Biliary Tract Cancer: Implicated Immune-Mediated Pathways and Their Associated Potential Targets

There is a well-established link between biliary tract cancers (BTC) and chronic inflammatory conditions such as primary sclerosing cholangitis, chronic cholecystitis, chronic cholelithiasis, liver fluke-associated infestations, and chronic viral hepatic infections. These associated risk factors highlight the potential for development of immune-modulatory agents in this poor-prognostic disease group with limited treatment options. Clinical trials have evaluated the role of immune cells, inflammatory biomarkers, vaccines, cytokines, adoptive cell therapy, and immune checkpoint inhibitors in patients with BTC. Although these have demonstrated the importance of the immune environment in BTC, currently none of the immune-based therapies have been approved for use in this disease group. The role of immunomodulatory agents is a developing field and has yet to find its way 'from bench to bedside' in BTC.

[Evaluation of prognostic factors for the development of cholelithiasis in patients with metabolic syndrome]

The aim of study to determine the leading clinical and immunological parameters, reflecting the high risk of development and progression of gallstone disease in patients with metabolic syndrome.

MATERIALS AND METHODS

An assessment of clinical, biochemical and immunological parameters in 54 patients with gallstone disease associated with the metabolic syndrome and in comparison groups (31 with metabolic syndrome without gallstone disease and 29 with gallstone disease only) were made. For modeling the significant correlation and prediction of the effect of different combinations of factors on the risk of gallstone disease formation in patients with metabolic syndrome was used the multiple logistic regression analysis.

RESULTS

In accordance with our results the main risk factors of gallstone formation in patients with metabolic syndrome are the age (P = 0.02), waist volume (P = 0.0002), the increase of serum concentration of GGTP (P = 0.00001), MMP-9 (P = 0.002) and TIMP-1 (P = 0.02).

CONCLUSION

The results of our study have shown that in patients with metabolic syndrome was estimated the high risk of gallstone disease formation compared and the most significant factors of it formation are the patients age, waist volume and increase of serum concentration of GGTP, MMP-9 and TIMP-1.

[Changes in liver function and immune function following laparoscopic and traditional open cholecystectomy: a comparative study]

OBJECTIVE

To compare the effect of laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) on liver function and immune function.

METHODS

Forty-two patients with normal liver function underwent LC (n=21) or OC (n=21) according to the patients' preference. One day before and 7 days after the operations, the liver functions (ALT, AST, TBIL, ALB) and immune functions (CD3, CD4, CD8, NK cell percentage, IgA, IgM, IgG and C3, C4) of the patients were measured.

RESULTS

No statistical differences were found in the liver functions or immune functions between the two groups after the operation.

CONCLUSION

LC and OC show no significant difference in the effects on the liver function and immune function.

Gallbladder wall inflammatory cells in pediatric patients with biliary dyskinesia and cholelithiasis: a pilot study

BACKGROUND/PURPOSE

Inflammation has been implicated in functional gastrointestinal disorders, including functional dyspepsia and irritable bowel syndrome. This study was undertaken to evaluate gallbladder wall inflammatory cells in children with abdominal pain related to gallstones and biliary dyskinesia to determine the candidate cell types that may be contributing to the pathophysiology of these entities.

METHODS

Gallbladder specimens from 20 patients with cholelithiasis, 20 biliary patients with dyskinesia, and 12 autopsy controls were evaluated in a blinded fashion. Eosinophil, tryptase-positive, and CD3+ cell densities were determined for the lamina propria and muscularis mucosa layers and compared between groups.

RESULTS

Patients with biliary dyskinesia and cholelithiasis had a 9- to 12-fold increase in mean and peak mast cell densities, respectively, in both layers as compared with controls. Peak (13.7 vs 8.4) and mean (9.2 vs 5.2) CD3+ cell densities were increased in the muscularis mucosae of cholelithiasis specimens as compared with biliary dyskinesia specimens.

CONCLUSION

Gallbladder wall inflammatory cell densities, particularly mast cells, differ between children with cholelithiasis, children with biliary dyskinesia, and controls. Future studies are warranted to define the roles for specific inflammatory cell types.

[Changes of the different neuropeptide containing nerve elements in the inflamed human gall bladder]

BACKGROUND, AIMS

The changes of different neuropeptide containing nerve elements might play a role in the pathogenesis of cholecystitis and the formation of gallstones, therefore the authors have investigated the density of the neuropeptide containing nerve fibres and immunocompetent cells in human gallbladder (control and cholecystitis).

METHODS

The different neuropeptide containing nerve elements and immunocytes were detected by avidin-biotin-peroxidase (ABC) immunohistochemistry.

RESULTS

In the control gallbladder the density of the different neuropeptide containing nerve fibres showed different pattern in all layers. In the inflamed gallbladder the number of the vasoactive intestinal polypeptide (VIP) positive nerve fibres increased significantly, very dense immunoreactive (IR) nerve fibres were located mainly in the tunica mucosa just below the epithelial lining. The number of the VIP IR nerve cell bodies was also increased. However, the number of the substance P (SP) IR nerve fibres was decreased significantly in the cholecystitis. The number of the neuropeptide Y (NPY) nerve fibres showed no changes, while their distribution was altered compared to the control. In the inflamed area the number of immunocompetent cells was strongly increased (being granulocytes, lymphocytes, plasma cells and mast cells) and some of them were also immunoreactive for SP, calcitonin gene-related peptide (CGRP) and VIP. Close contacts were detected between IR nerve fibres and the immunocytes in several cases.

CONCLUSIONS

During inflammation the changes of the neuropeptide containing nerve fibres might alter the function (causing dilation) of the gall bladder, the activated immunocytes can also synthesize neuropeptides (SP, CGRP, VIP), so the released materials (cytokines, chemokines, histamine, as well as neuropeptides) might act in an autocrine and/or paracrine way influencing the function of the organ and of the immune system.

[Characteristics of immune homeostasis in patients with cholelithiasis complicated by hepatitis and cholangitis]

The most distinctive and typical complications of cholelithiasis are cholangitis and hepatitis. The article presents an analysis of peculiarities of immune homeostasis in 41 patients with cholelithiasis complicated by hepatitis and cholangitis before and after surgical treatment and with the use of antihomotoxicologic and homeopathic medications.

Aspects of the humoral and cellular immune response in hepatitis associated with cholelithiasis

AIM

To investigate the immunological reactions of the liver in various gall bladder disease.

METHODS

IgG, IgA and IgM were measured in the blood and bile of patients with cholecystectomy. Immunofluorescence and electron microscopy techniques were used.

