Inflammatory response during abdominal and thyroid surgery: a prospective clinical trial on mediator release

A prospective randomized multicenter phase I/II clinical trial to evaluate safety and efficacy of NOVOCART disk plus autologous disk chondrocyte transplantation in the treatment of nucleotomized and degenerative lumbar disks to avoid secondary disease: safety results of Phase I-a short report

NOVOCART^® Disk plus, an autologous cell compound for autologous disk chondrocyte transplantation, was developed to reduce the degenerative sequel after lumbar disk surgery or to prophylactically avoid degeneration in adjacent disks, if present. The NDisc trial is an ongoing multi-center, randomized study with a sequential phase I study within the combined phase I/II trial with close monitoring of tolerability and safety. Twenty-four adult patients were randomized and treated with the investigational medicinal product NDisc plus or the carrier material only. Rates of adverse events in Phase I of this trial were comparable with those expected in the early time course after elective disk surgery. There was one reherniation 7 months after transplantation, which corresponds to an expected reherniation rate. Immunological markers like CRP and IL-6 were not significantly elevated and there were no imaging abnormalities. No indications of harmful material extrusion or immunological consequences due to the investigational medicinal product NDplus were observed. Therefore, the study appears to be safe and feasible. Safety analyses of Phase I of this trial indicate a relatively low risk considering the benefits that patients with debilitating degenerative disk disease may gain.

Postcolectomy Peritoneal Environment Increases Colon Cancer Cell Migration Capacity

Background. Clinical data and animal models support an association between postoperative inflammatory response and the risk of colorectal cancer recurrence. Our aim was to evaluate postoperative peritoneal inflammation and its impact on cultured colon cancer cells' migration capacity. Methods. 23 patients undergoing elective colorectal resection with uneventful recovery were prospectively enrolled. Patients were operated on for both malignant and benign etiologies. Peritoneal fluids collected at surgery initiation and after surgery were evaluated for their effect on migration potential of human colon cancer cells using an in vitro scratch assay and on TNF-α, IL-1β, IL-6, and IL-10 levels using bead-based fluorokine-linked multianalyte profiling. Results. Postoperative peritoneal fluid from all patients increased the migration capacity of colon cancer cells compared to preoperative levels. This effect was significant during the first two postoperative days and decreased thereafter. The increase in colon cancer cell migration capacity correlated with increased levels of peritoneal TNF-α and IL-10. Conclusion. In this pilot study, we have demonstrated that the intraperitoneal environment following colorectal resection significantly enhances colon cancer cells migration capacity. This effect is associated with postoperative intra-abdominal cytokines level. A larger scale study in colorectal cancer patients is needed in order to correlate these findings with perioperative parameters and clinical outcome.

Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review

Introduction

Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction.

Methods

We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury.

Results

Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental.

Conclusions

Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1093-4) contains supplementary material, which is available to authorized users.

The tryptophan kynurenine pathway, neopterin and IL-6 during vulvectomy and abdominal hysterectomy

Background

Surgery has wide ranging immunomodulatory properties of which the mechanism is poorly understood. In order to investigate how different types of surgery influence inflammation, we designed a longitudinal observational study investigating two inflammatory profiles of two separate patient groups undergoing gynaecological operations of differing severity. In addition to measuring the well known inflammatory markers neopterin and IL-6, we also determined the kynurenine/tryptophan ratio.

This study was a prospective, single center, two-armed observational study involving 28 female patients. Plasma levels of tryptophan, kynurenine, neopterin and IL-6 were determined from samples taken at: 24hrs pre-operative, prior to induction, ten minutes before the operation was expected to end, and at 24 and 96 hours post operative in patients undergoing abdominal hysterectomy and vulvectomy.

Results

There were 15 and 13 patients included in the vulvectomy and abdominal hysterectomy groups, respectively. In this study we show that anesthesia and surgery significantly increases the enzyme activity of indoleamine 2, 3 dioxygenase (IDO) as measured by the kynurenine/tryptophan ratio (P=0.003), while maintaining stable neopterin levels. However, abdominal hysterectomy causes a considerable IL-6 increase (P<0.001).

