Spinal but Not General Anesthesia Increases the Ratio of T Helper 1 to T Helper 2 Cell Subsets in Patients Undergoing Transurethral Resection of the Prostate

Immunomodulatory effects of intraoperative dexmedetomidine on T helper 1, T helper 2, T helper 17 and regulatory T cells cytokine levels and their balance: a prospective, randomised, double-blind, dose-response clinical study

Background

The ratio of T helper 1 (Th1) to T helper 2 (Th2) as well as T helper 17 (Th17) to regulatory T cells (Treg) represents the state and direction of immune response. Recent studies demonstrated that dexmedetomidine reduced the secretion of inflammatory cytokines. We performed this study to investigate the effect of different doses of intraoperative dexmedetomidine on the expression of Th1, Th2, T17 and Treg cytokines and their ratios.

Methods

Seventy-five patients undergoing laparoscopic cholecystectomy were randomly separated into one of three groups: the full dose group (n = 25), in which dexmedetomidine was infused with a 1.0 μg/kg loading followed by an infusion of 0.5 μg/kg/min after anaesthetic induction, or the half dose group (n = 26), in which the dose was half of that of full dose group, or the saline group (n = 24) which was control. T cell cytokines were quantified by sandwich enzyme-linked immunoassay for blood samples taken after anaesthetic induction (T0), at the end of surgery (T1), and 60 min after surgery (T2). IFN-gamma/IL-4 and IL-17/IL-10, which represent the ratio of Th1/Th2 and Th17/Treg cytokines, respectively, were calculated as indices of immune cell levels based upon serum cytokines levels in place of direct measurements. C-reactive protein (CRP) concentrations were measured on the next day following surgery.

Results

The full dose group was associated with higher ratios of IFN-gamma/IL-4 than those of half dose group and control [10.1 vs. 1.9 at T1 (P = 0.041) compared with half dose group, and 10.1 vs. 0.2 at T1 (P = 0.031), 7.4 vs. 0.1 at T2 (P = 0.025) compared with control]. IL-17/IL-10 ratios were higher in the full dose group than those in control [4.2 vs. 0.6 at T1 (P = 0.013), 3.0 vs. 0.3 at T2 (P = 0.011)]. The CRP levels were lower in the dexmedetomidine-treated groups in a dose-dependent manner.

Conclusions

Dexmedetomidine exhibits immunomodulatory effects, shifting the Th1/Th2 and T17/Treg cytokine balance toward Th1 and T17, respectively, in a dose-dependent pattern in patients with surgical and anaesthetic stress.

Trial registration

Clinical Research Information Service, Republic of Korea (CRIS); KCT0000503; Registration date: Aug 13, 2012.

Perioperative regional anaesthesia and postoperative longer-term outcomes

Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.

Cancer surgery: how may anesthesia influence outcome?

OBJECTIVE

To review the published literature regarding the effects of anesthesia on cancer surgery to prevent tumor cell proliferation/migration or induce apoptosis.

BACKGROUND

Surgery is the main treatment for potentially curable solid tumors, but most cancer-related deaths in patients who have received previous surgical treatment are caused by metastatic disease. There is increasing evidence that anesthetic technique has the potential to affect long-term outcome after cancer surgery.

METHODS

This work reviews the English published literature that was obtained by performing a search of the PubMed database up to January 2014. We selected articles that provided evidence or reviewed the possible actions of anesthetics on cancer cells or the influence of anesthesia in recurrence/outcome.

RESULTS

Inhaled anesthetics induce immunosuppression and activate inflammatory cascade activation, whereas propofol has a protective action. Opioids might promote cancer recurrence and metastasis. In vitro and in vivo studies have demonstrated that local anesthetics inhibit proliferation and migration of cancer cells and induce apoptosis.

CONCLUSIONS

Anesthesiologists should follow current best clinical practice and include all strategies that effectively decrease pain and attenuate stress. Regional anesthesia and multimodal analgesia, adding anti-inflammatory drugs, play an unquestionable role in the control of perioperative pain and may improve recurrence-free survival.

The tryptophan kynurenine pathway, neopterin and IL-6 during vulvectomy and abdominal hysterectomy

Background

Surgery has wide ranging immunomodulatory properties of which the mechanism is poorly understood. In order to investigate how different types of surgery influence inflammation, we designed a longitudinal observational study investigating two inflammatory profiles of two separate patient groups undergoing gynaecological operations of differing severity. In addition to measuring the well known inflammatory markers neopterin and IL-6, we also determined the kynurenine/tryptophan ratio.

