title: Pneumoperitoneum with carbon dioxide inhibits macrophage tumor necrosis factor-alpha secretion: source of transitional-cell carcinoma port-site metastasis, with prophylactic irrigation strategies to decrease laparoscopic oncologic risks.
abstract: OBJECTIVE
  Peritoneal macrophages play a critical role in maintaining local host resistance to infection and malignancy through the secretion of tumor necrosis factor-alpha (TNF-alpha). We hypothesized that attenuated TNF-alpha secretion, as a result of CO(2) pneumoperitoneum, could alter local immune surveillance, thereby contributing to the development of carcinomatosis and incisional metastasis. We further sought to determine if port-site metastasis could be prevented with prophylactic irrigants.
  
  
  METHODS
  C57BL/6 mice (n = 50) and the syngenic murine bladder tumor (MBT-2) cell line were used. Experiment 1: Mice were subjected to either CO(2) pneumoperitoneum at 6 mm Hg (n = 10) or a 3-cm midline incision (n = 10). Peritoneal macrophages (1 x 10(6)/animal) were collected and subjected to lipopolysaccharide challenge. TNF-alpha levels were quantified using the Quantikine Mouse TNF-alpha/TNFSF1A Immunoassay. Experiment 2: Peritoneal and port-site metastasis were evaluated 1 week after 1 x 10(6) MBT-2 cells/animal were spilled in an open group (n = 5) and through 5-mm trocars of a pneumoperitoneal group (n = 5). Experiment 3: 1 x 10(6) MBT-2 cells/animal were spilled intraperitoneally through 5-mm trocars of four groups (n = 20). Port sites in each group were then irrigated with either sterile water, mitomycin C (1.0 mg/mL), betadine (10%), or heparin (1000 U/mL). At 1 week, incisional sites were evaluated for gross and microscopic metastasis. In each experiment, Student t-test was used to quantify statistical differences.
  
  
  RESULTS
  Peritoneal macrophage TNF-alpha secretion was significantly inhibited in mice subjected to CO(2) pneumoperitoneum v control at 10 and 20 minutes (P = 0.015, P = 0.001, respectively). When 1 x 10(6) MBT-2 cells were spilled, a significantly higher average tumor burden developed in animals subjected to CO(2) pneumoperitoneum than in controls at 1 week (9.2 gm v 3.8 g, P = 0.002). All irrigants prevented the development of port-site metastasis, yet sterile water did so without toxic effect.
  
  
  CONCLUSIONS
  In a syngenic murine model, CO(2) pneumoperitoneum causes inhibition of peritoneal macrophage TNF-alpha secretion. Heavier intraperitoneal and incisional metastasis develops in C57BL/6 mice subjected to CO(2) pneumoperitoneum and a tumor challenge with 1 x 10(6) MBT-2 tumor cells compared with open controls. Inhibition of peritoneal macrophage TNF-alpha secretion may be considered an adverse event contributing to the development of transitional-cell carcinoma (TCC) port-site metastasis, especially if surgical oncologic principles are violated. Irrigating trocar sites and the peritoneal cavity with sterile water at the conclusion of laparoscopic nephroureterectomy and laparoscopic radical cystectomy may offer a safe prophylactic strategy to prevent this unfavorable event. Our murine model presents a novel avenue for the development of adjunct immunomodulatory therapies to perhaps further reduce oncologic risks during laparoscopic management of TCC.
authors.affiliation: Department of Urology and Pathology, The North Shore-Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Ost
authors.forename: Keyur P
authors.initials: KP
authors.lastname: Patel
authors.forename: Ardeshir R
authors.initials: AR
authors.lastname: Rastinehad
authors.forename: Pui Yan
authors.initials: PY
authors.lastname: Chu
authors.forename: Ann E
authors.initials: AE
authors.lastname: Anderson
authors.forename: Arthur D
authors.initials: AD
authors.lastname: Smith
authors.forename: Benjamin R
authors.initials: BR
authors.lastname: Lee
mesh_terms: D000818:Animals; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage; D000903:Antibiotics, Antineoplastic / Q000008:administration & dosage; D002245:Carbon Dioxide; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000517:prevention & control / Q000556:secondary*; D045744:Cell Line, Tumor; D005260:Female; D006493:Heparin / Q000008:administration & dosage; D066298:In Vitro Techniques; D010535:Laparoscopy / Q000009:adverse effects*; D017737:Macrophages, Peritoneal / Q000378:metabolism*; D051379:Mice; D008810:Mice, Inbred C57BL; D016685:Mitomycin / Q000008:administration & dosage; D009366:Neoplasm Seeding; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects*; D011206:Povidone-Iodine / Q000008:administration & dosage; D007507:Therapeutic Irrigation; D014409:Tumor Necrosis Factor-alpha / Q000378:metabolism*; D001749:Urinary Bladder Neoplasms / Q000601:surgery*
chemical_list: D000891:Anti-Infective Agents, Local; D000903:Antibiotics, Antineoplastic; D014409:Tumor Necrosis Factor-alpha; D002245:Carbon Dioxide; D016685:Mitomycin; D011206:Povidone-Iodine; D006493:Heparin