Mechanisms of the development of organ failure following surgical insult: the 'second attack' theory

Relationship between fat embolism and endothelial glycocalyx

Fat embolism (FE) is acknowledged as one of the significant causes of sudden death following traumatic injury. To clarify the relevance of vascular endothelial glycocalyx (EGC) damage and FE, temporal changes in the mRNA levels of inflammatory cytokines associated with EGC components were investigated in an experimental fat embolization rat model. Nine-week-old rats were used as FE models through triolein injection (TO) and femoral fracture (FX), and physiological saline was administered to the control group. RT-qPCR and fat staining were performed. The target genes were Il6, Il10, Tnf, Elane, Sdc1, Sdcbp, Vcan, Hyal1, Fn1, and CD14. Notably, FE was detected in 100% and 5.6% of the TO and FX groups, respectively, using fat staining. Bimodal peaks in the mRNA expression levels of Sdc1, Tnf, Elane, IL6, and IL10 were observed 4 and 20 h after treatment in both groups. In the TO group, mRNA expression peaked at 4 h and then declined to the lowest level at 16 h. The incidence of fat emboli due to trauma was consistent with that reported in previous studies. Bimodal mRNA peaks may correspond to FE progression, in which physical obstructions are followed by biochemical reactions. The fluctuation in Sdc1 expression suggests that the initial peak resulted from physical EGC damage. The subsequent peak could be because of EGC damage caused by the secretion of inflammatory cytokines induced by oleic acid from lipid droplet decomposition. These results suggest that EGC disorders caused by lipid droplets may induce lung damage during FE.

Preventive Effect of Antioxidative Nutrient-Rich Enteral Diet Against Liver Ischemia and Reperfusion Injury

BACKGROUND

Liver ischemia and reperfusion injury (IRI) is a major problem associated with liver surgery. This study is aimed to compare the preventive effect of an antioxidative nutrient-rich enteral diet (Ao diet) with an ordinal enteral diet (control diet) against liver IRI.

METHODS

The Ao diet was an ordinary diet comprising polyphenols (catechin and proanthocyanidin) and enhanced levels of vitamins C and E. Male C57BL/6 mice were fed the Ao or control diet for 7 days before ischemic insult for 60 minutes, followed by reperfusion for 6 hours. The levels of inflammatory cytokines, chemokines, and antioxidant enzymes and oxidative stress were evaluated.

RESULTS

After 7 days of pretreatment with the Ao diet, the serum levels of vitamins C and E in mice were markedly elevated. The levels of serum aspartate aminotransferase and alanine aminotransferase, as well as the scores of liver necrosis caused by ischemia and reperfusion, were significantly lower in the Ao diet group than in the control diet group. The gene expression levels of inflammatory cytokines and chemokines, such as interleukin-6 and CXCL1, were significantly lower in the Ao diet group. In the liver, the levels of antioxidant enzymes superoxide dismutase 1 (SOD1) and SOD2 were significantly higher and the malondialdehyde levels were significantly lower in the Ao diet group. Cell adhesion molecule expression was significantly lower, and neutrophil and macrophage infiltration was less in the Ao diet group.

CONCLUSIONS

Antioxidative nutrient supplementation to an ordinary enteral diet may mitigate liver IRI by causing an antioxidant effect and suppressing inflammation.

An Antioxidative Nutrient-Rich Enteral Diet Attenuates Lethal Activity and Oxidative Stress Induced by Lipopolysaccharide in Mice

BACKGROUND

Oxidative stress is related to various diseases, such as diabetes, cancer, inflammatory disease, and arteriosclerosis. The aim of this study is to evaluate enhancement effect in serum antioxidant capacity obtained from an antioxidative nutrient-rich enteral diet (AO diet). We also investigated the ability of the AO diet to attenuate lethality, the production of oxidized products, the production of inflammatory cytokines, and liver injury using lipopolysaccharide (LPS)-injected mice. LPS mice were used as a model to represent critically ill patients that have experienced a septicemia.