Conclusion

Surgery and associated anesthesia cause a significant tryptophan level decrease while significantly increasing IDO activity. Both types of surgery produce nearly identical neopterin time curve relationships, with no significant change occurring in either group. However, even though neopterin is unaffected by the severity of surgery, IL-6 responded to surgical invasiveness by revealing a significant increase during abdominal hysterectomy.

Preventively enteral application of immunoglobulin enriched colostrums milk can modulate postoperative inflammatory response

Several studies demonstrated acute inflammatory response following traumatic injury. Inflammatory response during surgical interventions was verified by a significant increase of endotoxin plasma levels and a decrease of the endotoxin neutralizing capacity (ENC). However, the incidence of elevated endotoxin levels was significantly higher (89%) than detected bacterial translocation (35%). Thus parts or products of Gram-negative bacteria seem to translocate more easily into the blood circulation than whole bacteria. Along with the bacterial translocation, the inflammatory response correlated directly with the severity of the surgical intervention. In comparison after major and minor surgery Interleukin-6 (IL-6) and C-reactive protein (CRP) was also significantly different. Similar effects in mediator release were shown during endovascular stent graft placement and open surgery in infrarenal aortic aneurysm. Open surgery demonstrated a significant stronger endotoxin translocation and a decrease of ENC. Strategies to prevent translocation seem to be sensible. Colostrum is the first milk produced by the mammary glands within the first days after birth. It contains a complex system of immune factors and has a long history of use in traditional medicine. Placebo-controlled studies verified that prophylactic oral application of immunoglobulin-enriched colostrum milk preparation diminishes perioperative endotoxemia, prevents reduction of ENC and reduces postoperative CRP-levels, suggesting a stabilization of the gut barrier. This effect may be caused by immunoglobulin transportation by the neonatal receptor FcRn of the mucosal epithelium.In conclusion, there is an association of perioperative endotoxemia and the subsequent increase in mediators of the acute phase reaction in surgical patients. A prophylactic oral application of colostrum milk is likely to stabilize the gut barrier i.e. reduces the influx of lipopolysaccharides arising from Gram-negative bacterial pathogens and inhibits enterogenic endotoxemia. This appears to be a major mechanism underlying the therapeutic effect in patients at risk for Gram-negative septic shock.

The Effects of Erythropoietin on Bacterial Translocation and Inflammatory Response in an Experimental Intestinal Obstruction Model in Rats / Uticaj Eritropoetina Na Bakterijsku Translokaciju I Inflamatorni Odgovor U Eksperimentalnom Modelu Intestinalne Opstrukcije Kod Pacova

Background:Intestinal obstruction results in distortion of balance of antiinflammatory cytokines and release of oxidants, and also leads to bacterial translocation, sepsis and multiple organ failure. Asymmetric dimethylarginine is related to multiple organ failure as a new prognostic marker. Erythropoietin reduces the inflammatory response by decreasing the levels of proinflammatory cytokines and cytokine-induced apoptosis. In this study, we aimed to investigate the effectiveness of erythropoietin in reducing the severity of bacterial translocation and inflammatory response after intestinal obstruction and the relation between asymmetric dimethylarginine and inflammatory markers.

Methods:Forty Wistar albino rats (200-250 g) were divided into 4 groups as follows: Group 1 (Sham), only ileocaecal junction dissection; Group 2 (Erythropoietin), ileocaecal junction dissection and 3000 lU/kg erythropoietin subcutaneously; Group 3 (Intestinal Obstruction), complete ileal ligation; Group 4 (Intestinal Obstruction + Erythropoietin), complete ileal ligation and 3000 IU/kg erythropoietin subcutaneously. After 24 hours, the rats were sacrificed by taking blood from the heart for biochemical analyses. Peritoneal swab culture, liver, mesenteric lymph nodes, spleen and ileum were collected for microbiological and histopathological examinations.

