic interplay between macrophages and their environment, proposing novel therapeutic avenues that harness the potential of macrophages in regenerative medicine. Moreover, this review critically evaluates the current challenges and future prospects of translating macrophage-centered strategies from the laboratory to clinical applications.

Laparoscopic Cystectomy with Totally Intracorporeal Versus Extracorporeal Orthotopic Neobladder for Bladder Cancer: A Single Center Experience

Objective: The objective of this study was to compare the perioperative, oncological, and functional results and complications of extracorporeal orthotopic neobladder (EON) and totally intracorporeal orthotopic neobladder (ION) after laparoscopic radical cystectomy (LRC) in patients with muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer. Methods: From January 2013 to October 2019, 152 patients underwent LRC and U-shape neobladder urinary diversion at a single tertiary referral hospital. We then compared the extracorporeal (n = 62) and intracorporeal (n = 90) orthotopic neobladder after laparoscopic cystectomy groups. Results: Of all patients, 90 with ION and 62 with EON were included in the study. Concerning perioperative outcomes, the ION group had lower estimated blood loss (455.7 versus 371.7 mL, P = .019), a shorter interval to solid food (6.9 versus 8.7 days, P = .006), and a shorter length of hospital stay (14.6 versus 16.0 days, P = .009). No statistically significant differences were identified in overall (P = .649), early (P = .509), and late (P = .367) complications. However, in terms of gastrointestinal complications, the ION group had a lower complication rate than the EON group (11.1% versus 27.4%, P = .018). There were no statistically significant differences in cancer-specific or noncancer-specific mortality. Daytime and nocturnal continence rates for the ION versus EON groups were 86.7% and 87.1% (P = 1) and 70.0% versus 66.1% (P = .614), respectively. Patients who underwent intracorporeal urinary diversion had a higher health-related quality of life within 3 months postoperative than the extracorporeal urinary diversion group. Conclusion: LRC with ION could be an alternative to EON with similar oncological and functional outcomes at tertiary referral centers. ION had advantages of faster bowel recovery, fewer gastrointestinal complications, and higher quality of life within 3 months postoperative. Clinical Trial Registration No. ChiCTR2100042063.

A rat model to investigate quality of recovery after abdominal surgery

Introduction

Major advances in therapies to optimize recovery after surgery have been limited by the lack of an animal model that can mimic major domains of postoperative sickness behavior in humans. We hypothesized that the integration of commonly impaired domains of quality of recovery in humans could be reproduced in a rat model.

Objectives

To create a rat model that can mimic surgical recovery in humans.

Methods

Adult male Sprague-Dawley rats were used in the development of a quality of recovery score after surgery. Six physiological parameters or behaviors were tested in naive, sham, and laparotomized animals. A quality of recovery score was constructed and ranged from 18 (no impairment) to 0 (gross impairment). We treated animals with a nutraceutical intervention consisting of aspirin and eicosapentaenoic acid. Inflammatory markers and specialized proresolving mediators were measured in serum and the intestinal mucosa of rats, respectively.

Results

We observed a significant reduction in quality of recovery scores on postoperative days 1 (median, interquartile: 6 [4.75-8.25] vs naive rats: 17.5 [15.5-18]), 2 (median, interquartile: 13 [11.25-13.25], P < 0.001 vs naive rats: 17 [17-18], P = 0.001), and 3 (median, interquartile: 14.5 [13.5-16] vs naive rats: 17 [15.75-18], P < 0.02). Surgery promoted a significant increase in the concentrations of inflammatory cytokines, but it reduced levels of interleukin-12p70 and macrophage colony-stimulating factor. Lipoxin B4 and 13-HODE were significantly higher in laparotomized rats. Aspirin + eicosapentaenoic acid substantially improved recovery scores and modulated the postsurgical inflammatory response.

Conclusion

Our novel rat model can be used to study mechanisms governing surgical recovery in rats.

Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy

This study aimed to investigate the effect of intraoperative fluid volume on the postoperative ileus (POI) recovery period. A retrospective review of the Korean robot-assisted radical cystectomy database identified 718 patients who underwent robot-assisted radical cystectomy (RARC). Regression analyses were performed to identify the associations between the amount of intraoperative fluid administration (crystalloid/colloid/total), POI period (time to flatus/bowel movements), and length of hospital stay (LOS) after adjusting for covariates. In addition, we analyzed the risk factors for gastrointestinal complications and prolonged POI using a logistic regression model. An increasing volume of the administered crystalloid/total fluid was associated with prolonged POI (crystalloid R2 = 0.0725 and P < 0.0001; total amount R2 = 0.0812 and P < 0.0001), and the total fluid volume was positively associated with the LOS (R2 = 0.099 and P < 0.0001). The crystalloid amount was a risk factor for prolonged POI (P < 0.001; odds ratio, 1.361; 95% confidence interval, 1.133-1.641; P < 0.001). In the context of RARC, increased intravenous fluids are associated with prolonged POI and longer LOS.

The Role of Active Inflammation and Surgical Therapy in Crohn's Disease Recurrence

An altered balance between effector and regulatory factors is supposed to sustain the tissue-damaging immune response in inflammatory bowel disease (IBD). Several studies demonstrate that severe active inflammation is a strong predictor for surgical complications and recurrence. Indeed, bowel resection in Crohn's disease (CD) patients has a high surgical recurrence rate. In this review, we examined the IBD inflammatory pathways, the current surgical treatments, and the almost inevitable recurrence. The question that might arise is if the cure of intestinal CD is to be found in the surgical approach. A selective search of two databases (PubMed and the Cochrane Library) has been carried out without considering a specific time horizon as inclusion criteria. The scope of this literature review was investigating on the role of inflammation in the management of CD. The following key words have been used to develop the query string: (i) inflammation; (ii) Crohn's disease; (iii) surgery; and (iv) postsurgical recurrence.

Impact of Awake Breast Cancer Surgery on Postoperative Lymphocyte Responses

BACKGROUND

Surgical stress and anesthesia affect the patient's immune system. Analysis of the lymphocyte response after breast-conserving surgery was conducted to investigate the differences between effects after general and local anesthesia.

