D. Decker

Surgical stress induces a shift in the type-1/type-2 T-helper cell balance, suggesting down-regulation of cell-mediated and up-regulation of antibody-mediated immunity commensurate to the trauma*

BACKGROUND Measuring serum cytokines, pituitary hormones, or acute phase proteins during or after surgery is not an optimal method for quantifying the impact of surgical procedures. In an effort to assess surgical stress by means of the immune response, we focused on changes in cell-mediated and antibody-mediated immunity as illustrated by the type 1/type 2 T-helper (Th1/Th2) cell balance. The sensitivity of this approach was evaluated by comparing laparoscopic and conventional cholecystectomy (LCE, CCE). METHODS In a pragmatic prospective study 43 patients with symptomatic cholelithiasis were operated on either by LCE (n = 25) or CCe (n = 18). Blood sampling was done 24 hours before surgery, immediately before incision, and 2, 24, and 48 hours after surgery. Cell surface markers and cytokine production were used to characterize the Th1/Th2 balance and were measured by means of flow cytometry and enzyme-linked immunosorbent assay techniques. RESULTS Activation of Th2 cells evokes the production and secretion of interleukin-4 (IL-4), which up-regulates the expression of immunoglobulin E receptors (Fo epsilon RII, CD23) on B cells. Phytohemagglutinin-induced IL-4 production in freshly isolated peripheral blood mononuclear cells from patients increased more after CCE than LCE (IL-4, +41% versus +17%; p < 0.05). Also the expression of CD23 on B cells was higher after CCE than LCE (+146% versus +63%; P < 0.01). CD30, a membrane molecule that belongs to the tumor necrosis factor receptor superfamily and probably is an important indicator of Th2 activity, was more evaluated on T cells from patients who underwent CCE. The Th1 response, characterized by phytohemagglutinin-induced IFN-gamma secretion in peripheral blood mononuclear cells and up-regulation of human leukocyte antigen-DR expression on monocytes, was lower after CCE than after LCE. CONCLUSIONS This study shows that surgical stress induces a shift in the Th1/Th2 balance toward Th2, suggesting that cell-mediated immunity is down-regulated and antibody-mediated immunity is up-regulated after surgery. The evaluation of this shift may be clinically meaningful and help quantify even less invasive surgical procedures. When comparing CCE and LCE in this not strictly randomized study, we found LCE to be the less stressful procedure.

HPV in anal squamous cell carcinoma and anal intraepithelial neoplasia (AIN). Impact of HPV analysis of anal lesions on diagnosis and prognosis.

Background and aimsMajority of cases of anal squamous cell carcinoma are human papilloma virus (HPV)-induced and result from anal intraepithelial neoplasia (AIN). This study was conducted to examine methods which may enable the routine diagnosis of HPV-induced changes in the anal rim and the consequences of such detection especially in view of a more sensitive diagnosis of AIN. Results were clinically correlated.MethodsThe study included biopsy samples from 87 patients who had been diagnosed with the following disease patterns: 47 invasive anal carcinoma, 33 AIN of varying severity and seven condylomatous lesions. In 52 of these cases, a tumour was clinically suspected. All biopsies were retrospectively examined for microscopic indications of HPV infection. After microdissection, additional HPV analysis via PCR was carried out.ResultsIn 38 of 47 cases of anal carcinoma, HPV DNA could be detected via PCR (80.9%), the majority of which were HPV 16 (33/38=86.8%). In 29 of the 33 cases of AIN, HPV DNA was detected (87.9%), most of these in AIN III (15/16=93.8%). Histological markers of HPV infection were detected in all 87 cases.DiscussionIn our series, the clinical diagnosis of the invasive anal carcinoma had a high sensitivity of 93.6%, with a specificity of 80%. The positive predictive value was 84.6%, and the negative predictive value 91.4%. In contrast, AIN had been detected clinically in none of the cases. In this situation, especially with high-risk patients, our findings recommend anal HPV screening in combination with anal cytology and anoscopy.ConclusionBased on our results, we urgently recommend for any histological report on excision of anal lesions to include a statement whether histological markers of HPV infection were detected. In individual cases, validation via HPV PCR must be considered.