This study was a prospective, single center, two-armed observational study involving 28 female patients. Plasma levels of tryptophan, kynurenine, neopterin and IL-6 were determined from samples taken at: 24hrs pre-operative, prior to induction, ten minutes before the operation was expected to end, and at 24 and 96 hours post operative in patients undergoing abdominal hysterectomy and vulvectomy.

Results

There were 15 and 13 patients included in the vulvectomy and abdominal hysterectomy groups, respectively. In this study we show that anesthesia and surgery significantly increases the enzyme activity of indoleamine 2, 3 dioxygenase (IDO) as measured by the kynurenine/tryptophan ratio (P=0.003), while maintaining stable neopterin levels. However, abdominal hysterectomy causes a considerable IL-6 increase (P<0.001).

Conclusion

Surgery and associated anesthesia cause a significant tryptophan level decrease while significantly increasing IDO activity. Both types of surgery produce nearly identical neopterin time curve relationships, with no significant change occurring in either group. However, even though neopterin is unaffected by the severity of surgery, IL-6 responded to surgical invasiveness by revealing a significant increase during abdominal hysterectomy.

Effects of dexmedetomidine on the ratio of T helper 1 to T helper 2 cytokines in patients undergoing laparoscopic cholecystectomy

STUDY OBJECTIVES

To investigate the effect of dexmedetomidine on T helper 1 (Th1) and T helper 2 (Th2) cytokines and their ratio during and after surgery.

DESIGN

Single-blinded, randomized, placebo-controlled clinical comparison study.

SETTING

Academic medical center.

PATIENTS

46 adult, ASA physical status 1 and 2 patients scheduled for laparoscopic cholecystectomy.

INTERVENTIONS

Patients were randomized to two groups: the dexmedetomidine group (n = 23), in which dexmedetomidine was infused with a 1.0 μg/kg loading dose followed by infusion of 0.5 μg/kg/h; or the saline group (n = 23).

MEASUREMENTS

Interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) as Th1 and Th2 cytokines, respectively, were quantified three times: after induction of anesthesia (T0), at the end of peritoneal closure (T1), and 60 minutes after surgery (T2). The IFN-gamma/IL-4 ratio was then calculated.

MAIN RESULTS

The dexmedetomidine group displayed higher levels of IFN-gamma at T1 and T2 (42.30 pg/dL vs 6.91 pg/dL at T1 [P = 0.025]; 40.51 pg/dL vs 8.29 pg/dL at T2 [P = 0.030]) than the saline group. The dexmedetomidine group was also associated with higher ratios of IFN-gamma/IL-4 (1.22 vs 0.32, respectively, at T1 [P = 0.012]; 1.53 vs 0.13, respectively, at T2 [P = 0.012]).

CONCLUSIONS

Dexmedetomidine plays an immunomodulatory role, shifting the Th1/Th2 cytokine balance toward Th1 in patients with surgical and anesthetic stress.

Perioperative cytokine response to infection associated with elective arterial surgery

OBJECTIVE

The aim was to assess the cytokine response to acute inflammation and infection in vascular surgery.

DESIGN OF STUDY

Single-center, prospective cohort study.

METHODS

Blood samples from 96 consecutive patients undergoing elective vascular surgery were analyzed for C-reactive protein (CRP), total leukocyte counts (LPK), neutrophil CD64 expression, and cytokines using enzyme-linked immunosorbent assay.

RESULTS

Of the 25 investigated cytokines, 22 had lower postoperative mean values compared to preoperative values. Interleukin (IL) 6 (IL-6) was the only cytokine that increased significantly postoperatively. Combined analysis of CRP and CD64 together with IL-6 or IL-10 showed an individually unique association with postoperative infection (P < .05).

CONCLUSION

We have shown a positive correlation with perioperative infection for the proinflammatory cytokines and the anti-inflammatory cytokine IL-10 as well as a number of chemokines. To our knowledge, this is the first report linking IL-10 and chemokine plasma levels to perioperative infection in vascular surgery.