RESULTS

The tests showed high blood values of immunoglobulins and their presence in the bile. The immunofluorescence was positive for IgG in the hepatic sinusoids. The electron microscopy showed aspects of "cellular cooperation".

CONCLUSIONS

On the basis of our results we can affirm that in cholelithiasis there exists an immune response to the persistent antigens, with the release of circulating immune complexes.

Lethal hypercytokinemia following hepatic resection under pringle maneuver: a case report

Clinical implications of acute reactant cytokines remain to be clarified in ischemia/reperfusion injury of humans. We report a lethal case of hypercytokinemia following continuous Pringle maneuver. A 36-year-old man with intrahepatic duct stones underwent left lobectomy under continuous hepatic inflow occlusion for 70 minutes. The postoperative course was stormy with rapid deterioration of liver functions, resulting in death due to multiorgan dysfunction on the 4th postoperative day. Analysis of cytokines demonstrated marked elevation of plasma acute inflammatory cytokines level (Interleukin-6 and -8) during surgery and immediate postoperative day. Our experience suggests that excessive production of inflammatory cytokines was detrimentally associated with multiorgan dysfunction including liver. The strategies against such hypercytokinemia should be considered when performing liver resection particularly under continuous Pringle maneuver.

Experimental model of acute pancreatitis in Wistar rat: glucocorticoid treatment profile

Severe acute pancreatitis may be triggered by an extrapancreatic insult at the peri-Vaterian duodenum such as that occurring in the short-term, 20 min closed duodenal loop model in Wistar rat, which mimics biliary acute pancreatitis or that following endoscopy. Glucocorticoids are immunological modulators whose therapeutic value is worth investigating. Wistar male rats were used under standardized conditions. Acute pancreatitis was induced by instillation of a 7% sodium tauraocholate solution with 5 drops of methylene blue to monitor absence of duodenal bilio pancreatic reflux into the peri-Vaterian duodenum for 20 min. Detection of biliopancreatic reflux with methylene blue was an exclusion criterion. Different doses and times of administration of subcutaneous hydrocortisone were evaluated. Biochemical assays were carried out in blood samples and pancreatic and lung tissue, while histpathological studies were done in the pancreas, lung liver, duodenum, spleen, kidneys, suprarenal glands, and stomach. Animals subjected to the experimental model developed severe acute pancreatitis. According to the dose and time of administration, hydrocortisone therapy was effective and beneficial at a dose of 4 mg/kg give 30 min before inducing acute pancreatitis. It was ineffective when doses were <4 mg/kg and given before sodium taurocholate harmful when the dose was >4 mg/kg and given either before or after. Thus, the proposed model is valid and useful to study the initiation mechanism of acute pancreatitis caused extrapancreatically while its amelioration by glucocorticoid is related the dose and time factor to achieve therapeutical results.

Cyclooxygenase-2 mediates mucin secretion from epithelial cells of lipopolysaccharide-treated canine gallbladder

Biliary mucin was regarded as a major contributing factor in formation of pigment stones as well as cholesterol ones. The aim of this study was to elucidate the mechanism of biliary mucin secretion in canine gallbladder epithelial (CGBE) cells treated by lipopolysaccharides (LPS) with special reference to cyclooxygenase (COX) -2. Confluent CGBE cells were incubated with following compounds for 8, 12, and 24 hr: (1) serum-free medium, (2) serum-free medium containing LPS (100 microm/ml), (3) serum-free medium containing LPS (100 microm/ml) with NS-398 (10 microM), and (4) serum-free medium containing LPS (100 microm/ml) with indomethacin (10 microM). Mucin assay and western blots for COX-1 and COX-2 were performed. Production of PGE2, and cAMP was also measured. Mucin secretion increased with time. At 12 hr, mucin secretion increased to 200% of control (from 100 +/- 5 to 200 +/- 45%, P < 0.05). LPS treatment significantly stimulated the COX-2 expression (P < 0.05). The productions of PGE2 and cAMP were increased from 299 +/- 68 to 524 +/- 163 pg/mg (P < 0.05) and from 0.2 +/- 0.1 to 0.92 +/- 0.4 pmol/ml (P < 0.05), respectively. NS-398, which completely inhibited COX-2 expression, significantly suppressed the level of PGE2 and cAMP as well as mucin secretion (P < 0.05). Indomethacin, which partially inhibited COX-2 expression, suppressed the production of PGE2, but not cAMP and mucin secretion. In conclusion, our results suggested that the PGE2 induced by COX-2 might play a role in mucin secretion from the gallbladder epithelium through the increment of cAMP.

Gram-negative bacteria killed by complement are associated with more severe biliary infections and produce more tumor necrosis factor-alpha in sera

BACKGROUND

We previously showed that gallstones contain bacteria and that illness severity correlates with bacterial presence. This study examined virulence differences of gram-negative biliary bacteria.

METHODS

Gallstones and bile were cultured, and sera obtained, from 210 patients. Infection severity was staged as: none-no clinical infection; moderate-fever, leukocytosis; or severe-bacteremia, cholangitis, hypotension, abscess, or organ failure. Gram-negative biliary bacteria were tested against patient (and control) serum for complement-mediated bacterial killing and induction of tumor necrosis factor-alpha (TNFalpha) production (using cultured monocytes) with and without sera. These results were correlated with infection severity.

RESULTS

A total of 98 (47%) patients had biliary bacteria. Infection severity distribution was none, 29%; moderate, 35%; and severe, 36%. Gram-negative organisms killed by complement were associated with more severe infections as follows: 13%, none; 60%, moderate; and 88%, severe infections (P =.024 and P <.0001, respectively vs none, chi-square test). TNFalpha production in sera increased 182 pg/mL with complement resistant bacteria, but increased 546 pg/mL with bacteria killed by complement (P <.0001, killed vs not killed, Student's t test). E coli and Klebsiella were the most virulent bacterial species. They were cultured from blood, usually killed by complement, and had the largest increase in TNFalpha production in sera.

CONCLUSIONS

Gram-negative biliary bacteria killed by complement (as opposed to complement-resistant) were associated with more serious biliary infections including bacteremia and induced more TNFalpha production in sera. This suggests a potential role for complement activation and cytokine production in biliary sepsis.

Enhanced inflammatory cytokine production at ischemia/reperfusion in human liver resection

BACKGROUND/AIMS

Clinical implications of acute reactant cytokine responses remain to be clarified in the setting of ischemia/reperfusion of human liver during liver resection and transplantation.

METHODOLOGY

In serial samples of portal and systemic venous blood we examined acute inflammatory cytokine activities at the time points--before i), at the end of clamping ii), and one hour iii) and day 1 iv) after continuous hepatic inflow occlusion in 25 patients undergoing elective hepatectomy (15 major and 10 minor). Responses of tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6 and interleukin-8 were compared with intraoperative parameters such as the duration of hepatic inflow occlusion and portal venous pressure during the occlusion, postoperative hepatocyte injury markers such as serum transaminases and bilirubin and also related complications.

