Immune responses and prediction of major infection in patients undergoing transhiatal or transthoracic esophagectomy for cancer.
OBJECTIVE
To investigate alterations in immune responses after transhiatal versus transthoracic esophageal resection and to evaluate the role of preoperative immune functions in predicting postoperative infectious complications.


BACKGROUND
Impaired immune defense is associated with a decreased resistance to infection. Patients undergoing esophageal resection via a transhiatal or transthoracic approach are prone to develop infectious complications. There are no randomized data on immune responses after two major surgical interventions.


METHODS
The study group consisted of 20 patients who were randomly allocated to a limited transhiatal or extended transthoracic esophagectomy for cancer. Blood samples were taken before the operation and at regular intervals thereafter from day 1 to day 10. Monocyte and T-helper type 1 (Th1) and type 2 (Th2) lymphocyte functions were assessed in stimulated whole blood cultures.


RESULTS
Both surgical groups had severely depressed in vitro production of interleukin (IL)-12, IL-10, interferon-gamma, IL-2, IL-4, and IL-13 on postoperative day 1. Depression of Th2-type cytokine production was more profound after transthoracic than after transhiatal esophagectomy (IL-4, P=.005; IL-13,P=.007). Postoperative reduction in Th1-type cytokine production was similar between the two groups (interferon-gamma, P=.40; IL-2, P=.06). Irrespective of the surgical approach, patients who developed major infectious complications after surgery presented with a diminished T-cell cytokine production before the operation compared to those who had a relatively uneventful recovery (IL-4, P=.045; interferon-gamma, P=.064). In regression analysis, the occurrence of postoperative major infection was best predicted by increased duration of anesthesia ( P<.0001) and low preoperative interferon-gamma production ( P=.006).


CONCLUSIONS
Both transhiatal and transthoracic esophagectomy induced severely depressed monocyte and T-lymphocyte cytokine production. The extent of the surgical procedure had a differential immunosuppressive impact on Th2-type but not on Th1-type cell activity, indicating that the two Th pathways were downregulated through distinct mechanisms. Preoperative interferon-gamma determination would be useful to anticipate the occurrence of postoperative major infectious complications.
van Sandick
Johanna W
JW
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. j.w.vansandick@wanadoo.nl
Gisbertz
Suzanne S
SS
ten Berge
Ineke J M
IJ
Boermeester
Marja A
MA
van der Pouw Kraan
Tineke C T M
TC
Out
Theo A
TA
Obertop
Hugo
H
van Lanschot
J Jan B
JJ
D000368:Aged; D000704:Analysis of Variance; D001769:Blood / Q000382:microbiology; D001774:Blood Chemical Analysis; D016207:Cytokines / Q000032:analysis / Q000276:immunology*; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005434:Flow Cytometry; D005500:Follow-Up Studies; D006801:Humans; D007108:Immune Tolerance / Q000502:physiology*; D007958:Leukocyte Count; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000276:immunology; D011237:Predictive Value of Tests; D011336:Probability; D012016:Reference Values; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000276:immunology*; D016176:T-Lymphocyte Subsets / Q000276:immunology*
D016207:Cytokines