Use of the Polyflex stent in the palliative therapy ofesophageal carcinoma

Background:Several prospective randomized trials have shown that self-expanding stents have advantages over conventional plastic tubes. Nevertheless, the optimal stent has not yet been developed. The Polyflex stent is a completely new model that represents an improvement over the old metal stents. We have used this stent in a prospective study and herein our present preliminary results. Methods:In 14 patients with nonresectable esophageal carcinoma, the Polyflex stent was implanted to reduce dysphagia. The grade of dysphagia, the complications following intervention, and the patients’ total survival time were documented prospectively every 4 weeks. Results:The implantation of the stent was successful in all cases. The grade of the dysphagia was reduced from 3.0 to 0.5 after stent implantation. One patient died during the hospital stay from a non–stent-induced complication. Stent dislocation occurred once, and tumor overgrowth at the stent margins was observed twice. The mean survival time was 6.2 months, and the reintervention rate was 21.3%. Conclusion:The new Polyflex stent, which is based on a completely new design, can be implanted without any difficulty and has had very good shortand long-term results. Therefore, it is a worthy alternative to the metal stents in current use.

Increased susceptibility to apoptosis in circulating lymphocytes of critically ill patients.

Abstract. Background and aims: Lymphocyte apoptosis may influence immune responsiveness in systemic inflammation. Therefore, we investigated whether early signs of apoptosis (i.e., annexin-V binding and cell shrinkage) in peripheral lymphocytes were different among patients with severe sepsis, critically ill, nonseptic patients after major surgery, and healthy individuals. Patients/methods: Ten patients with severe sepsis and ten critically ill, nonseptic patients after major surgery admitted to a surgical intensive care unit in a university hospital were included in the study. In addition, ten healthy blood donors were included for comparison. We investigated early signs of apoptosis using flow cytometric measurement of annexin-V binding to the cell surface and cell shrinkage of peripheral lymphocytes. Results: The percentage of apoptotic lymphocytes determined as annexin-V positive and propidium iodide negative cells was increased in freshly prepared cells of patients with severe sepsis (11.4±0.5%) and critically ill, nonseptic patients after major surgery (18.5±2.0%) relative to healthy blood donors (4.4±0.5%) (P<0.05). No significant difference between patients with severe sepsis and patients after major surgery were found. Annexin-V binding increased significantly after OKT-3 stimulation of lymphocytes in patients with severe sepsis (34.4±1.6%), patients after major surgery (33.8±3.4%), and healthy blood donors (21.1±2.8%). No significant difference among groups was detected following OKT-3 stimulation. Furthermore, freshly isolated peripheral lymphocytes of patients with severe sepsis and critically ill, nonseptic patients after major surgery revealed a significantly higher proportion of cell shrinkage than in healthy blood donors (55.0±2.2%, 21.5±2.4% vs 3.6±0.7%; P<0.05). Conclusion: Circulating lymphocytes of critically ill patients show a high degree of early signs of cellular apoptosis. This may contribute to hyporesponsiveness of immune cells in systemic inflammation.

Benign and Malignant Cells in Effusions : Diagnostic Value of Image DNA Cytometry in Comparison to Cytological Analysis

Identifying tumor cells in body cavity fluids reliably is a well-known diagnostic problem. Since cytometric quantitation of nuclear DNA content appears to be a promising new tool in the diagnosis and prognostic evaluation of many solid human tumors, we examined its validity in detecting malignant cells in cytologically positive effusions. For this purpose, image DNA cytometric measurements, including the evaluation of DNA-ploidy and the calculation of the DNA index (DI), were performed in 80 body cavity fluids. The results were correlated with cytology, clinical course and final histological diagnoses. We used aneuploidy, as shown by interactive image DNA cytometry, as a marker for the malignancy of cells that occur in body cavity fluids with a 100% specificity and 94.8% sensitivity. Cytological investigation showed a 92.3% specificity and 95.4% sensitivity. Combining both methods raised the specificity to 100% and the sensitivity to 98.5% and had a positive predictive value of 100% and a negative predictive value of 93.8%. The DNA-index (DI) was significantly higher in malignant effusions than in benign effusions: 1.5 +/- 0.74 (mean +/- SD) versus 1.11 +/- 0.26 (p < 0.05). Along with the difficult cytological evaluation of malignant cells in body cavity fluids, image DNA cytometry can be a helpful additional method for evaluating these cells. Combining the two techniques results in a highly specific and sensitive prediction of malignant cells. We, therefore, suggest using these methods for the reliable identification of tumor cells in effusions.