Results:Erythropoietin reduced the secretion of inflammatory cytokines, oxidative damage and bacterial translocation, prevented the formation of inflammatory changes in the intestine, liver, spleen and mesenteric lymph nodes,and also significantly prevented the formation of intestinal damage after intestinal obstruction (p<0.05). Conclusions: Asymmetric dimethylarginine levels did not differ between the groups. Erythropoietin may be useful to preserve from intestinal injury and related sepsis in patients with intestinal obstruction. Asymmetric dimethylarginine is not a suitable prognostic marker.

Procalcitonin levels during pregnancy, delivery and postpartum

AIMS

To determine the normal value ranges of procalcitonin (PCT) in women with uncomplicated pregnancies.

METHODS

This prospective cohort study was conducted between May 2009 and February 2010 among 60 women without signs of clinical infection (31 vaginal deliveries, 29 cesarean sections) attending the maternity unit of the University of Geneva Hospitals. Sequential follow-up of PCT levels was performed at 24-28 weeks (n=7), 36-40 weeks (n=60), at delivery (n=59), and at days 2-3 (n=58) and 10 (n=53) postpartum using a sensitive PCT assay with a functional sensitivity of 0.06 μg/L.

RESULTS

Median levels of PCT were: 24-28 weeks: 0.043 μg/L (range 0.010-0.080); 36-40 weeks: 0.061 μg/L (range 0.010-0.110); at delivery: 0.068 μg/L (range 0.010-0.170); days 2-3: 0.200 μg/L (range 0.030-5.00); and day 10: 0.060 μg/L (range 0.020-0.120). At days 2-3 postpartum, three women had a PCT level between 0.25 μg/L and 0.5 μg/L and two women had a level higher than 0.5 μg/L.

CONCLUSIONS

This study provides reference values for PCT during the third trimester, at delivery and at the immediate postpartum period. A cut-off PCT level of 0.25 μg/L can be used during the third trimester, at delivery, and at the immediate postpartum period to rule out infection.

Standard versus video-assisted thyroidectomy: objective postoperative pain evaluation

BACKGROUND

This prospective, randomized study was designed to objectively demonstrate that minimally invasive video-assisted thyroidectomy (MIVAT) improves postoperative pain compared with standard thyroidectomy, via the dosage of biochemical mediators measured before and after surgery.

METHODS

Forty-nine patients undergoing total thyroidectomy were allotted to MIVAT (n = 23) or traditional thyroidectomy (OPEN) (n = 26) groups. At hospitalization (T0), interleukin (IL)-1, -2, -4, -6, -10, -3, tumor necrosis factor (TNF)-α, TGF-β, and MCP-1 were measured. The basal pain tolerance also was evaluated by VAS. Blood samples for interleukin measurement and VAS evaluations were obtained from all patients in the recovery room (T1) and 24 h after surgery (T2).

RESULTS

At T0, the MIVAT and the OPEN groups were not different in terms of basal pain tolerance and biochemical profile. At T1, VAS scores were significantly higher (p = 0.04), whereas TGF-β (p = 0.03) and MCP-1 (p = 0.03) levels were significantly lower in the OPEN than in the MIVAT group. No significant difference was demonstrated for other interleukins. A significant inverse relationship between VAS and TGF-β was demonstrated and confirmed through the correlation (p = 0.003) and regression (p = 0.003, p < 0.0001, R (2) = 0.172) coefficients; the stepwise regression also demonstrated that TGF was the most predictive factor of postoperative pain (p = 0.0038) through an inverse relationship. No statistically significant difference has been demonstrated at T2.

CONCLUSIONS

TGF-β serum levels immediately after surgery seem to correlate with pain evaluation, confirming that reduced postoperative distress is an objective outcome of MIVAT. This result confirms the results of studies based only on subjective pain evaluations.