Effects of surgery, general anesthesia, and perioperative epidural analgesia on the immune function of patients with non-small cell lung cancer

STUDY OBJECTIVE

To assess preoperative and postoperative immune function in patients undergoing surgical resection of non-small cell lung cancer during general anesthesia and postoperative epidural analgesia.

DESIGN

Observational single-center study.

SETTING

University-affiliated academic center.

PATIENTS

24 adult, ASA physical status 3 and 4 patients with stage 1, 2, or 3 non-small cell lung cancer. No study patient received preoperative chemotherapy or radiation.

INTERVENTIONS

Patients underwent thoracotomy with general anesthesia and postoperative epidural analgesia.

MEASUREMENTS

Bispectral index monitoring, sevoflurane requirements, and intraoperative transfusions were recorded. Total fentanyl consumption and pain (verbal numeric rating scale) were recorded 24 hours after surgery. Preoperative and 24-hour postoperative natural killer cell percentage and function and percentages of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) were measured. Plasma concentrations of the TH1 cytokine interleukin-2 and interferon-gamma and the TH2 cytokines interleukin-4 were measured at the same time points.

RESULTS

The percentage (preoperative, 13.07 ± 9.81% vs postoperative, 9.6 ± 6.57%, P < 0.001) and function (preoperative, 31.61 ± 21.96%; postoperative, 13.61 ± 9.36%; P < 0.001) of natural killer cells was significantly decreased after surgery, but the percentage of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) remained unchanged postoperatively; thus, the CD4/CD8 ratio remained unchanged. Postoperative plasma concentrations of the three cytokines were similar to preoperative levels; therefore, the TH1/TH2 ratio also remained unchanged.

CONCLUSIONS

Innate immunity is depressed in patients with non-small cell lung cancer after surgical resection, and immunity is not preserved by the use of postoperative epidural analgesia.

The effect of high-intensity focused ultrasound treatment on immune function in patients with uterine fibroids

PURPOSE

The aim of this study was to investigate the effect of high-intensity focused ultrasound (HIFU) on immune function in patients with uterine fibroids, in a randomised comparison to conventional myomectomy.

METHODS

The patients were assigned (1:1) to the HIFU group or the myomectomy (MY) group. Venous blood samples were collected 24 h before and 24 h and 72 h after operation. The percentages of CD4(+) and CD8(+) T cells and natural killer (NK) cells were quantified by flow cytometry (FCM). Serum levels of interleukin-2 (IL-2), IL-6 and IL-10 were determined using enzyme-linked immunosorbent assay.

RESULTS

HIFU was associated with early ambulation, fewer post-operative complications, and shorter hospital stay (p < 0.001). The percentages of CD4(+) and CD8(+) T cells and NK cells in the HIFU group were not significantly altered after treatment compared with before treatment. In contrast, the numbers of these cells in the MY group decreased significantly 24 h after conventional myomectomy (p < 0.001). The CD4(+)/CD8(+) T cell ratios were also decreased significantly 24 h and 72 h after conventional myomectomy (p < 0.001). Serum levels of IL-6 and IL-10 increased after treatment in both groups. Peak IL-6 and IL-10 levels were significantly lower in the HIFU group than in the MY group (p < 0.001). In contrast, IL-2 level decreased significantly in the MY group compared to the HIFU group at 24 h post-operation (p < 0.001).

CONCLUSIONS

Short-term post-operative immune function is better preserved after HIFU treatment. Better preserved immune function may reflect a reduction in tissue trauma after HIFU treatment and contribute to reduced post-operative complications.

[Perioperative tumour dissemination. 2. Effects of anaesthesia and analgesia]

There has been growing concern over the last few years on the effect that the anaesthetic drugs used during oncological surgery could have on long-term tumour progression. In laboratory studies, it has been observed how some substances used during the anaesthetic procedure influence tumour immunosurveillance, cell proliferation or tumour angiogenesis processes. The possible clinical relevance of the anaesthetic technique used as regards long-term tumour progression and survival is still to be determined. However, based on retrospective studies, it appears that those anaesthetic techniques combined with the use of regional anaesthesia and analgesia may be beneficial compared to those that are maintained on the use of opioids. Further research should help to clarify the long-term clinical relevance of the anaesthetic process during oncological surgery.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

General anaesthesia is associated with increased risk of surgical site infection after Caesarean delivery compared with neuraxial anaesthesia: a population-based study

BACKGROUND

This study compared the odds ratio (OR) of surgical site infection (SSI) within 30 days after operation with general anaesthesia (GA) or neuraxial anaesthesia (NA) in Taiwanese women undergoing Caesarean delivery (CD).

