The influence of surgical stress on T cells: enhancement of early phase lymphocyte activation

Effect of tramadol on perioperative immune function in patients undergoing gastric cancer surgeries

BACKGROUND

A prospective randomized controlled trial was designed to observe the effect of tramadol on T-lymphocyte subsets, activated T cell and natural killer (NK) cells of patients undergoing gastric cancer surgeries.

SUBJECTS AND METHODS

Thirty patients undergoing elective gastric cancer surgeries under general anesthesia were randomly divided into two groups. Before anesthesia induction, Group I did not receive any drugs and Group II received intramuscular tramadol 1 mg/kg. Peripheral venous blood samples were taken before anesthesia, 1 h after incision and postoperation. CD3(+), CD3(+) CD4(+), CD3(+) CD8(+), CD3(-)CD16(+) CD56(+) (NK) cells and CD3(+) human leukocyte antigen (HLA)-DR(+) (activated T cell) were measured by flow cytometer.

RESULTS

One hour after incision, CD3(+), CD3(+) CD4+, CD3(+) CD4(+)/CD3(+) CD8(+), CD3(-)CD16(+) CD56(+), and CD3(+) HLA-DR(+) cells in the experimental and control group were significantly decreased compared with their baselines (P < 0.05), while the values of Group I were lower than those of Group II (P < 0.05). After surgery, the values of Group I were lower than their baselines (P < 0.05). But the values of Group II had no significant difference compared with their baselines.

CONCLUSION

Tramadol can reduce the decrease of T-lymphocytes subsets and NK cells, thus improve the cellular immune function in the perioperation of gastric cancer.

Changes in lymphocyte phenotypes and cytokine production by surgical stress in a rat small intestinal resection model

Small intestinal resection rats are used widely as a malabsorption model, but the immunological changes are unclear. We examined the changes in systemic and mucosal immune status after a small intestinal resection in rats with a controlled nutritional status. Rats had 60% of their small intestine removed. At 5 days after the surgery, spleen cells and intraepithelial lymphocytes (IEL) were isolated. The phenotypes of spleen cells and IEL, the production patterns of Th1 and Th2 cytokines, and the proinflammatory cytokine levels in the plasma were measured. CD4+ T cells in the blood and spleen were significantly decreased in the Resection group (p<0.05). In contrast, IEL subpopulations were not different between the two groups. Interferon-gamma production from the spleen cells was significantly decreased in the Resection group (p<0.05). Interleukin (IL)-4 production was not different between the two groups. Plasma IL-6 concentrations were significantly elevated in the Resection group 6 h after surgery (p<0.05). In conclusions, small intestinal resection in rats suppressed systemic immunity, and this model is useful as a surgical stress model.

Leukocytosis after robotic hysterectomy: commonly observed but clinically insignificant

Laboratory studies are commonly performed after surgery, but with little evidence of clinical utility. We evaluated our experience with measuring a complete blood count (CBC) to determine peripheral blood leukocyte count (WBC) postoperatively following consecutive robotic hysterectomies. From January 2008 through November 2009, two surgeons (KM, HM) performed 204 robotic hysterectomies. Patient age, weight, height, indication for surgery, surgical procedure, operative time, estimated blood loss, hospital length of stay, postoperative fever, and complications were prospectively recorded and correlated with WBC measured on the day after surgery. The postoperative WBC was elevated (>11,000/μl) in 59/204 (29%) patients. Eight (4%) patients had marked leukocytosis (WBC >15,000/μl; maximum 16,600/μl). There was no correlation between postoperative leukocytosis and operative time, BMI, performance of lymphadenectomy, or length of hospitalization. The only factor significantly associated with elevated postoperative WBC was elevated preoperative WBC (P < .001). Also, there was no correlation between postoperative leukocytosis with fever or infectious complications. The mean T max was 37.1ºC and T max over 38ºC was seen in nine patients. Of the five women who developed infectious complications, only one (diagnosed with pneumonia) had a minimally elevated postoperative WBC (11,600/μl); the other four (pneumonia and pelvic abscess, two each) had normal postoperative WBC. Routine measurement of WBC after robotic hysterectomy is not useful. In about 25% of cases there will be a slight leukocytosis, and rarely (about 4%) will the WBC exceed 15,000/μl. In no case was measurement of postoperative WBC clinically relevant.

Surgical stress-induced immune cell redistribution profiles predict short-term and long-term postsurgical recovery. A prospective study

BACKGROUND

The experience of undergoing surgery is known to induce a short-term, fight-or-flight physiological stress response. As an optimum immune response at the site of surgery would enhance tissue repair, we examined surgical stress-induced immune cell redistribution profiles as predictors, and potential mediators, of short and long-term postoperative recovery. We tested the a priori hypothesis that predefined adaptive immune cell redistribution profiles observed during surgery will predict enhanced postoperative recovery.

METHODS

This prospective longitudinal study involved fifty-seven patients undergoing meniscectomy. Knee function was assessed preoperatively and at one, three, eight, sixteen, twenty-four, and forty-eight weeks postoperatively with use of the clinically validated Lysholm scale, which assesses mechanical function, pain, mobility, and the ability to perform daily activities. Surgery-induced immune cell redistribution was measured in the blood at baseline, before surgery, and after surgery.