MATERIALS AND METHODS

Fifty-six patients with breast cancer were enrolled for BCS through local or general anesthesia. Total leukocytes, total lymphocytes, lymphocyte-subsets including CD3⁺, CD19⁺, CD4⁺, CD8⁺, CD16⁺CD56⁺ and CD4⁺/CD8⁺ ratio was examined at baseline and on postoperative days 1, 2 and 3.

RESULTS

Baseline data showed no statistical difference between the two groups. Within-group ANOVA test showed significant differences for total leukocyte count (p<0.001), total lymphocyte count (p=0.009) and proportion of natural-killer cells (p=0.01) in the control group. Between-group analysis showed lower median values of total lymphocytes in the awake surgery group on postoperative days 1, 2 and 3 (p=0.001, p=0.02 and p=0.01, respectively) when compared to the control group. Patients who underwent surgery under general anesthesia had higher total lymphocyte counts on postoperative day 2 (p=0.04).

CONCLUSION

In this randomized study, breast-conserving surgery plus local anesthesia had a lower impact on postoperative lymphocyte response when compared to the same procedure performed under general anesthesia.

Do patients benefit from total intracorporeal robotic radical cystectomy?: A comparative analysis with extracorporeal robotic radical cystectomy from a Korean multicenter study

Purpose

This study aimed to compare complications, perioperative parameters, and oncologic outcomes between robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion (ECUD) and RARC with intracorporeal urinary diversion (ICUD).

Materials and Methods

Between 2007 and 2017, 362 patients who underwent RARC with ECUD or ICUD at multiple tertiary referral institutions were assessed. The primary endpoints were complication rates. The secondary outcomes were perioperative recovery parameters and oncological outcomes including estimated recurrence-free survival (RFS) and recurrence pattern between the 2 groups. Additionally, the complication rates of 2 expert surgeons with experience of >100 RARCs were analyzed.

Results

The ICUD group showed lower overall, gastrointestinal, and genitourinary complications (p=0.001, p=0.036, and p=0.036, respectively) than the ECUD group. Concerning perioperative outcomes, the ICUD group had a significantly longer operation time (p=0.002), although recovery parameters such as time to flatus passage, oral intake, and length of hospital stay were significantly shorter in this group (p=0.001, p<0.001, and p<0.001, respectively). There was no difference in oncologic outcomes such as positive margin rate (p=0.944) and 2-year RFS (p=0.496), and in the recurrence pattern between groups. In the comparison of the expert surgeons' complication rates, the major and total complication rates did not show differences (p=0.814 and p=0.102, respectively) while the minor complication rates were lower in the ICUD group (p=0.058).

Conclusions

This multi-institutional cohort study demonstrated the benefits of the ICUD approach, as indicated by lower complication rates and better recovery parameters, although the oncological results were similar to those of ECUD.

Advantages of laparoscopic compared to conventional surgery are not related to an innate immune response of peritoneal immune activation: an animal study in rats

PURPOSE

Laparoscopic surgery (LS) has proved superior compared to conventional surgery (CS) regarding morbidity, length of hospital stay, rate of wound infection and time until recovery. An improved preservation of the postoperative immune function is assumed to contribute to these benefits though the role of the local peritoneal immune response is still poorly understood. Our study investigates the peritoneal immune response subsequent to abdominal surgery and compares it between laparoscopic and conventional surgery to find an immunological explanation for the clinically proven benefits of LS.

METHODS

Wistar rats (N = 140) underwent laparoscopic cecum resection (LCR; N = 28), conventional cecum resection (CCR; N = 28), laparoscopic sham operation (LSO; N = 28), conventional sham operation (CSO; N = 28), or no surgical treatment (CTRL; N = 28). Postoperatively, peritoneal lavages were performed, leukocytes isolated and analyzed regarding immune function and phagocytosis activity.

RESULTS

Immune function was inhibited postoperatively in animals undergoing LCR or CCR compared to CTRL reflected by a lower TNF-α (CTRL 3956.65 pg/ml, LCR 2018.48 pg/ml (p = 0.023), CCR 2793.78 pg/ml (n.s.)) and IL-6 secretion (CTRL 625.84 pg/ml, LCR 142.84 pg/ml (p = 0.009), CCR 169.53 pg/ml (p = 0.01)). Phagocytosis was not affected in rats undergoing any kind of surgery compared to CTRL. Neither cytokine secretion nor phagocytosis activity differed significantly between laparoscopic and conventional surgery.

CONCLUSIONS

According to our findings the benefits associated with LS compared to CS cannot be explained by differences in the postoperative peritoneal innate immune response. Further studies are needed to elucidate the causes for a more favorable postoperative outcome in patients after LS compared to CS.

Rapid Increase in Serum Levels of Matrix Metalloproteinase-9 (MMP-9) Postoperatively is Associated With a Decrease in the Amount of Intracellular MMP-9

We have previously demonstrated a significant decrease in the serum concentration of intact insulin-like growth factor-binding protein (IGFBP-3) after laparotomy. IGFBP-3, a major IGF binding protein, inhibits the growth of tumor cells via several mechanisms. Our goal was to determine, in a murine model, whether matrix metalloproteinase-9 (MMP-9), a known protease of IGFBP-3, is responsible for the postoperative decrease in serum IGFBP-3 levels. Six IGFBP-3 transgenic mice on a CD-1 background were used in this study. These mice over-express human IGFBP-3. Sham laparotomy, in the form of a midline abdominal incision, was the test procedure. General anesthesia was established using ketamine and xylazine immediately before a 30-minute sham laparotomy and before preoperative blood sampling, done via retro-orbital venipuncture, 48 hours before surgery. The animals were sacrificed and blood was drawn 24 hours postoperatively. Plasma MMP-9 activity was measured using zymography at each time point (48 hours before and 24 hours after operation). MMP-9 activity was also measured in mononuclear cell lysates at both time points. Zymography analysis demonstrated significantly higher plasma levels of MMP-9 postoperatively compared with preoperative levels (81 RU vs 40 RU; P < .05). In contrast, mononuclear cell levels of MMP-9 were significantly higher preoperatively compared with postoperative levels (37.5 RU vs. 0.75 RU, P < .05). Plasma levels of MMP-9, a known protease of IGFBP-3, are significantly elevated postoperatively. In addition, mononuclear cells that store MMP-9 are depleted of it postoperatively. This suggests that rapid MMP-9 release by mononuclear cells leads to an increase in serum levels of this protease postoperatively. Further studies will elucidate mechanisms of MMP-9–related IGFBP-3 depletion.

