The effects of surgical trauma on human granulopoiesis

Cellular Immunoprofile of Peritoneal Environment During a HIPEC Procedure

BACKGROUND

We characterized the peritoneal immune cellular profile during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in this pilot study.

METHODS

We prospectively performed flow cytometric analysis of peritoneal fluid collected at laparotomy and during HIPEC at 0, 30, 60, and 90 min. Analysis consisted of standard flow cytometric leukocyte gating and the use of antibodies for stem cells, B lymphocytes, T-helper, T-suppressor, and natural killer (NK) cells.

RESULTS

The mean peritoneal carcinomatosis index (PCI) score was 19.8 ± 11.5 (median 19). Twelve patients had a completeness of cytoreduction (CCR) score of 0-1, and three patients had a CCR score of ≥ 2 (20%). The proportion of peritoneal NK cells remained stable (p = 0.655) throughout perfusion. The CD4/CD8 ratio (p = 0.019) and granulocyte/lymphocyte ratio (p = 0.018) evolved during cytoreduction, with no further change during HIPEC. Two distinct temporal patterns of peritoneal T lymphocytes became evident (the 'high' and 'low' CD4/CD8 ratio groups) and patients maintained their high versus low peritoneal CD4/CD8 ratio status throughout the duration of HIPEC. High CD4/CD8 was associated with longer cytoreduction (p = 0.019) and borderline higher PCI score (p = 0.058). No association was identified with age (p = 0.131), sex (p = 1.000), CCR status (p = 0.580), occurrence of complication (p = 0.282), or ascites volume (p = 0.713).

CONCLUSION

The cellular immunoprofile of peritoneal fluid during HIPEC is stable but changes during cytoreduction. Two distinct immune groups emerged, based on CD4/CD8 ratios in the peritoneal perfusate. Further studies are warranted to evaluate peritoneal immunity and the clinical significance of novel peritoneal immune phenotype.

Haematological indices as surrogate markers of factors affecting mortality after hip fracture

This study investigated the relationship between different components of the full blood count, such as haemoglobin (Hb), total white cell count, total lymphocyte count on admission and total neutrophil count as possible surrogate markers of conditions that lead to increased mortality in hip-fracture patients. A total of 791 patients were studied with 81.2% being females. The 1-year mortality was 26.4%(32.9% in males compared with 24.9% in females). A significant increase in mortality was seen in anaemic patients, especially with Hb 80–100 g l(-1) (1-year mortality was 49.2%, p-value < 0.001) and patients with lymphocyte count ≤ 1.1 × 10(9) l(-1) (33.2% mortality, p-value < 0.0001). There was no relationship between total white cell count or neutrophil count and mortality. This information clearly suggests that Hb and total lymphocyte counts may be surrogate markers for increased mortality after a hip fracture and can be used for audit purposes to adjust for different case mixes between groups.

The effect of preoperative radiotherapy on systemic collagen deposition and postoperative infective complications in rectal cancer patients

PURPOSE

Preoperative, high-dose radiotherapy for rectal cancer reduces local recurrence rates and improves overall survival. However, adverse effects in varying degrees include impaired wound healing and local infection. This study investigates the influence of preoperative, high-dose radiotherapy on subcutaneous accumulation of collagen in a primary rectal cancer group operated on with or without adjuvant radiotherapy.

METHODS

Forty-two eligible patients who underwent total mesorectal excision surgery with or without radiotherapy were included in the study. Polytetrafluoroethylene tubings were implanted in the arm ten days before surgery (three days before the start of radiotherapy). Implants were extracted the day before surgery. New implants were inserted before surgery and were extracted ten days after surgery. The hydroxyproline and proline contents of the implants were measured and the hydroxyproline/proline ratio was calculated as a measure for deposited collagen relative to protein. Blood loss, postoperative complications, and blood levels of hemoglobin, leukocytes, and albumin were recorded.

RESULTS

The two groups were similar in relation to Dukes stage, age, and body mass index. Infectious complications developed in 39 percent of patients after radiotherapy compared with 16 percent in the nonirradiated group. In the irradiated patients with infective complications we found a significant decrease in the hydroxyproline/proline ratio compared with that of irradiated patients without infections (P = 0.037). There was a significant decrease in the leukocyte count preoperatively and postoperatively in the irradiated group compared with surgery alone.

CONCLUSIONS

High-dose, short-term radiotherapy does not have a systemic effect on collagen accumulation, but a significant reduction is manifested in infected patients. Radiotherapy also impairs leukocyte production and increases the postoperative infective complication rate.

Impaired postoperative neutrophil leucocytosis and acute complications following short course preoperative radiotherapy for operable rectal cancer

AIM

Postoperative mortality following total mesorectal excision is increased if this is performed more than 3 days after the completion of short course preoperative radiotherapy. Suppression of neutrophil leucocytosis which is normally seen following surgery has been a suggested reason. This study was to determine the relationship between postoperative complications and perioperative neutrophil counts.

METHOD

A database of 176 patients treated at a single radiotherapy centre in 1998 and 1999 was used. A two-sample Wilcoxon test was used to compare preoperative neutrophil counts, postoperative neutrophil counts and their ratio in patients with and without complications.

