Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections - Results of a prospective randomized trial
ABSTRACT Surgical trauma and anesthesia are known to cause transient postoperative suppression of the immune system. In randomized controlled trials, it has been shown that laparoscopic colorectal resections have short-term benefits not observed with conventional colorectal resections. We hypothesized that these benefits were due to the reduction in surgical trauma, leading to a diminished cytokine response and less depression of cell-mediated immunity after laparoscopy.
In a prospective randomized trial, colorectal cancer patients without evidence of metastatic disease underwent either laparoscopic (n = 20) or conventional (n = 20) tumor resection. Postoperative immune function was assessed by measuring the white blood cell (WBC) count, the CD4+ and CD8+ lymphocytes, the CD4+/CD8+/ratio, and the HLA-DR expression of CD14+ monocytes. In addition, the production of interleukin-6 (IL = 6) and TNF-a were measured after ex vivo stimulation of mononuclear blood cells with lipopolysaccharide (LPS) and compared to the plasma levels of these cytokines. Postoperative mean levels of the immunologic parameters for the two groups were calculated and compared using the Mann-Whitney U test.
Preoperatively, there were no differences between the two groups in terms of patient characteristics or immunologic parameters. Although the postoperative peak concentrations of white blood cells were significant lower in the laparoscopic group than the conventional group (p < 0.05), there were no differences between the two groups in the subpopulation of lymphocytes (CD4+, CD8+). HLA-DR expression of CD14+ monocytes was lower in the conventional group on the 4th postoperative day (p < 0.05). The laparoscopic group showed higher values in cytokine production of mononuclear blood cells after LPS stimulation. Postoperative plasma peak concentrations of IL-6 and TNF-a were lower after laparoscopic resection.
Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Cellular cytokine production was preserved only in the laparoscopic group, while cytokine plasma levels were significantly higher in the conventional group. These findings may have important implications for the use of laparoscopic colorectal resection, especially in patients with malignant disease.
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- "The total lymphocyte counts, CD4+ T cell counts, CD8+ T cell counts and the CD4/8 T cell ratio decreased equally after surgery in both the LC and OC groups (17). According to a randomized control trial by Ordemann et al., the mHLA-DR expression examined 1 h before surgery and 6 h, 12 h and 24 h postoperatively, was found to be preserved in LC, in contrast to OC . Finally, Veenhof et al., in a prospective, randomized trial evaluating the immune response in patients after open (18 patients) and laparoscopic (22 patients) surgery for rectal cancer, showed that the LC group presented higher expression of HLA-DR two hours after surgery, compared with the OC group (P = 0.015) . "
ABSTRACT: Colorectal cancer (CRC) is the third leading cause of cancer mortality worldwide and laparoscopic colectomy has been established as equivalent to the open approach in terms of oncological results and patients' safety. Survival benefits have been reported in favor of laparoscopic colectomy (LC) in stage III CRC patients. Different immune responses after surgery, in terms of innate and cellular immunity, may potentially explain some of the reported differences. This review summarizes the literature on differences in immune response after the laparoscopic and the open approach for CRC. A literature search of electronic databases was conducted and all studies published on 'colorectal cancer', 'laparoscopic and open colectomy' 'immune response' and 'surgical stress laparoscopy versus open' were collected. Among these, the ones referring to CRC and those that had any clinical relevance offering information on perioperative parameters were used. Despite the heterogeneity of studies, they support the view that innate immune response is activated to a greater degree in open colectomy (OC), which may be related to the more extensive trauma and surgical stress. On the other hand, cellular immunity is better preserved after LC. These differences are more pronounced in the immediate postoperative period. LC has been related to decreased up-regulation of innate immunity and better-preserved cellular immunity. The latter may be related to better anti-tumor activity and may be beneficial in terms of oncological survival in a subgroup of LC patients.09/2013; 1(2):85-94. DOI:10.1093/gastro/got014
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- "The measurement of inflammatory mediators during surgical procedures is thought to provide insight into the physiological impact of surgery on the patient; however, little data, outside of oncological data, have been able to show a correlation with clinical outcomes. For cancer patients, the hypothesized benefit of minimally invasive surgery is the reduction in the degree of immunosuppression compared with that of standard open techniques [6, 7]. Differences in immunosuppression translated into differences in cytokine levels have been correlated with prolonged survival for advanced-stage colorectal cancer . "