RESULTS

Mixed-model repeated-measures analyses revealed a main effect of immune cell redistribution: patients who showed the predefined "adaptive" lymphocyte and monocyte redistribution profiles during surgery showed enhanced recovery. Interesting differences were also observed between the sexes: women as a group showed less adaptive redistribution and correspondingly showed significantly delayed maximum recovery, requiring forty-eight weeks, compared with men, who required only sixteen weeks. Inter-individual differences in leukocyte redistribution predicted the rate of recovery across both sexes.

CONCLUSIONS

Immune cell redistribution that is induced by the stress of undergoing surgery can predict (and may partially mediate) postoperative healing and recovery. These findings may provide the basis for identifying patients (either prospectively or during surgery) who are likely to show good as opposed to poor recovery following surgery and for designing interventions that would maximize protective immune responses and enhance the rate and extent of recovery.

The effect of preoperative ketorolac on WBC response and pain in laparoscopic surgery for endometriosis

Surgical stress causes changes in the composition of white blood cells (WBCs). Ketorolac is believed to have analgesic effects and to reduce the stress response and may therefore improve postoperative outcomes. The aim of this study was to assess the effect of preoperative ketorolac on the WBC subsets in patients who had laparoscopic surgery for endometriosis. Fifty patients who had laparoscopic surgery for endometriosis were randomly assigned to one of two groups: the ketorolac group (n = 25) received ketorolac 0.5 mg/kg before the induction of anesthesia, and the control group (n = 25) received saline. White cell count, differential, and pathology studies were done immediately after surgery, on postoperative day 1, and on postoperative day 3. We compared the baseline values within and between the two groups. We also assessed postoperative pain and side effects. The time that elapsed before the first patient request for analgesia, total meperidine dose and VAS (Visual Analog Scale) for postoperative pain were significantly lower in the ketorolac group than in the control group. Compared to the pre- surgical values, there was an increase in total WBC count and percentage of neutrophils, but a decrease in percentages of lymphocytes, monocytes, eosinophils, basophils, and leucocytes. Total WBC count, neutrophils, monocytes, eosinophils and leucocytes showed significant differences between the two groups. The incidences of postoperative side effects, such as nausea, dizziness, headache, and shoulder pain were not different between the groups. Preoperative ketorolac reduced postoperative pain and influenced the WBC response in laparoscopic surgery for endometriosis.

Expression of CD97 and Adhesion Molecules on Circulating Leukocytes in Patients Undergoing Coronary Artery Bypass Surgery

OBJECTIVE

Leukocyte activation is thought to be responsible for the adverse effects and postoperative complications following cardiopulmonary bypass (CPB). A novel cell surface molecule, CD97, is a sensitive marker of leukocyte and primary lymphocyte activation. The present study aimed to determine the activation of different leukocyte subsets by comparing the expression of CD97 and adhesion molecules (CD11, CD18) in patients receiving coronary surgery with or without CPB.

METHODS

30 patients were enrolled and scheduled for coronary bypass surgery under CPB (20 patients, group A) and with off-pump (OP) operation (10 patients, group B). Blood samples were taken before and during surgery, and over the following first week.

RESULTS

Here, we report an early decrease in CD97 expression of granulocytes (PMN) and monocytes (MC) followed by an intensive increase reaching the maximum on postoperative days 2 and 3 in patients operated with CPB. The rate of active CD97-positive lymphocytes showed a marked, gradual increase until postoperative day 3 and remained elevated up to day 7 after CPB. OP surgery resulted in moderate alteration in the presence of CD97 on PMN, MC and lymphocytes. The expression of adhesion molecules was similar to CD97 in all leukocyte subsets.

CONCLUSION

The findings about CD97 expression suggest considerable leukocyte activation following coronary bypass with CPB compared to OP surgery. The collected data show that the lymphocytes are highly activated and involved in leukocyte sequestration after CPB. Moreover, the importance of CD97 in CPB-related inflammatory response can be stated.

Upregulation of IFN-gamma and soluble interleukin-2 receptor release and altered serum cortisol and prolactin concentration during general anesthesia

The effects of surgery, surgical stress, and anesthesia compromise the optimal function of the immune system. Recent studies demonstrate the influence of anesthesia on the immune response by modulation of neural-immune interactions. To evaluate the immunologic effects of general anesthesia with the hypnotic agent propofol and the opioid fentanyl, two drugs used frequently in anesthesia, we studied 30 patients undergoing elective orthopedic surgery before and during narcosis. We found a significant enhancement of interferon-gamma (IFN-gamma) and soluble interleukin-2 receptor (sIL-2R) release in lipopolysaccharide (LPS)-stimulated whole blood cultures after induction of anesthesia. Similar results were observed in cultures stimulated with polyclonal T cell activators, such as staphylococcal enterotoxin B (SEB) and phytohemagglutinin (PHA). IL-1beta and IL-8 release was not affected, but the anti-inflammatory cytokine IL-10 decreased after skin incision. Serum prolactin significantly increased immediately after induction of anesthesia, whereas serum cortisol levels declined. Our results point to enhanced proinflammatory T lymphocyte and natural killer (NK) cell activity, probably caused by prolactin and cortisol modulation in the serum. This may disturb the balance of human proinflammatory and anti-inflammatory pathways during surgery and general anesthesia.