RESULTS

There was no association between acute complications and preoperative (P = 0.25) or postoperative (P = 0.45) neutrophil count. The post/preoperative ratio was significantly higher in patients without complications (median 1.61 vs 1.16, P = 0.02).

CONCLUSIONS

There appears to be an inverse relationship between the magnitude of postoperative neutrophil leucocytosis and the risk of acute complications following short course preoperative radiotherapy.

Enhancement of neutrophil chemiluminescence after elective gastrointestinal surgery

Neutrophil count and luminol-dependent chemiluminescence were measured pre-operatively and on the second, sixth and ninth days after operation in nine patients undergoing major, elective gastrointestinal surgery. The aim of the study was to test the hypothesis that elective surgery as a form of injury has no prolonged deleterious effect on neutrophil activity in non-septic patients. A significant increase in neutrophil count was demonstrated in all patients at Day 2 (P less than 0.01) and Day 9 (P less than 0.01). Neutrophil chemiluminescence increased on Day 2 and Day 6, the increase on Day 6 being significant (P less than 0.02). In the first 9 days after elective gastrointestinal surgery, a biphasic neutrophilia occurs and the metabolic response of neutrophils to an opsonized particle is not impaired. These data would support the hypothesis that major elective surgery has no deleterious effects on neutrophil activity, and indeed that neutrophil activity may be enhanced.

Hematopoietic colony-forming cells from mice after wound trauma

The changes produced in the pluripotential and progenitor cell compartments of the hind leg bone marrow and spleen of skin-wounded mice were examined over a 2-week post-trauma period. Pluripotent cells (colony-forming unit-spleen, CFU-s) were significantly increased in the spleen and slightly reduced in the leg marrow the first week after trauma. Granulocyte macrophage colony-forming cells (GM-CFC) were significantly increased in the spleen throughout the 2-week period and were increased in the leg marrow during the first post-trauma week. Macrophage colony-forming cells (M-CFC) were significantly decreased in the spleen during the 2-week period and were slightly elevated in the leg marrow during that time. The peripheral blood contained significantly increased concentrations of CFU-s and GM-CFC but not M-CFC. Serum of wounded mice supported growth of GM-CFC but not M-CFC. The growth-promoting factor was extractable by CHCl3 treatment. Serum C-reactive protein concentrations were significantly increased for a 5-day period after wound trauma.

Hemopoiesis in pregnant beagles following low-dose total-body irradiation and surgery

Hemopoietic perturbations were observed in gravid beagles subjected to whole-body ionizing radiation during midpregnancy followed by the additional trauma of surgery, with alterations in peripheral blood hemogram parameters, bone marrow morphology, and concentration of marrow-derived granulocytic- and erythrocytic-committed stem cells. However, the trauma of surgery combined with irradiation had no apparent effects on the contralateral uterine horn with the remaining pups, with no indications of miscarriage, absorption of pups, or other complications of pregnancy.

Hydrocortisone--a possible physiological regulator of human granulopoiesis

The effect of hydrocortisone (HC) on the formation of granulocyte-macrophage (GM) colonies was assessed in vitro in cultures of normal human bone marrow. Subphysiological concentrations (less than or equal to 10(-8) mol/l) of HC had no impact on GM colony formation, but at physiological and therapeutic levels (10(-7) mol/l-10(-5) mol/l) the hormone stimulated the production of an increased number of colonies. By contrast, physiological concentrations of progesterone (10(-9) mol/l-10(-7) mol/l) were without effect and even at 10(-6) mol/l there was no influence of progesterone alone on GM colony formation. However, progesterone at 10(-6) mol/l inhibited the stimulant effect of HC to a degree which was related inversely to the concentration of HC and the duration of the culture interval. The data from this study suggest that the neutrophilia which accompanies glucocorticosteroid therapy is matched by an increase in the production of granulocytes and that HC may play a rôle, which is mediated by steroid receptors, in the physiological regulation of human granulopoiesis.

Effects of surgery on neutrophil granulocyte function

The high incidence of postoperative infections raises the possibility of a reduced defense to infection during this period. For this reason, neutrophil function and enzyme activity were investigated after surgical trauma. The microbicidal ability of neutrophils was markedly impaired within 2 h of elective abdominal hysterectomy, but phagocytosis was unaffected. Loss of microbicidal activity was associated with loss of the lysosomal enzyme myeloperoxidase. It is suggested that these changes are due to activation and partial degranulation of circulating neutrophils. Defective microbial killing by individual cells should be compensated by an accompanying rise in the number of circulating neutrophils.

Skin wound-enhanced survival and myelocytopoiesis in mice after whole-body irradiation

Skin wounding at 24 h before whole-body 60Co irradiation of mice raised the LD50/30 from 8.09 to 9.71 Gy resulting in a dose reduction factor of 1.2. Concentrations and quantities of myeloproliferative cells were examined at 3, 7, 10, and 14 days after 7 Gy, skin wounding 24 h before 7 Gy and in control non-treated mice. Wounding before irradiation provoked an increase in marrow and splenic clonogenic cells that was earlier and greater than that noted for irradiated mice. Supranormal levels of splenic CFu-s and CFU-c were found in animals wounded before irradiation. M-CFC values were depressed throughout, although greater for combined injured animals than for irradiated mice.