Immunomodulation in surgical practice

Calligraphy of Nanoplasmonic Bioink-Based Multiplex Immunosensor for Precision Immune Monitoring and Modulation

Immunomodulation therapies have attracted immense interest recently for the treatment of immune-related diseases, such as cancer and viral infections. This new wave of enthusiasm for immunomodulators, predominantly revolving around cytokines, has spurred emerging needs and opportunities for novel immune monitoring and diagnostic tools. Considering the highly dynamic immune status and limited window for therapeutic intervention, precise real-time detection of cytokines is critical to effectively monitor and manage the immune system and optimize the therapeutic outcome. The clinical success of such a rapid, sensitive, multiplex immunoanalytical platform further requires the system to have ease of integration and fabrication for sample sparing and large-scale production toward massive parallel analysis. In this article, we developed a nanoplasmonic bioink-based, label-free, multiplex immunosensor that can be readily "written" onto a glass substrate via one-step calligraphy patterning. This facile nanolithography technique allows programmable patterning of a minimum of 3 μL of nanoplasmonic bioink in 1 min and thus enables fabrication of a nanoplasmonic microarray immunosensor with 2 h simple incubation. The developed immunosensor was successfully applied for real-time, parallel detection of multiple cytokines (e.g., interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and transforming growth factor-beta (TGF-β)) in immunomodulated macrophage samples. This integrated platform synergistically incorporates the concepts of nanosynthesis, nanofabrication, and nanobiosensing, showing great potential in the scalable production of label-free multiplex immunosensing devices with superior analytical performance for clinical applications in immunodiagnostics and immunotherapy.

A Systematic Review and Meta-Analysis Examining the Impact of Age on Perioperative Inflammatory Biomarkers

BACKGROUND

Dysregulation of immune responses to surgical stress in older patients and those with frailty may manifest as differences in inflammatory biomarkers. We conducted a systematic review and meta-analysis to examine differences in perioperative inflammatory biomarkers between older and younger patients, and between patients with and without frailty.

METHODS

MEDLINE, Embase, Cochrane, and CINAHL databases were searched (Inception to June 23, 2020). Observational or experimental studies reporting the perioperative level or activity of biomarkers in surgical patients stratified by age or frailty status were included. The primary outcome was inflammatory biomarkers (grouped by window of ascertainment: pre-op; post-op: <12 hours, 12-24 hours, 1-3 days, 3 days to 1 week, and >1 week). Quality assessment was conducted using the Newcastle-Ottawa Scale. Inverse-variance, random-effects meta-analysis was conducted.

RESULTS

Forty-five studies (4263 patients) were included in the review, of which 36 were pooled for meta-analysis (28 noncardiac and 8 cardiac studies). Two studies investigated frailty as the exposure, while the remaining investigated age. In noncardiac studies, older patients had higher preoperative levels of interleukin (IL)-6 and C-reactive protein (CRP), lower preoperative levels of lymphocytes, and higher postoperative levels of IL-6 (<12 hours) and CRP (12-24 hours) than younger patients. In cardiac studies, older patients had higher preoperative levels of IL-6 and CRP and higher postoperative levels of IL-6 (<12 hours and >1 week).

CONCLUSIONS

Our findings demonstrate a paucity of frailty-specific studies; however, the presence of age-associated differences in the perioperative inflammatory response is consistent with age-associated states of chronic systemic inflammation and immunosenescence. Additional studies assessing frailty-specific changes in the systemic biologic response to surgery may inform the development of targeted interventions.

Postoperative Rise of Circulating Mitochondrial DNA Is Associated with Inflammatory Response in Patients following Pancreaticoduodenectomy

INTRODUCTION

Accumulation of plasma mitochondrial DNA (mtDNA) following severe trauma has been shown to correlate with the development of systemic inflammatory response syndrome (SIRS) and may predict mortality. Our objective was to investigate the relationship between levels of circulatory mtDNA following pancreaticoduodenectomy (PD) and the postoperative course.

METHODS

Levels of plasma mtDNA were assessed by real-time PCR of the mitochondrial genes ND1 and COX3 in 23 consecutive patients who underwent PD 1 day prior to surgery, within 8 h after surgery, and on postoperative day (POD)1 and POD5. The abundance of mtDNA was assessed relative to preoperative levels and in relation to parameters reflecting the postoperative clinical course.

RESULTS

When pooled for all patients, the circulating mtDNA levels were significantly increased after surgery. However, while a significant (at least >2-fold and up to >20-fold) rise was noted in 11 patients, no change in mtDNA levels was noted in the other 12 following surgery. Postoperative rise in circulating mtDNA was associated with an increased rate of postoperative fever until day 5, decreased hemoglobin and albumin levels, and increased white blood cell counts. These patients also suffered from increased rates of delayed gastric emptying. No significant differences were demonstrated in other postoperative parameters.

CONCLUSION

Circulating mtDNA surge is associated with an inflammatory response following PD and may potentially be used as an early marker for postoperative course. Studies of larger patient cohorts are warranted.