RESULTS

Portal interleukin-6 levels were significantly elevated during hepatic inflow occlusion, as compared with the systemic events (P < 0.02, at time point ii), but there were no differences in the interleukin-8 levels between the portal and systemic circulation. The increase in portal interleukin-6 levels during liver resection (time points, ii and iii) significantly correlated with the duration of hepatic inflow occlusion (48 +/- 9 min, mean +/- SD), portal venous pressure (500 +/- 127 mmH2O), and postoperative serum levels of transaminases (day 1; S-ALT, 705 +/- 1023 U/L; S-AST 892 +/- 1255 U/L) and maximum bilirubin (2.6 +/- 2.5 mg/dL). Interleukin-8 levels in the portal circulation showed no such correlation, but the levels in systemic blood showed significant positive relationships with the intra- and postoperative parameters. One patient who died had an enhanced generation of the cytokines in the presence of an elevated portal venous pressure.

CONCLUSIONS

These observations suggest that overproduction of acute reactant cytokines (interleukin-6 from the portal system and interleukin-8 from the systemic circulation) in hepatic ischemia/reperfusion relates positively with postoperative hepatocyte injury in humans. We propose that hepatectomy done under a prolonged continuous inflow occlusion should be reconsidered when an enhanced generation of acute cytokines is anticipated, especially in case of a markedly high portal pressure during hepatic pedicle clamping.

[Immunomorphologic detection of apoprotein B antigenic determinants in the gallbladder wall in cholesterosis and cholelithiasis]

The presence and location of apoprotein B (Apo B) antigenic determinants in cholesterosis and cholelithiasis in gall bladder wall were detected for elaboration of modified Apo B role in pathogenesis of these diseases. Macroscopically changed parts of gall bladder (GB) wall of patients with gall bladder cholesterosis (GBC), and also macroscopically unchanged parts of GB wall of patients with cholelithiasis (CL) after cholecystectomy were studied. Macroscopically unchanged parts of GB wall obtained during autopsy of persons without symptoms of GB pathology were used as a control. Apo B location was studied with monoclonal (MAB 5F8 to Apo B) and polyclonal (PAB) antibodies; Apo B modified by malonic dialdehyde and oxidized by Cu2+ (4C11), Apo A with MAB1C5. Antibodies to CD 68 (specific marker of macrophages) was positive control, antibodies to trichinella--negative control. The most intensive accumulation of modified Apo B was revealed in foam cells region with accumulate lipids and form polyps that testifies to connection of apoproteins with lipids and foam cells and suggests their role in pathogenesis of GBC. More intensive staining of GB epithelial cells, particularly on GB peripheral parts by antibodies to apoproteins compared with surrounding tissues shows that bile is the source of detected modified apoproteins. Increase of absorption and accumulation of apoproteins in GB wall were also revealed in CL but these processes are less intensive than in GBS.

A comparative study between conventional and laparoscopic cholecystectomy: evaluation of phagocytic and T-cell-mediated antibacterial activities

Over the past few years, many reports have pointed out that open, but not minimally invasive, cholecystectomy was associated with reduced immune functions. Also, after laparoscopic surgery, a reduced impairment of T cell functions and lower levels of proinflammatory cytokines, epinephrine, and norepinephrine were found in comparison with those detected in patients who underwent conventional cholecystectomy. We investigated polymorphonuclear cell- and monocyte-mediated phagocytosis and killing and T-cell-mediated antibacterial activity in 12 patients who underwent open cholecystectomy versus another group of 12 patients who underwent laparoscopic cholecystectomy. Our data show that polymorphonuclear and monocyte killing activities are preserved or are less affected in patients who undergo laparoscopy when compared with patients who undergo conventional operation. On the other hand, in both groups of patients, T-cell-mediated antibacterial activity was significantly reduced in the preoperative period, and, therefore, we could not draw conclusions on the effects of the surgical techniques used on the above immune parameter. The overall data suggest that laparoscopic cholecystectomy is a valid alternative to open surgery because of the moderate postoperative immune suppression and decreased risk of postsurgical infections.

[Local and common humoral immunity in cholelithiasis and biliary sludge]

Analysis of local and systemic humoral immunity in 75 patients with cholelithiasis (36 patients) and biliary "sludge" (39 patients) are presented in this article. The bile of these patients were examined. The sIgA reduce in the bile, that testifies to the suppression of local humoral immunity but IgG and IgM increase due to inflammatory changes of gallbladder were revealed. Increase of all immunoglobulins, especially IgA, was revealed in blood serum. The both groups of the patients had demonstrated the same changes but with different expressiveness. This fact testifies to the similarity of pathological processes in these patients.

Detection of intracellular interleukin-2 production in peripheral T lymphocytes by flow cytometry in patients with pancreatobiliary malignancies

BACKGROUND AND AIMS

To date, it has been reported that cellular immunity is decreased in patients with cancer and investigations into cytokine production has been insufficient. Therefore, we examined intracellular cytokine production by using flow cytometry in patients with cancer and discussed the reasons for the impairment of their immune system.

METHODS

Eleven patients with hepatobiliary malignancies (68.5+/-11.8 years of age), eight age-matched controls (70.0+/-12.0 years of age) and 10 young volunteers (31.9+/-3.1 years of age) were used in the present study. Stimulated peripheral blood mononuclear cells from these patients were stained with fluorescence-labeled anticytokine monoclonal antibodies and analyzed with a Fluorescence activated cell sorter (FAC)Scan.

RESULTS

The percentage of positively stained T cells was calculated and compared with controls. Repeated measured ANOVA was used for statistical analysis. Interleukin (IL)-2 production was significantly decreased in patients with cancer compared to controls (P=0.0122), and it may suggest decreased cellular immune activity of the patients. Simultaneously, spontaneous intracellular IL-4 production was observed in patients and age-matched controls, but levels were significantly increased when compared with the young volunteers (P=0.0052, P=0.031, respectively).

CONCLUSIONS

It was of interest that spontaneous intracellular IL-4 production was detected in elderly subjects.

Systemic and cell-mediated immune response after laparoscopic and open cholecystectomy in patients with chronic liver disease. A randomized, prospective study

BACKGROUND

As impaired immune function observed in cirrhotic patients is known to increase the risk of postoperative complications, the immunological response to surgery was investigated.