METHODS

The AO diet contained polyphenol and enhanced vitamin C, vitamin E, and trace elements. Total antioxidant activities of the control enteral diet (Control diet) and the AO diet were measured by 1,1-diphenyl-2-picrylhydrazyl (DPPH) and 2,2'-azinobis-(3-ethylbenzthiazoline sulphonic acid; ABTS) radical-scavenging activities. Male BALB/c mice were fed either of these diets for 7 days and were injected with 5 mg/kg LPS. The survival of mice was monitored from day 0 to day 8. To evaluate oxidative stress, inflammation, and liver injury, blood and liver samples were collected, and tumor necrosis factor-alpha (TNF-alpha), interleukin-6, thiobarbituric acid-reactive substances (TBARS), protein carbonyl contents, aspartate aminotransferase, alanine aminotransferase, and radical-scavenging activities were measured.

RESULTS

The survival rate of mice receiving the AO diet or the Control diet was 73.9% and 33.3%. In the AO diet group, levels of serum TNF-alpha, serum protein carbonyl contents, plasma, and liver TBARS were significantly lower than in the Control diet group. DPPH and ABTS radical-scavenging activities of the AO diet itself were significantly higher than that of the Control diet, and serum activities in the AO diet group were also higher.

CONCLUSIONS

The antioxidative nutrient supplementation of an enteral diet may be useful and offer relief from septic symptoms.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost

STUDY DESIGN

Single-institution retrospective study.

OBJECTIVE

To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization.

SUMMARY OF BACKGROUND DATA

Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown.

METHODS

This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest.

RESULTS

From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were $89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = -$178,899 to -$4661).

CONCLUSION

Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.

The effects of sivelestat sodium hydrate on uterine contraction and the concentration of maternal and fetal blood cytokines in a sheep model of intra-amniotic infection induced by lipopolysaccharide

OBJECTIVE

To evaluate the effects of a neutrophil elastase inhibitor, sivelestat sodium hydrate, in a sheep model of intra-amniotic infection(IAI) induced by lipopolysaccharide (LPS) injected into the intra-amniotic compartment.

METHODS

We examined 15 chronically instrumented ewes, the ewes were assigned randomly as group A (five ewes) administered an antibiotic after LPS administration, group B (five ewes) administered a neutrophil elastase inhibitor (0.2 mg/kg/h) with an antibiotic after LPS administration, and group C (five ewes) a sham operation group. Uterine contraction was evaluated by fetal tracheal pressure and concentrations of PGE2, IL-6, IL-8, TNF-α in maternal and fetal blood before and after LPS administration were measured chronologically.

RESULTS

(1) All ewes of group A delivered within 72  h, but only one ewe of group B delivered. Uterine contraction of group B was suppressed about 60% in comparison with group A. (2) Maternal blood concentrations of PGE2, IL-6, IL-8, and TNF-α level of group A increased chronologically and when compared with groups B and C the increase was significantly higher. (3) There were no significant changes in the fetal blood cytokines in any of the three groups.

CONCLUSION

Administration of neutrophil elastase inhibitor might suggest a useful strategy to prevent premature delivery resulting from intrauterine infection.

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86%vs 25%, P = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI (P < 0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II (P < 0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1beta and tumor necrosis factor-alpha were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1beta of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair.

METHODS

E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years.

RESULTS

There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001).

CONCLUSIONS

The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.

The quantitative analysis of tissue injury markers after mini-open lumbar fusion

STUDY DESIGN

A prospective and comparative analysis of tissue injury after mini-open lumbar fusion and conventional technique.

OBJECTIVE

To evaluate the tissue injury quantitatively after mini-open lumbar fusion.

SUMMARY OF BACKGROUND DATA

The advantages of minimally invasive techniques demonstrated by clinical reports have been a smaller scar, lesser pain, and rapid rehabilitation. It has not been established, however, that the minimally invasive technique has less tissue injury and less systemic response than the conventional spine surgery.

METHODS

Twenty patients who had undergone posterior decompression and the fusion of the L4-L5 segment for spinal stenosis were studied prospectively. Ten patients that had the conventional posterior decompression and posterior lumbar interbody fusion (PLIF) at L4-L5 were enrolled in a control group. The remaining 10 patients who underwent MISS techniques (paramedian mini-open approach using a tubular retractor) were enrolled in a study group. The serum enzymes representing skeletal muscle injury (creatinine kinase and aldolase), pro-inflammatory cytokines (IL-6, IL-8), and anti-inflammatory cytokines (IL-10, IL-1 receptor antagonist) were analyzed with ELISA techniques. They were checked on the day before operation and 1, 3, 7, and 14 days after operation.