ABSTRACT: Risk of gastric spillage during transgastric surgery is a potential complication of NOTES procedures. The aim of this study was to determine risk outcomes from gastric spillage in a rat survival model by measuring local and systemic inflammatory markers, adhesive disease, and morbidity. We performed a minilaparotomy with needle aspiration of 2 ml of gastric contents mixed with 2 ml of sterile saline (study group, SG) or 4 ml of sterile saline (control group, CG) injected into the peritoneal cavity of 60 male rats. Inflammatory markers (TNFalpha, IL-6, and IL-10) were analyzed at 1, 3, 6, and 24 h postoperatively by obtaining plasma levels and peritoneal washings. At necropsy, the peritoneal cavity was examined grossly for adhesions. Adhesions were seen more frequently in the SG versus the CG (100% vs. 33.3%, p < 0.014). There was a significant difference in the peritoneal TNFalpha levels in the SG compared with the CG, which peaked 1 h after surgery (p < 0.02). Both peritoneal IL-6 and IL-10 levels were higher in the SG versus the CG, which peaked 3 h after surgery (p < 0.005 and p < 0.001, respectively). All peritoneal inflammatory markers returned to undetectable levels at 24 h for both groups. Plasma cytokines were undetectable at all time intervals. The inflammatory response was found to be a localized and not systemic event, with plasma cytokine levels remaining normal while peritoneal washings revealed a brisk, short-lived localized inflammatory response. There was a significantly higher rate of adhesive disease in the SG compared with the CG; this, however did not translate into a difference in apparent clinical outcome. We conclude that gastric leakage in this NOTES rodent model induces a localized inflammatory response, followed by mild to moderate adhesive disease. This may be important in human NOTES.Surgical Endoscopy 08/2009; 24(3):531-5. DOI:10.1007/s00464-009-0636-7 · 3.26 Impact Factor
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ABSTRACT: LAPAROSCOPIC APPROACH IN COLO-RECTAL SURGERY FOR CANCER: IS IT LAWFULL ? (Abstract): A lot of surgeons were performing laparoscopic approach for colo-rectal surgery from at least 10 years. Even some reported results were "excellent", there are discussions about this subject. I performed a review of the literature; I found 11 randomised studies wich compared laparoscopic vs. open colectomies. Fesability of laparoscopic technique was established by a randomised multi-center study: operation time was increased with about one hour (vs. open surgery) and conversion rate was 15 -16%. The technique is difficult and conversion rate decreased with experience of the surgeon. Postoperative course was better in laparoscopic surgery (from point of view of postoperative pain, postoperative ileus, respiratory complications, hospital stay and quality of life). Laparoscopic colo-rectal surgery is more expensive that open technique. In all this papers, I didn't find significant "oncologic" difference between laparoscopic and open colo-rectal resections. Conclusions: laparoscopic colectomies are safe for experienced surgeons; laparoscopic technique is indicated in selection cases. La chirurgie colo-rectale laparoscopique est régulièrement pratiquée par de multiples équipes depuis de plus 10 ans. De nombreux "centres experts" ont rapporté d'excellent résultat. Pourtant la question de sa légitimité reste d'actualité. Dans les recommandations 2000 en chirurgie colo rectale , les experts réunis par le NIH prônaient de continuer à respecter la règle édictée en 1994 par la Société Américaine des chirurgiens colo-rectaux: la colectomie par laparoscopie pour cancer colo-rectal ne devrait pas être pratiquée en dehors d'études contrôlées . Cette attitude reste également recommandée en France . Ces recommandations sont fondées sur l'absence de données factuelles ("evidence based") suffisantes concernant le "bénéfice" et surtout l'absence de risque carcinologique de l'intervention. Le but de ce travail est de recenser les données factuelles disponibles (essais randomisés, méta-analyses, études prospectives) et d'en analyser la pertinence. METHODE Une recherche bibliographique électronique, conduite en juillet 2004, a permis de retrouver 11 essais randomisés, parfois publiés plusieurs fois, qui comparent colectomie laparoscopique et colectomie par laparotomie pour cancers colo-rectaux [4-21]. Deux autres essais incluant diverses affections dont une majorité de cancers ont été publiés [22,24]. Ces essais sont énumérés dans le tableau 1. Il s'agit souvent de petits essais, de qualité méthodologique rarement excellente , ou de résultats préliminaires des grands essais en cours. Seuls, trois essais peuvent faire état d'un recul supérieur à deux ans [18-20]. Les principales études prospectives non randomisées récentes [28-34] ont été analysées ainsi que les méta-analyses et les revues systématiques [33-36].