METHODS

Twenty-eight patients with postnecrotic liver cirrhosis or chronic hepatitis C and symptomatic gallstone disease were randomly allocated to laparoscopic (LC) or open cholecystectomy (OC). Changes in concentrations of cytokines (TNF-alpha, IL-1beta, IL-6, IL-8 and IL-10) were followed and the effect of surgical trauma on the distribution of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD19) and NK cell cytotoxicity were measured.

RESULTS

After OC a decrease in circulating CD3 (p < 0.05) and CD4 (p < 0.05) and an increase in CD19 (p < 0.05) cells were detected in contrast to LC after which only CD16 cells decreased (p = 0.05). The number of CD3 cells was higher after LC than after OC (p < 0.01), whereas the number of CD19 cells was higher after OC than after LC (p < 0.01). NK cell cytotoxicity was reduced after LC (p < 0.05). In cirrhotic patients circulating cytokines were unaffected by OC, whereas TNF-alpha (p < 0.05) and IL-1beta (p < 0.05) were reduced after LC. In chronic hepatitis IL-1beta decreased after OC (p = 0.05) and IL-10 was significantly higher after LC than following OC (p < 0.05).

CONCLUSION

The immune response is less pronounced after a laparoscopic procedure compared to a conventional approach in patients with chronic liver disease.

[A study of the immune in formation of calcium bilirubinate gallstones in different rabbit models--the changes of the immunoglobulins in serum and bile and the immunoglobulins forming cells in the gallbladder mucoderm]

The changes of Ig-forming cells in the gallbladder mucoderm and the immunoglobulins in serum and bile were studied in the rabbit models. One hundred rabbits were randomly divided into the control group (Con, n = 10), simple biliary obstruction group (BO, n = 45) and biliary obstruction and infection group (BOI, n = 45). The results showed that the concentrations of serum immunoglobulin A (IgA) in BO and BOI groups increased remarkably in all phases (P < 0.001), The concentrations of serum IgG in both groups increased with the formation of gallstones. The IgA and IgG contents of bile samples in BO and BOI groups with negative bacterial culture were much higher than those of control group (P < 0.05), but the Ig content of bile with positive culture was slightly lower than that of the control group. Only a few Ig-forming cells were found in the gallbladder mucoderm of normal rabbits. The counts of Ig-forming cells in the mucoderm in BO group remained unchanged, but increased much higher in BOI group (P < 0.001), especially in IgG formation. This experiment demonstrates the immunoglobulins of serum and bile change significantly during the formation of gallstones. The Ig content of bile has a relationship with bacterial infection. IgA plays an important role in gallstone formation. The gallbladder of rabbit may be an important place of Ig-formation. The quantity of Ig forming cells in biliary tract may have a close relationship with the gallstone formation.

[Is cell-mediated immunity affected by laparoscopic cholecystectomy?]

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.

Carcinoma of the gallbladder--is it a sequel of typhoid?

Gallbladder diseases, including carcinoma, are common in the northern part of India and so are Salmonella typhi infection and typhoid carrier state. This study was aimed to find out the association of typhoid carrier state in patients with cholelithiasis, carcinoma of the gallbladder, and controls. The three groups are comparable in age and sex composition. This is the first study of its kind from an area of high endemicity for both typhoid infection and carcinoma of the gallbladder. A case-control study was carried out to detect typhoid carrier state among the patients with biliary diseases and healthy controls, using indirect haemagglutination assay measuring antibodies against highly purified S. typhi Vi polysaccharide antigen. A significantly high Vi positivity was observed in patients with gallbladder carcinoma (29.4%) compared to controls (5%) (chi2 = 6.325, P < 0.004, OR = 7.19) and patients with cholelithiasis (10.7%) (chi2 = 5.066, P < 0.01, OR = 3.86). There is 8.47 times more risk of developing carcinoma of the gallbladder in culture-positive typhoid carriers than the noncarriers. The present study suggests the typhoid carrier state to be one of the possible mechanisms of gallbladder carcinogenesis.

Measurement of intracellular gamma-interferon, interleukin-4, and interleukin-10 levels in patients following laparoscopic cholecystectomy

Major surgery suppresses intracellular T-cell cytokine production. Laparoscopic surgery has been reported to have no effect on in vitro lymphocyte reactivity, but its effects on intracellular cytokine production are unknown. This study measured T-cell intracellular gamma-interferon, interleukin-4 (IL-4), and interleukin-10 (IL-10), along with serum interleukin-6 (IL-6) and cortisol levels, immediately before and 1 day after laparoscopic cholecystectomy in a cohort of six Air Force and veteran patients. Stimulated intracellular levels of gamma-interferon were slightly, but not significantly, elevated during the postoperative period in all T-cell subsets. There were no postoperative changes in stimulated IL-4 or IL-10 levels. Postoperative serum IL-6 levels, but not serum cortisol levels, were significantly elevated compared to preoperative values. In conclusion, laparoscopic surgery causes slight trauma but has no effect on T-cell intracellular interferon, IL-4, and IL-10 responses.

Cytokine production by CAPAN-1 and CAPAN-2 cell lines

Recently, there has been a great deal of interest in the role of cytokines in acute pancreatitis. Serum levels of IL-1, IL-6, and TNF-alpha have been demonstrated to be elevated in acute pancreatitis. We hypothesized that cytokines may be produced primarily by pancreatic parenchymal cells. Reasoning that ductal epithelium is the cell type most likely to be exposed to noxious stimuli in common causes of pancreatitis, such as ERCP and passage of a gallstone, we examined the response of well differentiated pancreatic ductal adenocarcinoma cell lines to stimuli known to stimulate cytokine production in other cells. CAPAN-1 and CAPAN-2 cells were incubated with endotoxin or TNF-alpha. The supernatant was assayed for production of IL-1, IL-6, and IL-8 by ELISA. The cells were assayed for activation of the transcription factor NF-kappaB by electrophoretic mobility shift assay. There was no detectable production of IL-1 by either cell line. CAPAN-1 cells had concentration-dependent production of IL-6 and IL-8 in response to both endotoxin and TNF-alpha. CAPAN-2 cells had concentration-dependent production of IL-6 and IL-8 in response to TNF-alpha. They had low level expression of IL-8 that was unaffected by any concentration of LPS, and no detectable production of IL-6 in response to LPS. These findings suggest that pancreatic duct cells may take an active part in the pathogenesis of acute pancreatitis through the production of cytokines.