RESULTS

Serum creatinine kinase and most of the inflammatory cytokines were significantly high in the control group on postoperative days 1 and 3 and returned to the normal level on postoperative day 7. Serum aldolase was significantly high on postoperative day 1, and IL-8 remained elevated until postoperative day 7 in the control group.

CONCLUSION

Mini-open lumbar fusion may significantly contribute to the reduction of muscle injury and systemic inflammatory reactions during the acute postoperative period. This study suggests that mini-open lumbar fusion may also play an important role in preventing medical morbidity after spinal surgery.

Factor XIII Therapy of Anastomotic Leak, and Circulating Growth Factors

Wound healing is far more rapid in the gastrointestinal tract than in the skin. Once dehiscence of a surgical anastomosis in the gastrointestinal tract occurs, the high collagenase activity in the gastrointestinal tract may delay wound healing and promote the formation of a nonhealing fistula. Because factor XIII promotes cross-linking of fibrin during the early phase of wound healing, we investigated the effect of factor XIII concentrate on 16 anastomotic leaks and a nonhealing fistula. A 240-U dose of factor XIII concentrate (Fibrogammin P) was administrated intravenously for 5 days. Factor XIII activity and plasma levels of epidermal growth factor (EGF), transforming growth factor (TGF)-beta, and interleukin-6 were measured before treatment and 1 day and 7 days after the end of treatment. Clinical outcomes were evaluated on the basis of the findings of contrast radiography, computed tomography, and drainage volume. Improvement relevant to the therapy was observed in 15 cases (88.2%). Factor XIII activity increased to more than 70% of the normal value in 11 cases (64.7%) but remained at 40% to 70% of the normal value in 6 cases (35.3%). Plasma EGF and TGF-betalevels increased in patients with improvement but were unchanged in patients without improvement. Our findings suggest that factor XIII significantly accelerates wound healing of anastomotic leaks and nonhealing fistulas by increasing circulating growth factors after systemic administration.

Interleukin-10 gene therapy attenuates pulmonary tissue injury caused by mesenteric ischemia-reperfusion in a mouse model

To investigate the role of interleukin (IL)-10 gene therapy on the reperfusion-induced lung injury, we utilised the technique of liposomal gene delivery before the induction of intestinal ischemia. Plasmid DNA encoding human IL10 (hIL-10) or empy vector was injected intraperitoneally 24 h before the study. Male Balb/c mice randomized into three groups: Sham operated control (n = 12), empty plasmid vector (n = 12), and hIL-10 gene therapy group (n = 12). The ischemia was generated by selective occlusion of superior mesenteric artery for 60 min and followed by reperfusion for 30 min. Lung tissue neutrophil infiltration was determined by myeloperoxidase assay and neutrophil counts. For the determination of lung tissue microvascular permeability, Evans blue dye injection was made and the lung edema was assessed by wet/dry ratio. hIL-10 protein expression was studied by immunostaining and ELISA. We found that pre-ischemic hIL-10 overexpression attenuated dye extravasation, leukocyte sequestration and reduced pulmonary tissue injury compared to the empty vector-injected control. Our study indicates that pre-ischemic hIL-10 overexpression attenuates lung injury caused by intestinal ischemia-reperfusion.

The isolated perfused liver response to a 'second hit' of portal endotoxin during severe acute pancreatitis

BACKGROUND/AIM

During severe acute pancreatitis (AP), the liver may show an exaggerated response to the inflammatory products of gut injury transported in the portal vein. Our aim was to explore liver proinflammatory mediator production after a 'second hit' of portal lipopolysaccharide (LPS) during AP.

METHODS

Twenty-four rats underwent one of three 'first-hit' scenarios: (1) severe AP induced by intraductal glycodeoxycholic acid injection and intravenous caerulein infusion, (2) sham laparotomy, or (3) no first intervention. Eighteen hours later, all animals received a 'second hit' of portal LPS in an isolated liver perfusion system. Tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, and IL-6 concentrations were measured in portal and systemic serum, and in the perfusate 30 and 90 min after the 'second hit'. Neutrophil activation by the perfusate was assayed using dihydrorhodamine-123 fluorescence.

RESULTS

We observed a six-fold increase in IL-6 concentration across the liver during AP. All livers produced TNF-alpha after the portal LPS challenge, but this was not exaggerated by AP. No differential neutrophil activation by the perfusate was seen.