The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgical procedures in abdominal surgery. Malnutrition and immune dysfunction in patients with pancreatic cancer (PC) may lead to a higher risk of postoperative infectious complications. Although immunonutrition (IN) is recommended for enhanced recovery after surgery (ERAS) in patients undergoing PD for 5-7 days perioperatively, its role in patients undergoing pancreatectomy is still unclear and controversial. It is known that the proper surgical technique is very important in order to reduce a risk of postoperative complications, such as a pancreatic fistula, and to improve disease-free survival in patients following PD. However, it has been proven that IN decreases the risk of infectious complications, and shortens hospital stays in patients undergoing PD. This is a result of the impact on altered inflammatory responses in patients with cancer. Both enteral and parenteral, as well as preoperative and postoperative IN, using various nutrients, such as glutamine, arginine, omega-3 fatty acids and nucleotides, is administered. The most frequently used preoperative oral supplementation is recommended. The aim of this paper is to present the indications and benefits of IN in patients undergoing PD.

Effect of Mycobacterium cell wall fraction on endometrial histomorphometry of mares resistant and susceptible to persistent breeding-induced endometritis

Mycobacterium cell wall fraction (MCWF) is a biological component made up of molecules with immunostimulant properties, which is therapeutically used to modulate persistent breeding-induced endometritis (PBIE). The aim of this study was to analyze the effect of this immunomodulator on the endometrial histological structure during the diestrus of PBIE-resistant and -susceptible mares that either received treatment with MCWF or not. The experiment was conducted with 10 resistant mares (RM) and 9 susceptible mares (SM). In the first estrous cycle of the trial, all mares were inseminated with dead semen as an inflammatory stimulus (Group A); at the next cycle, all mares were inseminated with dead semen and treated with a MCWF commercial immunomodulator (Group B). In both groups, endometrial biopsies were taken on day 7 post-ovulation (diestrus). Endometrial biopsies of untreated-RM (UTRM, n = 6), untreated-SM (UTSM, n = 7) MCWF-treated-RM (TRM, n = 6) and MCWF-treated-SM (TSM, n = 6) were evaluated. They were randomly chosen as representative mares of Group A and B, respectively. The height of lining and glandular epithelia, glandular diameter, glandular density and glandular area were evaluated. The histological structure revealed lymphocytic infiltration and dilated, tortuous glands with some glandular nests, particularly in UTSM. The histomorphometrical results showed no differences (ρ > 0.05) between the analyzed groups. This would indicate that post-service treatment with the MCWF immunomodulator does not modify the endometrial histoarchitecture but, apparently, its action would be mainly based on the stimulation of the cellular and humoral immune responses.

Combined Effectiveness of Honey and Immunonutrition on Bacterial Translocation Secondary to Obstructive Jaundice in Rats: Experimental Study

BACKGROUND Obstructive jaundice is a serious, life-threatening condition that can lead to death as a result of sepsis and multiorgan failure due to bacterial translocation. Treatment should be started as soon as possible after diagnosis. MATERIAL AND METHODS Forty 24-week-old male Sprague Dawley rats, with an average weight of 250 g to 300 g, were included in this study. The rats were randomly placed into five groups, each group consisted of eight rats. The sham group underwent only common bile duct (CBD) dissection and no ligation was performed. CBD ligation was applied to the other groups. After the operation, one CBD group was fed with rat chow only, the others were fed with rat chow supplemented with honey, or immunonutrients, or honey plus immunonutrients. After 10 to 12 days, all rats were sacrificed; blood and tissue samples were collected for biochemical, microbiological, and histopathological evaluation. RESULTS In the groups that were fed with honey and immunonutrients, alanine aminotransferase (ALT) levels were decreased significantly compared to the other groups. Statistically significant differences were detected in terms of bacterial translocation (BT) rates among liver and spleen samples, and laboratory values of serum, except for MLNs of the BDL+HI group, when compared to other groups. We found mean mucosal thickness of ileum samples have been improved notably in the BDL+HI group compared to the other groups, especially compared to the C/BDL group. CONCLUSIONS Immunonutrition applied with honey had immunostimulant effects, decreased BT due to an additive effect, and had positive effects on intestinal mucosa.

Prospective Randomized Trial on Postoperative Administration of Diet Containing Eicosapentaenoic Acid, Docosahexaenoic Acid, Gamma-linolenic Acid, and Antioxidants in Head and Neck Cancer Surgery Patients with Free-flap Reconstruction

OBJECTIVES

The purpose of this prospective, randomized study was to evaluate the effects of a diet containing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), gamma-linolenic acid (GLA), and antioxidants in head and neck cancer surgery patients with free-flap reconstruction.

METHODS

In this randomized, prospective study, 62 patients with head and neck cancers were assigned to receive a general control diet (Ensure^® H; Abbott Japan, Tokyo, Japan) or the study diet (Oxepa^®; Abbott Japan) containing EPA, DHA, GLA, and antioxidants (eg vitamins A, E, and C). The primary assessment item was the degree of postoperative inflammation, as assessed by measuring maximum body temperature and levels of C-reactive protein (CRP) and procalcitonin from the day of surgery to postoperative day 8. Secondary assessment items were lengths of stays in the intensive care unit (ICU) and hospital.