Mechanisms of improved wound healing in Murphy Roths Large (MRL) mice after skin transplantation.

Scars arise in the late phase of wound healing and are characterized by fibroplasia. Previous controversial studies have discussed the regenerative wound healing capacity of Murphy Roths Large (MRL) mice. The aim of this study was to investigate the mechanisms of improved wound healing in a skin transplantation model. Skin grafts from MRL and haplotypically identical B10.BR mice were cross‐transplanted. At day 10, B10.BR and MRL grafts on B10.BR recipients deposited collagen and showed severe apoptosis. Grafts of MRL recipients were not affected by such alterations and showed an enhanced healing progress. They were characterized by higher partial pressure of tissue oxygen, increased microcirculation, exceptionally intense neovascularization, and a blunted inflammatory response. This phenotype was accompanied by increased vascular endothelial growth factor expression, augmented by enhanced signal transducer and activator of transcription 3 (STAT3) phosphorylation. These effects were combined with a decreased STAT1 expression and phosphorylation. STAT1 pattern variation was associated with decreased Smad7 levels. Furthermore, MRL recipients showed improved stem cell recruitment to the wound area. The basic accelerated wound healing mechanism in MRL mice found in this skin transplantation model is improved engraftment; this is based on enhanced neovascularization and reduced inflammation. These effects are most likely due to higher vascular endothelial growth factor levels and changes in the STAT/Smad signal pathway, which may enhance transforming growth factor‐β signaling, reducing proinflammatory responses.

L-carnitine ameliorates abnormal vulnerability of steatotic rat livers to cold ischemic preservation.

Background. Up to 30% of all livers retrieved for organ transplantation exhibit steatotic transformations. Chronic organ-donor shortage has led to the acceptance of these organs for transplantation, although a higher risk of graft nonfunction is associated with the preservation of steatotic livers. Methods. A dietary steatosis was induced in Wistar rats by fasting them for 2 days and feeding them with a fat-free diet. Fatty livers (n=14) were retrieved and flushed with 60 mL of histidine, tryptophane, alpha-ketoglutarate (HTK) solution. In half of the experiments, L-carnitine (5 mM) was added to the HTK. Functional integrity of the livers was evaluated by isolated reperfusion with KHB in a recirculating system at 37°C for 45 minutes. Results. Addition of L-carnitine to the HTK promoted a significant reduction of the enzyme leakage from the livers upon reperfusion. Release of alanine-aminotransferase was reduced to one third (127±22 vs. 423±61 U/L), and the loss of glutamate dehydrogenase in the perfusate could be reduced significantly (42±7 vs. 542±134 U/L) when compared with livers stored without additional medication. Morphologic corroboration of these data was obtained by electron microscopy. Although normal appearance of liver mitochondria was preserved at the end of the cold ischemic storage, reperfusion of cold-stored fatty livers entailed massive alterations and frequent destruction of hepatic mitochondria. However, these morphologic impairments were remarkably mitigated in the carnitine-treated group. Conclusions. L-carnitine represents a feasible metabolic adjunct for a safe and more successful preservation of ischemia–reperfusion-sensitive steatotic livers.