[The characteristics of the local immune reactions in patients with acute cholecystitis]

Among the investigated 27 gallbladders (GB) using immunofluorescent and histological methods 9 were nonaffected, 7--excised for an acute calculous cholecystitis and 11--for the destructive one. It was established, that the plasmocytes, producing immunoglobulins of main classes, play an important role in the immune defense of the GB mucosa. The stress and hyperfunctioning of the local immune homeostasis mechanisms were revealed in the acute calculous cholecystitis; in the destructive one--the local immune defense disorder, showing the essential lowering of the secretory immunoglobulin A (SIgA) level and the immunocytes-producers IgA quantity, the ratio between plasmocytes and immune complexes, which appear in the vessels wall and perivasal stroma of GB.

Effects of laparoscopic and conventional (open) cholecystectomy on human leukocyte antigen-DR expression in peripheral blood monocytes: correlations with immunologic status

It is well known that surgery significantly decreases immune responses. Laparoscopic cholecystectomy (LC) is a "miniinvasive" surgical procedure; and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. Immune activity [neutrophils, total lymphocytes count, lymphocytes subpopulations, human leukocyte antigen-DR (HLA-DR)] was evaluated in 53 patients 1 day before surgery and respectively, 1, 3, and 6 days after surgery; 26 patients underwent "open" cholecystectomy and 27 LC. A day after surgery, patients with open cholecystectomy showed a significant increase (p < 0.05) in plasma neutrophils, while they were almost unchanged in LC patients. Monocyte antigen HLA-DR was reduced in patients with "open" cholecystectomy. We recorded two cases (7.6%) of respiratory tract infection in the "open" group. In conclusion, LC strongly reduces postoperative (p.o.) pain and hospitalization, and it promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with less p.o. morbidity compared to that seen with open surgery.

Minimal modulation of lymphocyte and natural killer cell subsets following minimal access surgery

BACKGROUND

Trauma, whether accidental or surgically induced, is known to cause significant modulation of the cell-mediated immune response. Minimal access surgery (MAS) has been shown to improve postoperative recovery and enhance rehabilitation. The degree of immunosuppression resulting from two MAS techniques was studied and compared by measuring the circulating T lymphocyte and natural killer (NK) cell subsets.

METHOD

This investigation was a randomized prospective study of patients admitted to the Professorial Surgical Unit, Aberdeen Royal Infirmary for elective cholecystectomy. Two methods of MAS were studied-laparoscopy and minilaparotomy.

RESULTS

Laparoscopy was found to cause significantly less reduction in the number of cells expressing T lymphocyte phenotypic surface markers (CD2, CD3, CD8, CD4:CD8 ratio), activation markers (CD71 and HLA-DR), and NK cell subsets (CD11b, CD16, CD56 and CD57), when compared with the minilaparotomy technique.

CONCLUSIONS

These data show that host defences are less suppressed after laparoscopic cholecystectomy, and this may have important implications for the use of laparoscopic techniques in major surgical resections, especially for malignant disease.

Downregulation of T helper type 1 immune response and altered pro-inflammatory and anti-inflammatory T cell cytokine balance following conventional but not laparoscopic surgery

BACKGROUND

The clinical advantages of laparoscopic procedures result from a minimized surgical trauma. The present study was performed to investigate immunosupression following laparoscopic operations as compared with open surgery. Our analysis focused on the T cell secretion of cytokines that regulate the critical balance of either T helper type-1 (Th1)- and Th2-mediated immune responses on pro- and antiinflammatory activities.

METHODS

In a prospective study, immunological data of 26 patients submitted to laparoscopic cholecystectomy (LCE) and 17 patients undergoing conventional cholecystectomy (CCE) for symptomatic cholecystolithiasis were compared. Patients with acute cholecystitis and patients developing postoperative complications or receiving immunosuppressive medication were excluded. Production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4, tumor necrosis factor (TNF)-alpha, and IL-10 by isolated T cells stimulated by cross-linking of CD3 and CD28 was evaluated preoperatively as well as on postoperative days 1 and 6 or 7. Cytokines were measured by immunoenzymometric assay.

RESULTS

IFN-gamma, TNF-alpha, and IL-2 production by T cells decreased significantly by 48.3%, 36.6%, and 36.8%, respectively, on postoperative day 1 after CCE, but not after LCE. These results indicate severe suppression of Th1-type and proinflammatory cytokines after the open operation. In contrast, IL-4 and IL-10 did not show significant changes in either group suggesting that Th2 cell response and anti-inflammatory activity remained normal.

CONCLUSIONS

The present study shows that open, but not laparoscopic cholecystectomy is associated with a marked suppression of T lymphocytes functions as indicated by deregulation of both the Th1/Th2 and the pro-/anti-inflammatory cytokine balance. The results therefore suggest that downregulation of Th1 cell-mediated immune response and pro-inflammatory activity of T cells is a hallmark of open, but not laparoscopic surgery.

[The influence of laparoscopic cholecystectomy vs laparotomy on the monocyte antigen expression (HLA-DR)]

It is well known that surgery significantly decrenses immune responses. Laparoscopic cholecystectomy (LC) is a so called "mini invasive" surgical presidia, and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compare to patients undergone open cholecystectomy. Immune-activity (neutrophils, total lymfocytes count, lymphocytes subpopulations, HLA-DR) was evaluated in 53 patients one day before surgery and p.o. after 1. 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC. One day after surgery patients with open cholecystectomy showed significant increase (p < = 0.05) of plasma neutrophils, while these parameters were almost unchanged in patients with L.C. Finally monocyte antigen HLA-DR was also reduced in patients with "open" cholecystectomy: in this group we also recorded 2 cases (7.6%) of respiratory tract infection. In conclusion LC, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with better p.o. morbidity compare to open surgery.

[Clinical and laboratory study of cefodizime (Modivid) in prophylaxis and treatment of surgical patients]

The results of the clinical and laboratory study of the efficacy of the prophylactic and therapeutic use of cefodizime (modivid) in patients with chronic calculous cholecystitis and burns are presented. Expediency of the preoperative prophylactic use of the drug and its significance in the treatment of infectious complications of the burn disease were verified. The immunological investigation gave evidence of an increase of the phagocytosis functional activity when cefodizime (modivid) was used prophylactically in cholecystectomy.

Detection of occult liver metastases in colorectal cancer by measurement of biliary carcinoembryonic antigen

About a 20-25% of the patients at diagnosis of colorectal carcinoma present with occult liver metastases. The aim of this work was to determine the prognostic significance of CEA bile level for the early detection of occult metastases. We determined the CEA blood level and the CEA bile level in 182 patients with colorectal carcinoma (3 Dukes' stage A, 86 Dukes' stage B, 53 Dukes' stage C, and 40 patients with liver metastases) and also in 42 patients with simple cholelithiasis, as the control group. In the patients with cholelithiasis, the mean values of CEA serum and bile levels were normal. In patients with colorectal carcinomas the CEA serum levels ranged from 3 to 110 ng/ml, and the CEA bile level from 3 to 226 ng/ml. Patients with liver metastases, had a mean CEA serum level of 193 ng/ml, while CEA bile level was 1,225 ng/ml. In conclusion, our results suggest that the determination of CEA bile is highly useful in the diagnosis of occult liver metastases.