CONCLUSION

TNF-alpha, IL-1beta, IL-6 and neutrophil activator production by the isolated perfused liver, in response to a 'second hit' of portal LPS, does not appear to be enhanced during AP.

The effect of continuous arterial infusion of gabexate mesilate (FOY-007) on experimental acute pancreatitis

The effectiveness of continuous arterial infusion of Gabexate Mesilate (FOY-007) on experimental acute pancreatitis was investigated. Acute necrotizing pancreatitis was induced by an injection of 10% Na-taurocholate (1ml/kg) into the main pancreatic duct of mongrel dogs. Animals were divided into three groups; Group A: non-treated control, Group B: after the induction of pancreatitis, injected with FOY-007 intravenously (5mg/kg/hr), Group C: after the induction of pancreatitis, injected with FOY-007 via the celiac artery. The changes in the values of amylase and lipase in serum and ascites etc. were examined. A histological examination was done and the FOY-007 concentration of the pancreas was measured. In both groups B and C, the serum levels of amylase and lipase reached significantly to low levels compared with those in group A. The extents of pancreatic parenchyma necrosis in each group were 36.1, 25.3 and 19.5%, respectively, and were significantly improved in group C. In addition, the FOY-007 levels in pancreas specimens in the intraarterial infusion group exceeded those in the intravenous infusion group by 32 times. The results suggest that continuous FOY-007 arterial infusion therapy is useful as a local treatment for severe acute pancreatitis.

Impact of chronic and acute high-fat feeding on acute experimental pancreatitis complicated by endotoxinaemia

BACKGROUND

Obesity is associated with increased severity in patients with acute pancreatitis (AP). The underlying mechanisms are unknown. Genetically obese rats exhibit decreased survival rate in experimental AP, but the clinical relevance of this model of obesity may be questioned. It is proposed that development of organ failure in AP occurs in two stages: initial priming of leucocytes followed by a second inflammatory attack. The aim was to evaluate the impact of diet-induced obesity on outcome in a 'two-hit' model of AP.

METHODS

Lipopolysaccharide (LPS) was injected i.p. 3 h after retrograde bile duct infusion of sodium taurocholate in rats. Three experiments were done: 1) an LPS dose-response experiment, 2) chronic high-fat feeding (HF) for 16 weeks, and 3) acute HF for 10 days. Control rats received normal chow. Obesity, morphology and survival rate were assessed.

RESULTS

LPS dose-dependently decreased survival rate and increased morphological severity. HF increased weight, intra-abdominal and liver fat. Only acute HF induced hyperlipidaemia. In AP, acute obese rats exhibited less pancreatic inflammation, but total histological severity between groups was not different. In the chronic experiment only obese animals succumbed before 24 h of pancreatitis, but 72-h survival rate was not statistically different in either high-fat experiment.

CONCLUSION

An addition of LPS to AP decreases survival rate and intensifies the peri-pancreatic processes. Despite significant obesity, neither hyperlipidaemia nor increased intra-abdominal or hepatic fat influenced local pancreatic injury or survival negatively. The amount of fat per se seems not to be responsible for the deleterious influence of obesity on acute pancreatitis.

[Pharmacological study on the effects of the adenosine uptake inhibitor KF24345 on inflammatory diseases]

Adenosine protects against cellular damage and dysfunction under several adverse conditions, including inflammation. We examined the effects of KF24345, a novel adenosine uptake inhibitor, on inflammatory diseases to investigate whether the adenosine uptake inhibition is useful for the treatment of inflammation. KF24345 inhibited adenosine uptake into washed erythrocytes (in vitro) and sampled blood cells from mice after its oral administration (in vivo). KF24345 significantly suppressed lipopolysaccharide-induced tumor necrosis factor-alpha production and leukopenia in mice, and the effects of KF24345 were abolished by the treatment with a non-selective or an A(2A)-selective adenosine receptor antagonist. In the experimental glomerulonephritis induced in mice by anti-glomerular basement membrane antiserum, KF24345 significantly inhibited proteinuria and glomerular damage without exhibiting the side effects observed following the treatment with prednisolone and cyclophosphamide. In addition, KF24345 ameliorated the severity of experimental acute pancreatitis induced by cerulein or choline-deficient and ethionine-supplemented diet in mice, and it decreased mortality accompanying severe acute pancreatitis. The anti-pancreatitis effects of KF24345 were abolished by the treatment with a non-selective or an A(2A)-selective adenosine receptor antagonist. These results suggest that KF24345 and adenosine uptake inhibitors can be a new therapeutic approach for various inflammatory diseases, including glomerulonephritis and acute pancreatitis.