Reduced Liver Apoptosis After Venous Systemic Oxygen Persufflation in Non-Heart-Beating Donors

Graft injury caused by warm ischemia in livers from non-heart-beating donors (NHBDs) strongly affects posttransplantation outcome and is associated with liver apoptosis, which is mediated by death receptors, such as Fas, a surface receptor of the tumor necrosis factor (TNF)-α family. The aim of this study was to test the ability of venous systemic oxygen persufflation (VSOP) to reduce apoptotic changes and Fas activation in the liver after warm ischemic insult in vivo. Livers of male Wistar rats were harvested 30 min after cardiac arrest from non-heart-beating donors (NHBD) with (NHBD + O2) or without (NHBD) application of gaseous oxygen during the cold storage period via the suprahepatic caval vein. After 24 h of storage in University of Wisconsin solution at 4°C, viability of the livers was assessed upon isolated reperfusion in vitro. Conventional signs of tissue damage like enzyme release and bile production showed a significantly elevated nonspecific cell injury in the NHBD group. TUNEL staining revealed increased DNA fragmentation of sinusoidal endothelial cells in the NHBD group and more apoptotic hepatocytes than in the control group. All these alterations could be almost abrogated by the use of VSOP in the NHBD + O2 group. The immunohistochemical staining of Fas antigen expression showed a significantly elevated Fas receptor expression in the NHBD and NHBD + O2 groups, in accord with an eightfold increase of Fas receptor mRNA detected by real-time reverse-transcription polymerase chain reaction (RT-PCR). These results demonstrate that the postischemic apoptotic rate of sinusoidal endothelial cells in NHBD livers can be reduced by the use of VSOP. A significant improvement in liver integrity and viability was obtained with this technique, without influencing the expression of Fas expression.

Pancreatogastrostomy after Pancreatoduodenectomy: A Safe, Feasible Reconstruction Method?

Pancreatogastrostomy is a safe reconstructive technique after pancreatoduodenectomy, even when performed as an educational operation in the hands of relatively inexperienced surgeons in a high-volume hospital. Sixteen surgeons with various case volumes operated on 190 consecutive patients and performed pancreatogastrostomy after pancreatoduodenectomy within the last 15 years in a university teaching hospital. Resections were performed for tumors localized in the head of the pancreas, the ampulla of Vater, or the distal common bile duct or duodenum (n = 169); for chronic pancreatitis (n = 16); and for miscellaneous reasons in five cases. The main outcome measures were postoperative mortality and morbidity, particularly the pancreatic leakage rate with special regard to the case volume of the performing surgeon. The overall mortality rate was 4.2% (n = 8), the 30-day mortality rate was 3.2% (n = 6), and mortality directly related to surgery was 2.6% (n = 5). Morbidity occurred in 45%, including severe surgical complications, which required reoperation (9%), and minor surgical complications that could be managed conservatively (30%). There were no significant differences in overall surgical morbidity rates when the groups with varying patient volume per surgeon were compared. The incidence of pancreatic leakage was 7.4%, which did not contribute to mortality in any case and showed no statistical differences between the surgical volume groups. We concluded that pancreatogastrostomy is safe and feasible even in the hands of inexperienced but supervised surgeons. The leakage rate is similar to the data from other high-volume centers. Once a leak is established, it can easily be managed conservatively, so it rarely contributes to severe complications or causes subsequent mortality. We recommend pancreatogastrostomy as a beneficial alternative to pancreatojejunostomy, even in the case of low surgical volume.

Endoscopic vs conventional hernia repair from an immunologic point of view.

AbstractBackground: In this study we tried to estimate the local surgical trauma in patients undergoing endoscopic or conventional hernia repair via the changes in peripheral blood T cell subpopulations (i.e., T-helper 1 (TH1) and TH2 cells), recently shown to be recruited differentially to inflammatory sites. Methods: Cells were identified flow-cytometrically by intracellular cytokine staining on a single cell level in 30 patients undergoing conventional (Shouldice) or total extraperitoneal patch (TEPP) hernia repair. Results: The TH1 cells decreased postoperatively in Shouldice patients on an average of 20.8–31.4%, whereas in TEPP patients only a minor decline (mean, 7.8–9.2%) was observed. The TH2 cells did not change significantly in TEPP patients, and a small increase (mean, 7.7%) was detected in Shouldice patients. Conclusions: Our results suggest that the postoperative reduction in TH1 cells reflects local surgical trauma and can be helpful in evaluating different surgical procedures. When conventional and endoscopic hernia repair were compared, the latter proved less traumatizing.