Frequent expression of MUC1 apomucin on biliary epithelial cells of damaged small bile ducts in primary biliary cirrhosis and chronic viral hepatitis: an immunohistochemical study

MUC1 apomucin is a specific target tumor antigen recognized by cytotoxic T cells in a major histocompatibility complex (MHC) unrestricted fashion in patients with pancreatic and breast cancer. This T-cell-mediated immune mechanism against MUC1 apomucin expressing cells has not been evaluated in nonneoplastic immune-mediated diseases. Therefore, we immunohistochemically surveyed the expression of MUC1 apomucin on biliary epithelial cells of small bile ducts in various hepatobiliary diseases, including primary biliary cirrhosis (PBC). MUC1 apomucin was detected using the monoclonal antibody DF3 and the streptavidin-biotin complex, in livers from 31 patients with PBC, 67 with chronic viral hepatitis (CH) with or without cirrhosis, 31 with extrahepatic biliary obstruction (EBO), 30 with hepatolithiasis, and from 23 normal individuals. MUC1 apomucin was infrequently and focally expressed in the biliary epithelial cells of the small bile ducts in 3 of 23 normal livers. In contrast, MUC1 apomucin was frequently and strongly expressed on the luminal surface of biliary epithelia] cells of small bile duct, in 22 of 31 patients with PBC, and in 50 of 67 patients with CH. In particular, high levels of MUC1 apomucin were expressed in bile ducts showing chronic nonsuppurative destructive cholangitis (CNSDC) in PBC and hepatitic duct injuries in CH. In EBO and hepatolithiasis, MUC1 apomucin was focally and weakly expressed in 29% and 30% of livers examined, respectively. More MUC1 apomucin was expressed in PBC and CH than in EBO, hepatolithiasis, and normal liver (P < .01, respectively). Frequent and high luminal expression of MUC1 apomucin on biliary epithelial cells in damaged small bile ducts in PBC and CH may be related to T-cell-mediated immunologic mechanisms in these diseases, probably by an MHC-unrestricted recognition process.

Carcinoembryonic antigen and blood group-related carbohydrate antigens in glycoproteins in human bile in hepatolithiasis. Japanese Study Group of Hepatolithiasis

We investigated whether carbohydrate antigens on biliary glycoproteins and carcinoembryonic antigen (CEA) are related to hepatolithiasis. CEA, ABO, and Lewis blood group-related antigens, as well as sialyl-Tn antigen in hepatic bile, were analyzed by Western blotting in samples from 12 patients with hepatolithiasis and 37 with other biliary diseases (choledocholithiasis, 13; cholecystolithiasis, 5; acute cholecystitis, 2; cholangiocarcinoma, 5; common bile duct carcinoma, 4; pancreatic carcinoma, 6; and metastatic carcinoma of liver, 2). CEA was positive on mucinous glycoprotein in six patients (50%) with hepatolithiasis and one case (17%) with pancreatic carcinoma. CEA was also positive on a glycoprotein of approximately 200 kd in eight patients (67%) with hepatolithiasis and two (33%) with pancreatic carcinoma. Lewis X was detected on the mucinous glycoprotein in almost all samples, as well as on glycoproteins of approximately 180 kd in all hepatolithiasis samples and approximately half of those from patients with other diseases. Sialyl-Tn antigen was detected on mucinous glycoprotein in four (80%) with cholangiocarcinoma, two (50%) with common bile duct carcinoma, and all pancreatic carcinoma samples. Mucinous glycoprotein and glycoproteins containing CEA and Lewis X antigens are enriched in hepatic bile of hepatolithiasis, and they may be closely related to the formation of intrahepatic calculi. Sialyl-Tn antigen in biliary mucinous glycoprotein will be a good marker of biliary and pancreatic carcinoma, and probably for cholangiocarcinoma complicated with hepatolithiasis.

[Comparative study of superoxide production of monocytes in primary biliary cirrhosis]

Monocytes appear to play a role in immunological abnormalities observed in primary biliary cirrhosis (PBC). Monocytes not only produce fibroproliferative factors, such as IL-1, TNF, and PDGF but also produce superoxide anion which can directly damage tissues, and thus may lead to fibrosis. The aim of this study was to compare the superoxide production in monocytes obtained from 12 control persons, 9 patients with non biliary cirrhosis, 6 untreated PBC patients, 6 patients with gallstones under urso- and chenodeoxycholicacid (Lithofalk) treatment and 32 PBC patients under ursodeoxycholicacid (UDCA) therapy. Monocytes were isolated and the production of superoxide anions with and without phorbol-myristate-acetate (PMA) stimulation was determined. In two occasion, the monocytes from control patients were preincubated with 10, 50, 100 microM UDCA. Unstimulated monocytes from PBC patients under UDCA therapy produce an average 43% more and the PMA stimulated monocytes an average 42% more superoxide than monocytes from the control or from the other cirrhotic patients. The UDCA preincubation did not influence the superoxide production of monocytes obtained from control patients. These findings suggest that the increased activity of monocytes may also play a role in liver damage and fibrosis in PBC.

[Validation of the early health-resort rehabilitation of patients who have undergone a cholecystectomy]

The paper addresses the issue of expediency of early sanatorium treatment of patients with prior cholecystectomy; indications and contraindications are determined as are optimal terms for refferring such patients to specialized departments of gastroenterologic sanatoria in Ukraine. Impact of sanatorium treatment on functional state of the liver and immune system in early periods after cholecystectomy was studied.

The utility of prophylactic laparoscopic cholecystectomy in transplant candidates

BACKGROUND

This study addresses the impact of laparoscopic cholecystectomy prior to kidney or pancreas transplant.

PATIENTS AND METHODS

Between January 1991 and July 1993, 551 patients were listed for transplant. Gallbladder ultrasound became part of the standard evaluation for all transplant candidates in October 1991. Pretransplant laparoscopic cholecystectomy was recommended for all patients found to have gallstones. To assess the benefit of this policy, patients transplanted prior to routine ultrasound (Group I; n = 88) were compared to those listed or transplanted after routine ultrasound (Group II; n = 406).

RESULTS

In Group I, 18% developed gallstone complications requiring surgery. Surgical morbidity occurred in 14% and mortality in 7% of these operations. Graft loss occurred in 20% having biliary complications versus 7% among other recipients. In Group II, gallstones were detected in 10%, and 9% subsequently had laparoscopic cholecystectomy with no morbidity or mortality.