Idiopathic interstitial pneumonia following stem cell transplantation

Idiopathic interstitial pneumonia (IIP) can occur after stem cell transplantation, but the aetiology is unknown. Based on the association between angiitis syndrome and Helicobacter pylori infection, we identified possible risk factors common to these two conditions. Among 83 patients who underwent stem cell transplantation, four developed IIP. We elucidated various parameters and clinical features in four patients with IIP and 79 patients without, after allogeneic stem cell transplantation. In all four patients, (1) the conditioning regimen induced total body irradiation, (2) serological reactivation of cytomegalovirus and/or human herpesvirus-6 preceded the onset of IIP, (3) their human leucocyte antigen types were among those suspected to increase susceptibility to angiitis syndrome, (4) serum anti-H. pylori antibody was positive before conditioning and remained positive throughout the post-transplantation course, (5) inflammatory cytokines (interleukin-6, 8 and 12) were increased during the period of leucocyte recovery after transplantation and (6) the levels of intercellular adhesion molecule-1, thrombomodulin and plasminogen activator inhibitor-1 were increased at the onset of IIP. These findings suggest the possibility that angiitis syndrome and H. pylori infection are involved in the pathogenesis of post-transplantation IIP.

Intestinal graft-versus-host disease: mechanisms and management

Allogeneic haematopoietic stem cell transplantation remains the treatment of choice for a number of malignancies. However, graft-versus-host disease (GVHD) has long been regarded as a serious complication of this procedure. Although GVHD may affect any organ, intestinal GVHD is particularly important because of its frequency, severity and impact on the general condition of the patient. Recent studies have led to progressive elucidation of the mechanism of GVHD. Donor T cells are critical for the induction of GVHD, because depletion of T cells from bone marrow grafts effectively prevents GVHD but also results in an increase of leukaemia relapse. It has been shown that the gastrointestinal tract plays a major role in the amplification of systemic disease because gastrointestinal damage increases the translocation of endotoxins, which promotes further inflammation and additional gastrointestinal damage. Consequently, the management of intestinal GVHD (and the intestine itself) is a subject that should be highlighted. In this article, approaches to the prevention of intestinal GVHD are discussed after being classified into three categories: regimens in common clinical use, regimens under investigation and original regimens used at our hospital. The standard regimen that is used most widely for prevention of GVHD is cyclosporin plus short-term methotrexate. Corticosteroids can be added to this regimen but careful consideration of the adverse effects of these hormones should be considered. Tacrolimus is a newer, more potent alternative to cyclosporin. T-cell depletion (TCD) after transplantation has been shown to prevent acute GVHD, however, the survival benefit of TCD has not been as great as expected. Mycophenolate mofetil can be useful for the treatment of acute GVHD as part of combination therapy. Regimens currently under investigation in animal experiments include suppression of inflammatory cytokines and inhibition of T-cell activation, and, specifically at our institution, hepatocyte growth factor gene therapy. The evidence-based therapy used at our institution includes systemic antibacterial therapy (including eradication of intestinal bacteria) to prevent the intestinal translocation of lipopolysaccharide and avoid the subsequent increase of various inflammatory cytokines. In addition, because of the similarities between intestinal GVHD and ulcerative colitis, sulfasalazine, betamethasone enemas and eicosapentaenoic acid have been used to treat intestinal GVHD in some patients.

Splenectomy ameliorates hepatic ischemia and reperfusion injury mediated by heme oxygenase-1 induction in the rat

BACKGROUND/AIMS

Ischemia/reperfusion (I/R) induces severe organic injury. I/R injury seems to be mainly caused by oxidative stress. The aim of this study was to determine the role of the spleen in experimental hepatic I/R injury in the rat. Stress protein heme oxygenase (HO)-1 plays a protective role against the oxidative injury. In normal state, HO-1 is highly expressed in the spleen.

METHODS

Liver HO-1 expression was assessed by Western blot before and after splenects. Liver injury was assessed by measurement of ALT and AST and by histopathology.