ROLE OF BACTERIAL ENDOTOXIN IN CHRONIC HEART FAILURE

Proinflammatory cytokines are now thought to play a key role in the pathophysiology of chronic heart failure, driving both symptomatic presentation and disease progression. We propose that this proinflammatory state, in turn, may be sustained through a chronic release of enterically derived bacterial endotoxin. Human trials have indicated that bacterial decontamination of the gut with concomitant decrease in lipopolysaccharide (LPS) has a positive outcome on heart disease patients. Antiendotoxin antibodies may thus represent therapeutic agents in this setting. Previously, antiendotoxin antibodies were targeted to the inner hydrophobic lipid A moiety of endotoxin in an attempt to neutralize its toxicity. These antibodies failed because they lacked specificity and bound to LPS weakly. In contrast, our studies on antiendotoxin antibodies have revealed that antibodies targeted to the hydrophilic oligosaccharides of the endotoxin have the potential to bind specifically with high affinity. Development of immunotherapeutics that can reduce systemic LPS or other agents, such as bactericidal/permeability-increasing protein that can neutralize LPS and limit inflammation safely, will enable the role of LPS in chronic heart failure to be elucidated and may pave the way to develop a new generation of effective therapeutic agents that may be directed to the treatment of chronic heart failure.

Carbamoyl phosphate synthase-1: a marker of mitochondrial damage and depletion in the liver during sepsis

OBJECTIVE

Mitochondrial damage and dysfunction are thought to play an important role in the pathogenesis of sepsis-induced organ failures. Unfortunately, specific markers of mitochondrial damage in vital organs do not currently exist. Recently, carbomyl phosphate synthase (CPS)-1, a protein primarily localized to liver mitochondria, was found to be present in high concentrations in the plasma of septic humans. Thus, we hypothesized that the circulatory release of CPS-1 would correlate with mitochondrial damage or impaired mitochondrial function in the liver in a clinically relevant model of sepsis.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University medical center research laboratory.

SUBJECTS

Male, Balb/C mice, aged 10-12 wks.

INTERVENTIONS

Animals were assigned to receive cecal ligation and puncture (CLP sepsis) or sham operation and compared with untreated controls. Plasma CPS-1 levels and liver mitochondrial variables, including morphology, respiratory activity, mass (i.e., cardiolipin content), and protein carbonylation, were assessed at various time points (8, 24, and 48 hrs and 6 days) after surgery.

MEASUREMENTS AND MAIN RESULTS

Oxidant stress (i.e., carbonylation) was detected within 8 hrs of CLP and persisted through 48 hrs. Plasma CPS-1 levels increased dramatically at 24 hrs, remained significantly elevated at 48 hrs, and normalized by 6 days in the sepsis group. Abnormalities of liver mitochondrial morphology and function coincided with increased plasma CPS-1 levels. Mitochondrial depletion in the liver was not due to cell death but was associated with increased lysosomal clearance. Increased expression of mitochondrial biogenesis factors preceded restoration of mitochondrial variables and normalization of CPS-1 levels by day 6.

CONCLUSIONS

Circulating CPS-1 is a marker of mitochondrial damage and depletion in the liver during the subacute phase of CLP sepsis. From a mechanistic standpoint, mitochondrial depletion is not due to cell death but is apparently related to the removal of damaged mitochondria by lysosomes (i.e., autophagy), followed by repletion of mitochondrial populations. Further studies are needed to determine the clinical utility of CPS-1 as a marker of sepsis severity.

Does transthoracic compared to transhiatal resection alter the early postoperative course of oesophagectomy?