RESULTS

The control diet group (n = 32) and study diet group (n = 30) showed no significant difference in energy administered through diet. No significant differences in the parameters of the primary assessment item were noted. Length of stay in the ICU was significantly shorter for the control diet group than for the study diet group (P = 0.011). No significant difference in duration of hospitalization was seen between groups.

CONCLUSION

No usefulness of a diet containing EPA, DHA, GLA, and antioxidants was demonstrated.

Combined effects of tauroursodeoxycholic Acid and glutamine on bacterial translocation in obstructive jaundiced rats:

BACKGROUND

Bacterial Translocation is believed to be an important factor on mortality and morbidity in Obstructive Jaundiced.

AIMS

We investigated the probable or estimated positive effects of tauroursodeoxycholic acid, which has antibacterial and regulatory effects on intestinal flora, together with glutamine on BT in an experimental obstructive jaundiced rat model.

STUDY DESIGN

Animal experimentation.

METHODS

Forty adult, male, Sprague Dawley rats were used in this study. Animals were randomised and divided into five groups of eight each: sham (Sh); control (common bile duct ligation, CBDL); and supplementation groups administered tauroursodeoxycholic acid (CBDL+T), glutamine (CBDL+G), or tauroursodeoxycholic acid plus glutamine (CBDL+TG). Blood and liver, spleen, MLN, and ileal samples were taken via laparotomy under sterile conditions for investigation of bacterial translocation and intestinal mucosal integrity and hepatic function tests on the tenth postoperative day.

RESULTS

There were statistically significant differences in BT rates in all samples except the spleen of the CBDL+TG group compared with the CBDL group (p=0.041, p=0.026, and p=0.041, respectively).

CONCLUSION

It is essential to protect hepatic functions besides maintaining intestinal mucosal integrity in the active struggle against BT occurring in obstructive jaundice. The positive effect on intestinal mucosal integrity can be increased if glutamine is used with tauroursodeoxycholic acid, which also has hepatoprotective and immunomodulatory features.

Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery

Background

Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery.

Methods

Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation.

Results

Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204).

Conclusion

Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Effect of major abdominal surgery on the host immune response to infection

PURPOSE OF REVIEW

The present review summarizes key studies on the effects of major abdominal surgery on the host response to infection published during the last 18 months.

RECENT FINDINGS

Surgical trauma causes stereotyped systemic proinflammatory and compensatory anti-inflammatory reactions. It is leukocyte reprogramming rather than general immune suppression. The list of recent findings is long. Preoperative infectious challenge was found to increase survival. Obesity is associated with increased production of interleukin-17A in peritonitis. Abdominal surgery alters expression of toll-like receptors (TLRs). The acute phase reaction down-regulates the transcription factor carbohydrate response element binding protein. Myosin light chain kinase activation is a final pathway of acute tight junction regulation of gut barrier and zonula occludens 1 protein is an essential effector. The brain is involved in regulating the immune and gut system. Elimination of lipopolysaccharide is challenging. Th1/Th2 ratio is lowered in patients with postoperative complications. Cholinergic anti-inflammatory pathways can inhibit tissue damage. The new substance PXL01 prevents adhesions. Postoperative infection causes incisional hernias. Hypothermia reduced human leukocyte antigen DR surface expression and delayed tumor necrosis factor clearance. Systems biology identified interferon regulatory factor 3 as the negative regulator of TLR signaling. Protective immunity could contribute defeating surgical infections.

SUMMARY

Systemic inflammation is the usual response to trauma. All organs seem to be involved and linked up in cybernetic systems aiming at reconstitution of homeostasis. Although knowledge is still fragmentary, it is already difficult to integrate known facts and new technologies are required for information processing. Defining criteria to develop therapeutic strategies requires much more insight into molecular mechanisms and cybernetics of organ systems.

Increased nitric oxide formation followed by increased arginase activity induces relative lack of arginine at the wound site and alters whole nutritional status in rats almost within the early healing period

Nitric oxide (NO) production and free amino acid fluxes at the wound side during the first 3 days following cutaneous wound were investigated. Experiments were performed on Albino Oxford rats (n=18) underwent cutaneous implantation of polyvinyl sponges. Intact animals (n=6) were controls. Nitrites, nitrates, free amino acids and urea were measured both in plasma and wound fluids. Inducible nitric oxide synthase (iNOS) gene expressions at wound site were analyzed, too. The highest levels of both iNOS gene expression and its activity (increased wound fluid citrulline and nitrites) were at the first day. Wound fluid nitrates were significantly above plasma levels throughout the whole period, while molar nitrate to nitrite ratio steadily increased. It was associated with gradual increase of both ornithine and urea as well as steadily decreases of arginine and increases of phenylalanine at the wound site. Gradual decrease in glycine to branched-chain molar ratio was observed both in plasma and wound fluids. In conclusion, an early locally induced alterations in Arg metabolism, due to increased NO formation followed by increased arginase activity, produces relative lack of Arg at the wound site and disturbs nutritional status of the whole body almost within early healing period following cutaneous wound in rats. It is likely that NO autoxidation at the wound side is influenced by substrate availability.