RESULTS

Although HO-1 was not detected in normal liver, levels of HO-1 protein gradually increased and peaked on 3 days after splenectomy. When splenectomy was performed 3 days prior to the hepatic (45-min) ischemia followed by (2-h) reperfusion, the levels of serum aspartate transaminase (AST) and alanine transaminase (ALT), as markers for hepatic injury, were improved compared to the rats with I/R alone. In addition, prior administration of zinc-protoporphyrin IX, a specific inhibitor of HO, suppressed the protective effect of the splenectomy on the subsequent hepatic I/R injury. Histopathological examination also confirmed these results.

CONCLUSIONS

Our findings suggest that the elevated HO-1 levels by splenectomy play a protective role against hepatic I/R injury.

Early-phase enhanced inflammatory reaction after spinal instrumentation surgery

STUDY DESIGN

The erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and body temperature were measured prospectively in patients after two types of spinal surgery without complications and three cases of infection after spinal instrumentation surgery.

OBJECTIVES

To investigate the effects of instrumentation on postoperative inflammatory reaction, and to describe early detection of postoperative wound infection.

SUMMARY OF BACKGROUND DATA

In thoracic and abdominal surgery as well as hip arthroplasty, C-reactive protein has proved more valuable than erythrocyte sedimentation rate for early detection of postoperative infectious complications. It has not yet been established, however, how inflammatory parameters change after surgery when spinal instruments have been inserted into the body.

METHODS

For this study, two groups of patients were examined: a control group that underwent spinal decompression surgery without instrumentation (n = 36) and another group that underwent spinal decompression and fusion surgery with spinal instrumentation (n = 37). The erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and body temperature were recorded 1 day before surgery and on days 0 to 4, 7, 11, 14, 21, 28, and 42 after surgery.

RESULTS

Inflammatory indexes (i.e., C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and body temperature) were significantly higher for the surgery with instrumentation than for the spinal decompression surgery without instrumentation. Multiple regression analysis showed that C-reactive protein and erythrocyte sedimentation rate peaks significantly correlated with the use of instrumentation (C-reactive protein: P = 0.000257, erythrocyte sedimentation rate: P = 0.000132). In the patients with infection after spinal instrumentation surgery, C-reactive protein, white blood cell count, and body temperature started to increase again 4 to 11 days after surgery. The elevation of erythrocyte sedimentation rate levels was prolonged.

CONCLUSIONS

Erythrocyte sedimentation rate and C-reactive protein display a significantly higher reaction after spinal surgery with instrumentation. Renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a critical sign of postoperative infection.

Altered cytokine response in rat acute pancreatitis complicated with endotoxemia

We demonstrated that the dynamic aspects of cytokine production in rat acute pancreatitis, which was induced by cerulein and aggravated by subsequent lipopolysaccharide (LPS) injection. A priming effect by induction of mild pancreatitis with cerulein enhanced the subsequent cytokine production by LPS injection. Alternatively, after induction of severe pancreatitis with cerulein and LPS, cytokine production was markedly suppressed for > or = 90 hours. Production of interleukin-2 (IL-2) by splenocytes decreased, and mortality rate after cecal ligation and puncture (CLP) increased significantly after induction of severe acute pancreatitis. These results suggest that the suppression of a cytokine response in severe acute pancreatitis may alter the defense system and, as a result, increase mortality after CLP.

Clinical benefits of steroid therapy on surgical stress in patients with esophageal cancer

BACKGROUND

Despite improvements in surgical techniques and perioperative care, severe complications lead to long hospital stays for some esophageal cancer patients. The purpose of this study was to evaluate the safety and effectiveness of perioperative steroid therapy on the postoperative clinical course.

METHODS

Fifty-seven patients operated for esophageal cancer in 1997 and 1998 were treated with perioperative steroid therapy. Fifty consecutive patients operated in 1995 and 1996 served as a control group. In the steroid group, each patient was given 250 mg of methylprednisolone intravenously before operation followed by 125 mg on postoperative days 1 and 2. Serum interleukin-6, polymorphonuclear cell elastase, and C-reactive protein levels, and the postoperative clinical course were compared between the groups.

RESULTS

Morbidity rates including hyperbilirubinemia, anastomotic leakage, and liver dysfunction were significantly lower in the steroid group than in the control group. Days until extubation and hospital stay were significantly shorter for the steroid group. Inflammatory mediators, body temperature, heart rate, and respiratory index after the surgical procedure were significantly lower in the steroid group. Adverse effects possibly caused by steroid therapy were not observed.