Several techniques for esophageal resections have been reported. However, clear clinical evidence is still lacking whether any of the procedures is superior to the others regarding morbidity and mortality in the early postoperative period. Two operative approaches for esophageal carcinoma, transhiatal and transthoracic, were compared with respect to operative morbidity, mortality and systemic inflammatory response. In our prospective study between 2000 and 2002 83 patients were investigated. In a retrospective post hoc analysis patients were divided into two groups due to the performed operational procedure, transhiatal (TH) or transthoracic (TT). Multiple Organ Dysfunction Score (MODS) was monitored daily (t1,t2,t3). Serum procalcitonin (PCT) levels were determined on admission to the ICU (t0), then 24 hourly (t24,t48,t72). Microalbuminuria (M:Cr) was measured before (tp), and after surgery (t0,t6,t24,t48,t72). For statistical analysis Wilcoxon rank sum test, Mann-Whitney U-test and chi-square test were used as appropriate. We examined 52 patients in the TH group, and 31 patients in the TT group. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Operations lasted significantly longer in the TT group: 375 (300-480) min compared to the TH group 240 375 (180-319) min, P < 0.001. ICU mortality was similar in both groups (TH: 46 survivors/6 non-survivors; TT: 27 survivors/4 non-survivors; P = 0.607, respectively). Daily MODS did not differ significantly between the two groups. The observed inflammatory markers (PCT and M:Cr) followed the pattern we described earlier, without significant difference. In this study there was no difference in the clinical and biochemical variables of the patients between the transthoracic and transhiatal groups. The observed early postoperative morbidity and mortality may indicate, that both procedures can be considered as procedures with similar postoperative risk.

Early alterations in the number of circulating lymphocyte subpopulations and enhanced proinflammatory immune response during opioid-based general anesthesia

The balance between proinflammatory and anti-inflammatory processes is of key importance in the reaction of the body to infection, injury, and surgical trauma. Drugs commonly used in anesthesia and intensive care may modulate immunological reactions by influencing intercellular communication through modification of cytokine response and fluctuation of peripheral immune cells such as natural killer (NK) cells, B cells, and T lymphocyte subpopulations (CD4+ and CD8+ cells). To examine the effects of general anesthesia with the hypnotic agent propofol and the opioid fentanyl, 30 patients undergoing minor elective orthopedic surgery were studied before and 20 min after application of the anesthetic drugs, but before the start of surgery. We found a significant enhancement of TNF-alpha and IL-1beta release in lipopolysaccharide (LPS)-stimulated whole blood cultures after induction of anesthesia. Similar results were observed with interferon-gamma (IFN-gamma) in cultures stimulated with phytohemagglutinin (PHA). Conversely, synthesis of the anti-inflammatory cytokine interleukin 10 (IL-10) decreased significantly in LPS-stimulated cultures. During general anesthesia, we found a decrease of circulating lymphocytes, characterized by a significant increase in the percentage of T lymphocytes in favor of CD4+ cells, increased B lymphocytes, and a significant decrease of NK cells. These data suggest that anesthesia with propofol and fentanyl promotes proinflammatory immune responses and influences peripheral lymphocyte composition in patients, which may subsequently affect pathophysiological processes during opioid-based anesthesia.

Different acute-phase response in newborns and infants undergoing surgery

In a prospective clinical study, we investigated the inflammatory response in 88 neonatal subjects (43 boys and 45 girls) who underwent major abdominal surgery owing to congenital malformation involving the gastrointestinal tract and compared it with the response in 20 infants (8 boys, 12 girls; mean age, 4 mo) who underwent elective surgery for resolution of an existing temporary stoma. In both groups, plasma levels of endotoxin, IL-6, and C-reactive protein as well as leukocyte counts were determined during and after surgery. Endotoxin was measured by the Limulus amebocyte test, IL-6 by ELISA, and C-reactive protein by nephelometry. Statistical analyses were performed using the Wilcoxon signed-rank test. A significant increase in circulating endotoxin and a leukocyte shift was observed in the infant group only. Postoperatively, IL-6 levels peaked between 2 and 6 h and C-reactive protein after 24 h in the infant group. In contrast, no significant increase in the levels of endotoxin, IL-6, and C-reactive protein in plasma were observed during and after surgery in the neonatal subjects, except those with gastroschisis. Newborns with gastroschisis developed an inflammatory response after surgery that was less pronounced than the response of infants older than 4 mo. The finding that endotoxemia in newborns does not follow surgical trauma is most likely because of the absence of bacterial colonization of the gastrointestinal tract.