Robot-Assisted Radical Cystectomy with Total Intracorporeal Urinary Diversion: Comparative Analysis with Extracorporeal Urinary Diversion

PURPOSE

To compare the perioperative outcomes, postoperative complications, and early oncologic outcomes of intracorporeal urinary diversion (ICUD) with those of extracorporeal urinary diversion (ECUD) following robot-assisted radical cystectomy (RARC) performed by a single surgeon at a tertiary referral hospital.

MATERIALS AND METHODS

We reviewed a prospectively maintained, institutional review board-approved database of 70 patients treated with RARC and pelvic lymph node (LN) dissection for bladder cancer performed from 2007 through 2014. Data were collected for 64 patients who underwent either ICUD or ECUD.

RESULTS

Thirty-eight patients underwent ECUD, and the remaining 26 underwent ICUD. Urinary diversion was performed extracorporeally in the first 37 cases and performed intracorporeally thereafter. There were no significant differences in patient characteristics between the ECUD and ICUD groups. Mean total operative time was 468 minutes for ECUD and 581 minutes for ICUD (P < .05). Mean estimated blood loss was 265 and 148 mL, respectively (P < .05). Minor and total complication rates for patients with the ECUD were higher than in patients with the ICUD (minor: 47.4% vs. 15.4%; total: 57.9% vs. 30.8%; P < .05). All patients showed negative surgical margin, while 21% in the ECUD group and 26.9% in the ICUD group had pathologic stage T3 or T4 (P > .05). The mean LN yield was 23.2 and 31.8, respectively (P < .05).

CONCLUSIONS

From our experience, the results show that ICUD after RARC can be successful, with the benefits of decreased blood loss and lower transfusion and complication rates than ECUD. A larger series and long-term follow-up data will be necessary to support our results.

High-fat enteral nutrition reduces intestinal mucosal barrier damage after peritoneal air exposure

BACKGROUND

Peritoneal air exposure is needed in open abdominal surgery, but long-time exposure could induce intestinal mucosal barrier dysfunction followed by many postoperative complications. High-fat enteral nutrition can ameliorate intestinal injury and improve intestinal function in many gastrointestinal diseases. In the present study, we investigated the effect of high-fat enteral nutrition on intestinal mucosal barrier after peritoneal air exposure and the underlying mechanism.

METHODS

Male adult rats were administrated saline, low-fat or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Rats undergoing anesthesia without laparotomy received saline as control. Twenty four hours after surgery, samples were collected to assess intestinal mucosal barrier changes in serum D-lactate levels, intestinal permeability, intestinal tight junction protein ZO-1 and occludin levels, and intestinal histopathology. The levels of malondialdehyde and the activity of superoxide dismutase in the ileum tissue were also measured to assess the status of intestinal oxidative stress.

RESULTS

High-fat enteral nutrition significantly decreased the serum D-lactate level and increased the intestinal tight junction protein ZO-1 level when compared to the group treated with low-fat enteral nutrition (P < 0.05). Meanwhile, histopathologic findings showed that the intestinal mucosal injury assessed by the Chiu's score and the intestinal epithelial tight junction were also improved much more in the high-fat enteral nutrition-treated group (P < 0.05). In addition, the intestinal malondialdehyde level was lower, and the intestinal superoxide dismutase activity was higher in the high-fat enteral nutrition-treated group than that in the low-fat enteral nutrition-treated group (P < 0.05).

CONCLUSIONS

These results suggest that high-fat enteral nutrition could reduce intestinal mucosal barrier damage after peritoneal air exposure, and the underlying mechanism may be associated with its antioxidative action. Perioperative administration of high-fat enteral nutrition may be a promising intervention to preserve intestinal mucosal barrier function in open abdominal surgery.

Laparoscopic cholecystectomy in elderly patients: an evaluation of immunity

OBJECTIVE

We sought to investigate the impact of laparoscopic cholecystectomy (LC) on the inflammatory response and immunological function of elderly patients compared with that on the younger ones.

METHODS

Between June 2012 and June 2013, this prospective study investigated a total of 112 patients having the surgery of LC due to symptomatic cholelithiasis or polyps, among whom 52 were elderly patients with the age beyond 65 years old and the remaining 60 were younger than the age. Peripheral venous blood samples were taken from these patients prior to surgery and on post-operative days 1, 3 and 7, respectively. The perioperative clinical outcomes and immunological function results were analyzed and compared between the two groups divided by age.

RESULTS

The demographics of the two groups did not differ except for the age. Surgical trauma seemed more serious for elderly patients as illustrated by the longer operating time, hospital stay and more quantity of patients got complication. Both groups indicated changes in inflammatory and immune aspects. Compared with the younger ones, elderly patients showed less quantity of preoperative basic immune cells, delayed immune responses after the surgical trauma of LC and hyporeactivity of inflammatory response when accepting LC.

CONCLUSIONS

An examination of the inflammatory reaction and immune response after LC demonstrated that there are significant differences observed in two groups divided by age. Further studies with more samples are required to determine the exact relationship of perioperative immune change and higher adverse outcome rate of aged people.

Development of a standardized laparoscopic caecum resection model to simulate laparoscopic appendectomy in rats

Background

Laparoscopic appendectomy (LA) has become one of the most common surgical procedures to date. To improve and standardize this technique further, cost-effective and reliable animal models are needed.

Methods

In a pilot study, 30 Wistar rats underwent laparoscopic caecum resection (as rats do not have an appendix vermiformis), to optimize the instrumental and surgical parameters. A subsequent test study was performed in another 30 rats to compare three different techniques for caecum resection and bowel closure.

Results

Bipolar coagulation led to an insufficiency of caecal stump closure in all operated rats (Group 1, n = 10). Endoloop ligation followed by bipolar coagulation and resection (Group 2, n = 10) or resection with a LigaSure™ device (Group 3, n = 10) resulted in sufficient caecal stump closure.

Conclusions

We developed a LA model enabling us to compare three different caecum resection techniques in rats. In conclusion, only endoloop closure followed by bipolar coagulation proved to be a secure and cost-effective surgical approach.