METHODS

An epidemiologic design was used. The study population was based on the records of all deliveries in hospitals or obstetric clinics between January 2002 and December 2006 in Taiwan. Anonymized claim data from the Taiwan National Health Insurance Research Database (NHIRD) were analysed. Women who received CD were identified from the NHIRD by Diagnosis-Related Group codes. The mode of anaesthesia was defined by order codes. Multivariate logistic regression was used to estimate the OR and associated 95% confidence interval (CI) of post-CD SSIs for GA when compared with NA. The outcome was whether a woman had been diagnosed as having an SSI during the hospitalization or was re-hospitalized within 30 days after CD for the treatment of SSIs using five or 81 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

RESULTS

Among the 303 834 Taiwanese women who underwent CD during the 5 yr observation period, the 30 day post-CD SSI rate was 0.3% or 0.9% based on five or 81 ICD-9-CM codes. The multivariate-adjusted OR of having post-CD SSIs in the GA group was 3.73 (95% CI, 3.07-4.53) compared with the NA group (P<0.001) using five ICD-9-CM codes for the definition of SSI.

CONCLUSIONS

GA for CD was associated with a higher risk of SSI when compared with neuraxial anaesthesia.

Surgery induced immunosuppression

Surgery and anaesthesia result in a variety of metabolic and endocrine responses, which result in a generalised state of immunosuppression in the immediate post-operative period. Surgery induced immunosuppression has been implicated in the development of post-operative septic complications and tumour metastasis formation. In addition the effectiveness of many treatments in the adjuvant setting is dependent on a functioning immune system. By understanding the mechanisms contributing to surgery-induced immunosuppression, surgeons may undertake strategies to minimise its effect and reduce potential short-term and long-term consequences to patients.

Differential effects of propofol and isoflurane on the activation of T-helper cells in lung cancer patients

It is suggested that activation and differentiation of T-helper cells are required for peri-operative anti-tumor and anti-infection immunity. The present study aimed to evaluate whether propofol stimulates the activation and differentiation of these cells in patients undergoing pulmonary lobectomy for non-small-cell lung cancer. Thirty patients were randomly allocated to receive propofol or isoflurane throughout surgery. The CD4(+)CD28(+) percentage (p < 0.0001) and the ratio of interferon-gamma:interleukin-4 (p = 0.001) all increased with propofol but showed no change with isoflurane. In contrast, cortisol increased with isoflurane (p < 0.0001) but not with propofol over time (p = 0.06). We conclude that propofol promotes activation and differentiation of peripheral T-helper cells.

Immunomodulation in the critically ill

Immunotherapy in the critically ill is an appealing notion because of the apparent abnormal immune and inflammatory responses seen in so many patients. The administration of a medication that could alter immune responses and decrease mortality in patients with sepsis could represent a ‘magic bullet’. Various approaches have been tried over the last 20 yr: steroids; anti-endotoxin or anti-cytokine antibodies; cytokine receptor antagonists; and other agents with immune-modulating side-effects. However, in some respects, research along these lines has been unsuccessful or disappointing at best. The current state of knowledge is summarized with particular reference to sepsis and the acute respiratory distress syndrome.

Persistently high levels of immunosuppressive cytokines in patients after radical prostatectomy

A significant proportion of men undergoing 'curative' radical prostatectomy (RP) for organ-confined prostate cancer relapse within 5 years. A number of adverse risk factors have been identified, but to date no adjuvant treatment as improved the outlook for these men. We proposed that these patients, despite small tumour burdens, may be immunosuppressed from their cancer, which may be amenable to immune modulation. We investigated their immune profile using sensitive functional cytokine assays, both pre- and post-surgery. In comparison with controls, RP patients expressed higher levels of both T helper type 1 (Th1) (interleukin (IL)-2 and tumour necrosis factor-alpha) and Th2 cytokines (IL-4, -5 and -10) with little change after removal of tumour. Further analysis based on known poor-prognostic factors indicated a trend to expression of higher levels of Th2 cytokines IL-4 and IL-5 in worse prognosis patients rather than the mixed Th1/2 found across the whole cohort. Persistently high levels of both Th1 and Th2 cytokines were detected in RP compared to control patients, despite the removal of relatively small tumour burdens. Cytokine expression studies may be useful as surrogate marker of potential disease progression, and could be used to identify patients who may benefit from immune modulation post-surgery.