CONCLUSIONS

Transplant recipients with unsuspected gallstones were found to have a high incidence of acute biliary complications. Urgent biliary surgery carried significant morbidity and mortality in these immunosuppressed patients and appeared to increase the risk of graft failure as well. A policy of screening gallbladder ultrasound and pretransplant laparoscopic cholecystectomy seems to reduce these concerns and is recommended for all transplant candidates.

Immune function in patients undergoing open vs laparoscopic cholecystectomy

BACKGROUND

Abnormal release of inflammatory mediators following surgical injury is associated with immunological alteration, which may predispose to sepsis. Laparoscopic surgery is associated with reduced postoperative complications, but mechanisms are unclear. We hypothesized that early recovery following laparoscopic surgery may relate to minimal impairment of immune function.

DESIGN

Analysis of the temporal immune responses in two similar groups of patients randomized to open (n = 22) vs laparoscopic (n = 22) cholecystectomy. Patients were matched for age, height, weight, and operation time. Immune parameters, including monocyte superoxide anion (O2-) and tumor necrosis factor release, neutrophil O2- levels and chemotaxis, total white blood cell counts, partial arterial oxygen pressure, and serum cortisol and C-reactive protein levels were assessed preoperatively and on postoperative days 1 and 3.

RESULTS

There were significant increases (P < .001) in monocyte release of O2- and tumor necrosis factor, neutrophil release of O2- and chemotaxis, and white blood cell count in the open vs laparoscopic cholecystectomy study groups, with a concommitant decrease in partial arterial oxygen pressure. These findings correlated with significantly higher postoperative septic complications in the open cholecystectomy group (P < .05). There were no significant differences in either plasma cortisol or C-reactive protein levels between groups. All measurements were carried out in a blinded fashion.

CONCLUSIONS

This study demonstrates that laparoscopic surgery appears to be associated with similar metabolic responses compared with open surgery, while immune parameters vary greatly between groups. The beneficial effects of laparoscopic surgery may relate, in part, to preservation of immune function in the postoperative period.

[Thymogen immunocorrection in the surgical treatment of complicated forms of cholelithiasis]

On the basis of experimental and clinical investigations the authors showed immunity depression in complicated forms of cholelithiasis. Thymogene appeared to be efficient for immunocorrection that permitted to lower the frequency of postoperative complications and lethality.

Carcinoembryonic antigen (CEA) and CEA-related substances in the bile of patients with biliary diseases

The levels of carcinoembryonic antigen (CEA) in the bile of 10 patients with biliary cancer and 9 patients with cholelithiasis were examined immunochemically by the Western blot analysis. All samples of bile from the patients with biliary cancer showed three bands that corresponded to CEA, nonspecific crossreacting antigen, and biliary glycoprotein 1, respectively. The upper band (CEA) disappeared from the bile of patients who underwent curative operations, but it persisted in the bile of patients who underwent noncurative operations. All samples of bile from the patients with cholelithiasis did not show the upper band (CEA), even in those samples that had high levels of CEA by the conventional enzyme immunoassay. We suggest that, in order to diagnose the presence of tumor, to assess the therapeutic efficacy of surgery, and to detect any residual tumor, not only should the level of bile CEA be measured but also a Western blot analysis of the bile should be performed since it is more reliable.

Human gallstones contain pronucleating nonmucin glycoproteins that are immunoglobulins

OBJECTIVE

Pronucleating nonmucin glycoproteins in human cholesterol and black gallstones were isolated and identified.

SUMMARY BACKGROUND DATA

Gallbladder bile contains nonmucin glycoproteins that are pronucleating of cholesterol monohydrate crystals. Little is known about the presence or activity of these proteins within gallstones.

METHODS

Nonmucin glycoproteins were isolated from single cholesterol (n = 8), multiple cholesterol (n = 8), and black pigment (n = 8) gallstones by concanavalin A lectin-affinity chromatography. The proteins were separated by sodium dodecyl sulfate gradient electrophoresis. Western blot analysis was performed for Fab immunoglobulin fragments, and heavy chains from the immunoglobulin G, A, E, and M subclasses. A crystal observation time assay was performed on the combination of isolated nonmucin glycoproteins from gallstones and isolated Fab fragments.

RESULTS

Nonmucin glycoproteins of molecular weights 10, 15, 17, 22, 28, and 208 kD were identified in gallstones. These six nonmucin glycoproteins shortened the crystal observation time by more than 50% (p < 0.01) compared with model bile. Western blot analysis confirmed the identity of the 22- and 28-kD proteins as immunoglobulin Fab fragments. These were seen in all gallstones, irrespective of the gallstone type. The isolated Fab 28-kD fragment from the gallstones of 23 patients shortened the extrapolated crystal observation time by 78% (p < 0.01). However, commercially available Fab fragments had no effect on either cholesterol crystal appearance or growth.

CONCLUSIONS

Nonmucin glycoproteins that are pronucleating for cholesterol monohydrate crystals are also found in human cholesterol and black pigment gallstones. Fab immunoglobulin fragments were found in all gallstones irrespective of the gallstone type. Fab immunoglobulin fragments from gallstones shortened the crystal observation time but not crystal growth or total crystal content compared with model bile or commercially available Fab fragments. These data suggest that an antigen-immune (Fab) complex may contribute to cholesterol crystal function.

Biliary and serum immunoglobulin alterations in patients of cholelithiasis

IgG, IgA and IgM were estimated in serum, common bile duct bile and gall bladder bile by single radial immunodiffusion technique in 30 patients of cholelithiasis, which included 22 patients of cholelithiasis with non functioning gall bladder (sub group A) and 8 patients of cholelithiasis with functioning gall bladder (sub group B). 30 age and sex matched controls were also included in the study. Serum IgG, IgA and IgM were significantly raised in patients of cholelithiasis as compared to controls. However, in gall bladder bile although IgA and IgM were significantly lower (more so in sub group A) than that of control group (p < 0.001 and p < 0.001 respectively but there was no change in IgG. While in common bile duct bile, rise in all the three immunoglobulins was statistically insignificant when compared to controls.

[The characteristics of the immune status of patients with chronic calculous cholecystitis]

Under study was the state of the immune status in 89 patients with chronic calculous cholecystitis and 30 donors. It was shown that the level of the immune parameters in patients with chronic calculous cholecystitis as compared with donors might be considered as the secondary immune deficiency. This category of patients represents a group of high risk in relation to postoperative infectious complications. At the postoperative period in patients with chronic calculous cholecystitis it is necessary to investigate the immune status for correction of its disturbances.