A robust scoring system to evaluate sepsis severity in an animal model

Background

The lack of a reliable scoring system that predicts the development of septic shock and death precludes comparison of disease and/or treatment outcomes in animal models of sepsis. We developed a murine sepsis score (MSS) that evaluates seven clinical variables, and sought to assess its validity and reliability in an experimental mouse model of polymicrobial sepsis.

Methods

Stool collected from the cecum of C57BL/6 (B6) mice was dissolved in 0.9% normal saline (NS) and filtered, resulting in a fecal solution (FS) which was injected intraperitoneally into B6 mice. Disease severity was monitored by MSS during the experimental timeline. Blood and tissue samples were harvested for the evaluation of inflammatory changes after sepsis induction. The correlation between pro-inflammatory markers and MSS was assessed by the Spearman rank correlation coefficient.

Results

Mice injected with FS at a concentration of 90 mg/mL developed polymicrobial sepsis with a 75% mortality rate at 24 hours. The MSS was highly predictive of sepsis progression and mortality, with excellent discriminatory power, high internal consistency (Cronbach alpha coefficient = 0.92), and excellent inter-rater reliability (intra-class coefficient = 0.96). An MSS of 3 had a specificity of 100% for predicting onset of septic shock and death within 24 hours. Hepatic dysfunction and systemic pro-inflammatory responses were confirmed by biochemical and cytokine analyses where the latter correlated well with the MSS. Significant bacterial dissemination was noted in multiple organs. Furthermore, the liver, spleen, and intestine demonstrated histopathological evidence of injury.

Conclusions

The MSS reliably predicts disease progression and mortality in an animal model of polymicrobial sepsis. More importantly, it may be used to assess and compare outcomes among various experimental models of sepsis, and serve as an ethically acceptable alternative to death as an endpoint.

Peritoneal air exposure elicits an intestinal inflammation resulting in postoperative ileus

BACKGROUND

The pathogenesis of postoperative ileus (POI) is complex. The present study was designed to investigate the effects of peritoneal air exposure on the POI intestinal inflammation and the underlying mechanism.

METHODS

Sprague-Dawley rats were randomized into five groups (6/group): the control group, the sham group, and three exposure groups with peritoneal air exposure for 1, 2, or 3 h. At 24 h after surgery, we analyzed the gastrointestinal transit, the serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10, the myeloperoxidase activity, and the levels of TNF-α, IL-1β, IL-6, and IL-10 in the ileum and colon. The oxidant and antioxidant levels in the ileum and colon were analyzed by measuring malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and total antioxidant capacity (T-AOC).

RESULTS

Peritoneal air exposure caused an air-exposure-time-dependent decrease in the gastrointestinal transit. The length of peritoneal air exposure is correlated with the severity of both systemic and intestinal inflammations and the increases in the levels of MDA, SOD, GSH-Px, and T-AOC.

CONCLUSIONS

The length of peritoneal air exposure is proportional to the degree of intestinal paralysis and the severity of intestinal inflammation, which is linked to the oxidative stress response.

Recovery of immunological homeostasis positively correlates both with early stages of right-colorectal cancer and laparoscopic surgery

Differences in postoperative outcome and recovery between patients subjected to laparoscopic-assisted versus open surgery for colorectal cancer (CRC) resection have been widely documented, though not specifically for right-sided tumors. We investigated the immunological responses to the different surgical approaches, by comparing postoperative data simultaneously obtained at systemic, local and cellular levels. A total of 25 right-sided CRC patients and controls were managed, assessing -in the immediate followup- the conventional perioperative parameters and a large panel of cytokines on plasma, peritoneal fluids and lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMC) tissue cultures. A general better recovery for patients operated with laparoscopy compared to conventional procedure, as indicated by the analysis of typical pre- and post-surgical parameters, was observed. The synchronous evaluation of 12 cytokines showed that preoperative plasma levels of the proinflammatory cytokines IL-6, IL-8, IL-1β, TNFα were significantly lower in healthy donors versus CRC patients and that such differences progressively increase with tumor stage. After surgery, the IL-6 and IL-8 increases were significantly higher in open compared to laparoscopic approach only in CRC at early stages. The postsurgical whole panel of cytokine levels were significantly higher in peritoneal fluids compared to corresponding plasma, but with no significant differences depending on kind of surgery or stage of disease. Then we observed that, pre- compared to the corresponding post-surgery derived LPS-stimulated PBMC cultures, produced higher supernatant levels of the whole cytokine panel. In particular IL-6 in vitro production was significantly higher in PBMC derived from patients subjected to laparoscopic versus open intervention, but -again- only in CRC at early stages of disease. Our results thus show that laparoscopy compared to open right resection is associated with a shorter compromission of the immunological homeostasis, mainly in early stages of right-CRC patients.

Laparotomy and laparoscopy diversely affect macrophage-associated antimicrobial activity in a murine model

Background

Surgical intervention-related trauma contributes largely to the development of postoperative immunosuppression, with reduced resistance to secondary bacterial infection. This study compared the impact of laparotomy versus laparoscopy on macrophage-associated bactericidal ability and examined whether laparotomy renders the host more susceptible to microbial infection.

Results

BALB/c mice were randomized into control, laparotomy, and laparoscopy groups. Laparotomy, but not laparoscopy, significantly downregulated CR3 expression on macrophages, diminished macrophage-induced uptake and phagocytosis of E. coli and S. aureus, and impaired macrophage-mediated intracellular bacterial killing. Consistent with this, mice that underwent laparotomy displayed substantially higher bacterial counts in the blood and visceral organs as well as a significantly enhanced mortality rate following bacterial infection, whereas mice subjected to laparoscopy did not show any defects in their bacterial clearance.

Conclusion

Laparotomy has an adverse effect on host innate immunity against microbial infection by impairing macrophage-mediated phagocytosis and killing of the invaded bacteria. By contrast, laparoscopy appears to preserve macrophage-associated bactericidal ability, thus alleviating the development of postoperative immunosuppression.

Laparoscopic and open splenectomy for splenomegaly secondary to liver cirrhosis: an evaluation of immunity

OBJECTIVE

We sought to investigate the perioperative inflammatory response and immunological function of patients with portal hypertension-induced splenomegaly who underwent laparoscopic (LS) or open splenectomy (OS).