CONCLUSIONS

Perioperative steroid therapy was safe and effective for the inhibition of inflammatory mediators and the improvement of the postoperative clinical course of patients with esophageal cancer.

Tumor necrosis factor alpha acts on cultured human vascular endothelial cells to increase the adhesion of pancreatic cancer cells

We studied the effect of tumor necrosis factor alpha (TNFalpha), one of the major inflammatory cytokines, on the adhesive reaction of pancreatic cancer cells to human umbilical vein endothelial cells (HUVECs) and on the hepatic metastasis of cancer cells in vivo. After TNFalpha stimulation, the expression of E-selectin, an adhesion molecule to neutrophils on HUVECs, increased. In addition, the adhesion of pancreatic cancer cells to HUVECs increased after TNFalpha stimulation, as was observed with neutrophils. The TNFalpha-induced adhesive response depended on the extent of sialyl Lewis(a) expression on cancer cells. The hepatic metastasis in vivo was often observed when cancer cells expressing a high amount of sialyl Lewis(a) were inoculated intrasplenically after increase in plasma TNFalpha concentration by lipopolysaccharide administration. Because sialyl Lewis(a) on cancer cells is a ligand for E-selectin on HUVECs, as sialyl Lewis(x) on neutrophils, TNFalpha upregulated the adhesive interaction between sialyl Lewis(a) on cancer cells and E-selectin on HUVECs. These results suggest that production of TNFalpha after surgical trauma may stimulate the hematogenic metastasis of cancer cells with a high sialyl Lewis(a) expression.

Measurement of soluble Fas antigen and ligand in circulating serum and intra-abdominal or cerebrospinal fluid during gastrointestinal or cerebrovascular surgery

PURPOSE

Soluble Fas antigen (sFas) and ligand (sFasL), which are associated with apoptosis, have not been evaluated in gastrointestinal or cerebrovascular surgery. The aim of this study was to measure these substances in serum, intra-abdominal fluid, or cerebrospinal fluid, and to speculate a pathophysiologic role for Fas-FasL apoptosis in surgery.

MATERIALS AND METHODS

Arterial blood and intraabdominal or cerebrospinal fluid were collected at intervals from 27 gastrointestinal surgical patients, 10 cerebrovascular surgical patients, and 10 spinal anesthesia patients.

RESULTS

Serum sFas levels did not change during and after surgery. Intra-abdominal and cerebrospinal sFas levels were identical to and lower than those in serum. Serum sFasL levels did not change during surgery, but decreased after surgery. Intra-abdominal and cerebrospinal sFasL levels were higher than and identical to those in serum. In spinal anesthesia, cerebrospinal sFas and sFasL levels were lower than those in serum.

CONCLUSIONS

Serum sFasL decreases after surgery, whereas intra-abdominal or cerebrospinal sFasL increases, although sFas in each site does not change, suggesting redistribution of activated lymphocytes into local surgical wounds and induction of apoptosis in this site.

Complications after bone marrow transplantation are manifestations of systemic inflammatory response syndrome

Bone marrow transplantation has been established as a useful treatment for various hematological disorders and is now performed widely, but the mortality rate is still high due to various complications. A clear therapeutic policy for such complications has not yet been established because of their complex nature. We investigated whether the major complications occurring after bone marrow transplantation could be classified as aspects of the systemic inflammatory response syndrome. Subjects were 10 patients who developed severe complications after bone marrow transplantation (graft-versus-host disease, thrombotic microangiopathy, respiratory disorders, and cytomegalovirus interstitial pneumonitis) and 16 patients without complications. Their symptoms, serum cytokines, and factors related to vascular endothelial damage were compared before and after transplantation. Whereas all 10 patients who developed complications had fever in the aplastic phase after transplantation, 15 of the 16 patients without complications remained afebrile (P < 0.001, t-test). When compared with the patients who did not develop complications, the patients with complications also showed significantly higher cytokine levels during the recovery phase after transplantation (P < 0.0001, t-test). Thus, the patients with complications developed fever in the aplastic phase and showed an increase of cytokines during the recovery phase, which triggered the occurrence of vascular endothelial damage shown by factors such as the thrombomodulin and plasminogen activator inhibitor type 1. This sequence of events corresponds with that occurring during systemic inflammatory response syndrome, so many of the complications of bone marrow transplantation can be considered as manifestations of this syndrome.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) as a new prediction scoring system for postoperative morbidity and mortality following elective gastrointestinal surgery