[Immune complex in the wall of the gallbladder in patients with cholelithiasis: deposition and its pathological significance]

The gallbladder specimens from 53 patients with cholelithiasis were studied by immunohistochemical method. Deposition of immune complex (IC) was observed on the mucosal and glandular epithelium in 84% of patients with gallstones and 47% of patients with choledocholithiasis. IgG and C3 were the most frequent complement component demonstrated at the site of IC deposition, but Clq, factor B and C4 were also present in many cases, suggesting the local complement activation. We conclude that IC may play a pathogenetic role in the injury of the mucosa and tissue of gallbladder in patients with cholelithiasis.

Cell kinetic analyses and expression of carcinoembryonic antigen, carbohydrate antigen 19-9 and DU-PAN-2 in hyperplastic, pre-neoplastic and neoplastic lesions of intrahepatic bile ducts in livers with hepatoliths

We evaluated cell proliferative activity and expression of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9) and DU-PAN-2 in various bile duct lesions in livers with hepatoliths, using histochemical and immunohistochemical methods. Histologically, the bile duct lesions were divisible into hyperplasia, dysplasia, adenocarcinoma in situ and invasive adenocarcinoma. All cases showed mucosal hyperplasia in stone-bearing bile ducts. Livers with invasive adenocarcinoma frequently contained adenocarcinoma in situ and dysplasia, and livers with adenocarcinoma in situ occasionally harboured dysplasia. Proliferating cell nuclear antigen (PCNA) labelling index was low in hyperplasia (mean +/- SD = 20.5 +/- 8.7%), intermediate in dysplasia (35.4 +/- 15.9%), and high in adenocarcinoma in situ (46.4 +/- 9.3%). The mean number of argyrophilic nucleolar organizer regions (AgNORs) was low in hyperplasia (1.52), intermediate in dysplasia (2.26) and high in adenocarcinoma in situ (2.69). There was a significant positive correlation between PCNA labelling index and AgNORs count. CEA was expressed on invasive adenocarcinoma cells and adenocarcinoma in situ cells in most cases and on dysplastic cells in about a half, while CEA was never present in hyperplastic epithelia. Expression of CA 19-9 was low in adenocarcinoma, intermediate in dysplasia and rather high in hyperplasia. There was no significant difference in DU-PAN-2 expression among these bile duct lesions. These data suggest that cell replicative activity is low in hyperplasia, intermediate in dysplasia and high in adenocarcinoma in situ, and that CEA appears in the following order: dysplasia, adenocarcinoma in situ, invasive adenocarcinoma. We suggest that carcinogenesis in biliary epithelial in livers with stones is a multi-step process through hyperplasia, dysplasia and adenocarcinoma in situ to invasive adenocarcinoma.

Bile secretory immunoglobulin A in biliary infection and cholelithiasis

Bile samples from 71 patients with cholelithiasis and a control group of 10 subjects without hepatobiliary diseases were cultured for bacteria and measured for secretory immunoglobulin A (SIgA) using enzyme immunoassay specific for SIgA. The results of bile bacterial culture were all positive in patients with primary bile duct pigment stones, and significantly lower bile SIgA levels were observed than in normal controls (P less than 0.005). It was also shown that the constitutent ratios of SIgA to total bile immunoglobulin and the bile-serum ratio of SIgA were markedly lower in these patients than in normal controls (P less than 0.001, P less than 0.001). In patients with cholecystolithiasis, bile SIgA concentrations of patients with biliary infections were remarkably lower than those of patients without biliary infection (P less than 0.01) and those of normal controls (P less than 0.01). These results suggest a close relationship between biliary tract infection and low concentrations of bile SIgA.

[Determination of partially cellular and local immune function in patients with spleen deficiency syndrome]

The immune function status as reflected by the peripheral blood OKT system T cell subset classification and the lymphocyte in vitro interleukin 2 (IL2) secretory function were determined in 30 patients with Spleen deficiency syndrome and 20 normal subjects in this study. Experimental results decreased cellular immune function and disturbance of immune regulatory mechanism in the patients. Its manifestations were decreased number of total T lymphocytes and helper T cells (Th), relatively increased suppressor T cells (Ts), abnormal rate of Th to Ts, no marked change of IL2 secretory function of T cell in vitro, increased SIgA level before stimulating with acid but marked decreased SIgA level after stimulating. All these suggest the compensatory stage of local immune function.

[Phagocytic link of immunity in patients surgically treated for chronic calculous cholecystitis]

Twenty-two females, 38 to 75 years of age, who underwent planned operation for chronic uncomplicated calculous cholecystitis were examined in the pre- and postoperative period. Postoperative pneumonia developed in 4 (13.4%) patients, no other complications occurred. Functional neutrophil activity was studied according to the following parameters: spontaneous and induced NBT test, myeloperoxidase activity, amount of cationic proteins, expression of Fc receptors, spontaneous and induced luminol-dependent chemiluminescence, neutrophil bactericidal action against H-thymidine-labelled Staphylococcus aureus (strain 209), amount of blood immunoglobulins, and the modulating effect of serum of patients on the chemiluminescence of neutrophils of healthy donors. The control group consisted of 35 volunteers whose ages ranged from 18 to 50 years. Basic differences were revealed between the indices of neutrophil activity in patients with an uneventful postoperative period and those of patients with infectious complications in the preoperative period which became much graver in the early postoperative period. This suggests that neutrophilic dysfunctions play a significant role in the development of postoperative infectious complications in this category of patients.

[General anesthesia and surgery inhibited natural killer cell cytotoxicity in patients with cancer or benign disease undergoing upper abdominal surgery]

In this study, effect of enflurane anesthesia combined with epidural analgesia on natural killer cell cytotoxicity (NKCC) was investigated in 20 patients. Patients were divided into two groups: the first group with adenocarcinoma of stomach (Group 1); the second with cholecystolithiasis (Group 2). Four samples were taken; 1) on arrival at operating room; 2) during anesthesia and 1 hour after skin incision; 3) on 1st postoperative day; and 4) on 4th or 5th postoperative day. NKCC was determined with a chromium release assay against K 562 cell. NKCC was already significantly higher before induction in Group 1 compared with Group 2 and normal value. In Group 1, NKCC decreased significantly compared with baseline during operation, but in group 2 NKCC was unchanged during operation. NKCC in group 2 was inhibited significantly less than Group 1 during 5 postoperative days, while NKCC was significantly inhibited postoperatively in both groups compared with the baseline. We conclude that enflurane anesthesia combined with epidural analgesia and surgery did not decrease NKCC below normal value during operation, but it was significantly inhibited during 5 postoperative days in both groups. There were differences in responses to stress of anesthesia and surgery between patients with and without cancer.