METHODS

This prospective study investigated a total of 34 patients with splenomegaly due to portal hypertension who underwent either LS (n = 18) or OS (n = 16) between May 2009 and September 2010. Peripheral venous blood samples were taken from these patients prior to surgery and on postoperative days (POD) 1, 3, and 7. The perioperative clinical outcomes and immunological function results were analyzed and compared within each surgical group.

RESULTS

The demographics of the two groups did not differ. The patients in the LS group experienced longer operating time, less intraoperative blood loss, earlier resumption of diet, and shorter postoperative hospital stay. Both the open and laparoscopic groups exhibited statistically significant differences in interleukin -6 and C-reactive protein levels, and total lymphocyte, CD4 T, and natural killer cell numbers on POD 1 and 3 compared with pre splenectomy. The immune responses in the LS group were significantly lower than those in the OS group. The LS group exhibited better preserved cellular immune response and faster recovery than the OS group on POD 7.

CONCLUSIONS

An examination of the inflammatory reaction and cellular immune response after LS and OS demonstrated that there are significant differences in the immune responses observed in the two groups. Further human studies are required to determine the permanent effects of LS on immune function.

Surgical treatment for colorectal cancer

The rapid in development of surgical technology has had a major effect in surgical treatment of colorectal cancer. Laparoscopic colon cancer surgery has been proven to provide better short-term clinical and oncologic outcomes. However this quickly accepted surgical approach is still performed by a minority of colorectal surgeons. The more technically challenging procedure of laparoscopic rectal cancer surgery is also on its way to demonstrating perhaps similar short-term benefits. This article reviews current evidences of both short-term and long-term outcomes of laparoscopic colorectal cancer surgery, including the overall costs comparison between laparoscopic surgery and conventional open surgery. In addition, different surgical techniques for laparoscopic colon and rectal cancer are compared. Also the relevant future challenge of colorectal cancer robotic surgery is reviewed.

Prior laparotomy or corticosterone potentiates lipopolysaccharide-induced fever and sickness behaviors

Stimulating sensitized immune cells with a subsequent immune challenge results in potentiated pro-inflammatory responses translating into exacerbated sickness responses (i.e. fever, pain and lethargy). Both corticosterone (CORT) and laparotomy cause sensitization, leading to enhanced sickness-induced neuroinflammation or pain (respectively). However, it is unknown whether this sensitization affects all sickness behaviors and immune cell responses equally. We show that prior CORT and prior laparotomy potentiated LPS-induced fever but not lethargy. Prior CORT, like prior laparotomy, was able to potentiate sickness-induced pain. Release of nitric oxide (NO) from peritoneal macrophages stimulated ex vivo demonstrates that laparotomy, but not CORT sensitizes these cells.

Laparoscopic procedures for colon and rectal cancer surgery

After over a decade of debate and controversy, it is now well established that laparoscopic colon surgery for cancer when compared with open surgery, results in short-term benefits while maintaining at least equivalent long-term outcomes. Consequently, more and more patients are undergoing laparoscopic colon surgery, but the adoption rate still remains relatively low in the United States. Similarly, there are many potential benefits to performing rectal surgery laparoscopically. Although not well documented, laparoscopic rectal surgery is under active investigation and may result in the usual short-term benefits associated with laparoscopic surgery. In this article, short- and long-term outcomes of patients undergoing laparoscopic colorectal surgery for cancer are reviewed. In addition, different technical options for laparoscopic approaches to colon and rectal cancer are compared.

Immunologic and oncologic implications of laparoscopic surgery: what is the latest?

Laparoscopic surgery has been associated with many short-term benefits such as a shorter time to recovery, return of bowel function, less pain, and a decrease in wound infection rate. Several animal and human experiments have demonstrated an immunologic and oncologic benefit of minimally invasive surgery. Whether these results will translate into similar results in human settings is unclear. Although the first published prospective randomized clinical trial suggests better long-term outcomes for patients undergoing laparoscopic surgery, results from other ongoing randomized, controlled clinical trials are needed to verify this controversial result.

Comparison of immunologic outcomes of laparoscopic vs open approaches in clinical stage III colorectal cancer

PURPOSE

Improved survival in patients with stage III colon cancer after a laparoscopic colectomy (LC) has been reported by Lacy et al. (Lancet 359:2224-2229, 6), and preserved immunity was suggested as the reason for the survival advantage. The aim of our study was to clarify the existence of an immunological benefit after laparoscopic colon cancer surgery (LC) compared to open colon surgery (OC).

METHODS

From January 2006 to November 2007, 74 patients with clinical stage III colon cancer were prospectively assigned to undergo a LC (n = 35) or an OC (n = 39). The immune factors were examined preoperatively, and on the first and fifth days postoperatively (POD1 and POD5).

RESULTS

The cellular immune factors were significantly decreased; however, there was no significant difference between the LC and OC groups except for the mHLA-DR. The LC group had a better preserved mHLA-DR on POD5 than did the OC group (p = 0.015), in addition to a faster recovery (p < 0.005).

CONCLUSION

The mHLA-DR on POD5 was affected less by the LC compared to the OC. The LC demonstrated minimal immunological advantage when compared to the OC. However, further study is required to clarify the immunological benefits of the LC on colorectal cancer prognosis.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

Systemic immune response after open versus laparoscopic cholecystectomy in acute cholecystitis: a prospective randomized study

OBJECTIVE

Laparoscopic surgery is thought to reduce the postoperative immunologic effects of surgical trauma. The aim of this study is to evaluate the influence of surgical trauma on systemic inflammation and the immune response in acute cholecystitis.

MATERIAL AND METHODS

Thirty-three patients with acute calculous cholecystitis were assigned to laparoscopic cholecystectomy (LC, n=18) or open cholecystectomy (OC, n=15). Blood samples were obtained preoperatively and on postoperative day 1 (24 h after surgery) and day 3 (72 h after surgery), and blood concentration of C-reactive protein (CRP), leukocyte subpopulations, as well as levels of tumor necrosis factor-alpha (TNF-alpha) ex vivo secretion by peripheral blood mononuclear cells (PBMCs) were measured in both groups.