Overwhelming surgical stress exceeding a patient's reserve capacity causes a disruption of homeostasis, leading to various postoperative complications. This study was undertaken to develop a new scoring system, "E-PASS", standing for the Estimation of Physiologic Ability and Surgical Stress, that predicts the postsurgical risk by quantification of the patient's reserve and surgical stress. E-PASS comprises the preoperative risk score (PRS), the surgical stress score (SSS), and the comprehensive risk score (CRS) that is determined by both scores. These scores were computed by a multiple regression analysis conducted on 292 consecutive patients who underwent elective common gastrointestinal operations at one hospital between 1992 and 1995 (internal group). The usefulness of the scores was evaluated in 989 consecutive patients who underwent the same surgical procedures during the same period at another hospital (external group). The morbidity and mortality rates increased similarly in both groups as the CRS increased. A marked step-up of both rates was observed at a CRS > 1.0, reaching mortality rates of 20% in the internal subjects and 28.5% in the external subjects. These results suggest that the E-PASS scoring system is reproducible, and that it may be useful for surgical decision making. This system requires no special examinations and can be used in every hospital.

Tumor necrosis factor-alpha production after esophageal cancer surgery: differences in the response to lipopolysaccharide stimulation among whole blood, pleural effusion cells, and bronchoalveolar lavage fluid cells

The body's defense mechanism in response to stress may appear to be the sum of activation and suppression. We investigated chronological changes in tumor necrosis factor-alpha (TNF-alpha) production by local effusion cells and whole blood of esophageal cancer patients who had undergone radical resection. Whole blood, pleural effusion cells, and bronchoalveolar lavage fluid (BALF) cells were obtained from the 20 patients. Whole blood was stimulated with Escherichia coli (1 microg/ml), Staphylococcus aureus (10 microg/ml), and lipopolysaccharide (LPS) (1 microg/ml), and pleural effusion cells and BALF cells were stimulated with LPS; 24-H incubation and TNF-alpha concentration in supernate was measured by enzyme-linked immunosorbent assay (ELISA). Within 3 h after starting the operation, TNF-alpha production in whole blood was significantly (P < 0.05) decreased compared with preoperative value by each stimulation, and this suppression persisted up to day 3. These reductions in postoperative TNF-alpha production correlated with intraoperative hemorrhage. On the other hand, the LPS-induced release of TNF-alpha into pleural effusion cells and BALF cells were markedly increased during the study period. These results indicate that large quantities of cytokines are produced by a second attack, such as infection, in areas where immunocytes accumulate. We believe that the body reacts to surgical stress in a variety of ways. Circulating blood and immunocytes that accumulate in damaged organs are thought to react very differently to stress.

Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery

OBJECTIVES

Progression from systemic inflammatory response syndrome (SIRS) to sepsis, severe sepsis, and septic shock has been demonstrated in a variety of patients. However, the presence of SIRS alone was not helpful in predicting the development of multiple organ dysfunction syndrome (MODS) since SIRS includes many nonprogressive conditions. This study was conducted to investigate the clinical significance of SIRS in postoperative patients.

DESIGN

Retrospective study.

SETTING

The surgical department of a university hospital.

PATIENTS

Two hundred ninety-two consecutive patients who received elective common gastrointestinal surgery (esophagectomy, pancreatoduodenectomy, hepatectomy, gastrectomy, colorectal resection, and laparoscopic cholecystectomy) between 1992 and 1995.

INTERVENTIONS

Patients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of SIRS, complications, and end-organ dysfunction.

MEASUREMENTS AND MAIN RESULTS

Duration of SIRS or positive criteria's number of SIRS after surgery significantly correlated with surgical stress parameters (blood loss/body weight and operation time) and peak serum C-reactive protein concentrations. SIRS that continued or reappeared after postoperative day 3 was an early sign of postoperative complications. SIRS continuing consecutively for 2 days after postoperative day 3 had a 70.6% positive predictive value and a 92.5% negative predictive value for postoperative complications. Septic complications and prolongation of SIRS were associated with MODS. Five of six patients who met the SIRS criteria for >30 days developed severe MODS, and three of them died.

CONCLUSIONS

SIRS is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from SIRS may arrest the progression of organ dysfunction.