Differential effects of three antibiotics on T helper cell cytokine expression

OBJECTIVES

To test whether ciprofloxacin, moxifloxacin and clarithromycin affect the expression of the T helper (Th) cell cytokines, interferon-gamma and interleukin-4. Quinolone and macrolide antibiotics are routinely used for the treatment of critically ill patients with sepsis. These antibiotics modulate some aspects of immune cell function. Alteration in the profile of Th cell cytokine expression will affect the T helper cell ratio and subsequent immune responses.

METHODS

Following ethics committee approval and informed consent, mononuclear cells were isolated from 20 healthy volunteers using single density gradient centrifugation. Cells were incubated with ciprofloxacin (0--100 mg/L), moxifloxacin (0--50 mg/L) or clarithromycin (0--125 mg/L) and stimulated with phorbol myristate acetate and ionomycin. For flow cytometric analysis, cells were stained with antibodies to CD3 and CD4, prior to permeabilization with saponin and intracellular staining with anti-interleukin-4 and anti-interferon-gamma.

RESULTS

Both moxifloxacin and ciprofloxacin dose-dependently decreased interferon-gamma and interleukin-4 expression by Th cells (both P<0.0001). Only interleukin-4 expression however, was affected by clarithromycin (P=0.04). There was no change in the Th1/Th2 ratio for moxifloxacin or ciprofloxacin, but the Th1/Th2 ratio increased with increasing concentrations of clarithromycin, from a median [range] of 5.3 [1.3--16.0] without antibiotic to 9.1 [1.8--18.8] at 125 mg/L (P=0.017).

CONCLUSIONS

Moxifloxacin and ciprofloxacin had pronounced effects on both Th1 and Th2 cytokine expression, without altering Th1/Th2 ratios. However, clarithromycin decreased only interleukin-4 expression such that the Th1/Th2 ratio increased. Since a Th1 profile is considered favourable for resolution of infection, elucidation of immunomodulatory profiles of antibiotics may permit more rational antibiotic choice in future.

Differential modulation of interleukin-6 and interleukin-10 by diclofenac in patients undergoing major surgery

BACKGROUND

Prostaglandins modulate cytokine release though increases in cAMP, regulating interleukin (IL) 6 and IL-10. Diclofenac inhibits cyclo-oxygenase activity and hence prostaglandin production. We hypothesized that diclofenac would affect release of IL-6 and IL-10 and modulate the immune response.

METHODS

In a randomized, double-blind, placebo-controlled study, we investigated the effect of diclofenac in patients undergoing major urological surgery. Patients were randomized to receive either diclofenac (50 mg orally every 8 h the day before surgery and 75 mg i.m. every 12 h on the day of surgery, n = 23) or placebo (n = 23). Standardized combined general anaesthesia and epidural analgesia was administered. Serum IL-6, IL-10 and cortisol were measured before surgery and 30 min and 2, 6, 12 and 24 h after skin incision. Temperature, leucocyte count and C-reactive protein concentration were measured before surgery and after 24 h.

RESULTS

IL-6 and IL-10 concentrations increased, reaching peak levels at 12 and 6 h respectively in both groups. At 12 h, the IL-6 concentration was significantly lower in patients receiving diclofenac than in those receiving placebo (P = 0.003). In contrast, IL-10 concentration at 6 h was higher in diclofenac-treated patients (P = 0.008), and this was associated with less pyrexia (P = 0.03), a lower leucocyte count (P = 0.0002) and a lower C-reactive protein concentration (P = 0.0039). Serum cortisol concentration was similar in the two groups of patients until 24 h, when the concentration was lower in patients who received diclofenac (P = 0.002). Cortisol concentration correlated with IL-6 concentration at 24 h.

CONCLUSIONS

Administration of diclofenac was associated with lower IL-6 and higher IL-10 concentrations, and lower leucocyte count, C-reactive protein concentration and temperature. Diclofenac may have an anti-inflammatory role in major surgery.