RESULTS

Hospitalization was significantly shorter in the LC group than in the OC group (LC group: 3.7+/-1.2 days versus OC group: 6.3+/-2.7 days, p=0.010). There was no postoperative morbidity in the LC group, but two patients in the OC group had postoperative complications. Postoperative TNF-alpha ex vivo secretion by PBMCs and PBMC counts in the OC group were significantly lower than those in the LC group (p=0.002). The CRP level declined by postoperative day 3, but was significantly less in the OC group than in the LC group (p<0.001). Postoperative monocyte counts significantly decreased in the OC group compared with those in the LC group (p=0.001).

CONCLUSIONS

A laparoscopic approach appears to cause less surgical trauma and immunosuppression than open surgery in patients with acute cholecystitis.

Laparoscopic resection of curable colon and rectal cancer: an evidence-based review

The initial enthusiastic application of laparoscopic techniques to colorectal surgical procedures was tempered in the early 1990s by reports of tumor implants in the laparoscopic incisions. Substantial evidence has accumulated, including evidence from randomized controlled trials, to support that laparoscopic resection results in oncologic outcomes similar to open resection, when performed by well-trained, experienced surgeons. This review was developed in conjunction with guidelines published by the Society of American Gastrointestinal and Endoscopic Surgeons. Data from the surgical literature concerning laparoscopic resection of curable colorectal cancer was evaluated regarding diagnostic evaluation, preoperative preparation, operative techniques, prevention of tumor implants, and training and experience. Recommendations are accompanied by an assessment of the level of supporting evidence available at the time of the development of the guidelines.

Major surgical trauma induces proteolysis of insulin-like growth factor binding protein-3 in transgenic mice and is associated with a rapid increase in circulating levels of matrix metalloproteinase-9

BACKGROUND

The authors previously demonstrated a significant decrease in plasma levels of intact insulin-like growth factor binding protein-3 (IGFBP-3) after major open but not after laparoscopic-assisted surgery in humans. They postulated that this decrease may have an effect on postoperative tumor growth. It also has been shown that plasma levels of matrix metalloproteinase-9 (MMP-9), a protease capable of degrading IGFBP-3, are transiently increased after open colectomy in humans. The authors aimed to develop an animal model that would allow further study of the effect that surgical trauma has on plasma levels IGFBP-3 and MMP-9. In addition, they set out to assess the concentration of MMP-9 in circulating monocytes before and after surgery.

METHODS

The 30 mice included in this study were divided into three groups: sham laparotomy, carbon dioxide (CO2) pneumoperitoneum, and anesthesia control. All mice were IGFBP-3 transgenics (overexpressing human IGFBP-3) on a CD1 background. The mice were anesthetized using ketamine and xylazine. Blood was drawn retroorbitally 48 h before the procedure. The duration of the procedure was 30 min. The animals were killed 24 h postoperatively and blood was drawn. Intact IGFBP-3 levels were measured using a combination of Western blot analysis and enzyme-linked immunoassay (ELISA) at the two time points: before and after the operation. Plasma and peripheral blood mononuclear cell levels of MMP-9 were measured at each time point using zymography. Mononuclear cell lysates were used to determine intracellular MMP-9 levels.

RESULTS

Plasma levels of intact IGFBP-3 were significantly lower than preoperative levels after sham laparotomy. A mean decrease of 76.6% was noted (p < 0.05). Zymography demonstrated significantly higher plasma MMP-9-related proteolytic activity than observed preoperatively after sham laparotomy (78.5 vs 42.3 Relative Units [RU]; p < 0.05). In the pneumoperitoneum group, no significant decrease was found between the pre- and postoperative levels of intact IGFBP-3. A nonsignificant increase in MMP-9 was noted after CO2 pneumoperitoneum (38 RU preoperatively vs. 46.4 RU postoperatively; p > 0.05). The anesthesia control group did not demonstrate a significant change in either circulating intact IGFBP-3 levels or MMP-9 levels. Mononuclear intracellular levels of MMP-9 were significantly lower after laparotomy than the preoperative levels (3 vs 37 RU). The postprocedure intracellular levels of MMP-9 were not significantly decreased in the pneumoperitoneum or anesthesia control group.

CONCLUSION

Plasma levels of intact IGFBP-3, a cell growth regulating factor, were found to be decreased significantly after laparotomy. This decrease was not seen after pneumoperitoneum. Depletion of intact IGFBP-3 after laparotomy correlated with a rapid release of MMP-9 from mononuclear cells and an increase in circulating plasma MMP-9 levels. Matrix metalloproteinase-9 may play an important role in IGFBP-3 proteolysis after surgical trauma. Furthermore, circulating mononuclear cells are one source of MMP-9 after surgery. Finally, the model used reproduces events in humans after surgery, and thus should permit further study on the mechanism of IGFBP-3 proteolysis after surgical trauma.

Minimally invasive management of colon cancer

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.

Laparoscopy vs minilaparotomy and full laparotomy preserves circulatory but not peritoneal and pulmonary immune responses

PURPOSE

Laparoscopy has been associated with lower inflammatory responses. However, it has been postulated that minilaparotomy, in contrast to full laparotomy, is equally minimally invasive.

OBJECTIVE

The aim of this study was to investigate local, systemic, and distant organ immune responses after different surgical approaches to the abdominal cavity, such as minilaparotomy, full laparotomy, and laparoscopy, in a small animal model.

METHODS

Male Lewis rats received a permanent central venous catheter and were randomized to 4 groups (n = 6 per group). The animals were subjected to anesthesia alone (control), minilaparotomy (1 cm), full laparotomy (7 cm), or laparoscopy for 60 minutes. Blood was collected via the central venous catheter before as well as 1 hour and 6 hours after the start of intervention. Peritoneal and bronchoalveolar lavages, as well as heart puncture, were performed after 24 hours.

RESULTS

All surgical interventions led to a significant migration of polymorphonucleocytes into the abdominal cavity. Full laparotomy resulted in a significant increase in nitric oxide production by peritoneal macrophages as compared with control. Macrophage nitric oxide production after laparoscopy and minilaparotomy was not significantly different. A shift in the expression of OX-6 and CD54 was only detected after full laparotomy. Systemically, O(2)(-) release by circulating mononuclear cells was significantly increased after minilaparotomy and full laparotomy, but not after laparoscopy. The systemic levels of IL6 were significantly accelerated only after full laparotomy, with a maximum after 6 hours. In the lungs, function of alveolar macrophages was not altered in any group.

