Gastrointestinal
Abdominal Surgical Interventions: Local and Systemic Consequences for the Immune System—a Prospective Study on Elective Gastrointestinal Surgery11

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Background

Little is known about the local accumulation and function of immune cells in peritoneal fluid after elective surgery of the upper and lower gastrointestinal tract. Our study was designed to investigate whether systemic immune cell response mirrors the local response. We focused on the cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-α and on monocytes, natural killer (NK) cells, and T cells that play an important role in eliciting the innate and adaptive immune response.

Methods

Blood samples were taken prospectively from 25 patients 24 h before surgery, as well as 24 h and 48 h afterward. Abdominal drainage fluids were collected intraoperatively 1 h after the abdomen was opened and 24 h and 48 h postoperatively. Apart from the white blood cells, intracellular T-helper-cell (TH1/TH2) cytokine production (interferon-γ, IL-2, IL-4, IL-13) and HLA-DR on monocytes were measured by four-color flow cytometry, IL-6, and TNF-α with the fast immunoluminescence method.

Results

Cells of the innate immune system (NK cells, monocytes, NK-T cells, CD5+ B cells) rapidly decreased in abdominal fluids (P < 0.05: +24 h; +48 h) after surgery, which was paralleled by a concomitant decline in peripheral blood. The percentage of abdominal interferon-γ, IL-2, IL-4, and IL-13-producing TH cells increased in a way that distinctly counteracted the decrease of the natural immune cells. HLA-DR expression on monocytes in peripheral blood declined significantly (P < 0.05: +24 h; +48 h). In contrast, monocytes in abdominal fluids had high HLA-DR expression. Furthermore, abdominal fluids contained significantly higher concentrations of TNF-α (P < 0.05: +24 h; +48 h) and IL-6 (P < 0.05: +24 h) compared with peripheral blood.

Conclusions

Specific immune cell recruitment and cytokine production play an important role in post-trauma events. Measuring distinct local immune cell repertoires and cytokines provides answers as to how the different phases of postoperative immune events proceed. The evaluation of the local response may provide additional criteria for the evaluation of operative trauma. This knowledge may be helpful in detecting postoperative pathological aberrancies.

Introduction

The activation of different immune cells and the cytokine network is an important part of the integral immune response to infection and trauma. Elective surgical trauma induces a systemic–inflammatory response that includes innate and adaptive immunity. Antigenic products arising from tissue destruction activate cellular elements of the innate immune system, such as macrophages, neutrophils, natural killer (NK) cells, and endothelial cells. These activated cells in turn synthesize different mediators, including cytokines like tumor necrosis factor (TNF)-α and interleukin (IL)-6 [1]. The adaptive immune response is demonstrated by two subsets of committed T-helper cells that are able to secrete different patterns of cytokines: the proinflammatory type-1 helper cells produce the cytokines IL-2 and interferon (IFN)-γ (TH1; IL-2- and IFN-γ-producing cells) and the anti-inflammatory type-2 helper cells produce the cytokines IL-4 and IL-13 (TH2; IL-4- and IL-13-producing cells). In former studies, some authors have shown that elective operative trauma induces a shift in the TH1/TH2 balance toward TH2 that is commensurate with the extent of trauma [2, 3, 4].

In contrast to the systemic activation of different cells and cytokines in the blood compartment, the role of the local, peritoneal response to surgery is poorly understood. The postoperative systemic cellular and cytokine response may originate from the peritoneal cavity and, thus, be an indirect reflection of the local response. However, to date only a small number of studies have dealt with the local immune response of patients undergoing elective gastrointestinal surgery [5, 6, 7, 8].

To investigate whether the systemic immune cell response mirrors the local response and whether measuring distinct local immune cell repertoires may be helpful in detecting postoperative infectious complications, we examined different local and systemic mediators and cells of the innate and adaptive immunity in patients undergoing elective gastrointestinal surgery.

Section snippets

Patients

A total of 25 patients requiring elective surgery of the gastrointestinal tract were investigated in a prospective study. For demographic data and type of surgery, see Table 1. Ethical approval was provided by the Bonn University Ethics Committee, and patients’ care conformed with the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from the patients.

Of the 25 patients requiring elective surgery, 11 patients had stomach-related surgery. Of these, four

Results

During the study period, none of the patients in the study showed any complications resulting from the surgical procedure, wound infections, or postoperative complications.

Discussion

Early postoperative inflammation is an important response from the organism to body insult (i.e., inflammation, infection and trauma) [19]. Until now, many investigations evaluated surgical trauma by the systemically detectable immune response and the systemic metabolic response. Our current view of the value of measurements of different immune response parameters in the drainage fluid from the abdominal cavity after abdominal trauma is more fragmentary.

The present study confirms and extends

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    This study was supported by a grant from the German Research Foundation (Deutsche Forschungsgemeinschaft DE 516/3-2).

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