CONCLUSIONS

Any approach to the peritoneal cavity causes local inflammatory responses. Full laparotomy alters peritoneal macrophage functions more pronouncedly than does minilaparotomy or laparoscopy. Systemic inflammatory responses, such as free oxygen radical release, are significantly increased by both minilaparotomy and full laparotomy, whereas laparoscopy preserves systemic immune function. Our results may lead to further preference for the laparoscopic approach over minilaparotomy and full laparotomy.

Cœlioscopie et cancer en gynécologie : le point en 2005

All the surgical procedures, which may be required to treat a gynecologic cancer, can be performed endoscopically. However prospective randomized studies required to confirm the oncologic efficacy of the technique are still lacking in gynecology, whereas such studies are available in digestive surgery. Animal studies suggested that the risk of tumor dissemination in non traumatized peritoneum is higher after a pneumoperitoneum than after a laparotomy. Experimental studies also emphasized two points: the surgeon and the surgical technique are essential, all the parameters of the pneumoperitoneum may influence the postoperative dissemination. Changing these parameters we may, in the future, be able to create a peritoneal environment adapted to oncologic patients in order to prevent or to decrease the risks of peritoneal dissemination and/or of postoperative tumor growth. Until the results of prospective randomized studies become available, the preoperative selection of the patients and the surgical technique should be very strict. In patients with endometrial cancer, the laparoscopic approach should be reserved to clinical stage I disease, if the vaginal extraction is anticipated to be easy accounting for the volume of the uterus and the local conditions. In cervical cancer, the laparoscopic approach should be reserved to patients with favorable prognostic factors: stage IB of less than 2 cm in diameter. Laparoscopy is the gold standard for the surgical diagnosis of adnexal masses. But the puncture should be avoided whenever possible. The surgical treatment of invasive ovarian cancer should be performed by laparotomy whatever the stage. In contrast restaging of an early ovarian cancer initially managed as a benign mass, is a good indication of the laparoscopic approach. The laparoscopic management of low malignant potential tumors should include a complete staging of the peritoneum. Knowledge of the principles of endoscopy and of oncologic surgery is required. Teaching and diffusion of endoscopic oncological techniques are among the major challenges of gynecologic surgery within the next few years.

Immunologic effects of hand-assisted surgery on peritoneal macrophages: Comparison to open and standard laparoscopic approaches

BACKGROUND

Exaggerated activation of peritoneal immunity after major abdominal surgery activates peritoneal macrophages (PMs), which may lead to a relative local immunosuppression. Although laparoscopy (L) is known to elicit a smaller attenuation of peritoneal host defenses, compared with open (O) surgery, effects of the hand-assisted (HA) approach have not been investigated to date.

METHODS

Eighteen pigs underwent a transabdominal nephrectomy via O, HA, or L approach. PMs were harvested at 4, 12, and 24 hours through an intraperitoneal drain and stimulated in vitro with lipopolysaccharide. The production of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) by the purified macrophage cultures was measured with the use of a standard enzyme-linked immunosorbent assay technique. Statistical comparison was performed by using analysis of variance and Student t test.

RESULTS

In vitro lipopolysaccharide-induced IL-6 and TNF-alpha production by PMs increased over the 24-hour period in all 3 groups. Stimulated PMs harvested at 12 and 24 hours postoperatively secreted higher levels of IL-6 in the O group, compared with both the HA group (P = .02, P = .01) and L group (P = .04, P = .001). PMs harvested at 4, 12 and 24 hours postoperatively also produced more TNF-alpha in O group, compared with both the HA group (P = .03, P = .03, and P = .01) and L group (P = .01, P = .05 and P = .03). There was no significant difference between H and L groups in production of either cytokine.

CONCLUSIONS

Abdominal surgery attenuates peritoneal host defenses regardless of the surgical approach employed. However, for the first time, we demonstrated that the HA approach, similar to laparoscopy, is superior to open surgery in the degree of PM activation. Overall, in addition to clinical benefits of minimal access, HA surgery may confer an immunologic advantage over laparotomy.

Is minimal access surgery for cancer associated with immunologic benefits?

Minimal-access surgical techniques have been shown to be beneficial to patients in terms of shorter convalescence, reduced pain, and improved cosmesis. Although systemic immune function is better preserved following laparoscopic procedures when compared with their respective open approaches, CO2 pneumoperitoneum may significantly affect local (i.e., infra-abdominal) cellular immunity by reducing regional macrophage function. Results to date are conflicting with regard to the impact of closed and open methods on intraabdominal immunity. Impaired cellular immunity after CO2 pneumoperitoneum may have significant undesirable intra-abdominal effects on tumor surveillance after oncological surgery; however, at present, there is no clinical evidence to support this position. The VATS techniques avoid the use of CO2 insufflation, which may offer some advantages from the immune function perspective over laparoscopic procedures accomplished with CO2 pneumoperitoneum. Better preservation of early postoperative cellular immune function and attenuated disturbance in the inflammatory mediators are likely contributing factors to the clinical benefits that follow laparoscopic surgery and VATS. Larger multi-center randomized trials are needed to confirm the potential benefits of minimal-access surgery on patient survival after cancer surgery. Future research should focus on the effects of minimal-access surgery on other mediators (such as MMP-9, IGFBP-3, IL-12, IL-17, and IL-23) that may be important in tumor cell dissemination, deposition, and propagation in the early postoperative period. Furthermore, additional searches for other factors or mediators, heretofore unrecognized, should be carried out. Such studies will, we hope, increase our knowledge and understanding of the impact of surgery on immune and other physiologic functions.

Urological laparoscopy: basic physiological considerations and immunological consequences

PURPOSE

The applications of laparoscopy to urological surgery continue to grow at a steady pace. A complete understanding of the physiological and immunological changes associated with pneumoperitoneum is required. We reviewed the physiology of laparoscopy with regard to the major organ systems and summarize the effects of pneumoperitoneum on immune function.

MATERIALS AND METHODS

Articles published in the scientific literature from 1990 to 2004 with relevance to laparoscopic physiology and the immune response to pneumoperitoneum were reviewed using PubMed.

RESULTS

Pneumoperitoneum induces predictable pulmonary and renal responses. The cardiovascular and hemodynamic responses are phasic and dynamic in nature, and only generalizations regarding cardiac function can be made. Renal parenchymal and venous compression during pneumoperitoneum are the etiology of oliguria during laparoscopy. The effects are reversible and cause no adverse effects on renal function. There is a general trend toward systemic immune preservation and peritoneal immune depression during insufflation based laparoscopy. Attenuated peritoneal immunity has been demonstrated most consistently by altered macrophage function.

CONCLUSIONS

Physiological changes incurred as a result of pneumoperitoneum have minimal adverse effects in healthy individuals undergoing laparoscopic surgery. Interest has grown in the impaired peritoneal immune response to CO2 pneumoperitoneum. Altered intraperitoneal immunity may represent a new avenue for the development of adjuvant therapies for minimally invasive treatments of urological malignancies and for the prevention of port site metastasis. Further elucidation and investigation into the immunological responses to pneumoperitoneum during urological laparoscopic procedures is called for.

Immunological advantages of advanced laparoscopy

Surgical trauma causes significant alterations in host immune function. Compared with open surgery, laparoscopic surgery is associated with reduced postoperative pain and more rapid return to normal activity. Experimental data have also shown more aggressive tumor establishment and growth rates following open surgery and laparoscopic surgery. Surgery-related immunosuppression may be partly responsible for the differences in cancer growth and outcome noted. It is clear that the choice of abdominal surgical approach has immunologic consequences. Further studies are needed to better the time course and extent of surgery-related alterations in the immune system and their clinical importance. A better understanding of the impact of surgery on the immune system may provide opportunities for pharmacologic manipulation of postoperative immune function to improve clinical results.

Estrogen protects against brain lipid peroxidation in ethanol-withdrawn rats

This study examined whether 17beta-estradiol (E2) administration protects against ethanol withdrawal (EW)-associated oxidative insults by assessing oxidative markers thiobarbituric-acid-reacting-substances (TBARS). Ovariectomized rats implanted with E2 (EW/E2) or oil pellets (EW/Oil) received chronic ethanol (7.5% wt./vol., 5 weeks) or control dextrin diet (Dextrin/Oil). At 24 or 48 h of EW, rats were tested for overt EW signs and the cerebellum, hippocampus, and cortex were prepared for TBARS assessment in the presence and absence of FeCl3. For control experiments, we assessed E2 effects on blood ethanol concentrations and TBARS levels during ethanol exposure prior to EW. The EW/Oil group showed enhanced endogenous- and FeCl3-stimulated membrane TBARS levels in the cerebellum and hippocampus in a manner inhibited by E2 treatment. There was a relationship between the severity of EW and elevation of TBARS levels, particularly in the cerebellum. The enhanced TBARS levels at 24 h of EW appeared to diminish at 48 h in the hippocampus, but persisted in the cerebellum. E2 treatment did not alter blood ethanol concentrations and ethanol exposure alone did not enhance TBARS levels. These data suggest that EW rather than ethanol enhances brain lipid peroxidation that is transient and brain-region specific. Estrogens protect against the brain lipid peroxidation in a manner independent of blood ethanol concentrations.

The net immunologic advantage of laparoscopic surgery

The trauma of surgery evokes a variety of physiologic and immunologic alterations that should contribute to host defense. However, an exaggerated response to injury may result in immunosuppression and lead to significant postoperative morbidity and mortality. Laparoscopic surgery may result in less induced surgical trauma than conventional open surgery. Decreased postoperative pain and speedy functional recovery of laparoscopic patients may be attributable to the reduced inflammatory response and minimal immunosuppression. Inflammation, an early protective homeostatic immune response to injury, is characterized by the production of proinflammatory cytokines and by activation of cellular and humoral immune mechanisms. Postoperative levels of the inflammatory cytokines have been consistently lower after laparoscopic procedures, indicating a smaller degree of surgical insult and acute inflammatory reaction. Surgical stress derails the functions of both polymorphonuclear and mononuclear cells, which may lead to an increased risk of postoperative infection. Comparative studies of cellular immunity after laparoscopic and conventional surgery demonstrate immunologic advantage conferred by laparoscopy. Exaggerated activation of peritoneal immunity may lead to a relative local immunosuppression, resulting in ineffective intraperitoneal bacterial clearance and serious postoperative infections. Functions of the peritoneal macrophages are better preserved when laparotomy is avoided. Decreased perioperative stress may be particularly important for oncologic patients. Laparoscopic approaches may result in diminished perioperative tumor dissemination and better cancer outcomes. Although laparoscopy is "minimally invasive," systemic immune responses still are undeniably activated. However, laparoscopic surgery appears to induce a smaller injury, resulting in proportionally decreased immunologic changes. In addition to improved cosmesis and faster functional recovery, a patient undergoing laparoscopic surgery may benefit most from a net immunologic advantage.

Breast models: a useful tool for instruction

Background

In the late '80s the successes of the laparoscopic surgery for gallbladder disease laid the foundations on the modern use of this surgical technique in a variety of diseases. In the last 20 years, laparoscopic colorectal surgery had become a popular treatment option for colorectal cancer patients.

Discussion

Many studies emphasized on the benefits stating the significant advantages of the laparoscopic approach compared with the open surgery of reduced blood loss, early return of intestinal motility, lower overall morbidity, and shorter duration of hospital stay, leading to a general agreement on laparoscopic surgery as an alternative to conventional open surgery for colon cancer. The reduced hospital stay may also decrease the cost of the laparoscopic surgery for colorectal cancer, despite th higher operative spending compared with open surgery. The average reduction in total direct costs is difficult to define due to the increasing cost over time, making challenging the comparisons between studies conducted during a time range of more than 10 years. However, despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients due to technical limitations or the characteristics of the patients that may affect short and long term outcomes.

Conclusions

The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology. Laparoscopic surgery for colon cancer demonstrates better short-term outcome, oncologic safety, and equivalent long-term outcome of open surgery. For rectal cancer, laparoscopic technique can be more complex depending on the tumor location. The advantages of minimally invasive surgery may translate better care quality for oncological patients and lead to increased cost saving through the introduction of active enhanced recovery programs which are likely cost-effective from the perspective of the hospital health-care providers.